Abstract
Purpose
The suprapatellar approach for intramedullary nailing of tibial fractures is gaining popularity with reported improved patient outcomes when compared to infrapatellar techniques. The aim of this study was to investigate the learning curve of the suprapatellar technique using radiation exposure as an outcome measure.
Methods
Data were analysed from a prospectively collected database over a 3-year period at a Major Trauma Centre in the United Kingdom. 83 study patients with an acute isolated extra-articular fracture of the tibia treated with intramedullary tibial nailing were included. Cases requiring additional intra-operative procedures were excluded. Four consultant trauma surgeons with no previous experience of the suprapatellar technique used this approach for 40 consecutive operations. Six consultant trauma surgeons used the infrapatellar approach for 43 patients and acted as a control group. Patient demographics, fluoroscopy time and radiation dose area product (DAP) were collected for each operation. A segmented linear regression modelling method was employed to analyse learning.
Results
Fluoroscopy time and DAP per surgeon showed no evidence of a learning curve when using a suprapatellar tibial nailing technique in group or individual analysis. Fluoroscopy time and DAP were stationary in the infrapatellar group analysis, confirming the absence of time-dependent trends over the study period.
Conclusions
Consultant trauma surgeons experienced no significant learning-related increase in radiation exposure when introducing a suprapatellar technique for intramedullary nailing of uncomplicated tibial fractures. Future work is required to investigate the effects of learning on other outcome measures.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Blachut PA, O’Brien PJ, Meek RN, Broekhuyse HM. Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft: a prospective, randomized study. J Bone Jt Surg A. 1997;79(5):640–6.
Sanders RW, Dipasquale TG, Jordan CJ, Arrington JA, Sagi HC. Semiextended intramedullary nailing of the tibia using a suprapatellar approach: radiographic results and clinical outcomes at a minimum of 12 months follow-up. J Orthop Trauma. 2014;28:S29–39.
Anderson TRE, Beak PA, Trompeter AJ. Intra-medullary nail insertion accuracy: a comparison of the infra-patellar and supra-patellar approach. Injury. 2018;50(2):484–8.
Beltran MJ, Collinge CA, Patzkowski JC, Masini BD, Blease RE, Hsu JR. Intra-articular risks of suprapatellar nailing. Am J Orthop. 2012;41(12):546–50.
Yang L, Sun Y, Li G. Comparison of suprapatellar and infrapatellar intramedullary nailing for tibial shaft fractures: a systematic review and meta-analysis. J Orthop Surg Res. 2018;13(1):146.
UK Government. The Ionising Radiation (Medical Exposure) Regulations 2017 (No. 1322). 2017.
Valsamis E, Chouari T, O’Dowd-Booth C, Rogers B, Ricketts D. Learning curves in surgery: variables, analysis and applications. Postgrad Med J. 2018;94(1115):525–30.
Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008;15(11):988–94.
Stryker Orthopaedics. T2 tibial nailing system operative technique, 325 Corporate Dr. Mahwah NJ 07110. 2018.
Schoonjans F, Zalata A, Depuydt CE, Comhaire FH. MedCalc: a new computer program for medical statistics. Comput Methods Programs Biomed. 1995;48(3):257–62.
Valsamis EM, Golubic R, Glover TE, Husband H, Hussain A, Jenabzadeh AR. Modeling learning in surgical practice. J Surg Educ. 2018;75(1):78–87.
Valsamis EM, Rickets D, Husband H, Rogers B. Segmented linear regression models for assessing change in retrospective studies in healthcare. Comput Math Methods Med. 2019;2019:9810675. https://doi.org/10.1155/2019/9810675.
The Mathworks Inc. “MATLAB: MathWorks,” www.mathworks.com/products/matlab. 2016. [Online]. Accessed 26 Apr 2019.
Tornetta P, Collins E. Semiextended position for intramedullary nailing of the proximal tibia. Clin Orthop Relat Res. 1996;328:185–9.
Zelle BA, Boni G. Safe surgical technique: Intramedullary nail fixation of tibial shaft fractures. Patient Saf Surg. 2015;9(1):40.
Duan X, Al-Qwbani M, Zeng Y, Zhang W, Xiang Z. Intramedullary nailing for tibial shaft fractures in adults. Cochrane Database Syst Rev. 2012;1:CD008241.
Williamson M, Iliopoulos E, Williams R, Trompeter A. Intra-operative fluoroscopy time and radiation dose during suprapatellar tibial nailing versus infrapatellar tibial nailing. Injury. 2018;49(10):1891–4.
Blattert TR, Fill UA, Kunz E, Panzer W, Weckbach A, Regulla DF. Skill dependence of radiation exposure for the orthopaedic surgeon during interlocking nailing of long-bone shaft fractures: a clinical study. Arch Orthop Trauma Surg. 2004;124(10):659–64.
Smith KM, Duplantier NL, Crump KH, Delgado DA, Sullivan SL, McCulloch PC, Harris JD. Fluoroscopy learning curve in hip arthroscopy—a single surgeon’s experience. Arthrosc J Arthrosc Relat Surg. 2017;33(10):1804–9.
Kirby GSJ, Guyver P, Strickland L, Alvand A, Yang GZ, Hargrove C, Lo BPL, Rees JL. Assessing arthroscopic skills using wireless elbow-worn motion sensors. J Bone Jt Surg Am. 2014;97(13):1119–27.
Funding
No funding was present for this study.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare no conflict of interest.
Ethical approval
No ethical approval was required for this study.
Informed consent
No consent was required from patients for this study.
Rights and permissions
About this article
Cite this article
Valsamis, E.M., Iliopoulos, E., Williams, R. et al. Suprapatellar tibial nailing: a learning curve analysis. Eur J Trauma Emerg Surg 46, 1107–1113 (2020). https://doi.org/10.1007/s00068-019-01177-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00068-019-01177-3