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[Overdozer]

I was thinking about doing LON for the second surgery so I can cut down some time and started searching for information about knee pain and nailing. Here's what I've found:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4063087/

Intramedullary nailing is the treatment of choice for the majority of tibial shaft fractures and anterior knee pain is the most common complication of this surgery; however, its etiology is still unknown.

Question: if chronic knee pain is the most common complication of IM nailing and considering its high incidence, HOW it is the treatment of choice? Are they retarded? Article is of year 2014.

http://www.ors.org/Transactions/55/0764.pdf

The potential causes of anterior knee pain after intramedullary (IM) nailing of the tibia are not completely understoo d. Knee pain usually begins several months after IM nailing of the tibia and nail removal does not always provide pain relief 1 . From more than 20 factors potentially associated with knee pain, only two factors are strongly correlated with knee pain: activity level 2, 3, 4 and size of the tibia 5 . Clinical studies suggest that the knee pain is activity - related in most patients and is exacerbated by kneeling. The current study tests the hypothesis that the entry hole resulted from tibial nailing could cause anterior knee pain by significantly altering the local strain distribution in the proximal tibia. Using the finite element method, this study explores the etiology of anterior knee pain after intramedullary nailing and examines the effects of standing, walking, and kneeling on a normal tibia model, a nailed tibia model and a tibia model with the IM nail removed.

The hypothesis of the current study was that the entry hole resulted from tibial nailing could cause anterior knee pain by significantly altering the local stress and strain distribution. The strain values recorded for the tibia with the nail removed in single - limb kneeling were significantly greater than the values recorded for the intact tibia. Strain values recorded around the hole for the tibia with the nail removed were higher than the strain values for the intact tibia for all the loading configurations considered. For each load case, the highest principal strain values were found in the nailed tibia model. Removing the nail does not reduce the strain to normal values encountered in an intact tibia

http://www.bjj.boneandjoint.org.uk/content/88-B/5/576

However, one of the most common problems associated with tibial primarily, and retrograde femoral nailing secondarily, is chronic anterior knee pain.15,43,45–51 This can be an important handicap for the patient, affecting his employment and daily or leisure activities. Its incidence has been reported to be as high as 86%.52 It may be present even in patients who have an intact knee as with antegrade femoral nailing.7,15,30,43,44,51,53,54 Its aetiology is unclear, but a multifactorial origin has been suggested.

http://upoj.org/wp-content/uploads/v24/09_Courtney.pdf

While much has been written about the incidence of anterior knee pain through a patellar splitting or parapatellar approach, the clinical effects of knee pain after suprapatellar nails have yet to be addressed in the literature.  Our data show no difference in the Oxford Knee Score between the two groups.

So the suprapatellar nailing, praised by Dr. Monegal and proclaimed to be 'completely safe' regarding knee pain, appears to be barely studied. Also:
http://www.amjorthopedics.com/fileadmin/qhi_archive/ArticlePDF/AJO/041120546.pdf

Based on this cadaveric study, tibial nailing in the semi- extended position with a superomedial arthrotomy and lateral patellar mobilization (ie, suprapatellar nailing) is associated with risks to anterior knee anatomy at the starting point comparable to other previously described tibial nailing techniques. A superomedial arthrotomy places the portal closer to the medial meniscus, compared with a quadriceps splitting approach. We feel that the technique may offer significant advantages in the management of proximal tibia fractures undergoing nailing; however, because risks to the patellofemoral joint have not been clearly elucidated by this or other studies, it may not be the approach of choice for more simple fractures not predisposed to malalignment. Additional clinical studies are warranted to further define the role of this technique in the management of tibia fractures, including those of the proximal third.

http://theglobaljournals.com/ijsr/file.php?val=November_2014_1416664332__124.pdf
nov 2014

Background  -Intramedullary tibial nail  needs to give a careful  thought. Its correlation with chronic anterior knee
pain seems to be crucial factor.

