An Original Study

Functional Knee Outcomes in Infrapatellar

and Suprapatellar Tibial Nailing: Does
Approach Matter?
P. Maxwell Courtney, MD, Anthony Boniello, MD, Derek Donegan, MD, Jaimo Ahn, MD, PhD,
and Samir Mehta, MD

The classic infrapatellar approach to intramedullary

Abstract nailing involves placing the knee in hyperflexion over a
We conducted a study to determine differences in knee bump or radiolucent triangle and inserting the nail through
pain in patients who underwent either traditional in- a longitudinal incision in line with the fibers of the patellar
frapatellar nailing or suprapatellar nailing. From a single tendon. Deforming muscle forces often cause proximal-third
institution, we identified patients who had an isolated tibial fractures and segmental fractures to fall into valgus and
tibial shaft fracture (Orthopaedic Trauma Association procurvatum. To counter these deforming forces, orthopedic
type 42 A-C) surgically fixed with an intramedullary nail surgeons have used some novel surgical approaches, including
between 2009 and 2012. Each patient was contacted use of blocking screws5 and a parapatellar approach that could
by telephone by an investigator blinded to surgical ex- be used with the knee in semi-extended position.6 Anterior
posure, and the Oxford Knee Score (OKS) question- knee pain has been reported as a common complication of
naire was administered. Operative time and quality of tibial nailing (reported incidence, 56%).7 In a prospective
reduction on postoperative radiographs were com- randomized controlled study, Toivanen and colleagues8 found
pared between the 2 approaches. no difference in incidence of knee pain between patellar
Twenty-four patients underwent infrapatellar nailing, tendon splitting and parapatellar approaches.
and 21 patients had a suprapatellar nail placed with Techniques have been developed to insert the nail
approach-specific instrumentation. Mean OKS (maxi- through a semi-extended suprapatellar approach to facilitate
mum, 48 points) was 40.1 for the infrapatellar group and intraoperative imaging, allow easier access to starting-
36.7 for the suprapatellar group (P = .293). Compared site position, and counter deforming forces. Although
with the infrapatellar approach, suprapatellar nailing outcomes of traditional infrapatellar nailing have been well
improved radiographic reduction in the sagittal plane documented, there is a paucity of literature on outcomes of
(2.90° vs 4.58°; P = .044) and required less operative using a suprapatellar approach. Splitting the quadriceps tendon
fluoroscopy time (81 vs 122 s; P = .003). causes scar tissue to form superior to the patella versus the
We found no difference in OKS between the infrapa- anterior knee, which may reduce flexion-related pain or
tellar and suprapatellar approaches. Although further kneeling pain.9 The infrapatellar nerve is also well protected
study is needed, the suprapatellar entry portal appears with this approach.
to be a safe alternative for tibial nailing with use of ap- We conducted a study to determine differences in functional
propriate instrumentation. knee pain in patients who underwent either traditional
infrapatellar nailing or suprapatellar nailing. We hypothesized
that there would be no difference in functional knee scores
between these approaches and that, when compared with

W
ith an incidence of 75,000 per year in the United the infrapatellar approach, the suprapatellar approach would
States alone, fractures of the tibial shaft are among result in improved postoperative reduction and reduced
the most common long-bone fractures.1 Diaphyseal intraoperative fluoroscopy time.
tibial fractures present a unique treatment challenge because of
complications, including nonunion, malunion, and the potential Materials and Methods
for an open injury. Intramedullary fixation of these fractures has This study was approved by our institutional review board. We
long been the standard of care, allowing for early mobilization, searched our level I trauma center’s database for Current Procedural
shorter time to weight-bearing, and high union rates.2-4 Terminology (CPT) code 27759 to identify all patients who had

Authors’ Disclosure Statement: Dr. Ahn reports he is a consultant for Synthes. The other authors report no actual or potential conflict of interest
in relation to this article.

www.amjorthopedics.com December 2015 The American Journal of Orthopedics®  E513

Functional Knee Outcomes in Infrapatellar and Suprapatellar Tibial Nailing: Does Approach Matter?

