Review Article

Knee Pain After Intramedullary

Nailing of Tibia Fractures:
Prevalence, Etiology, and
Treatment

Julius A. Bishop, MD
Sean T. Campbell, MD
Jonathan-James T. Eno, MD
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKbH4TTImqenVFao8o3NFiILgcZ/8cNz6igE/a5NIFK6wV+/FW9f0f5eedTNDTlPjLY= on 09/09/2018
Abstract
Intramedullary nailing is often the treatment of choice for fractures of the
tibia, but postoperative knee pain is common after this procedure.
Potential etiologies include implant prominence, injury to intra-articular

structures, patellar tendon or fat pad injury, damage to the infrapatellar

Michael J. Gardner, MD
branch of the saphenous nerve, and altered biomechanics. Depending on
the etiology, described treatment options include observation, implant
removal, assessment and treatment of injured intra-articular structures,
and selective denervation. Careful attention to appropriate starting point
and implant selection combined with more recently described
semiextended nailing techniques may aid in prevention of knee pain.

T ibia fractures are commonly treat-

From the Department of Orthopaedic
Surgery, Stanford University,
Stanford, CA (Dr. Bishop,
Dr. Campbell, and Dr. Gardner), and
the Department of Sports Medicine
and Shoulder Surgery, Hospital for
Special Surgery, New York City, NY
(Dr. Eno).
J Am Acad Orthop Surg 2018;26:
e381-e387
DOI: 10.5435/JAAOS-D-18-00076
Copyright 2018 by the American
Academy of Orthopaedic Surgeons.
ed with intramedullary nailing.
Even after successful union, rates of
persistent knee pain have historically
been high. With increasing awareness
of the various sources of postnailing
knee pain and the introduction of new
surgical techniques intended to address
these issues, more recent studies have
described lower incidences of such
pain. However, despite modern treat-
ment, knee pain after tibial nailing
remains a disabling problem for some
patients. Here, we present a brief his-
torical perspective on postnailing knee
pain and review the proposed etiolo-
gies and the most recent surgical tech-
niques for avoiding knee pain and
treating it when it occurs.
Prevalence of Knee Pain
Historically, high rates of postopera-
tive knee pain after tibial nailing have
been reported. In a retrospective review
of 107 patients treated between 1990
and 1991, Keating et al1 found a 57%
incidence of postoperative anterior
knee pain. Similarly, Court-Brown
et al2 demonstrated anterior knee
pain in 56% of 169 patients treated
with tibial nailing. One systematic
review of 20 articles published
between 1990 and 2005 found that
among 1,460 patients, the mean
incidence of knee pain was 47% at
an average follow-up of 24 months
and was as high as 86%.3
More recent studies, however, have
reported decreasing incidences of post-
operative knee pain. In 2013, Jankovic
et al4 found a 36% incidence of ante-
rior knee pain among 62 patients, but
none of the patients in that series
reported severe pain, and 98% were
satisfied with their treatment. In a 2016
study, Obremskey et al5 found that
only 48 of 437 patients (11%) had
high levels of knee pain 12 months
postoperatively, although 48% re-
ported at least some pain. The devel-
opment of new nailing techniques has
coincided with this decrease, although
other improvements, such as changes

September 15, 2018, Vol 26, No 18 e381

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Knee Pain After Intramedullary Nailing of Tibia Fractures

