To determine the incidence and natural history of knee pain following tibial nailing.

A retrospective analysis of patients treated by tibial nailing evaluating a consecutive series of patients with isolated tibial shaft fractures.

A level one trauma center in Vancouver, British Columbia.

A group of 107 consecutive patients with 110 tibial fractures treated by interlocking tibial nailing.

Patients were contacted and interviewed by the authors. Clinical records and radiographs were analysed.

Incidence of knee pain; time of onset; relationship of nail position on radiographs to knee pain; relationship to knee pain to site of nail insertion; response to nail removal.

At a mean follow-up period of thirty-two months (12-58 months), sixty-one (57%) patients (63 of 110 knees) had developed anterior knee pain. There was no correlation between nail protrusion and knee pain. Insertion of the nail through the patella tendon was associated with a higher incidence of knee pain compared to the paratendon site of nail insertion (77% and 50% respectively). Of patients with knee pain, 80% (49/61) required nail removal. At a mean duration of 16 months following nail removal, pain was completely relieved in 22 patients and partially relieved in 17. In the remaining 10 patients, there was no improvement.

Based on this data, we would recommend a parapatellar tendon incision for nail insertion, and nail removal for those patients with a painful knee. The causes of knee pain after tibial nailing are multi-factorial and require further study.