Archives of Orthopaedic and Trauma Surgery

, Volume 139, Issue 7, pp 943–949 | Cite as

Decrease surgery time by using an alternative lateral parapatellar approach for tibia shaft fracture nailing

  • Andreas LadurnerEmail author
  • Yves P. Acklin
  • Thomas S. Mueller
  • Christoph Sommer
Trauma Surgery



Medial parapatellar or transpatellar ligament approaches are commonly used for nail osteosynthesis in tibia shaft fractures. The lower leg is normally in a hanging position to allow guide wire insertion and reaming of the tibia. However, this position complicates fracture reduction and retention, as well as image intensification throughout the procedure. A lateral parapatellar approach with the lower leg in a semi-extended, horizontal position has been previously described for proximal tibial fracture fixation. The purpose of the presented study was to share the lateral parapatellar approach technique used in our institution and to analyse its feasibility for tibia shaft fracture fixation when compared to a medial parapatellar and transpatellar incision technique.

Materials and methods

All patients with tibial shaft fractures treated at our institution between 2009 and 2012 by intramedullary nailing through either a transpatellar, a medial parapatellar or a lateral parapatellar approach were reviewed. Demographics, injury pattern and the operative procedure, especially operation and fluoroscopy time, were analysed.


73 patients were enrolled into the study. Twenty-six patients were treated by use of a lateral parapatellar approach, whilst a transpatellar or a medial parapatellar approach was chosen in 29 and 18 cases, respectively. Patients’ characteristics were similar regarding gender and body mass index. When compared to the transpatellar (126 ± 30 min) or the medial parapatellar approach (105 ± 29 min), surgical time was significantly shorter in the lateral parapatellar approach group (96 ± 29 min). Likewise, shorter image intensifier time was documented when a lateral parapatellar approach was chosen (211 ± 189 s) compared to the transpatellar (347 ± 204 s) or the medial parapatellar approach (241 ± 222 s).


The extra-articular semi-extended tibial nailing technique using a lateral parapatellar approach was associated with a significant decrease in time of surgery, while fluoroscopy time was shorter but not significantly different between the three groups.


Tibia fracture Treatment Intramedullary nail Approach Operation time Image intensifier time 



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

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.


This study was approved by the local research ethics committee.


