UNASSIGNED: Prior to the popularization of magnetic intramedullary nails (MILNs), gradual deformity correction using external fixation was the norm in limb lengthening. Trauma literature has shown MILN via a suprapatellar approach (SP) to be associated with less knee pain than either an infrapatellar entry (IP) or external fixation. Yet, no research has investigated chronic knee pain and MILNs. We assessed differences in chronic knee pain following lengthening via an IP or SP approach with an MILN versus external fixation.
UNASSIGNED: We reviewed 147 limbs (55 MILN/IP, 22 MILN/SP, 71 external fixator) in 124 patients who underwent tibial lengthening with ≥12 months follow-up between February 2012 and July 2020. Knee pain was assessed pre- and postoperatively at 6 and 12 months, with the Lysholm Knee Scoring Scale (LKSS) and numeric pain scale (0-10). Differences in knee pain outcomes were compared across methods, with subgroup analysis of MILN/SP and MILN/IP.
UNASSIGNED: Mean LKSS was 96.3 for external fixation and 88.5 for MILN (P = .011). In the MILN subgroups, mean LKSS was 91.7 for IP and 85.3 for SP. The IP group reported a lesser mean pain score (0.6 versus 2.1) at 12 months. Bilateral nail recipients demonstrated no knee pain differences versus unilateral. At 12 months postoperative, external fixation had better knee outcomes.
UNASSIGNED: Tibial lengthening with external fixation was associated with less chronic anterior knee pain and better functional outcomes than MILN overall. In terms of MILN approach, IP surpassed SP on subjective pain scores. Larger tibial lengthening and knee pain studies are warranted.

BACKGROUND: The application of the suprapatellar (SP) approach has challenged the traditional infrapatellar (IP) approach in the surgery treatment of tibial shaft fractures, yet the advantages and disadvantages still remain controversial. We included more high-quality studies for this meta-analysis and systematic review to evaluate the clinical outcomes and prognosis of both approaches and thus to provide new ideas for surgeons.
METHODS: We searched literatures from PubMed, Cochrane Library, Web of Science, and EMBASE databases from January 2000 to December 2022. We extracted general information including sample size, gender, proportion of open fracture, follow-up time, and outcome indicators including entrance accuracy, fluoroscopy time, operation time, intraoperative blood loss, Lysholm score, VAS pain score, range of motion (ROM) function score, reposition accuracy, and revision cases. Cochrane Collaboration\'s tool and the Newcastle-Ottawa Scale were used to evaluate literature qualities. Meta-analysis was performed using RevMan 5.4 software.
RESULTS: A total of 23 studies were generated that qualified for inclusion, 17 of which were used for meta-analysis. This study found statistically significant differences in coronal plane entrance accuracy, fluoroscopy time, Lysholm score, and VAS pain score.
CONCLUSIONS: The results of our meta-analysis showed that the SP approach was significantly better than the IP approach in angle and distance entrance accuracy of coronal plane, angle entrance accuracy of sagittal plane, fluoroscopy time, Lysholm score, and VAS pain score. There were no significant differences in sagittal angle accuracy, operative time, intraoperative blood loss, and ROM score.

OBJECTIVE: This scoping review was conducted to summarise the outcome tools reported in the assessment of tibial shaft fractures treated with intramedullary (IM) nailing, with a key focus on knee pain and function, and performance-based outcomes.
METHODS: PubMed and Embase databases were searched on May 31, 2023. All study designs and populations were included, including ex vivo studies without fracture. Studies with only open or intra-articular fractures, or other fracture fixation, were excluded. Reported outcome tools and pertinent study characteristics were extracted and summarised.
RESULTS: Of 488 articles identified, 179 met the inclusion criteria. For in vivo studies (n = 152), there were 13,705 fractures; the IM nailing approach not described for 30% of these. There were 133 unique patient outcomes, with a binary assessment of knee pain (29% of studies) and Lysholm score (21%) most common. Only 10/152 (7%) in vivo studies included an objective, performance-based measure of knee function. Fracture union was most frequent (52%) of 81 different clinical outcomes. For ex vivo studies (n = 29), there were 408 tibias included, with nail insertion location most prevalent (66% of studies) of 34 reported outcomes.
CONCLUSIONS: The heterogeneity of outcome tools reported limits comparison between studies and the most commonly reported patient outcomes may not be the most appropriate. Future studies should report the IM nailing approach and consider capturing both patient-reported and performance-based outcomes to help inform surgical decision making.

