^DEFINITION

^{Retrograde femoral nailing can be defined as any femoral nailing technique with a distal entry from the condyles or through an intercondylar, intra-articular starting point.}

^{For this chapter, retrograde femoral nailing will refer to nails with an intercondylar starting point that extend through the shaft region to the proximal femur. In certain fracture situations, shortened nails (supracondylar nails) can be used with the same starting point for fixation of distal femoral fractures.}

 

 

^ANATOMY

 

^{The femoral shaft is tubular in shape over the extent of the isthmus, gradually flaring infraisthmally into the distal femur, which is trapezoidal in cross-section.}

 

^{The entry point for the retrograde femoral nail is located at the distal end of the patellofemoral grove, just anterior to the posterior cruciate ligament insertion (FIG 1A).}

 

 

^{Radiographically, this is located in the midline or just medial to the midline between the condyles on the anteroposterior (AP) view and laterally just anterior to the line of Blumensaat as it meets the trochlear grove (FIG 1B,C).5, 12, 14, 15, 18 This flat articular area has minimal to no contact with the patella until 120 degrees}

^{of flexion.1, 5}

 

 

 

^{FIG 1 • A. Distal femur viewed end on, with ideal starting point for retrograde femoral nailing identified (asterisk) just anterior to the posterior cruciate ligament insertion. B,C. AP and lateral radiographs of the knee, with the initial starting guidewire positioned at the ideal starting point for retrograde femoral nailing. The radiographic landmark for the trochlear groove (TG) is indicated on the AP radiograph and for the line of Blumensaat (BL) on the lateral radiograph.}

 

 

^{Pertinent proximal anatomy includes neurovascular structures anterior to the proximal femur, close to interlocking screw insertion sites.24}

 

^{The femoral artery is medial to the proximal femur, with branches that cross the anterior femur more than 4 cm distal to the lesser trochanter.}

 

^{Branches of the femoral nerve cross more proximal starting 4 cm distal to the piriformis fossa.}

 

^{Damage to neurovascular structures caused by proximal locking screw insertion can be avoided or minimized by avoiding medial dissection and with placement at or above the lesser trochanter (FIG 2).}

 

^PATHOGENESIS

 

^{Femoral shaft fractures are markers of high-energy injuries.10, 12, 13, 14, 23, 27}

 

^{Studies have shown that 38% of trauma patients diagnosed with a femoral shaft fracture have additional injuries.3, 7, 8, 26}

 

^{In femur fracture patients with associated injuries, the most common findings are other musculoskeletal injuries}

 

^P.439

^{(93%), thoracic injuries (62%), head injuries (59%), abdominal injuries (35%), and facial injuries (16%).7}

 

 

 

^{FIG 2 • Cross-sectional view of the proximal femur, with proximal interlocking screw insertion shown and pertinent medial neurovascular structures.}

 

 

^{Ipsilateral femoral neck fractures occur in 1% to 6% of all femoral shaft fractures and are initially missed in up}

^{to 20% to 50% of cases.29 Recognition of these injuries before intramedullary stabilization is important to minimize potential complications (refer to section on Imaging and Other Diagnostic Studies).}

 

^{All trauma patients should undergo the standard advanced trauma life support (ATLS) examination to rule out associated life-threatening injuries.}

 

^{Although less common, femoral shaft fractures can occur in isolated sports injuries and in low-energy injuries associated with pathologic bone, such as with osteoporosis or metastatic bone disease.}

 

^{PATIENT HISTORY AND PHYSICAL FINDINGS}

 

^{Pain and deformity of the thigh are usually obvious but may be obscured in the morbidly obese patient.}

 

^{The fractured limb should be closely examined to avoid missing any open wounds, particularly in the posterior aspect of the thigh. Skin abrasions and apparently minor wounds should be assessed to determine if they communicate with the fracture.}

 

^{Swelling is a common finding with femoral shaft fractures. Compartment syndrome of the thigh is rare but can occur.28}

 

^{The entire lower extremity and pelvis needs to be evaluated because of the high rate of associated musculoskeletal injuries.}

 

^{A thorough neurologic and vascular examination must also be performed. Although femoral nerve damage is very unusual, sciatic nerve damage can occur.4, 6, 34}

 