to nail design, have occurred during
this period as well.
Development of New
Nailing Techniques
Surgical technique likely plays a role in
the development of postnailing knee
pain. Traditionally, the entry site for
tibial nailing has been accessed via a
transpatellar tendon or medial para-
patellar approach, with the knee hyper-
flexed. The transtendinous approach,
in particular, has been suggested as a
risk factor for postoperative knee pain,
although this has not been demon-
strated definitively in randomized
trials.1,6,7
More recently, alternative ap-
proaches have been implemented and
popularized. The common feature of
these approaches is that they involve
semiextended positioning and shifting
the incision away from the patel-
lar tendon. In 1996, Tornetta and
Collins8 described the use of semiex-
tended positioning as a reduction aid
during the nailing of challenging prox-
imal tibia fractures. They described
performing a medial parapatellar
incision and arthrotomy and sub-
luxing the patella to gain access to
the appropriate starting point. Rec-
ognizing that the appropriate start-
ing point was closer to the lateral
half of the patellar tendon than the
medial half in 63% of cases, other
authors described a semiextended
lateral parapatellar approach with
lower rates of knee pain than had
previously been reported in the lit-
erature.9-13 An alternative modifica-
tion to the semiextended technique
is a suprapatellar approach that in-
volves splitting the quadriceps tendon
and using a cannula to protect the
patellofemoral joint.14 Early adopters
of this technique published a series of
37 patients treated with suprapatellar
nailing from 2007 to 2011 and found
that no patients reported anterior knee
pain after 1 year.14
Several studies have directly com-
pared semiextended nailing to tradi-
tional hyperflexion techniques in terms
of knee pain and patient-reported
outcomes. A retrospective study com-
paring nailing through a medial para-
tendinous approach to a suprapatellar
approach in 74 patients found no dif-
ference in patient-reported outcomes
related to knee pain.15 Another retro-
spective study compared 102 patients
treated with a semiextended lateral
parapatellar approach to those treated
with hyperflexed medial parapatellar
or tendon-split approaches and
also found no difference in knee
pain between the groups.13 Most
recently, a prospective, randomized
pilot study of 25 patients treated
with either suprapatellar or in-
frapatellar nails found that supra-
patellar nailing resulted in markedly
better patient-reported outcome scores
related to pain and a zero rate of
anterior knee pain after 1 year.16 These
and select other comparative studies
are summarized in Table 1.6,7,13,15,16
Proposed Etiologies
Damage to Intra-articular
Structures
A number of intra-articular structures,
including the menisci, anterior cruciate
ligament, and articular cartilage, are
at risk during tibial nailing. To avoid
these, Tornetta et al17 established the
concept of a “safe zone” for nail
insertion. In their 1999 article, the
authors placed nails into 40 cadaver
tibiae. They found a 20% rate of injury
to articular cartilage and a 30% rate of
near-meniscal injury and determined
that the safe zone is on average 9 mm
lateral to the midline and 3 mm lateral
to the tibial tubercle (Figure 1).17
Subsequent research plotted the safe
zone on 54 cadaver tibiae and retro-
spectively compared this to implant
position in 30 patients.18 The authors
identified 27% of patients as being at
risk for an injury and confirmed this in
four of the eight patients, either with
an arthrogram or on inspection during
subsequent implant removal. Three of
these patients had a medial meniscal
injury, and one had an injury to the
lateral articular cartilage.18 A more
recent study examined intra-articular
injury using a suprapatellar or a para-
patellar approach on 10 matched
cadaver specimen pairs.19 The authors
used pre-nailing arthroscopy to confirm
the state of the knee at baseline and then
dissected the specimens after nail
placement. Of 20 total specimens, they
found cartilage injury in 4, inter-
meniscal ligament injury in 6, and
anterior cruciate ligament injury in
1.19 Other authors performed pre- and
post-nailing arthroscopy of the patel-
lofemoral joint in 11 patients after
they underwent suprapatellar nailing
and found a new cartilage injury in
3, although none of these were
symptomatic at 1-year follow-up.16
Implant Prominence
Nail prominence has been proposed
as a potential cause of postoperative

Dr. Bishop or an immediate family member serves as a paid consultant to DePuy Synthes, Globus Medical, and KCI; has received research or
institutional support from Conventus; and serves as a board member, owner, officer, or committee member of the Western Orthopaedic Association.
Dr. Gardner or an immediate family member serves as a paid consultant to Biocomposites, BoneSupport AB, Conventus, Globus Medical, Pacira
Pharmaceuticals, SI-Bone, StabilizOrtho, and DePuy Synthes; has stock or stock options held in Conventus and Imagen Technologies; has received
research or institutional support from Medtronic, SmartDevices, SMV Scientific, DePuy Synthes, and Zimmer Biomet; and serves as a board member,
owner, officer, or committee member of the American Orthopaedic Association, the Orthopaedic Research Society, and the Orthopaedic Trauma
Association. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held
in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Campbell and Dr. Eno.

e382 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Julius A. Bishop, MD, et al

