Nailing of the Tibia - Chronic Knee Pain?

Edit Post

I was thinking about doing LON for the second surgery so I can cut down some time and started searching for information about knee pain and nailing. Here's what I've found:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4063087/
QuoteIntramedullary nailing is the treatment of choice for the majority of tibial shaft fractures and anterior knee pain is the most common complication of this surgery; however, its etiology is still unknown.

Question: if chronic knee pain is the most common complication of IM nailing and considering its high incidence, HOW it is the treatment of choice? Are they retarded? Article is of year 2014.

http://www.ors.org/Transactions/55/0764.pdf
QuoteThe potential causes of anterior knee pain after intramedullary (IM) nailing of the tibia are not completely understoo d. Knee pain usually begins several months after IM nailing of the tibia and nail removal does not always provide pain relief 1 . From more than 20 factors potentially associated with knee pain, only two factors are strongly correlated with knee pain: activity level 2, 3, 4 and size of the tibia 5 . Clinical studies suggest that the knee pain is activity - related in most patients and is exacerbated by kneeling. The current study tests the hypothesis that the entry hole resulted from tibial nailing could cause anterior knee pain by significantly altering the local strain distribution in the proximal tibia. Using the finite element method, this study explores the etiology of anterior knee pain after intramedullary nailing and examines the effects of standing, walking, and kneeling on a normal tibia model, a nailed tibia model and a tibia model with the IM nail removed.

QuoteThe hypothesis of the current study was that the entry hole resulted from tibial nailing could cause anterior knee pain by significantly altering the local stress and strain distribution. The strain values recorded for the tibia with the nail removed in single - limb kneeling were significantly greater than the values recorded for the intact tibia. Strain values recorded around the hole for the tibia with the nail removed were higher than the strain values for the intact tibia for all the loading configurations considered. For each load case, the highest principal strain values were found in the nailed tibia model. Removing the nail does not reduce the strain to normal values encountered in an intact tibia

http://www.bjj.boneandjoint.org.uk/content/88-B/5/576
QuoteHowever, one of the most common problems associated with tibial primarily, and retrograde femoral nailing secondarily, is chronic anterior knee pain.15,43,45–51 This can be an important handicap for the patient, affecting his employment and daily or leisure activities. Its incidence has been reported to be as high as 86%.52 It may be present even in patients who have an intact knee as with antegrade femoral nailing.7,15,30,43,44,51,53,54 Its aetiology is unclear, but a multifactorial origin has been suggested.

http://upoj.org/wp-content/uploads/v24/09_Courtney.pdf
QuoteWhile much has been written about the incidence of anterior knee pain through a patellar splitting or parapatellar approach, the clinical effects of knee pain after suprapatellar nails have yet to be addressed in the literature.  Our data show no difference in the Oxford Knee Score between the two groups.

So the suprapatellar nailing, praised by Dr. Monegal and proclaimed to be 'completely safe' regarding knee pain, appears to be barely studied. Also:
http://www.amjorthopedics.com/fileadmin/qhi_archive/ArticlePDF/AJO/041120546.pdf
Quote Based on this cadaveric study, tibial nailing in the semi- extended position with a superomedial arthrotomy and lateral patellar mobilization (ie, suprapatellar nailing) is associated with risks to anterior knee anatomy at the starting point comparable to other previously described tibial nailing techniques. A superomedial arthrotomy places the portal closer to the medial meniscus, compared with a quadriceps splitting approach. We feel that the technique may offer significant advantages in the management of proximal tibia fractures undergoing nailing; however, because risks to the patellofemoral joint have not been clearly elucidated by this or other studies, it may not be the approach of choice for more simple fractures not predisposed to malalignment. Additional clinical studies are warranted to further define the role of this technique in the management of tibia fractures, including those of the proximal third.

http://theglobaljournals.com/ijsr/file.php?val=November_2014_1416664332__124.pdf
nov 2014
QuoteBackground  -Intramedullary tibial nail  needs to give a careful  thought. Its correlation with chronic anterior knee
pain seems to be crucial factor.

QuoteThere has been a growing concern about the tibial nailing being accompanied by an increase in the incidence of anterior knee pain. Suggested contributing factors include younger, more active patients, nail prominence above the proximal tibial cortex, meniscal tear, unrecognized articular injury, increased contact pressure in the patellofemoral articulation, damage to the infrapatellar nerve, and surgically induced scar formation. Some authors have suggested that a transtendinous approach is associated with more frequent anterior knee pain than is a medial paratendinous approach. The cause of this knee pain is still unclear.

