Comparison of suprapatellar and infrapatellar intramedullary nailing for tibial fractures: a systematic review and meta-analysis of randomized controlled trials

Abstract Background Intermedullary nailing (IMN) is the gold standard for the surgical treatment of extra-articular tibial fractures. The suprapatellar (SP) nailing approach offers several advantages over the conventional infrapatellar (IP) approach. However, most existing evidence is derived from retrospective observational studies. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the efficacy of the SP and IP approaches in extra-articular tibial fracture management. Methods RCTs were searched in PubMed, EMBASE, Web of Science, ClinicalTrials.gov, the Cochrane Library, and Google Scholar through December 31, 2024. Perioperative outcomes, visual analog scale (VAS) pain score, knee function metrics, and postoperative complications were compared using weighted mean difference (WMD) or risk ratio (RR) with 95% confidence interval (CI). The certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results RCTs were searched in PubMed, EMBASE, RCTs were searched in PubMed, EMBASE, SP approach was associated with significantly shorter operative time (WMD=-13.19 min, 95%CI: -24.37 to -2.02, p=0.021) and fluoroscopy time (WMD=-20.23, 95%CI:-39.74 to -0.71, p=0.042). Additionally, the SP approach resulted in lower VAS pain score (WMD=-1.10, 95%CI: -1.90 to -0.31, p=0.007) and improved Lysholm knee score (WMD=4.22, 95%CI: 2.34 to 6.10, p<0.001) and KUJALA score (WMD=12.95, 95%CI: 10.78 to 15.13, p<0.001). No significant differences were observed in intraoperative blood loss, length of hospital stay, range of motion, union time, or complication rates (delayed union, nonunion, infection, secondary operation). Conclusions The SP nailing approach is a safe and effective alternative to the traditional IP approach and may be recommended for the surgical treatment of extra-articular tibial fractures.