European Journal of Cardiovascular Medicine

Being one of the most common fractures encountered by orthopedic surgeons today, tibial shaft fractures have increased incidence in both males and females. There is an equal bimodal distribution of tibial fractures with preponderance towards young male₍₁₎. In young people , the risk of these fractures increases upto 37.5 % ₍₂₎. The intramedullary nail acts as an internal splint and permits early weight bearing₍₃₎ .Several complications have been described during the postoperative care of intramedullary nailing including infection ,compartment syndrome, deep vein thrombosis, malunion, nonunion and anterior knee pain₍₄₎. Out of all , anterior knee pain carries special significance as it decides the daily activities of the individual₍₅₎.

Transpatellar approach is more likely to be associated with knee pain in the post-operative period due to its incision through the tendon, to the retro tendinous fat pad injury, which is highly innervated .Where as when the parapatellar approach is used, the patella tendon , the retro patellar fat pad and the tissues are retracted and theoretically chances of tissue injury would be less. Henc the pain is related to the site of incision ₍₆₎. Despite the widely held views about the incision site being related to anterior knee pain , there is no definite conclusion for which approach is recommended. Hence this study is undertaken to compare the outcomes (anterior knee pain) of post-operative tibial intramedullary nailing using a patellar tendon splitting approach vs Medial parapatellar approach.

This is a Prospective- randomized control study. All cases satisfying the inclusion criteria will be chosen. Patients will be randomly assigned to the two study groups. Fifty percent of the patients will undergo intramedullary nailing of tibia using patellar tendon splitting approach (group1) with an incision of 1.5cm. Fifty percent of the patients will undergo intramedullary nailing of tibia using medial parapatellar approach (group2) without splitting patella tendon and postoperatively they will be assessed for clinical and functional outcomes at regular intervals namely1,3 and 6 months respectively and assessed with VAS score.

MEDIAL PARAPATELLAR APPROACH      PATELLA TENDON SPLITTING APPROACH

STATISTICAL ANALYSIS

All quantitative variables will be estimated using measures of central location (mean, median) and measures of dispersion (standard deviation and standard error). Normally distributed data will be compared using the Student t test for both groups. For skewed data, Mann–Whitney U test will be used. Qualitative or categorical variables will be described as frequencies and proportions. Proportions will be compared using the χ2 or Fisher exact test as applicable. P<0.05 will be considered statistically significant. Statistical analysis will be carried out using Statistical Package for Social Sciences software version 16.0 for Windows (SPSS Inc.).

In group 1, the majority of subjects were in the age group <30 and 41 to 50 years (35%) and in group 2, majority of subjects were in the age group 31 to 40 years (35%). In group 1, 80% were males and 20% were females and in group 2, 85% were male  and 15% were female. Duration of surgery in group 1 was 109.40 ± 10.53 mins and in group 2 was 94.85 ± 12.79 mins.  In group 1, 75%  of them were closed fracture, 15% were GA grade 1, 10% were GA grade 2. In group 2 85%  were closed fracture, 10% were GA grade 1 and 5% were GA grade 2. Mean VAS score at 1 month follow up in group 1 was 6.5 and in group 2 it was 6.2. At 3 months in group 1 it was 3.7 and in group 2 it was 3.3. At 6 months follow up it was 1.7 in group1 and 1.7 in group 2.

Küntscher first reported use of the V-shaped nail in 1940 Since the 1940s, intramedullary nailing of tibial fractures has progressed, there has been many advances in method, principle, and design, of the tibial nail for routine operative care of tibial fractures. Although intramedullary nailing is now the standard of care for the treatment of most diaphyseal lower extremity fractures, the strategy of nailing a diaphyseal fracture has essentially remained unchanged: either a patellar tendon-splitting or a parapatellar approach has been used. Labronici et.al₍₇₎ found that the transpatellar approach is the most commonly used approach for its better access for nail insertion and ease of access, whereas the medial parapatellar approach had reduced incidence of knee pain and to avoid tendonitis. Ahmad.et .al ₍₈₎in their study compared Visual Analog Scores (VAS) between medial parapatellar tendon approach and the transpatellar tendon approach demonstrating that anterior knee pain is significantly less with a medial parapatellar tendon approach than a transpatellar tendon approach. Khan.et.al₍₉₎ in their retrospective study found that the medial parapatellar approach has a lower mean pain score than the transpatellar tendon splitting approach. Although there are mixed opinions about the superiority of these two approaches, our study shows that the medial parapatellar approach is better.

Medial para patellar approach is better than patellar tendon splitting approach for intramedullary nailing of tibial fractures in terms of VAS score, Duration of surgery, length of incision and functional outcome.

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