a tibial shaft fracture fixed with an intramedullary implant when expected values in a cell were less than 5, the Fisher
between January 2009 and February 2013. Radiographs, exact test.
operative reports, and inpatient records were reviewed. Patients We then conducted an a priori power analysis to determine
older than 18 years at time of injury and patients with an isolated the appropriate sample size. To detect the reported minimally
tibial shaft fracture (Orthopaedic Trauma Association type clinically important difference in the OKS of 5.2,10 estimating an
42 A-C) surgically fixed with an intramedullary nail through approximate 20% larger patient population in the infrapatellar
either a traditional infrapatellar approach or a suprapatellar group, we would need to enroll 24 infrapatellar patients and 20
approach were included in the study. Exclusion criteria were suprapatellar patients to achieve a power of 0.80 with a type I
required fasciotomy, Gustilo type 3B or 3C open fracture, prior error rate of 0.05.11 This analysis is also based on an estimated
knee surgery, additional orthopedic injury, and preexisting OKS standard deviation of 6, which has been reported in
radiographic evidence of degenerative joint disease. several studies.12,13
In addition to surgical approach, demographic data,
including body mass index (BMI), age, sex, and mechanism Results
of injury, were documented from the medical record. Each We identified 176 patients who had the CPT code for
patient was contacted by telephone by an investigator blinded intramedullary fixation of a tibial shaft fracture between
to surgical exposure, and the 12-item Oxford Knee Score January 2009 and February 2013. After analysis of radiographs
(OKS) questionnaire was administered (Figure). Operative and medical records, 82 patients met the inclusion criteria.
time, quality of reduction on postoperative radiographs, and Thirty-six (45%) of the original 82 patients were lost to
intraoperative fluoroscopy time were compared between follow-up after attempts to contact them by telephone. One
the 2 approaches. We determined quality of reduction by patient refused to participate in the study. Twenty-four
measuring the angle between the line perpendicular to the patients underwent traditional infrapatellar nailing, and 21
tibial plateau and plafond on both the anteroposterior and patients had a suprapatellar nail placed with approach-specific
lateral postoperative radiographs. Rotation was determined instrumentation. Nine patients had an open fracture. There was
by measuring displacement of the fracture by cortical widths. no significant difference between the groups in terms of sex,
The infrapatellar and suprapatellar groups were statistically age, BMI, mechanism of injury, or operative time (Table 1).
analyzed with an unpaired, 2-tailed Student t test. Categorical There was also no difference (P = .210) in fracture location
variables between groups were analyzed with the χ2 test or, between groups (0 proximal-third, 14 midshaft, 10 distal-
third vs 3 proximal-third, 10 midshaft, 8 distal-third). Mean
age was 37.6 years (range, 20-65 years) for the infrapatellar

1. How would you describe the pain you usually have

in your knee? Demographic Data of Patients
Table 1.
2. Have you had any trouble washing and drying yourself Who Underwent Tibial Intramedullary Fixation
(all over) because of your knee? Through Infrapatellar or Suprapatellar Approach,
3. Have you had any trouble getting in and out of the car Mean (SD)
or using public transport because of your knee?
(with or without a stick) Approach
4. For how long are you able to walk before the pain Infrapatellar Suprapatellar
in your knee becomes severe? (with or without a stick) Demographic Data (n = 24) (n = 21) P
5. After a meal (sat at a table), how painful has it been for
you to stand up from a chair because of your knee? Sex, % .082
Male 11 (46) 15 (71)
6. Have you been limping when walking, because of your
knee? Female 13 (54) 6 (29)

7. Could you kneel down and get up again afterwards? Age, y 37.6 38.5 .839
8. Are you troubled by pain in your knee at night in bed?
Follow-up, mo 25.2 11.8 <.001
9. How much has pain from your knee interfered with
your usual work? (including housework) Body mass index 26.4 26.5 .975
10. Have you felt that your knee might suddenly give way Mechanism of injury, % .150
or let you down?
Fall 14 (58) 6 (29)
11. Could you do household shopping on your own? Motor vehicle collision 5 (21) 9 (43)
12. Could you walk down a flight of stairs? Sports 4 (17) 3 (14)
Gunshot wound 1 (4) 3 (14)

