Anterior Knee Pain in Paratendinous Approach of Tibial Interlocking Nail

Vol 31 | Issue 2 | Aug – Dec 2016 | page: 22-25| Gaurav Menwal, Gyaneshwar Tonk, Amit Kumar Gupta, Pranav Kothiyal, Alok Kumar

Authors: Gaurav Menwal[1], Gyaneshwar Tonk[1], Amit Kumar Gupta[1], Pranav Kothiyal[1], Alok Kumar[1 ]

[1] Department OF Orthopaedics, LLRM Medical College, Meerut

Address of Correspondence:

Dr. Gaurav Menwal
Senior Resident Orthopaedics, LLRM Medical College, Meerut


Aim: Anterior knee pain has been described as the most common complication after intramedullary nailing of fracture shaft of tibia. Dissection of the patellar tendon and its sheath during transtendinous nailing is thought to be as one of the contributing causes of chronic anterior knee pain. The purpose of this prospective study was to estimate the incidence of anterior knee pain after intramedullary nailing of a tibial shaft fracture with paratendinous incision technique.
Material And Methods: From April 2012 to October 2013 forty patients with closed tibial shaft fractures were admitted and treated in our institution, as 12 patients did not complete their follow up or were lost in follow up, so 28 patients were analyzed finally. For assessment we used visual analogue scales to report the level of anterior knee pain. The scales described by Lysholm and Gillquist and by Tegner et al., were also used to quantitate the functional results. Ethical clearance of the study was taken from the institutional ethical committee.
Results: 8 patients out of 28 (28%) treated with paratendinous nailing technique had persistent anterior knee pain after minimum final follow up of 24 weeks. The Lysholm, Tegner functional scoring systems showed a better significant functional outcome.
Conclusion: A paratendinous approach for nail insertion does not reduce the incidence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture. In long term, anterior knee pain seems to disappear from many patients.
Keywords: Tibial shaft fracture, Anterior knee pain, Intramedullary nailing, Transtendinous technique, Paratendinous technique.

Intramedullary nailing has been described as the treatment of choice for many displaced tibial shaft fractures in adults [1]. Several complications have been described after IM nailing including infection, compartment syndrome, deep vein thrombosis, thermal necrosis of bone, implant failure, non-union and mal-union of fracture [4].
However one of the commonest complications after tibial nailing is chronic anterior knee pain with incidence as high as 86% [9]. Although most knee pain is mild, it can significantly affect patients quality of life, and can be an important handicap for the patient, affecting his employment and daily/leisure activities [6]. After surgery complaints of anterior knee pain exacerbated by walking, squatting, kneeling and stair climbing are common [8]. However the exact etiology of this complication is still unknown [5]. Some investigators have proposed that a transpatellar tendon approach for nail insertion is associated with a higher prevalence of anterior knee pain than a medial paratendinous approach [3].
The purpose of this prospective study was to evaluate the prevalence of anterior knee pain in patients of various age groups treated with a paratendinous approach for tibial nailing. We have also evaluated the functional outcome of patients after closed intramedullary nailing.

