Functional outcomes of medial parapatellar versus patellar tendon splitting approaches in intramedullary nailing of tibial shaft fractures: a prospective comparative study

Background: Anterior knee pain remains the most common complication following intramedullary nailing of tibial shaft fractures. The surgical approach used for nail insertion is an important factor influencing postoperative knee morbidity. Methods: This prospective observational study included 42 patients with tibial shaft fractures treated with intramedullary interlocking nailing between April 2024 and March 2026. Patients were managed using either patellar tendon splitting or medial parapatellar approach. Functional outcomes were assessed using Visual Analog Scale (VAS) for pain and Lysholm Knee Score (LKS) at 6 weeks, 3 months, 6 months, and 1 year. Results: Both groups were comparable in baseline characteristics. Fracture union was achieved in all patients by 6 months. While overall pain prevalence was similar at 1 year (p=0.533), VAS scores were significantly lower in the medial parapatellar group from 3 months onward (p<0.001). The medial parapatellar group demonstrated significantly better knee flexion, reduced extension lag, and higher Lysholm scores at all follow-up intervals (p<0.001). Conclusions: Both approaches are effective for achieving fracture union; however, the medial parapatellar approach results in superior functional outcomes and lower pain severity. It may be preferred when feasible.