Table 1
Select Studies Comparing Different Approaches for Tibial Nailing With a Pain-related Outcome Measure
No. of Primary
Patients Pain-related
Study Interventions (Mean Outcome
Study Design Compared Follow-up) Measure Results

Toivanen Prospective Paratendinous versus 42 (3.2 yr) VAS scores No notable difference
et al6 randomized transtendinous
approach
Väistö Prospective Paratendinous versus 28 (8 yr) VAS scores No notable difference
et al7 randomized transtendinous
approach
Jones Retrospective Suprapatellar 74 (range, Kujala and No notable difference
et al15 versus medial 1.9-2.3 yr) SF-12 scores
paratendinous
approach
Chan Prospective Suprapatellar versus 25 (1.3 yr) VAS, Lysholm No notable differences,
et al16 randomized infrapatellar knee, and except bodily pain
approach SF-36 scores subsection of the SF-36,
in which the suprapatellar
group had significantly
better scores (ie, less
pain; P = 0.035)
Bakhsh Retrospective Semiextended 102 NRS pain and Lysholm No notable differences,
et al13 lateral parapatellar (2.6-5.1 yr) knee scores except more likely to
versus medial self-report “no limp” on
parapatellar versus Lysholm subsection in
transtendinous the transtendinous
group

NRS = numeric rating scale, SF-12 = Medical Outcomes Study 12-Item Short Form, SF-36 = Medical Outcomes Study 36-Item Short Form, VAS =
visual analog scale

pain; however, overall, data are incon-
clusive. One retrospective review found
that in 107 patients treated with a tibial
nail, 63 had a prominent implant.1
However, the authors reported no
difference in rates of knee pain
between patients with prominence and
those without and found that even
when the nail was prominent by
.5 mm, only 43% of patients re-
ported pain.1 Other work retrospec-
tively reviewed 70 patients treated with
tibial nailing and found that anterior
prominence was markedly associated
with pain while resting, and superior
prominence was correlated with pain
during activities such as walking or
kneeling.20 In a long-term retrospective
study of 13 patients treated with a
tibial nail with 14-year median follow-
up, nail prominence was not correlated
with subjective pain scores or tender-
ness to palpation on physical exami-
nation.21 Another study reported 45
patients who underwent tibial nailing
and grouped patients into “no pain,”
“mild pain,” or “moderate to severe
pain” cohorts.22 The authors found a
notable difference in the rate of nail
prominence between these groups,
with more prominent nails in the
“moderate to severe” group.
Patellar Tendon and Fat Pad
The patellar tendon has been implicated
as a pain generator after tibial nailing. A
retrospective review of 107 patients
who underwent tibial nailing revealed
that patients who had nail insertion
via a transtendinous approach had
higher rates of postoperative knee pain
(77%) compared with those who
underwent paratendinous nailing
(50%).1 However, a subsequent study
found evidence to the contrary,
with a randomized controlled trial
of 42 patients showing no difference
in intensity or prevalence of pain
between transtendinous and para-
tendinous approaches.6 Another study
involved ultrasonography of the pa-
tellar tendons of 36 patients at an
average of 2.5 years after tibial nail-
ing.23 The authors found a 67% rate of
anterior knee pain but found no dif-
ference in tendon thickness, circulation,
and calcific changes between the pa-
tients with and without pain, and no
difference between the transtendinous
and paratendinous nailing groups. The
retropatellar fat pad has also been
investigated as a source of postnailing
pain. One cadaver study that com-
pared various infrapatellar approaches
to tibial nailing found that the medial

