Intramedullary Nailing of Tibial Shaft Fracture with
Special Attention Given to Anterior Knee Pain
Acta Universitatis Tamperensis, No. 1590
By Olli Vaisto
Tampere University Press
Distributed by Coronet Books
$82.50 Paper Original
A tibial shaft fracture is a common trauma, especially amongst young and middle-age people. Its prevalence is lower amongst children and older people. During the last few decades, locking intramedullary (IM) nailing has become a popular method for treating closed tibial shaft fractures and, during the last few years, also for treating open tibial shaft fractures. The use of IM nailing in the treatment of tibial shaft fractures has the following advantages: closed reduction and preservation of the periosteal blood supply, the possibility of early mobilisation of the knee and ankle joint, the ease with which the limb can be observed postoperatively, a lower prevalence of wound infections, good biomechanical stability of the cortical bone, good possibility for bone union, and a faster recovery and return to work.
One common complication after IM nailing of a tibial shaft fracture is anterior knee pain (AKP), which may be an important handicap for the patient. The pain usually appears a few months after the nailing procedure. The incidence of AKP varies from 10% to 86% in different studies. The aetiology of AKP after IM nailing is multiple. Trauma-induced tissue damage, inappropriate methods of nailing, anatomical changes in the knee due to IM nailing, and the presence of the nail have been proposed. However, the exact aetiology of this common postoperative problem is still unknown.
In this study, it became evident that AKP cannot be reduced when the paratendinous approach is used instead of transtendinous incision, as there were AKP patients in both groups. No morphology changes were found to occur in the patellar tendon region of the patients with AKP in the ultrasonographic investigation, and there were no differences in the power Doppler measurements in the region of the scar or patellar tendon between the study groups. Three years after the IM nailing, there was a clear deficit in the thigh muscle strength of the operated leg when it was compared with the non-operated leg of patients with AKP. This difference decreased during the further long-term follow-up, and, at the time of the second examination, there were significant differences only between the strength of the extensor muscles in the operated and non-operated legs. The strength deficit was greater for the patients who still had AKP. After 8 years of follow-up, the AKP had disappeared for most of the patients, or it showed only reduced intensity in the remaining patients.
In this study, there was more AKP amongst the female than the male patients. This finding should be taken into account during postoperative rehabilitation. Some patients seem to benefit from thigh muscle rehabilitation after the operation. Such rehabilitation may reduce the incidence of AKP after IM nailing of tibial shaft fractures and thus make the return to work easier.
The treatment of tibial shaft fractures with locked IM nailing is effective; patients can return to work earlier than after conservative cast treatment. Almost all patients can return to their previous work and pretraumatic level of activity. With respect to AKP, it seems that young and physically active patients may benefit from IM nail removal. In general, fear of postoperative chronic AKP should not restrict the use of IM nails in the treatment of tibial shaft fractures. AKP is rarely severe, and it does not hinder daily living or reduce the quality of life. In addition, in the long term, AKP usually disappears.
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