There has been a growing concern about the tibial nailing being accompanied by an increase in the incidence of anterior knee pain. Suggested contributing factors include younger, more active patients, nail prominence above the proximal tibial cortex, meniscal tear, unrecognized articular injury, increased contact pressure in the patellofemoral articulation, damage to the infrapatellar nerve, and surgically induced scar formation. Some authors have suggested that a transtendinous approach is associated with more frequent anterior knee pain than is a medial paratendinous approach. The cause of this knee pain is still unclear.

20 patients (67%) in our study complained of anterior knee pain related to the nail entry site during the follow up. 80 % (16 of 20 in pain group) of the patients who developed knee pain had done so within 6 months of surgery. Out of the 20 pain group patients, 11(55%) reported Mild pain (VAS 2.1 – 4), 5(25%) Moderate pain (VAS 4.1 – 6), 4(20%) re - ported severe pain (VAS > 6.1). On analysis of functional knee score it was observed that the most common problem encountered was with kneeling, and 90% (18 of 20) of the patients experienced pain during this activ - ity. Half of these patients could not kneel at all because of knee pain
Squatting was the next, with 70% (14 of 20) of patients experiencing discomfort and one third of these patients finding the activity impossible.

What do you say? Is the current clinical evidence enough to claim any tibial nailing (LON, LATN, self-lengthening nails) is AIDS and is not advisable to anyone?

[KrP1]

However, one of the most common problems associated with tibial primarily, and retrograde femoral nailing secondarily, is chronic anterior knee pain.15,43,45–51 This can be an important handicap for the patient, affecting his employment and daily or leisure activities. Its incidence has been reported to be as high as 86%.52 It may be present even in patients who have an intact knee as with antegrade femoral nailing.7,15,30,43,44,51,53,54 Its aetiology is unclear, but a multifactorial origin has been suggested.

so even if you do LON or LATN in femurs , you could have knee pain?

[Overdozer]

so even if you do LON or LATN in femurs , you could have knee pain?

Yeah, they say that. Both with antegrade and retrograde nailing. Though with antegrade nailing I'd imagine the pain should be gone after nail removal. Not sure.

Screw nails I say. You pay 100 times more for a temporary comfort just to end up with chronic pain? Lol. And in the case of tibial nailing, you're basically a lab rat for them, as they don't even know exactly what causes the pain. Most don't even warn their patients about it.

[crimsontide]

i cant think of 1 person thats been affected by knee pain so much that it  alters their daily routine

frst off,  every single patient that went to china   had/has nailing done... if you do internals, you have nailing done, a large number of those that went to india, etc

there's people on this board that had nailing done.... doesnt seem to really affect them...

rozbruch and paley both said it happens rarely or never with them

 i doubt everyone is lying

[Overdozer]

i cant think of 1 person thats been affected by knee pain so much that it  alters their daily routine

frst off,  every single patient that went to china   had/has nailing done... if you do internals, you have nailing done, a large number of those that went to india, etc

there's people on this board that had nailing done.... doesnt seem to really affect them...

rozbruch and paley both said it happens rarely or never with them

 i doubt everyone is lying

Mr. Sweden admitted to knee pain, MDOW also reported knee pain when kneeling, though It would be more interesting to know if he can squat with weights. Other than that, we don't have that many diaries with tibial nailing. And no, they don't have to be lying, but personally, for me, it would be really hard to admit such a failure, after going through a LL-hell, wasting so much time, money, health. I'd imagine many also choose to be silent about their complications.

[Medium Drink Of Water]

Mr. Sweden admitted to knee pain, MDOW also reported knee pain when kneeling, though It would be more interesting to know if he can squat with weights. Other than that, we don't have that many diaries with tibial nailing. And no, they don't have to be lying, but personally, for me, it would be really hard to admit such a failure, after going through a LL-hell, wasting so much time, money, health. I'd imagine many also choose to be silent about their complications.

I get no knee pain when squatting.

[crimsontide]

and  doesnt internal tibias entail tibial nailing??  seems to be quite a few of these diaries

[crimsontide]

also, regarding knee issues while kneeling in  a hard surface... i get discomfort  now if i try that, and so does another patient that i talk to, and he also only did external

i dont think this issue is limited to nailing

[Medium Drink Of Water]

Interesting.  I assumed it was related to the nailing because the discomfort is right where the insertion/removal scar is.