September 15, 2018, Vol 26, No 18 e383

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Knee Pain After Intramedullary Nailing of Tibia Fractures
Figure 1
Illustration demonstrating the so-
called sweet spot lateral to the
midline, as identified by Tornetta
et al.17 (Reproduced with permission
from Tornetta P, Riina J, Geller J,
Purban W: Intraarticular anatomic
risks of tibial nailing. J Orthop Trauma
1999;13[4]:247-251.)
paratendinous approach better pre-
served the fat pad.24
Infrapatellar Branch of the
Saphenous Nerve
The cutaneous nerve branches about
the knee and their importance during
knee surgery have been well reviewed in
the literature. In the 1990s, many au-
thors published cadaver studies in
which they charted the path of the in-
frapatellar branch of the saphenous
(IPBS) nerve. The authors of two studies
found the nerve near the medial joint
line, running toward the tibial tubercle
and crossing over the patellar ten-
don.25,26 A more recent cadaver
study using computer-assisted map-
ping to demonstrate the highly variable
course of the IPBS nerve clearly showed
that these branches are at risk of injury
during infrapatellar nailing27 (Figure
2). A related clinical study retrospec-
tively reviewed 71 patients with nailed
tibia fractures at a mean follow-up of
84 months.28 Patient-reported out-
come measures were collected, and a
physical examination, including deter-
mination of sensation defects in the
IPBS distribution, was performed. The
authors found that 60% of patients
had sensory deficits, including par-
esthesias or neuropathic pain, and in
one patient a neuroma was excised.
e384
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Figure 2
Images demonstrating all possible locations of the infrapatellar branch of the
saphenous nerve mapped onto the so-called average knee (A) and the zones in
which an incision places the nerve at high risk (B). (Reproduced with permission
from Kerver ALA, Leliveld MS, den Hartog D, Verhofstad MHJ, Kleinrensink GJ:
Surgical anatomy of the infrapatellar branch of the saphenous nerve in relation to
incisions for anteromedial knee surgery. J Bone Joint Surg Am 2013;95
[23]:2119-2125.)
Among patients with knee pain, 78% tional anterior bone was removed (to
had sensory problems in the IPBS nerve simulate eccentric reaming), strain
distribution, which was markedly increased beyond the levels seen with
higher than the group with no pain nail insertion only. Despite these
(49%); this finding suggested a rela- findings, the study did not demon-
tionship between nerve injury and strate a clinical link between in-
pain.28 creasing strain levels and anterior
knee pain, and it is unknown whether
Altered Biomechanics and this is clinically relevant.29,30 The
Fracture Motion authors’ findings that nail removal
Altered biomechanics and fracture site did not normalize strain values could
motion may contribute to knee pain. indicate that there is some threshold
One study demonstrated a link beyond which increasing strain is
between altered proximal tibia bio- poorly tolerated; further work is
mechanics and intramedullary nail required in this area.29 A retro-
insertion. Mir et al29 created a finite spective study of 443 tibia fractures
element model of one matched pair treated with intramedullary nailing
of tibiae. The authors found that assessed knee pain scores and frac-
after intramedullary nailing, tibial ture union status at a mean follow-
strain increased markedly under up of 31 weeks and found that knee
load and decreased when the nail pain was correlated with fracture
was removed; however, strain did union.31 Although this finding could
not return to normal levels. They explain improving pain during early
also demonstrated that when addi- and mid-term follow-up, it does not
Journal of the American Academy of Orthopaedic Surgeons