  1. 1.
    Bakhsh WR, Cherney SM, McAndrew CM et al (2016) Surgical approaches to intramedullary nailing of the tibia: comparative analysis of knee pain and functional outcomes. Injury 47:958–961. CrossRefGoogle Scholar
  2. 2.
    Wähnert D, Gehweiler D (2017) Complications of intramedullary nailing—evolution of treatment. Injury 48:59–63. CrossRefGoogle Scholar
  3. 3.
    Taki H, Memarzadeh A, Trompeter A, Hull P (2017) Closed fractures of the tibial shaft in adults. Orthop Trauma 31:116–124. CrossRefGoogle Scholar
  4. 4.
    Rothberg DL, Stuart AR, Presson AP et al (2019) A comparison of the open semi-extended parapatellar versus standard entry tibial nailing techniques and knee pain: a randomized controlled trial. J Orthop Trauma 33:31–36. Google Scholar
  5. 5.
    Yang L, Sun Y, Li G (2018) Comparison of suprapatellar and infrapatellar intramedullary nailing for tibial shaft fractures: a systematic review and meta-analysis. J Orthop Surg Res 13:146. CrossRefGoogle Scholar
  6. 6.
    Wang C, Chen E, Ye C, Pan Z (2018) Suprapatellar versus infrapatellar approach for tibia intramedullary nailing: a meta-analysis. Int J Surg 51:133–139. CrossRefGoogle Scholar
  7. 7.
    Gustilo RB, Anderson JT (1976) Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Jt Surg Am 58:453–458CrossRefGoogle Scholar
  8. 8.
    Tscherne H, Oestern HJ (1982) A new classification of soft-tissue damage in open and closed fractures. Unfallheilkunde 85:111–115Google Scholar
  9. 9.
    Duan X, Al-Qwbani M, Zeng Y et al (2012) Intramedullary nailing for tibial shaft fractures in adults. Cochrane Database Syst Rev 1:CD008241. Google Scholar
  10. 10.
    Weil YA, Gardner MJ, Boraiah S et al (2009) Anterior knee pain following the lateral parapatellar approach for tibial nailing. Arch Orthop Trauma Surg 129:773–777. CrossRefGoogle Scholar
  11. 11.
    McAndrew CM, Ricci WM, Miller AN, Avery MC (2018) Distal tibial intramedullary nailing using an extraarticular, lateral parapatellar approach in the semiextended position. J Orthop Trauma 32 Suppl 1:34–35. CrossRefGoogle Scholar
  12. 12.
    Courtney PM, Boniello A, Donegan D et al (2015) Functional knee outcomes in infrapatellar and suprapatellar tibial nailing: does approach matter? Am J Orthop 44:513–516Google Scholar
  13. 13.
    Chen X, Xu H-T, Zhang H-J, Chen J (2018) Suprapatellar versus infrapatellar intramedullary nailing for treatment of tibial shaft fractures in adults. Medicine (Baltimore) 97:e11799. CrossRefGoogle Scholar
  14. 14.
    Williamson M, Iliopoulos E, Williams R, Trompeter A (2018) Intra-operative fluoroscopy time and radiation dose during suprapatellar tibial nailing versus infrapatellar tibial nailing. Injury 49:1891–1894. CrossRefGoogle Scholar
  15. 15.
    Kempf I, Grosse A, Beck G (1985) Closed locked intramedullary nailing. Its application to comminuted fractures of the femur. J Bone Jt Surg Am 67:709–720CrossRefGoogle Scholar
  16. 16.
    Müller LP, Suffner J, Wenda K et al (1998) Radiation exposure to the hands and the thyroid of the surgeon during intramedullary nailing. Injury 29:461–468CrossRefGoogle Scholar
  17. 17.
    Bishop JA, Campbell ST, Eno J-JT, Gardner MJ (2018) Knee pain after intramedullary nailing of tibia fractures. J Am Acad Orthop Surg 26:381–387. CrossRefGoogle Scholar
  18. 18.
    Strecker W, Suger G, Kinzl L (1996) Local complications of intramedullary nailing. Orthopade 25:274–291Google Scholar
  19. 19.
    Court-Brown CM (2004) Reamed intramedullary tibial nailing: an overview and analysis of 1106 cases. J Orthop Trauma 18:96–101CrossRefGoogle Scholar
  20. 20.
    Say F, Bülbül M (2014) Findings related to rotational malalignment in tibial fractures treated with reamed intramedullary nailing. Arch Orthop Trauma Surg 134:1381–1386. CrossRefGoogle Scholar
  21. 21.
    Puloski S, Romano C, Buckley R, Powell J (2004) Rotational malalignment of the tibia following reamed intramedullary nail fixation. J Orthop Trauma 18:397–402CrossRefGoogle Scholar
  22. 22.
    Sanders RW, DiPasquale TG, Jordan CJ et al (2014) Semiextended intramedullary nailing of the tibia using a suprapatellar approach. J Orthop Trauma 28:29–39. CrossRefGoogle Scholar
  23. 23.
    Franke J, Hohendorff B, Alt V et al (2016) Suprapatellar nailing of tibial fractures—indications and technique. Injury 47:495–501. CrossRefGoogle Scholar
  24. 24.
    Franke J, Homeier A, Metz L et al (2018) Infrapatellar vs. suprapatellar approach to obtain an optimal insertion angle for intramedullary nailing of tibial fractures. Eur J Trauma Emerg Surg 44:927–938. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Andreas Ladurner
    • 1
    Email author
  • Yves P. Acklin
    • 1
  • Thomas S. Mueller
    • 1
  • Christoph Sommer
    • 1
  1. 1.Department of Trauma SurgeryKantonsspital GraubündenChurSwitzerland

Personalised recommendations