• Timothy W Packer, Ali Z Naqvi, and Thomas C Edwards.
• Trauma and Orthopaedics Department, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, W2 1NY, UK.. Electronic address: timothy.packer@nhs.net.
• Injury. 2021 Mar 1; 52 (3): 307-315.

IntroductionIntramedullary nailing of diaphyseal tibial fractures has become the gold standard method of fixation with high rates of union and low complication rates reported. The suprapatellar (SP) approach may have many advantages over the traditional infrapatellar (IP) approach. Controversy exists due to potential damage to the patellofemoral joint leading to persistent anterior knee pain. This systematic review and meta-analysis aims to evaluate the clinical and procedural outcomes of the SP approach in comparison to the traditional IP approach.MethodIn this PRISMA compliant systematic review and meta-analysis, five databases including MEDLINE, EMBASE, Web of Science, Cochrane Library and CINAHL were searched from inception until May 2020. Randomised controlled trials (RCTs) and comparative observational studies involving adults with tibial fractures treated with intramedullary nail fixation using either the suprapatellar or infrapatellar approach were included. Data extracted included demographics, functional knee scores, fluoroscopy exposure, insertional accuracy and adverse events. The primary outcome was validated functional knee scores. Risk of bias was calculated using the Cochrane risk of bias tool version 2 (RoB 2) and Newcastle-Ottawa Scale (NOS).ResultsIn total 16 studies were included consisting of 5 RCTs and 11 comparative observational studies. This included 1750 total operations with 810 in the SP group and 940 in the IP group. Meta-analysis was performed on the studies where appropriate data was reported. The SP approach demonstrated superior Lysholm scores (Mean Difference (MD) 5.63 [95% Confidence Interval (CI): 2.81 to 8.44]), reduced fluoroscopy times (MD -38.12 sec [95% CI: -47.96 to -28.28]) and increased entry point accuracy (Standard Mean Difference (SMD) -0.90 [95% CI: -1.22 to -0.59]). No differences in complication rates or blood loss were found.ConclusionBased on the data presented in this review, intramedullary nailing of the tibia using the SP approach demonstrates superior Lysholm knee scores, greater entry point accuracy and reduced fluoroscopy exposure with equivalent risk of developing complications when compared to the IP approach.Copyright © 2020. Published by Elsevier Ltd.

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