[crimsontide]

i dont think so... the discomfort for me is right in the front, right below the top bony part.

I definitely    am not the same when i kneel now... i can  kneel on a bed with no issues, but on a hard floor, its very uncomfortable. i also never experienced it before the surgery... i didnt pay much attention to it until another guy  told me how it was really uncomfortable  when he kneels  on a hard surface..

no issues walking, squatting,etc... i think its pretty much the same situation youre in now

[KrP1]

i dont think so... the discomfort for me is right in the front, right below the top bony part.

I definitely    am not the same when i kneel now... i can  kneel on a bed with no issues, but on a hard floor, its very uncomfortable. i also never experienced it before the surgery... i didnt pay much attention to it until another guy  told me how it was really uncomfortable  when he kneels  on a hard surface..

no issues walking, squatting,etc... i think its pretty much the same situation youre in now

i think that it could be due to the big tensión in the muscles for  your lengthening

[crimsontide]

yes, might be... its not a huge issue... i just dont get on my knees much anyway

[Sweden]

Some mornings are hell in the knees. I feel them every time when I stand up from sitting down.

It takes a while for the knees to "wake up". They're stiff for an hour or so. Blood needs to flow down to them.
I've noticed that coffee help a little.

I can now run for an hour. Jump like 50% high as before. Jump down from 1 meter or more. I'm fast as a lightning when doing quick steps on the ground.

I do sports almost every day. I ride my bicycle, inlines and jog almost everywhere I go just bc I'm able to and enjoy it. I hated the time I was immobile. Got very depressed from it.

Yes, things are more difficult now than it was before but I can run faster than some of my students and I tried to sprint last week. It worked, it was fast and I had more to give but was afraid to push that hard.

I always feel much better after a run. It only needs to be for 15minutes at 70-80% of maximum. My record right now is around 14 minutes and 26 seconds on 3 kilometers.

It is impossible not to feel anything after having your tibia dried and then shoving a nail inside of it. Fixating it with screws all around the knee and splitting the patellar.

If you never do anything in your life maybe you feel fine and okay with the ache and after 2 years you're really used to it so you know how to behave for it to be a absolute minimum. You stand up in a certain way and sit down in a certain way. You adapt.

I wouldn't listen to lazy boring people who claim they don't feel anything.

I would rather be interested in the patient who can run fast, kick hard, move as one should and then tell you there will be aches for the rest of your life.

My feet hurts too every day. Just a little but it's there.
I still don't have full range of motion in them and wonder if any ever gotten that back fully as before?
Somehow I kind of doubt that.....

Tomorrow is running time, then hitting it hard in the gym, washing my cars, eating good food, second gym time in the evening and then 1 hour of Taekwondo.

My coach says I'm ready for competitions. My ultimate goal was to be able to compete one more time and I'm thinking of doing in after the summer.

I don't feel any pain when I'm warmed up - and blood flows everywhere.

[KrP1]

Some mornings are hell in the knees. I feel them every time when I stand up from sitting down.

It takes a while for the knees to "wake up". They're stiff for an hour or so. Blood needs to flow down to them.
I've noticed that coffee help a little.

I can now run for an hour. Jump like 50% high as before. Jump down from 1 meter or more. I'm fast as a lightning when doing quick steps on the ground.

I do sports almost every day. I ride my bicycle, inlines and jog almost everywhere I go just bc I'm able to and enjoy it. I hated the time I was immobile. Got very depressed from it.

Yes, things are more difficult now than it was before but I can run faster than some of my students and I tried to sprint last week. It worked, it was fast and I had more to give but was afraid to push that hard.

I always feel much better after a run. It only needs to be for 15minutes at 70-80% of maximum. My record right now is around 14 minutes and 26 seconds on 3 kilometers.

It is impossible not to feel anything after having your tibia dried and then shoving a nail inside of it. Fixating it with screws all around the knee and splitting the patellar.