Materials And Methods
This study comprised of 40 patients of displaced tibial shaft fracture treated with an intramedullary locking nail at L.L.R.M medical college, Meerut, between April 2012 and October 2013. Inclusion criteria of the study included patients aged more than 15 years, closed tibia fracture without intra-articular extension definitively treated by intramedullary nailing and absence of any co-morbid illness.
The exclusion criteria of the study were fracture shaft tibia treated with plating or primarily by external fixator followed by intramedullary nail, fractures treated conservatively with casting, patients with history of knee pain not related to intramedullary nailing and patients having other fractures around knee like Patella fracture. All the patients were thoroughly examined including all the injuries apart from the tibial fractures.
Every patient was investigated with blood profile, Antero- posterior and lateral views of X-rays. Following hospitalization a well-padded long leg plaster was given till definitive management by nailing; analgesics and other supportive measures were administered as required. Nailing was done at the earliest opportunity after getting clearance from the anaesthesia department.
All patients were informed of the study procedure, purposes, known risks and all gave written informed consent.
Mode of anaesthesia given to the patient was either general anaesthesia or regional (Spinal) anaesthesia depending on the anaesthetist choice. A medial longitudinal incision was made with care taken not to violate the patellar tendon or its sheath and the patellar tendon was retracted laterally. The entry portal in the bone was made immediately behind the patellar tendon in all patients. Reaming was done after insertion of guide wire.
The nail was inserted after selection of appropriate length. Proximal and distal locking screws were always used, and all nails were countersunk below the cortical bone of the proximal part of the tibia. Postoperatively radiographs were taken and the limb was kept elevated and passive exercises of toes were started immediate post operatively. Active exercises of knee and ankle were started as early as possible
All the patients were strictly followed minimally up to 24 weeks. The interval of follow up was 2 weeks, 6 weeks, 12 weeks and 24 weeks or earlier if required. Serial radiographs were taken to assess the radiological healing and photographic records were taken for final functional outcome. Patients were advised weight bearing between 8-16 weeks postoperatively after clinical and radiological examination of fracture union. The patients who did not come for follow up or were lost during the follow up were not included in the study (12 patients out of 40).
At follow ups patients were asked about the severity of pain and amount of disability. Patients were specifically asked whether they had knee pain. If patients complained of knee pain they were asked to localize the pain. Only pain over the anterior portion of the knee was taken as a positive response for knee pain. If the patients specifically points to pain over fracture site or screw head was not considered as anterior knee pain.
Patients were asked to grade the pain as per VAS scale, a 100mm visual-analogue scale, with 0 denoting no pain and 100 denoting the worst pain that the patient could imagine. In addition functional outcome was also seen using Tegner Lysholm score, a 100 point, validated, reliable and responsive outcome tool for functional assessment of knee. The statistical analysis in this study was carried out using SPSS 15 software for Windows program.

From out of 28 patients of fracture shaft tibia included in our study, there were 21 men (75%) and 7 women (25%) with a mean age 34.60 years with the youngest being 16 years old and the oldest being 60 years old. In the 28 patients of our study, 12 (43%) had right limb involved, 14 (50%) had their left limb involved; whereas 2(7%) of patients had a bilateral injury. In our study the mechanism of injury was road traffic accident in 20(71%) patients, fall from height in 7(25%) patients; whereas 1(4%) patients had assault as a mode of injury.
Fractures in the middle 1/3 of the shaft of tibia were the commonest consisting 18(64%) out of 28 cases. Involvement of lower 1/3 was in 7(25%) cases and 3 cases were in upper 1/3(11%). In our study no segmental fractures were found. The majority patients had short oblique fractures, 16 (57%) with a variety of comminution followed by transverse fractures 12(42%). Out of the 28 patients, 10 patients (36%) were treated within 48 hrs of sustaining trauma. 9 patients (32%) were treated within 4 days of sustaining trauma. This delay was mainly because of gross swelling of the operated part. 9 patients (32%) were operated within 7 days of sustaining trauma. The delay in this group was mostly because of associated injuries and delay in anaesthesia fitness.
At the time of final follow up of 24 weeks, 8 patients out of 28(28%), in which paratendinous technique was used, had persistent anterior knee pain. It was seen that at the follow ups of 2nd, 6th, 12th weeks, all the patients showed almost similar results in term of median, minimum and maximum values. Further, it was also noted that as the duration of follow up increases, median analogue score decreases with a minimum of 0 and maximum of 10. P-values at various follow ups were also statistically not significant (Table 1). Among those who even after 24 weeks had pain, the pain was worst on kneeling, squatting and after long term sitting. The above noted prevalence of anterior knee pain is the same as that reported intranstendinous approach [4,5,7]. With the numbers available, we could not find any association between the entry incision and anterior knee pain.
On evaluation of final functional outcome scores at 24 weeks, 9 patients (32%) had excellent results, 5 patients (18%) had good results and 14 patients (50%) had fair results. In our study patients, patients who had anterior knee pain at follow up had lower functional scores than those who never had knee pain or those whose knee pain has disappeared over time.


