Suprapatellar versus infrapatellar tibial nailing: the ongoing debate.

purposeThis study aims to critically appraise both suprapatellar (SPN) and infrapatellar (IPN) tibial nailing techniques in terms of fracture reduction, fluoroscopy use, anterior knee pain, and overall clinical outcomes, exploring whether one technique offers clear superiority over the other for all tibia fractures or in a select subset of fractures.

methodsA narrative review of current literature, including randomised controlled trials, meta-analyses, and high-volume cohort studies, was conducted. Outcomes assessed included malalignment rates, operative time, fluoroscopy exposure, postoperative anterior knee pain, and functional recovery, with particular attention to fracture location (proximal, diaphyseal, distal).

resultsSPN facilitates semi-extended knee positioning, reducing deforming forces and improving proximal fracture alignment, while also decreasing fluoroscopy time and, in some studies, operative duration. IPN remains effective for midshaft fractures but is associated with higher malalignment rates in proximal injuries and requires more technically demanding intra-operative imaging. Meta-analyses demonstrate improved coronal and sagittal alignment with SPN; however, large-scale trials report no significant differences in union rates, range of motion, or long-term functional outcomes. Anterior knee pain remains common with both approaches and is influenced by multiple surgical and patient-specific factors.

conclusionBoth SPN and IPN are effective for tibial nailing, with SPN offering situational advantages in proximal and distal fractures. Surgical success is primarily determined by the precise entry point, accurate nail trajectory, and meticulous soft tissue handling. Approach selection should consider fracture characteristics, surgeon expertise, and procedural logistics. Proficiency in both techniques remains essential in modern orthopaedic trauma practice.