If you never do anything in your life maybe you feel fine and okay with the ache and after 2 years you're really used to it so you know how to behave for it to be a absolute minimum. You stand up in a certain way and sit down in a certain way. You adapt.

I wouldn't listen to lazy boring people who claim they don't feel anything.

I would rather be interested in the patient who can run fast, kick hard, move as one should and then tell you there will be aches for the rest of your life.

My feet hurts too every day. Just a little but it's there.
I still don't have full range of motion in them and wonder if any ever gotten that back fully as before?
Somehow I kind of doubt that.....

Tomorrow is running time, then hitting it hard in the gym, washing my cars, eating good food, second gym time in the evening and then 1 hour of Taekwondo.

My coach says I'm ready for competitions. My ultimate goal was to be able to compete one more time and I'm thinking of doing in after the summer.

I don't feel any pain when I'm warmed up - and blood flows everywhere.

sweden im sorry that you have all those problems.
have you think about have x legs corrected? maybe that is the origin of some problems

[Sweden]

It's not a problem, it's just way of life. Nobody does this and gets away unaffected.

I don't need any surgeries more than the femur lengthening I want just because.

I'm confident I can do much more than you regarding motion in my legs. Not sure I'm faster than you but I'm absolutely not slow.

But I'm just curious: How in gods name does one get the last range of motion back in the ankles? Being able to lift the feet up to 90 degrees is far from what one should be able to.

[KrP1]

It's not a problem, it's just way of life. Nobody does this and gets away unaffected.

I don't need any surgeries more than the femur lengthening I want just because.

I'm confident I can do much more than you regarding motion in my legs. Not sure I'm faster than you but I'm absolutely not slow.

But I'm just curious: How in gods name does one get the last range of motion back in the ankles? Being able to lift the feet up to 90 degrees is far from what one should be able to.

haha are you sure that you could ? im a profesional  MMA fighter , and im very fast ...
just kidding , i did karate for some years when i was a child but nothing more about martial arts . yeah im sure you got more motion in your legs for what i saw in your videos but as i told you time ago your kicks were like slow motion , did this improve?

[Overdozer]

But I'm just curious: How in gods name does one get the last range of motion back in the ankles? Being able to lift the feet up to 90 degrees is far from what one should be able to.

I have 7.5 cm lengthened in my tibia. My ankle ROM is also limited, dorsiflexion is peaked at about 5 degrees, while on the other tibia it's 15-20 degrees. I've been doing some stretches like standing against the wall, but so far I can't tell I've made any progress. I'll be increaing my PT time to 8-10 hours a day to see should that be effective. And if that doesn't do it, achilles tendon release will be the only choice.

[crimsontide]

both of you , especially sweden havent gotten back rom iun the ankles because a release is needed


ive also said this for a while about ankle movement...  pt will not work for some people.
and yes, i have my ankle motion back, and have had it back for a while

its obvious sweden has needed a surgical release for a while, but at this point, might be best to just accept it.. it'll never be normal without surgical intervention..

 hard to   tell what's the source of the  knee problems when there are a few possibilities... x legs will wreak havoc on the knees, and he's had them years

don't think every dr splits the patellar. i would not want mine split

[notatroll]

However, one of the most common problems associated with tibial primarily, and retrograde femoral nailing secondarily, is chronic anterior knee pain.15,43,45–51 This can be an important handicap for the patient, affecting his employment and daily or leisure activities. Its incidence has been reported to be as high as 86%.52 It may be present even in patients who have an intact knee as with antegrade femoral nailing.7,15,30,43,44,51,53,54 Its aetiology is unclear, but a multifactorial origin has been suggested.

so even if you do LON or LATN in femurs , you could have knee pain?

i cant think of 1 person thats been affected by knee pain so much that it  alters their daily routine

frst off,  every single patient that went to china   had/has nailing done... if you do internals, you have nailing done, a large number of those that went to india, etc

there's people on this board that had nailing done.... doesnt seem to really affect them...

rozbruch and paley both said it happens rarely or never with them

 i doubt everyone is lying

Knee pain affects my daily routine. When I have knee pain, I limpg. Pain is sometimes unbearable.