| Background:Tibia by its evolution and anatomical location is exposed to frequent injury thereby being the most commonly fractured weight bearing long bone. Because one third of tibial surface is subcutaneous throughout most of its length, open or closed fractures are more common than other bones and it also has a precarious blood supply, which are enclosed by heavy muscles. The presence of hinge joints at the knee (proximal part of tibia) and the ankle (distal part of tibia) allows no adjustment for rotatory deformity after fracture and thus special care is necessary during reduction to correct such. Delayed union, nonunion and infection are relatively common complications of tibial shaft fractures mostly after conservative management but are minimized by Intramedullary (IM) nailing. Tibial diaphyseal fractures commonly affect young males and often result in loss of employment or other social and economic problems. Management of tibial shaft fractures range from cast and functional bracing, plate and screws, external fixation with half pins, wire and ring fixators and last but not the least with widely acknowledged IM fixation.Locked IM nailing currently is considered the treatment of choice for most Gustilo and Anderson type I, II and III (A) open fractures because of its bio-mechanical advantage of stabilizing rotation, maintaining alignment and length of the fractured fragments and allows early mobilization of the proximal and the distal joints and early weight bearing which out weighs other modalities of treatment. Anterior knee pain has been found to be the most common complication after IM nailing of tibial shaft fractures. Dissection of the patellar tendon and its sheath during nailing is thought to be a major contributing cause of anterior knee pain while using transpatellar approach (TPA) for Intramedullary Interlocking (IMIL) nail insertion. The purpose of this study was to assess whether the use of medial parapatellar approach (MPA) incision for nail entry portal instead of earlier said approach diminished the anterior knee pain or not.Materials and Methods:Thirty four patients with tibial shaft fractures indicated for IM nailing were allocated equally to surgical treatment with MPA or TPA as the entry portal site. This study was carried out over a period of 16 months (November, 2005 - February, 2007).Out of total 34 patients, 18 patients were in the MPA group and 16 in the TPA group. Three patients were lost in the follow up (1 from MPA and 2 from TPA group). So thirty one patients from both the groups were followed for a period of six months after nailing. At the follow-up period, the patients used two subjective methods {Visual Analogue Scale (VAS) and Impairment Scale (IS) } and two objective methods {Range of Motion (ROM) and Functional Evaluation(FE)} to report their level of anterior knee pain, ROM and impairment caused by that pain. Simple methods were adopted to quantitate the functional outcome which was examined using a series of routine daily activities.Results:Thirteen (92.86%) of the fourteen patients treated with TPA method and Thirteen (72.23%) of the eighteen patients treated with MPA method reported anterior knee pain at the final evaluation. The overall average of anterior knee pain in both the groups 86.12 %( MPA) and 96.43 %( TPA) and overall total incidence of anterior knee pain was 91.27%. No significant difference in age of patients, ROM and mean impairment scale on kneeling in the early postoperative period was noted. The mean impairment scale for squatting, stair descent and ascent, prolonged sitting and walking at any time postoperatively were not statistically significant between the study groups. However, statistical significance was appreciated in sex distribution, pain score by VAS at 3 weeks and impairment at rest by 3 weeks, ROM at 3 and 6 months and impairment on kneeling at 6 months, functional ability at 6 weeks and 6 months and ability to kneel by 6 months.Conclusion:MPA compared with TPA for nail insertion does not diminish the incidence of anterior knee pain or functional impairment by a clinically relevant amount after IM nailing of a tibial shaft. We could not however find any distinct association between the types of surgical incision approach with the intensity of anterior knee pain.
|
PDF Full Text Request