Recommendations for avoiding knee pain after intramedullary nailing of tibial shaft fractures

The proximal tibiofibular joint was analyzed in 30 patients, who reported knee pain after tibial nailing, and standard radiograph and computed tomography were performed to examine the proximal third of the tibia. Twenty patients (68.9%) presented the proximal screw crossing the proximal tibiofibular joint and 13 (44.8%) had already removed the nail and/or screw. Four patients (13.7%) reported complaint of knee pain. However, the screw did not reach the proximal tibiofibular joint. Five patients (17.2%) complained of knee pain although the screw toward the joint did not affect the proximal tibiofibular joint.When using nails with oblique proximal lock, surgeons should be careful not to cause injury in the proximal tibiofibular joint, what may be one of the causes of knee pain. Thus, the authors suggest postoperative evaluation performing computed tomography when there is complaint of pain.Tibial shaft fracture is considered the most common long bone in orthopaedic practice. Fixation with intramedullary nail has frequently been used and proven to be efficient in displaced tibial shaft fractures [1-8]. Tibial nailing is related with relatively low incidence of nonunion, malunion, infection and compartmental syndrome [9-11]. However, pain in the knee joint is the most common complication after tibial nailing. Its occurrence has been reported from 10 to 86% of the cases, particularly in young and active patients [12-16]. A recent meta-analysis of the literature has estimated an incidence of 47.4% [11]. Although the etiology of the knee pain after intramedullary nail is still unknown, many theories have been proposed [11,13,17-19].Several anatomic structures around the knee are prone to damage during nail insertion, including the patellar tendon [11,14], menisci, articular cartilage, the infrapatellar branch of the saphenous nerve and infrapatellar fat pad [14]. Additionally, the presence of prominent nail and/or screw and the associated muscular weakness have been descri