Figure. Oxford Knee Score questionnaire administered by Fracture location, % .210

telephone to each patient. Each question had specific answers Proximal third 0 (0) 3 (14)
corresponding to a score ranging from 0 (worst function) to 4 Midshaft 14 (58) 10 (48)
(best function). Distal third 10 (42) 8 (38)

E514  The American Journal of Orthopedics® December 2015 www.amjorthopedics.com

 P. M. Courtney et al

group and 38.5 years (range, 18-68 years) for the suprapatellar instrumentation may protect the trochlea and patellar cartilage.
group (P = .839). Mean follow-up was significantly (P < .001) Although the OKS questionnaire was originally developed
shorter for the suprapatellar group (12 mo; range, 3-33 mo) and widely validated to describe clinical outcomes of total
than for the infrapatellar group (25 mo; range, 4-43 mo). knee arthroplasty,15,16 it has also been evaluated for other
Mean OKS (maximum, 48 points) was 40.1 (range, 11-48) interventions, including viscosupplementation injections17 and
for the infrapatellar group and 36.7 (range, 2-48) for the high tibial osteotomy.18 We used the OKS questionnaire in our
suprapatellar group (P = .293). Table 2 summarizes the data. study because it is simple to administer by telephone and is
Radiographic reduction in the sagittal plane was improved not as cumbersome as the Knee Society Score or the Western
(P = .044) in the suprapatellar group (2.90°) compared with Ontario and McMaster Universities Osteoarthritis Index. It
the infrapatellar group (4.58°). There was no difference in is also more specific to the knee than generalized outcome
rotational malreduction (0.31 vs 0.25 cortical width; P = .599) measures used in trauma, such as the Short Form 36 (SF-36).
or in reduction in the coronal plane (2.52° vs 3.17°; P = .280). Sanders and colleagues19 reported excellent tibial alignment,
All patients in both groups maintained radiographic reduction radiographic union, and knee range of motion using semi-
within 5° in any plane throughout follow-up. There was no extended tibial nailing with a suprapatellar approach. For
difference (P = .654) in radiographic follow-up between the outcome measures, they used the Lysholm Knee Score and
infrapatellar group (11 mo) and the suprapatellar group (12 mo). the SF-36. Our clinical and radiographic results confirmed
The 1 nonunion in the suprapatellar group required return their finding—that the semi-extended suprapatellar approach
to the operating room for exchange intramedullary nailing. is an option for tibial nailing.
The suprapatellar approach required less (P = .003) operative OKS results by question (Table 3) showed that the
fluoroscopy time (80.8 s; range, 46-180 s) than the standard infrapatellar group had less pain walking down stairs. This
infrapatellar approach (122.1 s; range, 71-240 s). Two patients in result approached statistical significance (P = .063). As surgeons
the suprapatellar group and 8 in the infrapatellar group did not at our institution began using the suprapatellar approach only
have their fluoroscopy time recorded in the operative report. during the final 2 years of the study period, mean follow-up
was significantly (P < .001) less than for the infrapatellar group
Discussion (12 vs 25 mo). Although there was no statistically significant
We have described the first retrospective cohort-comparison difference in reduction quality on anteroposterior radiographs,
study of functional knee scores associated with traditional the suprapatellar approach had improved (P = .044) reduction
infrapatellar nailing and suprapatellar nailing. Although much on lateral radiographs (2.90° vs 4.58°).
has been written about the incidence of anterior knee pain Although operative time did not differ between our
with use of a patellar splitting or parapatellar approach, the 2 groups, significantly (P = .003) less fluoroscopy time was
clinical effects of knee pain after use of suprapatellar nails required for suprapatellar nails (80.8 s) than for infrapatellar
are yet to be addressed. In a cadaveric study, Gelbke and nails (122.1 s). Positioning the knee in the semi-extended
colleagues14 found higher mean patellofemoral pressures and position offers easier access for fluoroscopy and less radiation
higher peak contact pressures with a suprapatellar approach. exposure for the patient. Placing the nail in extension also
These numbers, however, were still far below the threshold
for chondrocyte damage, and that study is yet to be clinically
validated. Our data showed no difference in OKS between Table 3. Results of Oxford Knee Score by Question
the 2 groups. Despite being intra-articular, approach-specific Approach