BACKGROUND: This review was conducted to compare the efficacy of suprapatellar (SP) and infrapatellar (IP) approaches for treating distal tibial fractures with intramedullary nailing.
METHODS: This systematic review included studies comparing the outcomes of patients receiving nailing for distal tibial fractures using the SP and IP approaches. We searched the Cochrane CENTRAL, MEDLINE and Embase databases for relevant studies till 18th Sep. 2022. We used the Newcastle Ottawa Scale to assess study quality and a random-effects meta-analysis to synthesize the outcomes. We used the mean difference (MD) or standardized mean difference (SMD) with the 95% confidence interval (CI) for continuous data and the odds ratio (OR) with the 95% CI for dichotomous data.
RESULTS: Four studies with 586 patients (302 in the SP group and 284 in the IP group) were included in this systematic review. The SP group may have had little or no difference in pain and slightly better knee function (MD 3.90 points, 95% CI 0.83 to 5.36) and better ankle function (MD: 8.25 points, 95% CI 3.35 to 13.15) than the IP group 12 months after surgery. Furthermore, compared to the IP group, the SP group had a lower risk of malalignment (OR: 0.22, 95% CI 0.06 to 0.75; number needed to treat (NNT): 6), a lower risk for open reduction (OR: 0.58, 95% CI 0.35 to 0.97; NNT: 16) and a shorter surgical time (MD: - 15.14 min, 95% CI - 21.28 to - 9.00).
CONCLUSIONS: With more advantages, the suprapatellar approach may be the preferred nailing technique over the infrapatellar approach when treating distal tibial fractures.
METHODS: Level III, systematic review of non-randomized studies.

Over the last hundred years, there have been significant advancements in the way the Orthopaedic community treats tibial fractures. More recently, the focus of Orthopaedic trauma surgeons has been comparing the different techniques of insertion for tibial nails, specifically suprapatellar (SPTN) versus infrapatellar. The existing literature is convincing that there does not appear to be any clinically significant differences between suprapatellar and infrapatellar tibial nailing, with some apparent benefits of SPTN. Based on the current body of literature and our personal experience with SPTN, we believe the suprapatellar tibial nail will become the future for most tibial nailing procedures, regardless of fracture pattern. We have seen evidence of improved alignment in both proximal and distal fracture patterns, decreased radiation exposure and operative time, relaxation of the deforming forces, ease of imaging, and static positioning of the leg, which would be helpful for the unassisted surgeon, as well as no difference in anterior knee pain or articular damage within the knee between the two techniques.

BACKGROUND: Malalignment is a common event during the intramedullary nailing (IMN) of distal tibia fractures (DTFs). Although it is reported that the semi-extended IMN techniques such as suprapatellar (SP) and parapatellar (PP) approaches may be superior in preventing malalignment, the application of these techniques is concerning owing to the intra-articular involvement. We thus developed an extra-articular semi-extended infrapatellar (SEIP) approach which utilizes the infrapatellar (IP) space while maintaining the knee in a semi-extended position. However, there are no studies on the safety and efficacy of SEIP in treating DTFs. Therefore, in this study, the SEIP technique was examined, particularly in terms of the potential alignment improvement of DTFs, and this technique was compared with the traditional hyperflexed infrapatellar (HFIP) procedure.
METHODS: This randomized clinical trial (RCT) compared IMN malalignment while correcting extraarticular and nondisplaced intra-articular DTFs between April 2018 and June 2021 using the HFIP and SEIP techniques at a level I trauma center in China. The study participants were clinically and radiographically examined for at least 12 months of follow-ups. Intraoperative fluoroscopy time, operation time, blood loss, hospitalization duration, functional ankle score, and complications were assessed as well.
RESULTS: Among the 88 recruited participants, 45 (51%) underwent traditional HFIP IMN and 43 (49%) underwent SEIP IMN. Malalignment occurred in 9 patients (20.0%) from the HFIP cohort and in 2 patients (4.7%) from the SEIP cohort (P value = 0.030). In addition, the SEIP IMN technique significantly reduced the intraoperative fluoroscopy time, operation time, and improved the postoperative ankle function compared to the HFIP IMN technique. However, the intraoperative blood loss, hospitalization duration, infection, delay union, and nonunion remained the same between the two cohorts.
CONCLUSIONS: In summary, we demonstrated that the SEIP IMN provides markedly enhanced alignment of extraarticular and nondisplaced intra-articular DTFs compared to the traditional HFIP IMN procedure. The described technique represents an effective option for IMN of DTFs.
METHODS: Level 2. Trial registration The Chinese Clinical Trial Registry, ChiCTR2100043673. Registered 26 February 2021, retrospectively registered, http://www.chictr.org.cn/showprojen.aspx?proj=122263.

