Comparison of the Functional Outcomes of Intramedullary Nailing for Extra-articular Proximal Tibial Fractures Using Three Different Approaches: A Prospective Study and Review of Literature

Abstract Background: Fractures of the proximal third of the tibia pose substantial challenges in orthopedic trauma due to complex biomechanics and a high risk of malalignment. Various implants and surgical approaches are available for these injuries. Intramedullary nailing (IMN) is widely utilized; however, the optimal surgical entry approach is still debated. This study compares the functional outcomes of extra-articular proximal tibial fractures treated with IMN via three approaches: suprapatellar, infrapatellar, transpatellar, and lateral parapatellar (LPP). Aim and Objectives: This study aimed to evaluate and compare the functional outcomes of IMN using the suprapatellar versus infrapatellar (transpatellar and LPP) approaches for treating extra-articular proximal tibial fractures. Materials and Methods: This prospective study included 90 patients with extra-articular proximal tibial fractures, randomized equally into three groups of 30 patients each based on the surgical approach. Functional outcomes were assessed using the lower extremity functional scale (LEFS) and Visual Analog Scale (VAS) for pain at 2, 6, and 12 weeks and at 6 months postoperatively. Radiographic parameters, including nail entry deviation and fracture healing time, were analyzed. Statistical comparisons were made using analysis of variance and post hoc testing. Results: The suprapatellar group had the shortest mean operative time (85 ± 20 min), lowest intraoperative blood loss (119 ± 17 mL), and most accurate nail entry point, followed by LPP. LEFS scores were significantly higher in the suprapatellar group at early follow-ups ( P < 0.05), though comparable at 6 months. VAS scores were lowest in the LPP group at all intervals. Radiographic healing was fastest in the suprapatellar group (mean: 14.1 weeks), followed by the LPP and infrapatellar groups. Conclusion: Semi-extended IMN approaches, especially the suprapatellar approach, demonstrated superior functional outcomes, quicker recovery, improved radiographic alignment, and lower intraoperative morbidity compared to infrapatellar techniques. The LPP approach was associated with the least postoperative pain and better functional outcomes compared to the conventional infrapatellar approach. These findings suggest that the semi-extended approaches may be the preferred option for IMN in proximal tibial fractures, although additional long-term studies are recommended to confirm these results.