Review Question - QID 95

Chronic anterior knee pain at the insertion site is the most common frequently reported complication of closed nailing of a tibial shaft fracture. A high incidence of knee pain has been associated with IM nailing. The etiology of anterior knee pain remains unclear. It had been previously thought that the incidence of pain is higher when the nail was inserted by a patellar tendon-spliting approach versus a paratendon approach. According to the Keating paper, 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). Toivanen et al. investigated this question when the group randomized fifty patients with a tibial shaft fracture requiring intramedullary nailing equally to treatment with paratendinous or transtendinous nailing. Fourteen (67%) of the twenty-one patients treated with transtendinous nailing reported anterior knee pain at the final evaluation. Of these fourteen patients, thirteen were mildly to severely impaired by the pain. Fifteen (71%) of the twenty-one patients treated with paratendinous nailing reported anterior knee pain, and ten of the fifteen were impaired by the pain. The Lysholm, Tegner, and Iowa knee scoring systems; muscle-strength measurements; and functional tests showed no significant differences between the two groups. Compared with a transpatellar tendon approach, a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment by a clinically relevant amount after intramedullary nailing of a tibial shaft fracture.