explain persistent knee pain in pa-
tients with healed fractures.
Muscle Deconditioning
Several studies have attempted to
determine the relationship between
muscle function and pain after tibial
nailing. Nyland et al32 objectively
tested quadriceps and hamstring
strength in 10 patients who were
treated with a tibial nail and fol-
lowed for $1 year. The authors
found 25% and 17% mean reduc-
tion in quadriceps and hamstring
strength, respectively, compared to
the uninjured extremity in these
patients, measured as torque via a
calibrated dynamometer, but the
authors did not link this finding
definitively to increased knee pain. A
subsequent study involved strength
testing on 40 patients at a mean
follow-up of 8 years after intra-
medullary nailing of a tibial shaft
fracture.33 Among this group, eight
patients had persistent pain at final
follow-up, and these patients
demonstrated a markedly weaker
quadriceps on isokinetic testing.
Treatment
Prevention
Prevention is the first line of treatment
for postnailing knee pain. First, the
approach and surgical dissection
are important. Although randomized
studies have not definitively shown
less knee pain in patients treated with a
semiextended approach compared with
a flexed approach, the series describing
these approaches have demonstrated
reduced rates of pain compared with
historical data.4,6,7,10,13,15,16,19 Both
the suprapatellar and lateral extra-
articular parapatellar approaches
may have potential benefits in terms of
preventing anterior knee pain, as dis-
section of the fat pad is limited and in
both cases the incision minimizes
injury to the inferior branch of the
September 15, 2018, Vol 26, No 18
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
saphenous nerve.4,10,12 In addition,
both approaches avoid the region of
the knee where pressure is placed when
kneeling, which can be a problematic
activity for some patients.10 One
potential disadvantage of suprapatellar
nailing is that a second incision may
be necessary for implant removal.
The starting point for nail insertion
is also critical to avoid injury to intra-
articular structures, and the so-called
sweet spot has been well described at
the medial aspect of the lateral tibial
spine on the AP view and just anterior
to the articular portion of the plateau
on the lateral17 (Figure 1). With all
techniques, but the semiextended
techniques in particular, care must
be taken not to injure the cartilage of
the trochlea or patella. Finally, ac-
curate measurement of nail length is
important to limit prominence.
Observation
It is unclear to what extent knee pain
after tibial nailing resolves over time.
Väistö et al7 reported 8-year follow-up
of 28 patients who had been treated
with a tibial nail via either a trans-
tendinous or paratendinous approach
and found that pain resolved over time
in 46% of patients regardless of the
surgical approach. However, subse-
quent work by Ryan et al31 found that
although time from surgery and frac-
ture union were correlated, time from
surgery and pain scores were not. One
retrospective study of 53 patients
found that at a median 14-year
follow-up after tibial nailing, 27% of
patients were pain free, but 45%
had moderate pain.21 In one recent
large retrospective study of 437 pa-
tients treated with a tibial nail, 48%
of patients reported at least some pain
12 months after surgery.5
Implant Removal
Although the indications for and effi-
cacy of implant removal remain
controversial, several studies have
suggested that nail removal can be
Julius A. Bishop, MD, et al
helpful in relieving pain. Court-Brown
et al2 retrospectively studied 169 pa-
tients treated with tibial nailing. They
found that 56% of patients had knee
pain, which led to 62 instances of
implant removal. Of these 62 pa-
tients, 60 had either “complete” or
“marked” improvement in their
symptoms. A similar study of 110
tibia fractures in patients treated
with intramedullary nailing found
high rates of postoperative knee pain
(57%) and a 46% overall rate of
implant removal.1 Among patients
who had nail removal, 45% had
“complete” improvement of symp-
toms, 25% “partial” improvement,
and 20% no change. Neither of these
studies definitively showed that
implant removal itself was respon-
sible for the improvement in symp-
toms realized by the patients. Other
retrospective work has demonstrated
that among 31 patients treated with
tibial nailing and followed for a
median of 14 years, the nail was
removed in 58%; however, this was
not associated with a difference in
subjective pain compared with the
patients in whom the implants were
retained.21 In one prospective study,
Toivanen et al6 routinely performed
nail removal in 40 of 42 patients
approximately 18 months after the
initial procedure. The authors
reported that 83% of patients had
anterior knee pain before implant
removal, whereas 69% of patients
had pain at final follow-up after the
nail was removed. Similarly, Väistö
et al33 removed all the nails in their
cohort of 40 consecutive patients
treated with a tibial nail at a mean of
1.6 years after insertion and found
that 54% had at least some pain relief
after implant removal.
Partial Denervation
Some authors have reported their
experience with denervation around
the knee for the treatment of post-
nailing anterior knee pain.34,35 In a
e385
Knee Pain After Intramedullary Nailing of Tibia Fractures
retrospective study of 70 patients
treated with partial denervation for
persistent knee pain related to the
IPBS, the authors noted that 31
patients had pain after total knee
arthroplasty, 32 had pain after
trauma, and 7 had symptoms after
an osteotomy.34 A preoperative
diagnostic block with local anes-
thetic was done in all cases, and the
procedure itself involved dissection
of the nerve branch and subsequent
resection. The authors of that study
found a 31-point mean increase in
Knee Society Scores and 86%
patient satisfaction. To our knowl-
edge, no literature to date has spe-
