Intermedullary nailing (IMN) is the gold standard for the surgical treatment of extra-articular tibial fractures. The suprapatellar (SP) nailing approach offers several advantages over the conventional infrapatellar (IP) approach. However, most existing evidence is derived from retrospective observational studies.
RCTs were searched in PubMed, EMBASE, Web of Science, ClinicalTrials.gov, the Cochrane Library, and Google Scholar. Perioperative outcomes, visual analog scale (VAS) pain score, knee function metrics, and postoperative complications were compared using weighted mean difference (WMD) or risk ratio (RR) with 95% confidence interval (CI). The certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. All statistical analyses were performed using STATA 16.0 (StataCorp, TX, US).
The key findings of the study are:
• 13 RCTs encompassing 404 patients who underwent SP nailing and 396 who received IP nailing were included in the meta-analysis.
• RCTs were searched in PubMed, EMBASE, RCTs were searched in PubMed, EMBASE, SP approach was associated with significantly shorter operative time (WMD=-13.19 min, 95%CI: -24.37 to -2.02, p=0.021) and fluoroscopy time (WMD=-20.23, 95%CI:-39.74 to -0.71, p=0.042).
• The SP approach resulted in lower VAS pain score (WMD=-1.10, 95%CI: -1.90 to -0.31, p=0.007) and improved Lysholm knee score (WMD=4.22, 95%CI: 2.34 to 6.10, p<0.001) and KUJALA score (WMD=12.95, 95%CI: 10.78 to 15.13, p<0.001).
• No significant differences were observed in intraoperative blood loss, length of hospital stay, range of motion, union time, or complication rates (delayed union, nonunion, infection, secondary operation).
The authors concluded – “This meta-analysis of RCTs demonstrates that the SP approach offers several advantages over the IP approach, including shorter operative and fluoroscopy times, reduced postoperative pain, and improved knee function, with no increase in complication rates. These findings support the SP technique as a safe and effective alternative for the surgical treatment of extra-articular tibial fractures.”
Further reading:
Comparison of suprapatellar and infrapatellar intramedullary nailing for tibial fractures: a systematic review and meta-analysis of randomized controlled trials Hu and Huang BMC Musculoskeletal Disorders (2025) 26:895 https://doi.org/10.1186/s12891-025-09162-1
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