Question Infrapatellar Suprapatellar P

Patients’ Mean (SD) Oxford Knee Scores,
Table 2. 1 2.75 2.62 .749
Operative and Fluoroscopy Times, Reductions,
Radiographic Follow-Up, and Rotation 2 3.83 3.57 .252

3 3.54 3.14 .176

Approach
4 3.17 2.91 .417
Infrapatellar Suprapatellar
Result (n = 24) (n = 21) P 5 3.38 3.00 .220
Oxford Knee Score 40.1 (8.8) 36.7 (12.3) .293 6 3.17 3.19 .947
Operative time, min 145 (43) 147 (41) .884 7 3.25 2.71 .133
Fluoroscopy time, s 122.1 (41.6) 80.8 (36.7) .003 8 3.29 3.33 .908
Coronal plane reduction, ° 3.17 (1.99) 2.52 (1.94) .280 9 3.21 3.00 .571
Sagittal plane reduction, ° 4.58 (2.86) 2.90 (2.57) .044 10 3.42 3.29 .681
Radiographic follow-up, mo 11.1 (6.3) 12.4 (8.3) .654 11 3.54 3.05 .158

Rotation, cortical widths 0.25 (0.32) 0.31 (0.42) .599 12 3.54 2.91 .063

www.amjorthopedics.com December 2015 The American Journal of Orthopedics®  E515

Functional Knee Outcomes in Infrapatellar and Suprapatellar Tibial Nailing: Does Approach Matter?