cifically studied partial denervation
among tibia fracture patients.
However, this may be an option in
the subset of patients with symp-
toms suggestive of neurologic pain.
Summary
Knee pain after tibial nailing is com-
mon, although the incidence seems to
be decreasing overall. A variety of
potential etiologies, including injury
to intra-articular structures, implant-
related pain, injury to the retro-
patellar fat pad, and neurogenic pain
from cutaneous nerve branches, has
been described. Prevention, in the
form of meticulous dissection during
the approach, an appropriate start
point, and adequate implant selection,
is important in minimizing the risk of
this complication. Various potential
treatment strategies exist depending
on the etiology of the symptoms.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, reference 6 is
a level I study. References 5, 7, 16,
and 33 are level II studies. References
1, 11, 13, 15, 23, and 28 are level III
studies. References 2-4, 8, 10, 12,
14, 18, 20-22, 31, 32, and 34 are
e386
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
level IV studies. References 9, 30,
and 35 are level V expert opinion.
References printed in bold type are
those published within the past 5 years.
1. Keating JF, Orfaly R, O’Brien PJ: Knee pain
after tibial nailing. J Orthop Trauma 1997;
11:10-13.
2. Court-Brown CM, Gustilo T, Shaw AD:
Knee pain after intramedullary tibial nailing:
Its incidence, etiology, and outcome. J
Orthop Trauma 1997;11:103-105.
3. Katsoulis E, Court-Brown C, Giannoudis PV:
Incidence and aetiology of anterior knee pain
after intramedullary nailing of the femur and
tibia. J Bone Joint Surg Br 2006;88:576-580.
4. Jankovic A, Korac Z, Bozic NB, Stedul I:
Influence of knee flexion and atraumatic
mobilisation of infrapatellar fat pad on
incidence and severity of anterior knee pain
after tibial nailing. Injury 2013;44(suppl 3):
S33-S39.
5. Obremskey W, Angel J, Archer K, To P;
Tornetta P for SPRINT Investigators:
Character, incidence, and predictors of knee
pain and activity after infrapatellar
intramedullary nailing of an isolated tibia
fracture. J Orthop Trauma 2016;30:135-141.
6. Toivanen JA, Väistö O, Kannus P, Latvala K,
Honkonen SE, Järvinen MJ: Anterior knee
pain after intramedullary nailing of fractures
of the tibial shaft: A prospective, randomized
study comparing two different nail-insertion
techniques. J Bone Joint Surg Am 2002;84-A:
580-585.
7. Väistö O, Toivanen J, Kannus P, Järvinen M:
Anterior knee pain after intramedullary
nailing of fractures of the tibial shaft: An eight-
year follow-up of a prospective, randomized
study comparing two different nail-insertion
techniques. J Trauma 2008;64:1511-1516.
8. Tornetta P, Collins E: Semiextended
position for intramedullary nailing of the
proximal tibia. Clin Orthop Relat Res
1996;328:185-189.
9. Althausen PL, Neiman R, Finkemeier CG,
Olson SA: Incision placement for
intramedullary tibial nailing: An anatomic
study. J Orthop Trauma 2002;16:
687-690.
10. Weil YA, Gardner MJ, Boraiah S, Helfet
DL, Lorich DG: Anterior knee pain
following the lateral parapatellar approach
for tibial nailing. Arch Orthop Trauma
Surg 2009;129:773-777.
11. Rothberg DL, Daubs GM, Horwitz DS,
Kubiak EN: One-year postoperative knee
pain in patients with semi-extended tibial
nailing versus control group. Orthopedics
2013;36:e548-e553.
12. Kubiak EN, Widmer BJ, Horwitz DS: Extra-
articular technique for semiextended tibial
nailing. J Orthop Trauma 2010;24:704-708.
Journal of the American Academy of Orthopaedic Surgeons
13. Bakhsh WR, Cherney SM, McAndrew CM,
Ricci WM, Gardner MJ: Surgical
approaches to intramedullary nailing of the
tibia: Comparative analysis of knee pain
and functional outcomes. Injury 2016;47:
958-961.
14. Sanders RW, DiPasquale TG, Jordan CJ,
Arrington JA, Sagi HC: Semiextended
intramedullary nailing of the tibia using a
suprapatellar approach: Radiographic
results and clinical outcomes at a minimum
of 12 months follow-up. J Orthop Trauma
2014;28:245-255.
15. Jones M, Parry M, Whitehouse M, Mitchell S:
Radiologic outcome and patient-reported
function after intramedullary nailing: A
comparison of the retropatellar and
infrapatellar approach. J Orthop Trauma
2014;28:256-262.
16. Chan DS, Serrano-Riera R, Griffing R, et al:
Suprapatellar versus intrapatellar tibial
nail insertion: A prospective randomized
control pilot study. J Orthop Trauma 2016;
30:130-134.
17. Tornetta P, Riina J, Geller J, Purban W:
Intraarticular anatomic risks of tibial nailing.
J Orthop Trauma 1999;13:247-251.
18. Hernigou P, Cohen D: Proximal entry for
intramedullary nailing of the tibia: The risk
of unrecognised articular damage. J Bone
Joint Surg Br 2000;82:33-41.
19. Zamora R, Wright C, Short A, Seligson D:
Comparison between suprapatellar and
parapatellar approaches for intramedullary
nailing of the tibia: Cadaveric study. Injury
2016;47:2087-2090.
20. Bhattacharyya T, Seng K, Nassif NA,
Freedman I: Knee pain after tibial nailing:
The role of nail prominence. Clin Orthop
Relat Res 2006;449:303-307.
21. Lefaivre KA, Guy P, Chan H, Blachut PA:
Long-term follow-up of tibial shaft
fractures treated with intramedullary
nailing. J Orthop Trauma 2008;22:
525-529.
22. Song SY, Chang HG, Byun JC, Kim TY:
Anterior knee pain after tibial
intramedullary nailing using a medial
paratendinous approach. J Orthop Trauma
2012;26:172-177.
23. Väistö O, Toivanen J, Paakkala T, Järvelä T,
Kannus P, Järvinen M: Anterior knee pain
after intramedullary nailing of a tibial shaft
fracture: An ultrasound study of the patellar
tendons of 36 patients. J Orthop Trauma
2005;19:311-316.
24. Weninger P, Schultz A, Traxler H, Firbas W,
Hertz H: Anatomical assessment of the Hoffa
fat pad during insertion of a tibial
intramedullary nail: Comparison of three
surgical approaches. J Trauma 2009;66:
1140-1145.
25. Horner G, Dellon A: Innervation of the
human knee joint and implications for surgery.
Clin Orthop Relat Res 1994;301:221-226.

