Kneeling tolerance following intramedullary nailing or plate fixation of uncomplicated distal tibia fractures

Introduction: Distal tibia fractures often occur in younger, high demand patients, though the literature surrounding management remains contentious. This study sought to quantitatively determine differences in kneeling ability and self-reported knee function in patients managed with either intramedullary nailing (IMN) or open reduction internal fixation (ORIF) with compression plating following distal tibia fracture to assist in the preoperative consent process. Hypothesis: There is no difference in kneeling tolerance following either tibial nailing or plate fixation of distal tibia fractures. Material and methods: Retrospective sampling of public hospital data with outpatient prospective functional testing were completed. The primary outcome measure was the Kneeling Test (KT). Secondary outcome measures were The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Forgotten Joint Score (FJS) for the knee joint. There were 28 patients recruited (18 IMN and 10 ORIF) with a mean age of 44 years. Mean overall follow-up was 13.3 months (range 8–25, SD 3.6). All fractures had completely healed without postoperative complication. Results: The IMN affected limb had a significantly worse overall kneeling function than their non-affected limb (mean KT: 70.4 vs. 94.9 respectively, p < 0.005) Additionally, the IMN group performed significantly worse when compared to the ORIF group (mean KT 70.4 vs. 92.5 respectively, p < 0.005). No significant differences (p > 0.05) in kneeling function existed for the ORIF group when comparing affected to non-affected limbs. Secondary outcome analysis showed significantly worse overall WOMAC and FJS in the IMN group compared to the ORIF group (mean WOMAC 19.3 vs. 6.9 respectively, p = 0.040; mean FJS 38.3 vs. 75.9 respectively, p = 0.005). Discussion: The use of intramedullary nailing for the treatment of distal tibia fracture results in a mean reduction of 20% in kneeling tolerance in comparison to ORIF. The resulting kneeling tolerance is comparable to that of patients post-total knee arthroplasty. The present findings should assist in the consent process for patients with high kneeling demands in sportive, professional or cultural pastimes. Level of evidence: IV; retrospective cohort study with quantitative outcome measurement.