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A Comparison of the Open Semi-extended Parapatellar Versus Standard Entry Tibial Nailing Techniques and Knee Pain

A Randomized Controlled Trial

Rothberg, David L., MD*; Stuart, Ami R., PhD*; Presson, Angela P., PhD*; Haller, Justin M., MD*; Higgins, Thomas F., MD*; Kubiak, Erik N., MD

Journal of Orthopaedic Trauma: January 2019 - Volume 33 - Issue 1 - p 31–36
doi: 10.1097/BOT.0000000000001309
Original Article: OTA Highlight Paper

Objective: To determine if an open, semi-extended, parapatellar tibial nailing technique (SEK) imparts any undue knee symptoms/pain compared with the traditional infrapatellar tibial nailing technique (FK).

Design: Randomized controlled trial.

Setting: Level 1 trauma center.

Patients: Forty-seven patients with OTA/AO 42A-C tibial shaft fractures were included in the study.

Intervention: Patients were randomized to treatment with either a SEK or an FK technique.

Main Outcome: The main outcome was a symptoms subset of the International Knee Documentation Committee (SS-IKDC) pertaining to knee symptoms/pain.

Results: Final follow-up was collected at 1 year for 24 SEK and 23 FK patients. No significant differences were found between the groups in regards to demographics, injury, or surgery-related variables. The 2 techniques did have equivalent symptoms scores [mean for the difference (SEK − FK): 0.29, 90% confidence interval: −4.16 to 4.75] but did not have equivalent pain scores [mean for the difference (SEK − FK): 0.2, 90% confidence interval: −3.18 to 3.59]. When comparing demographic and injury-related variables to the SS-IKDC, only Kellgren–Lawrence classification was statistically significant (P = 0.026), where increasing presence of osteoarthritis was associated with lower scores.

Conclusions: The results of this single-center randomized controlled trial show that SEK and FK techniques for tibial nailing are equivalent in regards to knee symptoms (defined as ±5 points on the SS-IKDC) but not specifically pain that showed trends toward decreasing knee pain with the open SEK technique. This randomized controlled trial demonstrates that the use of the open semi-extended, parapatellar technique for tibial nailing should not be associated with any higher likelihood of knee pain/symptoms than the traditional flexed knee, infrapatellar technique.

Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

*Department of Orthopaedics, University of Utah, Salt Lake City, UT; and

Department of Orthopaedics, University of Nevada, Reno School of Medicine, Las Vegas, NV.

Reprints: David L. Rothberg, MD, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108 (e-mail:

Supported by the University Study Design and Biostatistics Center, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 5UL1TR001067-02 (formerly 8UL1TR000105 and UL1RR025764).

The authors report no conflict of interest.

Presented in part at the Annual Meeting of the Orthopaedic Trauma Association, October 7, 2016, National Harbor, MD.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Accepted July 16, 2018

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