helps eliminate the deforming forces that cause malreduction References

of proximal tibial shaft or segmental fractures. However, our 1. Praemer A, Furner S, Rice DP. Musculoskeletal Conditions in the United
States. Park Ridge, IL: American Academy of Orthopaedic Surgeons; 1992.
study was limited in that only 2 surgeons at our institution 2. Bone LB, Sucato D, Stegemann PM, Rohrbacher BJ. Displaced isolated
used the suprapatellar approach, and both were fellowship- fractures of the tibial shaft treated with either a cast or intramedullary nailing.
trained in orthopedic traumatology. This situation could have An outcome analysis of matched pairs of patients. J Bone Joint Surg Am.
1997;79(9):1336-1341.
introduced bias into the interpretation of fluoroscopy data, 3. Hooper GJ, Keddell RG, Penny ID. Conservative management or closed
as these surgeons may have been more comfortable with the nailing for tibial shaft fractures. A randomised prospective trial. J Bone Joint
procedure and less likely to use fluoroscopy. Both surgeons also Surg Br. 1991;73(1):83-85.
4. Alho A, Benterud JG, Høgevold HE, Ekeland A, Strømsøe K. Comparison
performed infrapatellar nailing during the study period, and of functional bracing and locked intramedullary nailing in the treatment of
there was no statistical difference in fracture patterns between displaced tibial shaft fractures. Clin Orthop Relat Res. 1992;(277):243-250.
the groups, thus minimizing bias. 5. Ricci WM, O’Boyle M, Borrelli J, Bellabarba C, Sanders R. Fractures of the
proximal third of the tibial shaft treated with intramedullary nails and blocking
This study was retrospective but had several strengths. screws. J Orthop Trauma. 2001;15(4):264-270.
Sample size met the prestudy power analysis to determine 6. Tornetta P 3rd, Collins E. Semiextended position of intramedullary nailing
a minimally clinically important difference in OKS results. of the proximal tibia. Clin Orthop Relat Res. 1996;(328):185-189.
7. Court-Brown CM, Gustilo T, Shaw AD. Knee pain after intramedullary
The investigator who administered the telephone survey was tibial nailing: its incidence, etiology, and outcome. J Orthop Trauma.
blinded to surgical approach. This study was also the first clinical 1997;11(2):103-105.
study to compare outcomes of infrapatellar and suprapatellar 8. Toivanen JA, Väistö O, Kannus P, Latvala K, Honkonen SE, Järvinen MJ.
Anterior knee pain after intramedullary nailing of fractures of the tibial shaft.
nailing. However, the study’s follow-up rate was a weakness. A prospective, randomized study comparing two different nail-insertion
The patient population at our academic, urban, level I trauma techniques. J Bone Joint Surg Am. 2002;84(4):580-585.
center is transient. We lost 36 patients (45%) to follow-up; their 9. Morandi M, Banka T, Gairarsa GP, et al. Intramedullary nailing of tibial frac-
tures: review of surgical techniques and description of a percutaneous
telephone numbers in the hospital records likely changed since lateral suprapatellar approach. Orthopaedics. 2010;33(3):172-179.
surgery, and we could not contact these patients. 10. Bohm ER, Loucks L, Tan QE, et al. Determining minimum clinically impor-
tant difference and targeted clinical improvement values for the Oxford 12.
Presented at: Annual Meeting of the American Academy of Orthopaedic
Conclusion Surgeons; 2012; San Francisco, CA.
Our retrospective cohort study found no difference in OKS be- 11. Dupont WD, Plummer WD Jr. Power and sample size calculations. A review
tween traditional infrapatellar nailing and suprapatellar nailing and computer program. Control Clin Trials. 1990;11(2):116-128.
12. Streit MR, Walker T, Bruckner T, et al. Mobile-bearing lateral unicompart-
for diaphyseal tibia fractures. Suprapatellar nails require less mental knee replacement with the Oxford domed tibial component: an
fluoroscopy time and may show improved radiographic reduc- independent series. J Bone Joint Surg Br. 2012;94(10):1356-1361.
tion in the sagittal plane. Although further study is needed, the 13. Jenny JY, Diesinger Y. The Oxford Knee Score: compared perfor-
mance before and after knee replacement. Orthop Traumatol Surg Res.
suprapatellar entry portal appears to be a safe alternative for 2012;98(4):409-412.
tibial nailing with use of appropriate instrumentation. 14. Gelbke MK, Coombs D, Powell S, et al. Suprapatellar versus infra-patellar
intramedullary nail insertion of the tibia: a cadaveric model for compari-
son of patellofemoral contact pressures and forces. J Orthop Trauma.
2010;24(11):665-671.
Dr. Courtney is Resident Physician, Department of Orthopaedic Sur- 15. Dawson J, Fitzpatrick R, Murray D, Carr A. Questionnaire on the percep-
gery, Hospital of University of Pennsylvania, Philadelphia, Pennsylva- tions of patients about total knee replacement. J Bone Joint Surg Br.
nia. Dr. Boniello is Resident Physician, Department of Orthopaedic 1998;80(1):63-69.
Surgery, Drexel University School of Medicine, Hahnemann Univer- 16. Dunbar MJ, Robertsson O, Ryd L, Lidgren L. Translation and validation
sity Hospital, Philadelphia, Pennsylvania. Dr. Donegan, Dr. Ahn, and of the Oxford-12 item knee score for use in Sweden. Acta Orthop Scand.
Dr. Mehta are Assistant Professors of Orthopaedic Surgery, Depart- 2000;71(3):268-274.
ment of Orthopaedic Surgery, Hospital of University of Pennsylvania, 17. Clarke S, Lock V, Duddy J, Sharif M, Newman JH, Kirwan JR. Intra-articular
Philadelphia, Pennsylvania. hylan G-F 20 (Synvisc) in the management of patellofemoral osteoarthritis
of the knee (POAK). Knee. 2005;12(1):57-62.
Address correspondence to: P. Maxwell Courtney, MD, Department 18. Weale AE, Lee AS, MacEachern AG. High tibial osteotomy using a dynamic
of Orthopaedic Surgery, University of Pennsylvania, 3737 Market St., axial external fixator. Clin Orthop Relat Res. 2001;(382):154-167.
Philadelphia, PA 19104 (tel, 215-662-3340; email, paul.courtney@ 19. Sanders RW, DiPasquale TG, Jordan CJ, Arrington JA, Sagi HC. Semiex-
uphs.upenn.edu). tended intramedullary nailing of the tibia using a suprapatellar approach:
Am J Orthop. 2015;44(12):E513-E516. Copyright Frontline Medical radiographic results and clinical outcomes at a minimum of 12 months
Communications Inc. 2015. All rights reserved. follow-up. J Orthop Trauma. 2014;28(suppl 8):S29-S39.

This paper will be judged for the Resident Writer’s Award.

E516  The American Journal of Orthopedics® December 2015 www.amjorthopedics.com