Working in the operating room, you quickly learn that no two tibial fractures are the same. Some are straightforward; others twist and turn in ways you wouldn’t expect. Traditionally, intramedullary nails were inserted below the kneecap using the infrapatellar approach. It works, but it can be tricky—especially with proximal or distal fractures. In recent years, I’ve noticed more colleagues turning to the suprapatellar nailing approach, which enters above the kneecap, and for good reasons.
Semi-Extended Knee Makes Everything Easier
One of the biggest frustrations with the traditional method is the knee position. You have to bend it sharply, which can make it hard to hold the fracture in place while inserting the nail. With the suprapatellar approach, the knee stays semi-extended. That small change makes a big difference. The fracture stays aligned more naturally, soft tissues aren’t stretched as much, and it’s easier to get the nail in without constantly readjusting.
Better Visualization Means Fewer Mistakes
When your line of sight is clear, everything runs more smoothly. The semi-extended position allows you to see the fracture and the tibial canal more directly. With fluoroscopy, you can check placement easily and reduce the chances of malalignment. This is especially useful in multi-level or comminuted fractures, where each fragment matters.
Fewer adjustments in the OR aren’t just about convenience—they lower the risk of complications and speed up the procedure.
Less Knee Pain for Patients
Anterior knee pain after tibial nailing is a real issue. Patients often mention discomfort months after surgery. By avoiding the patellar tendon, the suprapatellar approach reduces trauma to this sensitive area. As a result, patients recover faster and regain mobility with less discomfort compared to traditional infrapatellar nailing.
Time Efficiency in Real Cases
Above all, the suprapatellar approach can shave time off the procedure. The guidewire and nail follow a direct path, so there’s less trial and error. Shorter surgeries mean less anesthesia exposure and lower fatigue for the surgical team—something everyone in the OR appreciates, especially during multi-level fixations.
Important Considerations
It’s worth noting that this approach isn’t completely risk-free. Care must be taken to protect the cartilage in the patellofemoral joint. Using protective sleeves and following proper technique is essential. But once you’re familiar with the method, these risks are minimal compared to the benefits.
Final Thoughts
The suprapatellar approach isn’t just a trend—it’s a practical solution to challenges we face in tibial nailing. Semi-extended positioning, better visualization, reduced knee pain, and increased efficiency all make it a compelling option. For surgeons handling proximal, distal, or complex tibial fractures, it’s worth learning and incorporating into practice.
Patients walk away with less pain, faster recovery, and better alignment, and for a surgeon, the procedure feels smoother and more predictable. That’s why the suprapatellar approach is quickly becoming the preferred method in modern orthopedic practice.
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