Comparison of Patellofemoral Chondromalacia Following Suprapatellar and Infrapatellar Techniques of Tibial Nailing—A Randomized, Controlled Trial

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OBJECTIVES: To compare the incidence and severity of patellofemoral chondromalacia and its correlation with anterior knee pain following suprapatellar (SP) versus infrapatellar (IP) approaches for tibial intramedullary nailing. DESIGN: Prospective, randomized controlled trial. SETTING: Single-center study at a Level I Trauma Center. PATIENT SELECTION CRITERIA: Patients aged between 18 and 45 years who presented with OTA/AO type 42 fractures from September 2020 to March 2024 were randomized into SP and IP groups. Magnetic resonance imaging (MRI) at 6 months post-surgery assessed cartilage damage using the Modified Outerbridge Classification. Diagnostic knee arthroscopy was offered for further evaluation. OUTCOME MEASURES AND COMPARISONS: The primary outcome was frequency and severity of chondromalacia assessed through MRI (Modified Outerbridge Classification) and diagnostic knee arthroscopy at 6 months. Secondary outcomes were the correlation of MRI findings with knee pain (VAS (Visual Analogue Scale) score) and the comparison of the time taken for nail insertion with cartilage damage in the SP group. RESULTS: Both groups had 30 patients each. In the SP group, the mean age was 33.7 years (range 18-45 years) and 83.3% were men, while the IP group had a mean age of 29.3 years (range 18-45 years) and 83.3% were men. Overall, 57 underwent MRI knee (SP: 28, IP: 29) and 16 underwent diagnostic knee arthroscopy (SP: 9, IP: 7). MRI detected chondromalacia in 46.4% in the SP group and 44.8% patients in the IP group; there was no significant difference ( P -value 0.9). Arthroscopy revealed chondromalacia in all 9 (100%) patients who underwent diagnostic arthroscopy in the SP group as compared with 2 of 7 (28.6%) patients in the IP group ( P -value 0.003). Correlation between chondromalacia grading on MRI and VAS scores at 6 months follow-up was significant (r = 0.4, P -value 0.006). Time taken for nail insertion weakly correlated with the presence of chondromalacia on MRI in the SP group but was not statistically significant (r = 0.2, P -value 0.5). CONCLUSIONS: No differences were found in the occurrence of patellofemoral chondromalacia observed on MRI between the SP and IP nailing techniques. The SP approach demonstrated a higher frequency of patellofemoral chondromalacia on arthroscopic evaluation. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

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