Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 21464

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : RC01 - RC04 Full Version

Suprapatellar versus Infrapatellar Approach for Intramedullary Nailing in Tibial Shaft Fractures: A Prospective Interventional Study

Published: January 1, 2023 | DOI:
Girish Sahni, Sukhjot Singh, Ashish Kavia, Hari Om Aggarwal, Harjit K Singh Chawla

1. Professor, Department of Orthopaedics, Government Medical College Patiala, Punjab, India. 2. Junior Resident, Department of Orthopaedics, Government Medical College Patiala, Punjab, India. 3. Assistant Professor, Department of Physical Medicine and Rehabiliatation, Government Medical College Patiala, Punjab, India. 4. Professor, Department of Orthopaedics, Government Medical College Patiala, Punjab, India. 5. Assistant Professor, Department of Orthopaedics, Government Medical College Patiala, Punjab, India.

Correspondence Address :
Dr Harjit K Singh Chawla,
Assistant Professor, Department of Orthopaedics, Government Medical College Patiala, Punjab, India.


Introduction: Tibial diaphyseal fractures are the most prevalent type of tibia fracture. A well known surgical method for treating tibial shaft fractures was the traditional infrapatellar approach for tibia Intramedullary Nailing (IMN). However, due to increased valgus and procurvatum deformities, IMN insertion through the infrapatellar route poses problems. Recently, suprapatellar nailing in the semi-extended position has been promoted as a safe and effective surgical treatment.

Aim: To compare the clinical and functional outcomes of tibial shaft fractures treated with IMN utilising the Suprapattelar (SP) and Infrapatellar Methods (IP).

Materials and Methods: A prospective interventional study was conducted on 40 patients, in the Department of Orthopaedics, in Government Medical College, Patiala ,Punjab, India from November 2019 to May 2021. The patients were divided into two groups on the basis of tibial shaft fractures treated with IMN utilising the S.P and those treated with I.P techniques during a two year period (20 in each group) with six months follow-up. Group A patients were treated with IMN in tibia through suprapatellar technique and group B Patients were treated with IMN in tibia via infrapatellar approach. The outcomes of IMN in tibial shaft fractures via SP and IP approach were compared in terms of fluoroscopy time, average surgical time, anterior knee pain using Visual Analogue Scale (VAS) score, average blood loss, fracture union time and functional outcome (in terms of the lower extremity functional Score). For statistical analysis student t-test and chi-square test was used, p-value <0.05 was considered as significant.

Results: There were significant differences between SP and IP IMN in terms of fluoroscopy duration (94.25 vs 129.40 seconds, p-value-0.001), anterior knee pain (VAS score) (19.65 vs 29.85, p-value-0.001), average blood loss (49.30 vs 62.45 mL, p- value 0.001), and functional result (75.45 vs 70.05, p-value=0.001). The fracture union time between the two groups was non significant (90.50 vs 90.30 days, p-value=0.876).

Conclusion: In terms of fluoroscopy time, anterior knee pain, average blood loss, and knee ratings, the SP technique was superior to the IP strategy.


Anterior knee pain, Fluoroscopy time, Fracture union time, Functional outcome

The most common long bone fractures are tibia and fibula shaft fractures. Tibial diaphyseal fractures are the most common type of tibia fracture. Fibular fractures were present in 80% of these cases. (1). Adult tibia diaphyseal fractures were most common in young males between the ages of 15 and 19 years, with an annual incidence of 109 per 100,000 people. Adult tibia diaphyseal fractures were most common in women between the ages of 90 and 99 years, with an annual incidence of 49 per 1,000 population. (2) Among all long bones, diaphyseal tibia fractures have a rather significant risk of non-union and malunion of tibial shaft fractures have a bimodal distribution, with, low-energy spiral fractures more common in individuals over 50 years old and high-energy transverse and comminuted fractures more common in patients under 30. Falls from a standing height and sports injuries are the most prevalent causes of low-energy tibial fractures, whereas vehicle trauma is the most common cause of high-energy tibial diaphyseal fractures (1).

In the adult population, intramedullary nail fixation remains the treatment of choice for displaced and unstable tibial shaft fractures. Intramedullary nail fixing provides the advantage of requiring minimum surgical dissection and preserving the fracture's extraosseous blood supply. The use of intramedullary nail fixation was more limited to proximal and distal metaphysis fractures (3).

A well known surgical method for treating tibial shaft fractures was the traditional infrapatellar approach for tibia IMN However, due to quadriceps muscle power causing proximal fracture fragment displacement with the knee in flexion and an increased likelihood of valgus and procurvatum deformities following tibial nailing, IMN insertion through the infrapatellar route poses problems (3).

