Archives of Orthopaedic and Trauma Surgery

, Volume 129, Issue 6, pp 773–777 | Cite as

Anterior knee pain following the lateral parapatellar approach for tibial nailing

  • Yoram A. Weil
  • Michael J. Gardner
  • Sreevathsa Boraiah
  • David L. Helfet
  • Dean G. Lorich
Orthopaedic Surgery

Abstract

Background

Anterior knee pain after intramedullary nailing of tibial shaft fractures is a common clinical problem, with various etiologies. We have used a lateral parapatellar approach with atraumatic elevation of the infrapatellar fat pad to expose the starting point. Our hypothesis was that this approach leads to a low incidence of knee pain.

Methods

We conducted a retrospective study of 78 patients suffering from tibia fractures treated by a single surgeon. Fifty patients were available for the study. All fractures were fixed with a reamed intramedullary nail using the modified lateral approach. Complaints of knee pain and range of motion as well as keeling ability were examined in the clinic visit and recorded in the patients’ charts. Lysholm knee scores were collected following the last follow-up visit. Average follow-up was 13 months (range 6–26 months).

Results

Nine patients (19%) had subjective anterior knee pain when directly questioned. Eighty-two percentage of patients had no difficulty kneeling and this was significantly correlated with lack of knee pain. Good or excellent knee scores were reported by 92% of patients. Average knee flexion was 130°. There was a negative correlation between the presence of open fracture and outcome. No correlation was found between knee pain and nail insertion depth or coronal alignment.

Conclusion

The modified lateral parapatellar approach with careful dissection of the fat pad may significantly reduce anterior knee pain after intramedullary nailing of the tibial shaft.

