Comparison of set-up time between suprapatellar and infrapatellar tibial nailing: are we saving time?| Lo Scalpello - Journal

Abstract

Objective. Tibial shaft fractures are typically managed with intramedullary nailing (IMN). The suprapatellar (SP) approach allows easier reduction of proximal tibial fractures and a more precise entry point when compared to the infrapatellar (IP) technique. The aim of this work is to compare the set-up time of the operating room between SP and IP approaches.
Methods. A retrospective observational study was performed by consulting our surgical register. In all, 65 patients underwent IMN on through an SP approach and semi-extended knee, and 65 patients had an IP approach with a flexed knee on a traction table. The elapsed time from admission to the operating room and the beginning of the surgical procedure was noted for each patient.
Results. The average time in the group treated with the IP approach was 39.6 minutes, while in the group treated with the SP approach it was 12.5 minutes with an average time saving of 27.1 minutes per patient.
Conclusions. The potential superiority of the SP approach for IMN of the tibia is the subject of ongoing debate, but its advantages are widely reported in the literature. The result of our study suggests that the quicker and simpler set-up of the SP approach can facilitate the surgeon during the operation and allow significant time savings.

Introduction

Tibial shaft fractures can be a consequence of both of low and high energy trauma and are the most common long bone fractures (2% of all fractures in adults) ¹. Intramedullary nailing (IMN) is the standard of care for treating such fractures and good results have been well documented in the literature ². The traditional infrapatellar (IP) approach is popular for tibia IMN. However, this approach requires a flexed knee, and with this it is very difficult to reduce and maintain reduction of fractures of the proximal third of the tibia (apex-anterior deformity) ³. Other disadvantages include difficult visualization of proper anteroposterior and lateral view with C-arm and the difficult evaluation of rotational malalignment ⁴. Additionally, chronic postoperative knee pain is one of the most frequent complications after nail insertion, with an incidence between 10 and 80% ⁵.

The etiology remains unclear, but it is multifactorial ⁶. It may be related to the longitudinal division of the patellar tendon during the transtendinous approach, damage to intra-articular structures, injuries to the infrapatellar nerve, nail prominence and the insertion point of the nail ^6,7. To overcome these issues, Tornetta and Collins in 1996 developed a semi-extended nailing technique that employed a medial parapatellar arthrotomy with lateral subluxation of the patella ⁸. Kubiak and colleagues ⁹ described an extra-articular modification, whereas other investigators expanded on the idea of semi-extended nailing by proposing a suprapatellar (SP) entry site and since 2006 this approach has gained popularity ¹⁰. With this approach, valgus and procurvatum malalignment can be easily avoided – because of the extended position of the leg –and allows for easier anteroposterior and lateral imaging of the tibia during surgery. Several recent studies have compared SP and IP approaches for intramedullary tibial nailing, showing that SP nailing has many advantages over IP nailing ^10-12. Those advantages are even more evident when related to specific indications, such as proximal or distal third fractures of the tibia ¹³. The aim of this work is to report on our recent experience with the SP approach for tibial nailing and compare the set-up time of the operating room between the SP and IP approaches.

Materials and methods

A retrospective observational study was performed by consulting our surgical register.

Over the last 2 years we started to perform the SP approach for intramedullary tibial nailing, and we abandoned the traditional IP approach, which was the previous standard technique in our unit to treat tibial shaft fractures. We analyzed all tibial IMN procedures performed between January 2016 and March 2023 with the purpose of comparing the set-up time of the operating room between the IP and SP approach. A total of 130 skeletally mature patients with tibial fractures treated with IMN were included and divided in 2 groups; 65 patients were treated through a SP approach with semi-extended knee (Fig. 1).

Sixty-five patients were treated through the traditional IP approach, with the knee flexed and the leg in calcaneal traction on a trauma table (Fig. 2).

Polytrauma, patients with two or more long bone fractures, COVID-19 positive patients, and open tibia fractures Gustilo-Anderson (G-A) III were excluded from the study. The elapsed time from entry into the operating room, after anesthesia, and the beginning of surgery (set-up time) was noted for each patient of the two groups. The average time of the two groups was calculated and compared.

Results

The mean age of the patients treated through an SP approach was 45.2 years (range 16-85 years). The group included 46 males and 19 females. According to Gustilo-Anderson (G-A) classification there were 7 open fractures G-A I and 9 open fractures G-A II. In the IP group, the mean age of the patients was 42.8 years (range 16-94 years). The group included 40 males and 25 females. There were 11 open fractures G-A I and 7 open fractures G-A II. The average time in the group treated with the IP approach was 39.6 minutes (SD ± 16.1), while in the group treated with the SP approach it was 12.5 minutes (SD ± 4.3) with an average time saving of 27.1 minutes per patient (Tab. I).