Recent advances in nail design and reduction procedures have expanded the criteria for intramedullary nail fixing to include both proximal and distal tibia fractures including the metaphyseal area. Recently, suprapatellar nailing in the semi extended position has been promoted as a safe and effective surgical treatment. The method allows for the selection of an acceptable beginning point in a semiextended posture, which aids in fracture reduction (particularly in apex anterior deformities). Preliminary clinical data shows promising results, including a low percentage of post procedure knee pain (4).

As there were only few studies (5),(6),(7),(8),(9) done in past on this topic hence, the present study was conducted with an aim to compare the clinical and functional outcomes of tibial shaft fractures treated with IMN utilising the SP and IP methods.

Material and Methods

A prospective interventional study was conducted in the Department of Orthopaedics, in Government Medical College Patiala, Punjab, India, from November 2019 to May 2021 on 40 patients. The Institutional Ethical Committee approval was obtained (letter number BFUHS/21k21p-TH/5468). Informed consent was obtained from the subjects. Group A patients treated with IMN tibia through SP technique and group B patients treated with IMN tibia via IP approach were chosen through alternate odd and even numbers who presented to the department during the study period. A total of 40 fracture shaft tibia cases were included and Arbeitsgemeinschaft für Osteosynthesefragen (AO) fracture classification was used to grade the fractures (10).

Inclusion criteria: Age >18 years to <65 years, closed fractures of shaft tibia and fibula, open fractures of both bone legs up to Gustilo Anderson classification 3A (11), segmental fractures of tibia. Proximal third and distal third tibia shaft fractures, all diaphyseal fractures of tibia, and patients medically fit for surgery.

Exclusion criteria: Age <18 years, open fractures of both bone legs, Gustilo Anderson classification 3B and 3C (11), Old neglected shaft tibia fractures, intra-articular extension of fracture, and canal size less than 7 mm.

Study Procedure

Surgical approach: In the present study, tibial shaft fractures were fixed with IMN via midline patellar tendon split IP and SP approach (Table/Fig 1).

Standard Surgical technique of IMN insertion: Nail was inserted over the guide wire from the entry point made on the bare area of the tibia after provisional reduction by manipulation and traction.

Postoperative protocol: Intravenous antibiotics (2nd generation cephalosporins and aminoglycosides) for two days and on postoperative day one was administered and passive and active range of motion exercises at the knee and ankle joint was allowed. Partial weight bearing was allowed at six weeks and once the signs of fracture healing were present on x-rays then full weight bearing was allowed.

Follow-up: After surgery, patients were followed up at six weeks, three months, and six months. At each follow-up, serial AP and lateral X-ray images were collected, and the patient was assessed for radiological and clinical signs of the union. The lower extremity functional scale (12) was used to assess the functional outcome. The functional outcomes of IMN in tibial shaft fractures via SP and IP approach were compared in terms of fluoroscopy time, average surgical time, anterior knee pain (VAS score) (13), average blood loss, fracture union time, the functional outcome in terms of the lower extremity functional score. The maximum score for 20 related daily activities was 80. Each activity received a maximum of four points. A score of 70-80 implied an excellent functional outcome. A score of 60-70 indicated a good functional outcome. A score of 40-60 suggested a fair functional outcome. A score of less than 40, had a poor functional outcome.

Functional definitions:

Average blood loss: Average blood loss that occurs during the time of surgery.
Anterior knee pain: Pain that occurs in the anterior and central aspect of the knee. It was measured using the VAS scale (13).
Fracture union time: Time duration after the surgery to the union, which is calculated by the functional outcome score (12).

Statistical Analysis

The IBM Statistical Package for the Social Sciences (SPSS) 22 version was used for statistical analysis. The student's t-test and the chi-square test were used to compare the outcomes between the groups. It was considered significant if the p-value was less than 0.05.


Patients' socio-demographic data, such as age, gender, and fracture type, were evenly distributed between the two groups (Table/Fig 2).

The mean surgical time in group A was 87.25±13.98 minutes and in group B was 92.20±9.27 minutes (p-value=0.195) as shown in (Table/Fig 3).

Average blood loss in group A was 49.30±12.27 mL and in group B was 62.45±6 mL (p-value=0.001 ) (Table/Fig 4).

The average fluoroscopy time in group A was 94.25±8.66 seconds and in group B was129.40±6.58 seconds (p-value=0.001) (Table/Fig 5).

The mean VAS Score in group A 19.65±2.21 and in group B was 29.85± 2.68 (p-value=0.001) (Table/Fig 6).

Avg fracture healing time in group A was 90.50±3.32 and in group B was 90.30± 4.61 (p-value=0.876) (Table/Fig 7).