Quote20 patients (67%) in our study complained of anterior knee pain related to the nail entry site during the follow up. 80 % (16 of 20 in pain group) of the patients who developed knee pain had done so within 6 months of surgery. Out of the 20 pain group patients, 11(55%) reported Mild pain (VAS 2.1 – 4), 5(25%) Moderate pain (VAS 4.1 – 6), 4(20%) re - ported severe pain (VAS > 6.1). On analysis of functional knee score it was observed that the most common problem encountered was with kneeling, and 90% (18 of 20) of the patients experienced pain during this activ - ity. Half of these patients could not kneel at all because of knee pain
Squatting was the next, with 70% (14 of 20) of patients experiencing discomfort and one third of these patients finding the activity impossible.

What do you say? Is the current clinical evidence enough to claim any tibial nailing (LON, LATN, self-lengthening nails) is AIDS and is not advisable to anyone?

Edit Post

However, one of the most common problems associated with tibial primarily, and retrograde femoral nailing secondarily, is chronic anterior knee pain.15,43,45–51 This can be an important handicap for the patient, affecting his employment and daily or leisure activities. Its incidence has been reported to be as high as 86%.52 It may be present even in patients who have an intact knee as with antegrade femoral nailing.7,15,30,43,44,51,53,54 Its aetiology is unclear, but a multifactorial origin has been suggested.

so even if you do LON or LATN in femurs , you could have knee pain?

Edit Post

Quote from: KirP1 on April 29, 2015, 04:07:54 PMso even if you do LON or LATN in femurs , you could have knee pain?

Yeah, they say that. Both with antegrade and retrograde nailing. Though with antegrade nailing I'd imagine the pain should be gone after nail removal. Not sure.

Screw nails I say. You pay 100 times more for a temporary comfort just to end up with chronic pain? Lol. And in the case of tibial nailing, you're basically a lab rat for them, as they don't even know exactly what causes the pain. Most don't even warn their patients about it.

Edit Post

i cant think of 1 person thats been affected by knee pain so much that it  alters their daily routine

frst off,  every single patient that went to china   had/has nailing done... if you do internals, you have nailing done, a large number of those that went to india, etc

there's people on this board that had nailing done.... doesnt seem to really affect them...

rozbruch and paley both said it happens rarely or never with them

 i doubt everyone is lying

Edit Post

Quote from: crimsontide on April 29, 2015, 07:59:42 PMi cant think of 1 person thats been affected by knee pain so much that it  alters their daily routine

frst off,  every single patient that went to china   had/has nailing done... if you do internals, you have nailing done, a large number of those that went to india, etc

there's people on this board that had nailing done.... doesnt seem to really affect them...

rozbruch and paley both said it happens rarely or never with them

 i doubt everyone is lying

Mr. Sweden admitted to knee pain, MDOW also reported knee pain when kneeling, though It would be more interesting to know if he can squat with weights. Other than that, we don't have that many diaries with tibial nailing. And no, they don't have to be lying, but personally, for me, it would be really hard to admit such a failure, after going through a LL-hell, wasting so much time, money, health. I'd imagine many also choose to be silent about their complications.

Edit Post

Quote from: exclide on April 29, 2015, 08:56:36 PMMr. Sweden admitted to knee pain, MDOW also reported knee pain when kneeling, though It would be more interesting to know if he can squat with weights. Other than that, we don't have that many diaries with tibial nailing. And no, they don't have to be lying, but personally, for me, it would be really hard to admit such a failure, after going through a LL-hell, wasting so much time, money, health. I'd imagine many also choose to be silent about their complications.

I get no knee pain when squatting.

Edit Post

and  doesnt internal tibias entail tibial nailing??  seems to be quite a few of these diaries

Edit Post

also, regarding knee issues while kneeling in  a hard surface... i get discomfort  now if i try that, and so does another patient that i talk to, and he also only did external

i dont think this issue is limited to nailing

Edit Post

Interesting.  I assumed it was related to the nailing because the discomfort is right where the insertion/removal scar is.

Edit Post

i dont think so... the discomfort for me is right in the front, right below the top bony part.

I definitely    am not the same when i kneel now... i can  kneel on a bed with no issues, but on a hard floor, its very uncomfortable. i also never experienced it before the surgery... i didnt pay much attention to it until another guy  told me how it was really uncomfortable  when he kneels  on a hard surface..

no issues walking, squatting,etc... i think its pretty much the same situation youre in now