Discussion

Suprapatellar (SP) technique for intramedullary tibial nailing has become more popular over the years. This approach has been described and successfully used to improve alignment in proximal fragments ¹⁴. The semi-extended position counteracts procurvatum by minimizing the deforming force of the extensor apparatus and also facilitates maintaining fracture reduction and improving rotation control during reaming in proximal and distal third tibial fractures ^10,15. Avilucea et al. in 2016, studied this effect in distal fractures, obtaining correct alignment in 96.2% of SP and 73.9% of IP nails ¹⁶. In their meta-analyses Wang et al. and Xu et al. identified significant results in favor of the SP approach, with better alignment in the sagittal and coronal planes ^4,11.

The semi-extended position also facilitates the entry point of the nail. In 2010 Eastman et al. conducted a cadaver study to determine the correlation between the entry point of the nail and the degrees of knee flexion, achieving a significant result especially at 30°-50° flexion, when there is greater alignment in the sagittal plane between the nail and the medullary tibia ¹⁵. This, in turn, prevents mechanical conflict with the posterior cortex and the patella-locking effect seen in the IP approach. Therefore, the SP approach has shown significantly better surgical reductions and more precise nail entry point than the IP approach ^4,17. With the SP approach, it is easier to perform intraoperative biplanar fluoroscopy, which implies a reduction in both time and fluoroscopy dose ^4,10,18. In the literature, several studies have compared the SP versus IP approaches for tibial IMN, showing that the former can shorten intraoperative fluoroscopy time, correct coronal plane angulation and translation deformity, reduce the incidence of anterior knee pain and blood loss, and improve postoperative function ^11,18. Controversial disadvantages of the SP approach include femoropatellar (FP) cartilage injury, risk of septic knee arthritis and difficulty of implant removal ¹⁹. Regarding FP damage, Gelbke et al. concluded that there is no risk to the cartilage surface during SP nailing ²⁰. In addition, the use of specific trocar systems with protectors that attach to the patellofemoral surface further decrease the possibility of FP injury ²⁰. Cadaveric, preoperative and postoperative arthroscopy studies have been performed to assess FP cartilage damage, and patients undergoing the SP approach have been assessed radiologically and by MRI, but in most cases the findings have not been clinically correlated or have shown minimal advantage ^14,18. No significant differences in FP joint damage between the two approaches have been found in most comparative studies ¹⁸. There are no long-term studies or sufficient evidence available in the literature to advise against the SP approach. The SP approach has been associated with an increased risk of septic arthritis of the knee in open fractures, but in closed fractures there does not appear to be a significantly increased risk of septic knee arthritis ²¹. Regarding removal of the implant, the opinion of some authors is that it is no more complicated than in the IP approach while other authors resort to making another incision, at the IP level, to remove the nail ²². However, Branca Vergano et al. have recently published a case series of patients previously treated with SP intramedullary tibial nail and subsequently underwent hardware removal through the same SP approach ²³. The reported technique of nail removal was shown to be quick, safe, reproducible, and easy.

Conclusions

In conclusion, the potential superiority of the SP approach for intramedullary nailing of the tibia is the subject of an ongoing debate ²⁴, with its advantages and controversies widely reported in the literature. One of the main advantages of SP approach is patient positioning with a semi-extended knee which allows for better visualization with the C-arm, reduces malalignment of the fracture and reduces both operation and fluoroscopy time compared to IP nailing ^8,18. Positioning of the patient is a key component of the set-up for surgical procedures. Better theater set-up has been shown to improve patient outcomes and surgical efficiency and reduce the risk of occupational injury and physical fatigue of the surgeon ²⁵. The result of our study suggests that quicker and simpler patient positioning of SP approach compared to the IP approach can help the surgeon during the operation and allow significant time savings in the set-up phase.

Acknowledgements

The authors are grateful to Dr. Edward Benison for language editing of this manuscript.

Conflict of interest statement

The authors declare no conflict of interest.

Funding

This study did not receive any specific grant from funding agencies in the public, commercial, or not for-profit-sectors.

Author contributions

PB: study design, data collection, writing manuscript; LDL: data collection, editing manuscript; SL: manuscript supervision; LBV: study design, manuscript supervision.

Ethical consideration

During this retrospective (“non-interventional”) study, no experimental procedures have been conducted. Surgical data have been retrospectively analyzed and that did not change patient’s care and outcomes. Therefore, Ethical Committee approval was not necessary.

History

Received: June 8, 2025

Accepted: September 8, 2025

Figures and tables

Figure 1.Patient positioning for SP tibial nailing.

Figure 2.Patient positioning for IP tibial nailing.

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