Background With the increasingly accepted method of suprapatellar tibial nailing for tibial shaft fractures, we aimed to compare intraoperative and postoperative outcomes of infrapatellar (IP) vs suprapatellar (SP) tibial nails. Methods This is a retrospective cohort analysis of 34 SP tibial nails over three years vs 24 IP tibial nails over a similar time frame. We compared total radiation dose (TRD), patient positioning time (PPT), fracture healing and follow up time. Knee pain in the SP group was evaluated utilising the Hospital for Special Surgery (HSS) Knee Injury and Osteoarthritis Outcome Score (KOOS). Results Fifty-eight patients with a mean age of 43 years were included. Mean intraoperative radiation dose for SP nails was 61.78 cGy (range: 11.60-156.01 cGy) vs 121.09 cGy (range: 58.01-18.03 cGy) for IP nails (p < 0.05). Mean PPT for SP nails was 10 minutes vs 18 minutes for IP nails (p < 0.05). All fractures united in the SP group vs one non-union in the IP group. Mean follow up was 5.5 months vs 11 months in the IP and SP groups, respectively. Mean KOOS was 7 (range: 0-22) at six months for the SP group. Conclusion The semi-extended position (SP group) leads to reduced TRD because of ease of imaging. Patients showed improved outcomes with shorter follow up and fracture union in all patients (SP group). The KOOS revealed that SP nail patients had minimal pain and good knee function. This study establishes a management and patient-reported outcome measures (PROMs) baseline for ongoing evaluation of SP nails.

BACKGROUND: Anterior knee pain is often reported following intramedullary nailing of tibial shaft fractures. The aetiology remains unclear, but the surgical approach may play an important role. To date, no biomechanically validated method exists to assess patient outcomes specific to anterior knee pain in this cohort. The central aims of this study are to (1) evaluate the feasibility of a full-scale randomised controlled trial (RCT) investigating the influence of surgical approach on intramedullary nailing of tibial shaft fractures (suprapatellar versus infrapatellar nailing), (2) explore differences in clinical outcomes between the approaches, and (3) explore the development of a biomechanically validated methodology for assessing post-operative anterior knee pain and knee function specific to intramedullary nailing of tibial shaft fractures.
METHODS: This pilot study will follow a prospective randomised controlled design at the Royal Adelaide Hospital and The Queen Elizabeth Hospital (South Australia). This study aims to recruit 60 patients between 18 and 60 years old who will be randomly assigned to either the suprapatellar or infrapatellar approach following a decision for intramedullary surgical fixation by the treating surgeon. All nails in this study will be Stryker T2 Alpha nails. Patients will undergo standard radiograph, magnetic resonance imaging, and clinical assessments in-line with their standard operative care, and complete a number of patient-reported and performance-based outcome measures. Performance-based outcome measures will be assessed utilising three-dimensional motion capture techniques. Follow-up time points are 3, 6, 12, and 18 months. Feasibility outcomes include ability to meet enrolment and retention metrics, compliance with all questionnaires and assessment procedures, and the occurrence of any adverse events. The primary clinical outcome is the incidence of anterior knee pain at 12 months after surgery.
CONCLUSIONS: This study will establish the feasibility and inform the design of a large-scale RCT. Evaluation of all clinical data and patient outcomes will lead to the development of a new tool for assessing patient outcomes in this cohort. Limitations of the study include an unpredictable enrolment rate and loss to follow-up, small sample size, and the unknown ability of three-dimensional motion analysis to pick up the effects of anterior knee pain after tibial nailing.
BACKGROUND: This trial was prospectively registered on the 7 February 2020 on ANZCTR, ACTRN12620000109909 .

Complete suprapatellar plica is a rare congenital anomaly that separates the suprapatellar bursa from the knee joint cavity. Although the pathological incidence of this condition is not known, it can cause patellofemoral symptoms, anterior knee pain, and rarely hemarthrosis. We report a patient with a hematoma in an unusual location just three weeks after an arthroscopic procedure, associated with a complete suprapatellar plica undetected during primary surgery. The hematoma was not in the synovial cavity, rather between the quadriceps tendon and the synovial membrane and presenting with pain and catching. This unusual location has not been reported before. Repeat arthroscopic surgery with drainage of hematoma and plica resection relieved the symptoms.

UNASSIGNED: Chronic painful quadriceps tendinopathy is a relatively rare condition known to be difficult to manage. Conservative management is first-line treatment and if that fails open intra-tendinous revision surgery followed by a long rehabilitation period is used. There is sparse research on etiology and new treatment methods. This observational study aimed to evaluate the intra-articular findings in patients with chronic painful quadriceps tendinopathy resistant to conservative management.
UNASSIGNED: Seven male athletes (mean age 33 years, range 22-40) suffering from chronic painful quadriceps tendinopathy in altogether 10 tendons, not responding to conservative management including heavy strength training, were included. Clinical examination and ultrasound scanning were used for diagnosis. Arthroscopy was used for evaluation of the inside of the knee.
UNASSIGNED: In all 10 knees, there were obliterating major plica formations in the suprapatellar pouch.
UNASSIGNED: Obliterating plica formations in the suprapatellar pouch may be involved in the aetiology and pathology in quadriceps tendinopathy.