The mean lower extremity function score in group A was75.45± 2.09 and in group B was 70.05±3.05 (p-value=0.001) (Table/Fig 8). A score of 70-80 i.e. excellent functional outcome was seen in all 20 patients in suprapatellar and in 14 in infrapatellar approaches. In six patients with infrapatellar approaches, good outcome was observed. (Table/Fig 9) shows X-rays of pre and post-operative images.


As intramedullary nails cause minimal stress to adjacent soft tissues, have a lesser risk of malunion, and provide greater biomechanical strength, IMN is becoming more popular as a therapy for tibia fractures.The standard IP method and the SP approach in a semi-extended position are used for IMN implantation (11).

The mean surgery time was similar in both groups, which was in line with Wang C et al., (11), they exhibited a reduction in fluoroscopy time while maintaining the same overall operational time. Ponugoti N et al. (14), who did a meta-analysis comparing SP with IP, found similar results.

In a meta-analysis of SP versus IP IMN, Xu H et al., (15) found that in the SP approach fluoroscopy time was reduced. This could be due to the semi extended position, which allows for easier leg handling and access to the fluoroscopic image intensifier throughout the process. (16) Packer TW et al. (17) came to similar conclusions in their research. Because of the frequent use of intraoperative fluoroscopy, orthopaedic teams are exposed to greater radiation doses, which can raise the risk of thyroid cancer. As a result, the SP method is useful in lowering this risk for both the surgeon and the patient.

During the IP IMN technique, the average blood loss was greater. These findings were consistent with those of Yang L et al. who found comparable results in their study (18). Reducing peri-op blood loss was an important issue that promoted recovery and decreased blood transfusion requirements.

The VAS pain score in the SP group was considerably lower than in the IP group, according to this study. This finding is congruent with that of MacDonald D et al. (19), who evaluated VAS scores between the IP and SP procedures in 95 patients and found that the IMN insertion via SP approach is linked with less postoperative anterior knee discomfort than the IMN via IP approach (19). Patellar tendon splitting leading to the involvement of the infrapatellar nerve and intra-articular structural damage were all causes of post-operative knee pain, which the suprapatellar technique attempts to prevent (15). According to Yang L et al. (18) meta-analysis, the SP method was linked to a considerable drop in VAS scores.

The average fracture healing time was comparable across the SP and IP IMN approaches in the present study. The results were comparable to the study by Chen X et al., (5) who found no significant difference in fracture union time between the two groups. Because postoperative anterior knee discomfort was substantially reduced in the SP group due to early rehabilitation, the lower extremity functional score was higher in the SP group. The findings are in line with those of Gao Z et al. (6) and Ponugoti N et al. (14). According to a study by Lu Y et al. (7), the percentage of malalignment in the SP group was 4.8 percent, which was much lower than the rate of 14.3 percent in the IP group, which was in concordance with the index study. In addition, Stella M et al. (20) found that the IP group had a 26.1 percent incidence of angular deformity.

In the IP group, the pull of the quadriceps caused flexion of the proximal fragment, resulting in procurvatum and valgus deformity. In the SP approach, since the knee joint was in a semi flexed position(10-30 degree flexion) which allowed the quadriceps to relax and also guided the nail to gain an appropriate starting point, the blocking effect of the patella was also lost. All these factors lead to improvement in deformity rates (8). The future recommendation would be that study could be conducted on a large sample size to generalize the findings.


The present study was limited by it's small sample size. Randomization was not done for the allocation of the participants and it was one of the limitations which could cause selection bias.


The SP strategy resulted in better functional outcomes, less pain, less fluoroscopy time and radiation exposure, and a lower average total blood loss than the IP approach. As a result, the IMN via SP method can be deemed as the most successful therapeutic approach for the treatment of tibial shaft fractures.


