Effect of Transverse Versus Longitudinal Incisions on Anterior Knee Pain after Tibial Nailing (TRAVEL): A Multicenter Randomized Trial with 1-Year Follow-up

Background:Anterior knee pain is common after tibial nailing, and its origin is poorly understood. Literature suggests it may be related to infrapatellar nerve injury. The aim of this study was to compare the effect of a transverse (potentially infrapatellar nerve-sparing) incision versus a longitudinal incision for the insertion of a tibial nail with respect to anterior knee pain.Methods:Patients with a tibial shaft fracture undergoing treatment with use of an intramedullary nail were randomized to a transverse incision (n = 68) or longitudinal incision (n = 68) in multiple centers. The primary outcome measure was kneeling pain based on a numeric rating scale (NRS). Secondary outcome measures included knee pain during daily activities, functional outcome (Short Musculoskeletal Function Assessment and Lower Extremity Functional Scale), quality of life (EuroQol-5 Dimensions), activity resumption, complications, reoperations, and costs within 1 year after trauma.Results:At 12 months, the estimated marginal mean for kneeling pain was 2.4 (95% confidence interval [CI], 1.6 to 3.2) in the transverse incision group and 3.7 (95% CI, 3.0 to 4.5) in the longitudinal incision group. Regression analysis showed no significant difference between the groups over time. Knee pain scores for daily activities, functional outcome scores, and quality of life were also comparable between the groups. Signs of infrapatellar nerve injury were found less often after a transverse incision (18% versus 54%; p < 0.001). The median total (direct and indirect) costs per patient were 10,468 in the transverse incision group and 11,066 in the longitudinal incision group. Loss of productivity accounted for 67% and 52% of the total costs in the 2 groups, respectively.Conclusions:A transverse incision reduces injury to the infrapatellar nerve, but anterior knee pain scores and function are comparable after use of a transverse or longitudinal incision for tibial nail insertion.Level of Evidence:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.