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Technique depicted in Figure B is associated with an increased risk of septic arthritis
1%
26/2207
Technique depicted in Figure B is associated with larger nail placement
14%
313/2207
Technique depicted in Figure B is associated with improved postoperative fracture alignment
6%
141/2207
Technique depicted in Figure C is associated with an increased risk of septic arthritis
10%
228/2207
Technique depicted in Figure C is associated with improved postoperative fracture alignment
67%
1482/2207
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Compared to infrapatellar tibial nailing, suprapatellar tibial nailing is associated with improved postoperative fracture alignment. While antegrade tibial nailing results in postoperative anterior knee pain in approximately 20% of patients, there is no significant difference in the incidence of anterior knee pain when the conventional infrapatellar approach is compared to suprapatellar approaches, with some studies suggesting decreased anterior knee pain with suprapatellar nailing. In open tibial shaft fractures, no difference has been observed in the incidence of knee sepsis with either approach. However, several studies have demonstrated that intramedullary nail fixation through a suprapatellar approach is associated with a more accurate entry position and a more accurate fracture reduction when compared with an infrapatellar technique, particularly in more proximal and distal shaft fractures, without evidence of a functional impact on the patellofemoral joint. Lastly, intraoperative radiography is generally less cumbersome with suprapatellar nailing. Marecek et al. performed a multicenter comparison study of suprapatellar and infrapatellar approaches and the risk of knee sepsis after treatment of open tibia fractures. They reported no differences in the rates of infection, deep infection, or reoperation between suprapatellar and infrapatellar nailing groups. They concluded that the risk of knee sepsis after suprapatellar nailing of open fractures is low. Avilucea et al. performed a retrospective cohort study comparing postoperative alignment after suprapatellar versus infrapatellar nailing for distal tibial shaft fractures. They reported a significantly increased rate of primary angular malalignment of greater than 5 degrees in the infrapatellar compared to the suprapatellar nailing cohort. They concluded that in the treatment of distal tibial fractures, suprapatellar nailing results in a significantly lower rate of malalignment compared with the infrapatellar nailing. Jones et al. performed a study comparing the radiologic outcome and patient-reported function after suprapatellar and infrapatellar intramedullary nailing. They reported no difference in anterior knee pain, however, found a more accurate fracture reduction, both in terms of angulation and translation in the coronal plane, with the use of the suprapatellar technique. They concluded that when compared with infrapatellar nailing, the suprapatellar technique was not associated with more anterior knee pain, yet more accurate nail insertion and fracture reduction. Figure A depicts a displaced distal third tibial shaft fracture. Figure B depicts the infrapatellar tibial nailing technique. Figure C depicts the suprapatellar tibial nailing technique. Incorrect Answers: Answer 1 & 4: No significant difference has been reported in the incidence of knee sepsis with either technique. Answer 2: The size of the tibial nail that can be inserted is not affected by the technique utilized. Answer 3: The suprapatellar technique, not the infrapatellar, is associated with more accurate alignment.
2.4
(7)
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