Table 1: Comparision of VAS Score over period of time

Table 1: Comparision of VAS Score over period of time

Table 2: Comparision of LKS Score over period of time

Table 2: Comparision of LKS Score over period of time

As with other various treatment modalities, intramedullary nailing also has its pearls and pitfalls. Of which, chronic anterior knee pain is one of the most frequently reported complication of closed nailing. The source of anterior knee pain is multifactorial. Some investigators have proposed that a transpatellar tendon approach for nail insertion is associated with a higher prevalence of knee pain than a medial paratendinous approach.
In a retrospective study in which the nail was inserted via a paratendinous incision in 65 fractures and via a tendon splitting incision in 36 fractures, Keating et al (1997) [8] reported that insertion of an intramedullary nail paratendinously resulted in an incidence of knee pain of 50%, whereas this incidence in the tendon splitting incision group was 77%. This difference was significant (p<0.01). They thus recommended a parapatellar tendon incision for nail insertion [8]. Toivanen et al (2002) undertook a prospective randomized study of 56 patients with tibial shaft fracture requiring intramedullary nailing. At the time of the 8 year follow up, 4(29%) of the 14 patients treated with the transtendinous approach and 4(29%) of the patients treated with the paratendinous approach reported anterior knee pain, assessed with the visual analogue scale. They thus concluded that it was not possible to reduce the anterior knee pain by using a paratendinous approach rather than a transtendinous approach [10]. In our final follow up of six months 18 (65%) patients were painless and only 10 (35%) patients had chronic anterior knee pain. 8 patients out of 28(28%) treated with paratendinous nailing approach, had persistent anterior knee pain after final follow up of 24 weeks, while it was subsided in rest of the patients during this study.
There are many other factors than the surgical approach that may cause anterior knee pain after intramedullary nailing of a tibial shaft fracture. Possible causes include iatrogenic/injury related intra-articular damage, nail prominence, violation of patella tendon or damage to the infra patellar nerve.
Hernigou and Cohen (2000) investigated 12 pairs of cadaver knees after intramedullary nailing of the tibia. The intra-articular structures particularly at risk for damage during tibial nailing are medial meniscus, the lateral tibial plateau, and the transverse ligament. They also retrospectively analyzed 30 patients radiologically who had undergone tibial nailing and recorded unrecognized articular penetration and damage during surgery in 4patients [7].
In our study, 10 patients (35%) had persistent anterior knee pain after 24 weeks of follow up, of which 7(70%) were male and 3(30%) were females. Maximum patients having persistent knee pain were in the age group of 20-45 years. In their study Keating et al (1997) reported that the incidence of anterior knee pain is more common among younger than older patients [7]. This may be due to the more sedentary lifestyle of the elderly patients.
Keating et al and Toivanen et al [8] found no association between nail protrusion and anterior knee pain. In our study it is also seen that difference in the limb length and nail size do not differ significantly in the patients having knee pain as compared to those who do not have knee pain. Bleakney et al (2002) measured quadriceps musculature and atrophy using high-resolution real time ultrasonography (HRRTU) in 13 skeletally mature male patients with an isolated unilateral diaphyseal fracture of the femur or the tibia.2,3 They found clear differences in quadriceps morphology in the nailed and unnailed limb [9]. Patients who had anterior knee pain at final follow up had lower functional scores than those who never had knee pain or those whose knee pain has disappeared over time. Overall 43% excellent to good results and 57% fair results functionally are seen in this study. This also suggest that closed intramedullary nailing is an optimum treatment for tibial diaphyseal fractures.
We conclude that there is no co-relation of approach, either transtendinous or paratendinous with respect to anterior knee pain. There are many factors other than the surgical approach that may cause anterior knee pain after intramedullary nailing and additional studies to assess the role of these other factors in chronic anterior knee pain are warranted.
Although our data showed no differences between the groups, the groups were relatively small to accept this null hypothesis with full confidence and a longer study will establish the final results.


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How to Cite this Article: Menwal G, Tonk G, Gupta AK, Kothiyal P, Kumar A. Anterior Knee Pain in Paratendinous Approach of Tibial Interlocking Nail. Journal of Bone and Joint Diseases  Aug-Dec 2016;31(2):22-25 .

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