Boulton C, O’Toole R. Tibia and fibula shaft fractures. Court-Brown C, Heckman J, McQueen M, Ricci W, Tornetta P III, editors. Rockwod and Greens Fractures in Adults. 2015;2:2415-72.
Egol KA, Koval KJ, Zuckerman JD. Tibia/fibula shaft. Hand book of fractures. 5th ed.; 2019;1:454.
Cui Y, Hua X, Schmidutz F, Zhou J, Yin Z, Yan SG. Suprapatellar versus infrapatellar approaches in the treatment of tibia intramedullary nailing: a retrospective cohort study. BMC Musculoskelet Disord. 2019;20(1):573. Doi: 10.1186/s12891-019-2961-x. PMID: 31779596; PMCID: PMC6883512. [crossref] [PubMed]
Zelle BA, Boni G, Hak DJ, Stahel PF. Advances in intramedullary nailing: suprapatellar nailing of tibial shaft fracturesin the semi-extended position. Orthopedics. 2015;38(12):751-55. [crossref] [PubMed]
Chen X, Xu HT, Zhang HJ,Chen J. Suprapatellar versus infrapatellar intramedullary nailing for tibial shaft fractures in adults. Medicine(Baltimore). 2018;97(32):e11799. [crossref] [PubMed]
Gao Z, Han W, Jia H, Haigang MSc Suprapatellar versus infrapatellar intramedullary nailing for tibal shaft fractures, Medicine. 2018;97(24):e10917. [crossref] [PubMed]
Lu Y, Wang G, Hu B, Ren C, Sun L, Wang Z. et al. Comparison of suprapatellar versus infrapatellar approaches of intramedullary nailing for distal tibia fractures. J Orthop Surg Res. 2020;15:422. [crossref] [PubMed]
Freedman EL, Johnson EE. Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clinical Orthopaedics and Related Research. 1995; (315):25-33. PMID: 7634677. [crossref]
Tornetta P 3rd, Collins E. Semiextended position of intramedullary nailing of the proximal tibia. Clin Orthop Relat Res. 1996;(328):185-89. Doi:10.1097/00003086- 199607000-00029. [crossref] [PubMed]
Boulton C.Tibia and fibula shaft fractures In: Rockwood &Green’s Fractures In Adults.8th ed.Philadelphia:Lipincott Williams &Wilkins ;2015;2:2421-4.
Wang C, Chen E, Ye C, Pan Z. Suprapatellar versus infrapatellar approach for tibia intramedullary nailing: A meta-analysis. Int J Surg. 2018;51:133-139. Doi: 10.1016/j.ijsu.2018.01.026. Epub 2018 Jan 31. PMID: 29367045. [crossref] [PubMed]
Binkley JM, Stratford PW, Lott SA, Riddle DL, North American Orthopaedic Rehabilitation Research Network. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. Physical therapy. 1999;79(4):371-83. [crossref]
Crichton N. Visual analogue scale (VAS). J Clin Nurs. 2001;10(5): 697-06. [crossref] [PubMed]
Ponugoti N, Rudran B, Selim A, Nahas S, Magill H. Infrapatellar versus suprapatellar approach for intramedullary nailing of the tibia: a systematic review and meta-analysis. J Orthop Surg Res. 2021;16(1):94. Doi: 10.1186/s13018- 021-02249-0. PMID: 33509237; PMCID: PMC7844899. [crossref] [PubMed]
Xu H, Gu F, Xin J, Tian C, Chen F. A meta-analysis of suprapatellar versus infrapatellar intramedullary nailing for the treatment of tibial shaft fractures. Heliyon. 2019;5(9):e02199. Doi: 10.1016/j.heliyon.2019.e02199. PMID: 31517106; PMCID: PMC6734195. [crossref] [PubMed]
Zelle BA, Boni G. Safe surgical technique: Intramedullary nail fixation of tibial shaft fractures. Patient Saf. Surg. 2015;9(40):1-17. [crossref] [PubMed]
Packer TW, Naqvi AZ, Edwards TC. Intramedullary tibial nailing using infrapatellar and suprapatellar approaches: A systematic review and meta-analysis. Injury. 2021;52(3):307-15. Doi: 10.1016/j.injury.2020.09.047. Epub 2020 Sep 23. PMID: 32998824. [crossref] [PubMed]
Yang L, Sun Y, Li G.Comparison of suprapatellar and infrapatellar intramedullary nailing for tibial shaft fractures: A systematic review and meta-analysis. J OrthopSurg Res .2018;13(1):146 [crossref] [PubMed]
MacDonald DRW, Caba-Doussoux P, Carnegie CA, Escriba I, Forward DP, Graf M, et al. Tibial nailing using a suprapatellar rather than an infrapatellar approach significantly reduces anterior knee pain postoperatively: A multicentre clinical trial. Bone Joint J. 2019;101-B(9):1138-43. Doi: 10.1302/0301-620X.101B9. BJJ-2018-1115.R2). [crossref] [PubMed]
Stella M, santolini E, Felli L. semi extended tibial nail insertion using an extra articulate lateral parapatellar approach: A 24 month follow up prospective cohort study. J orthop Trauma.2019;33(10);e366-71. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2023/55398.17257

Date of Submission: Feb 02, 2022
Date of Peer Review: May 02, 2022
Date of Acceptance: Oct 07, 2022
Date of Publishing: Jan 01, 2023

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: Feb 07, 2022
• Manual Googling: Sep 30, 2022
• iThenticate Software: Oct 05, 2022 (9%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)