26. Ebraheim NA, Mekhail AO: The
infrapatellar branch of the saphenous
nerve: An anatomic study. J Orthop
Trauma 1997;11:195-199.
27. Kerver ALA, Leliveld MS, den Hartog D,
Verhofstad MHJ, Kleinrensink GJ:
Surgical anatomy of the infrapatellar
brach of the saphenous nerve in relation
to incisions for anteromedial knee
surgery. J Bone Joint Surg 2013;95:
2119-2125.
28. Leliveld MS, Verhofstad MH: Injury to
the infrapatellar branch of the saphenous
nerve, a possible cause for anterior knee
pain after tibial nailing? Injury 2012;43:
779-783.
September 15, 2018, Vol 26, No 18
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
29. Mir HR, Marinescu RC, Janda H, Russell TA:
Biomechanical effects of the nail entry zone
and anterior cortical bone loss on the proximal
tibia. J Orthop Trauma 2013;27:34-41.
30. Keating JF: Invited commentary: Anterior
knee pain after intramedullary nailing
of the tibia: Biomechanical effects of the nail
entry zone and anterior cortical bone loss. J
Orthop Trauma 2013;27:41-42.
31. Ryan SP, Tornetta P, Dielwart C, Kaye-Krall
E: Knee pain correlates with union after tibial
nailing. J Orthop Trauma 2011;25:731-735.
32. Nyland J, Bealle DP, Kaufer H,
Johnson DL: Long-term quadriceps femoris
functional deficits following intramedullary
Julius A. Bishop, MD, et al
nailing of isolated tibial fractures. Int
Orthop 2001;24:342-346.
33. Väistö O, Toivanen J, Kannus P, Järvinen M:
Anterior knee pain and thigh muscle strength
after intramedullary nailing of a tibial
shaft fracture: An 8-year follow-up of 28
consecutive cases. J Orthop Trauma 2007;
21:165-171.
34. Dellon AL, Mont MA, Mullick T,
Hungerford DS: Partial denervation for
persistent neuroma pain around the knee.
Clin Orthop Relat Res 1996;329:216-222.
35. Dellon AL: Partial knee joint denervation
for knee pain: A review. Orthop Muscul
Syst 2014;3:1-7.
e387