Keywords

Knee pain Intramedullary nailing Tibial fractures 

References

  1. 1.
    Althausen PL, Neiman R, Finkemeier CG, Olson SA (2002) Incision placement for intramedullary tibial nailing: an anatomic study. J Orthop Trauma 16(10):687–690. doi: 10.1097/00005131-200211000-00001 PubMedCrossRefGoogle Scholar
  2. 2.
    Bennell K, Hodges P, Mellor R, Bexander C, Souvlis T (2004) The nature of anterior knee pain following injection of hypertonic saline into the infrapatellar fat pad. J Orthop Res 22(1):116–121. doi: 10.1016/S0736-0266(03)00162-1 PubMedCrossRefGoogle Scholar
  3. 3.
    Bhattacharyya T, Seng K, Nassif NA, Freedman I (2006) Knee pain after tibial nailing: the role of nail prominence. Clin Orthop Relat Res 449:303–307PubMedGoogle Scholar
  4. 4.
    Bohnsack M, Hurschler C, Demirtas T, Ruhmann O, Stukenborg-Colsman C, Wirth CJ (2005) Infrapatellar fat pad pressure and volume changes of the anterior compartment during knee motion: possible clinical consequences to the anterior knee pain syndrome. Knee Surg Sports Traumatol Arthrosc 13(2):135–141. doi: 10.1007/s00167-004-0561-1 PubMedCrossRefGoogle Scholar
  5. 5.
    Bohnsack M, Meier F, Walter GF, Hurschler C, Schmolke S, Wirth CJ et al (2005) Distribution of substance-P nerves inside the infrapatellar fat pad and the adjacent synovial tissue: a neurohistological approach to anterior knee pain syndrome. Arch Orthop Trauma Surg 125(9):592–597. doi: 10.1007/s00402-005-0796-4 PubMedCrossRefGoogle Scholar
  6. 6.
    Bono CM, Levine RG, Rao JP, Behrens FF (2001) Nonarticular proximal tibia fractures: treatment options and decision making. J Am Acad Orthop Surg 9(3):176–186PubMedGoogle Scholar
  7. 7.
    Court-Brown CM, Gustilo T, Shaw AD (1997) Knee pain after intramedullary tibial nailing: its incidence, etiology, and outcome. J Orthop Trauma 11(2):103–105. doi: 10.1097/00005131-199702000-00006 PubMedCrossRefGoogle Scholar
  8. 8.
    Devitt AT, Coughlan KA, Ward T, McCormack D, Mulcahy D, Felle P et al (1998) Patellofemoral contact forces and pressures during intramedullary tibial nailing. Int Orthop 22(2):92–96. doi: 10.1007/s002640050216 PubMedCrossRefGoogle Scholar
  9. 9.
    Dogra AS, Ruiz AL, Marsh DR (2002) Late outcome of isolated tibial fractures treated by intramedullary nailing: the correlation between disease-specific and generic outcome measures. J Orthop Trauma 16(4):245–249. doi: 10.1097/00005131-200204000-00005 PubMedCrossRefGoogle Scholar
  10. 10.
    Ebraheim NA, Mekhail AO (1997) The infrapatellar branch of the saphenous nerve: an anatomic study. J Orthop Trauma 11(3):195–199. doi: 10.1097/00005131-199704000-00010 PubMedCrossRefGoogle Scholar
  11. 11.
    Gustilo RB, Anderson JT (1976) Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 58(4):453–458PubMedGoogle Scholar
  12. 12.
    Hernigou P, Cohen D (2000) Proximal entry for intramedullary nailing of the tibia. The risk of unrecognised articular damage. J Bone Joint Surg 82(1):33–41. doi: 10.1302/0301-620X.82B1.9818 CrossRefGoogle Scholar
  13. 13.
    Karachalios T, Babis G, Tsarouchas J, Sapkas G, Pantazopoulos T (2000) The clinical performance of a small diameter tibial nailing system with a mechanical distal aiming device. Injury 31(6):451–459. doi: 10.1016/S0020-1383(00)00024-3 PubMedCrossRefGoogle Scholar
  14. 14.
    Katsoulis E, Court-Brown C, Giannoudis PV (2006) Incidence and aetiology of anterior knee pain after intramedullary nailing of the femur and tibia. J Bone Joint Surg 88(5):576–580. doi: 10.1302/0301-620X.88B5.16875 CrossRefGoogle Scholar
  15. 15.
    Keating JF, Orfaly R, O’Brien PJ (1997) Knee pain after tibial nailing. J Orthop Trauma 11(1):10–13. doi: 10.1097/00005131-199701000-00004 PubMedCrossRefGoogle Scholar
  16. 16.
    Marx RG, Jones EC, Allen AA, Altchek DW, O’Brien SJ, Rodeo SA et al (2001) Reliability, validity, and responsiveness of four knee outcome scales for athletic patients. J Bone Joint Surg 83-A(10):1459–1469PubMedGoogle Scholar
  17. 17.
    Morganti CM, McFarland EG, Cosgarea AJ (2002) Saphenous neuritis: a poorly understood cause of medial knee pain. J Am Acad Orthop Surg 10(2):130–137PubMedGoogle Scholar
  18. 18.
    Tegner Y, Lysholm J (1985) Derotation brace and knee function in patients with anterior cruciate ligament tears. Arthroscopy 1(4):264–267. doi: 10.1016/S0749-8063(85)80095-5 PubMedCrossRefGoogle Scholar
  19. 19.
    Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res (198):43–49Google Scholar
  20. 20.
    Toivanen JA, Vaisto O, Kannus P, Latvala K, Honkonen SE, Jarvinen MJ (2002) Anterior knee pain after intramedullary nailing of fractures of the tibial shaft. A prospective, randomized study comparing two different nail-insertion techniques. J Bone Joint Surg Am 84(4):580–585PubMedGoogle Scholar
  21. 21.
    Tornetta P 3rd, Riina J, Geller J, Purban W (1999) Intraarticular anatomic risks of tibial nailing. J Orthop Trauma 13(4):247–251. doi: 10.1097/00005131-199905000-00004 PubMedCrossRefGoogle Scholar
  22. 22.
    Vaisto O, Toivanen J, Kannus P, Jarvinen M (2004) Anterior knee pain and thigh muscle strength after intramedullary nailing of tibial shaft fractures: a report of 40 consecutive cases. J Orthop Trauma 18(1):18–23. doi: 10.1097/00005131-200401000-00004 PubMedCrossRefGoogle Scholar
  23. 23.
    Vaisto O, Toivanen J, Paakkala T, Jarvela T, Kannus P, Jarvinen M (2005) Anterior knee pain after intramedullary nailing of a tibial shaft fracture: an ultrasound study of the patellar tendons of 36 patients. J Orthop Trauma 19(5):311–316PubMedGoogle Scholar
  24. 24.
    Williams RJ 3rd, Hyman J, Petrigliano F, Rozental T, Wickiewicz TL (2004) Anterior cruciate ligament reconstruction with a four-strand hamstring tendon autograft. J Bone Joint Surg 86-A(2):225–232PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Yoram A. Weil
    • 1
    • 2
  • Michael J. Gardner
    • 1
  • Sreevathsa Boraiah
    • 1
  • David L. Helfet
    • 1
  • Dean G. Lorich
    • 1
  1. 1.Orthopaedic Trauma ServiceThe Hospital for Special SurgeryNew YorkUSA
  2. 2.Orthopaedic Trauma ServiceHadassah Hebrew University Medical CenterJerusalemIsrael

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