^{Associated ligamentous injuries of the knee are common but may be difficult to assess until definitive stabilization of the femur has been obtained. Therefore, this examination should be repeated after nailing the femoral fracture.31, 32}

^{IMAGING AND OTHER DIAGNOSTIC STUDIES}

 

^{AP and lateral radiographs of the full length of the femur are essential, as well as formal AP and lateral radiographs of the hip and knee.}

 

 

^{Lateral knee radiographs should be closely evaluated for subtle patellar impaction fractures or nondisplaced fractures.}

 

^{Hip radiographs should be closely examined to rule out an associated femoral neck fracture, which has been shown to occur in 1% to 6% of femoral shaft fractures.29}

 

^{Some surgeons recommend a routine computed tomography (CT) scan examination of the femoral neck as part of the trauma scan to rule out a femoral neck fracture.}

 

 

^{A reported 20% to 50% of these injuries are missed on the initial plain radiographic examination.29 Because of the high association of missed coronal fractures in high-energy injuries, a CT scan of the knee}

^{should be obtained whenever formal knee radiographs reveal a supracondylar distal femur fracture and there is consideration for retrograde nailing.17}

 

^{Any coronal fractures seen on CT examination should be considered a contraindication for retrograde nailing owing to the possibility of compromising the distal interlocking screw fixation.}

 

^{SURGICAL MANAGEMENT}

^{Classifications and Relative Indications}

^{It is important to assess the extent of the fracture both proximally and distally with proper radiographs.}

^{Proximally, CT scans can supplement plain radiographs to determine fracture line extension into the peritrochanteric region and to check for occult femoral neck fractures.}

^{Distally, CT imaging is helpful to assess intra-articular extension and to check for coronal plane fractures.17}

^{All femoral shaft fractures, as classified by the Winquist system,33 are technically suitable for retrograde femoral nailing ( FIG 3).}

 

 

 

 

^{FIG 3 • Winquist femoral shaft fracture classification system.33 All fracture patterns in this system are amenable to retrograde femoral nailing.}

 

 

^P.440

 

^{Table 1 Relative Indications for Retrograde Intramedullary Nailing of the Femur}

^Indication

^Rationale

^{All femoral shaft fractures}

^{Shown in multiple studies to have equivalent union rates and}

^{outcomes to antegrade intramedullary nailing}

^Pregnancy

^{Ability to decrease the amount of radiation exposure to the fetus}

^{Bilateral femur fractures}

^{Decreased overall operative time because the lower extremities can}

^{be prepared and draped together, eliminating the need to reposition for the second procedure}

^{Floating knee injuries}

^{Single surgical approach}

^{Polytrauma patient}

^{Supine positioning without bump allows for multiple surgical team}

^{approach to patient.}

^{Unstable spine injuries}

^{Supine positioning without bump affords ability to maintain spine}

^{precautions throughout the procedure.}

^{Acetabular or pelvic}

^fractures

^{Avoids surgical incision about the hip that may limit future surgical}

^approaches

 

^{Ipsilateral hip and femoral}

^{shaft fractures}

^{Allows each fracture to be treated with the optimal implant}

^{Ipsilateral femoral shaft}

^{fracture below a total hip replacement stem}

^{Short supracondylar retrograde nails can be used to treat the}

^{fracture with a minimally invasive technique.}

^{Morbid obesity}

^{Easier and more limited surgical approach}

^{Soft tissue wounds about}

^{the hip}

^{Avoids surgical approach of compromised soft tissues}

 

 

^{Retrograde femoral nailing is not considered to be the standard of care for treatment of more proximal subtrochanteric fractures, but in certain patient circumstances, it may be the treatment of choice (Table 1).}

 

^{Subtrochanteric fractures with the lesser trochanter and piriformis fossa intact, Russell-Taylor IA}

^{fractures (FIG 4),25 may be amenable to retrograde femoral nailing if other patient factors favor a retrograde approach.}

 

^{Ideally, some proximal medial cortex remains intact to act as a buttress against the nail.}

 

^{It is important to know how far the proximal interlocking screw holes are from the tip of the nail in the retrograde nail system available in your hospital.}

 

^{We recommend being able to obtain two bicortical interlocking screws above the most proximal fracture line for very proximal fractures. If possible, they should be through holes, not slots, in the nail to provide more stability.}

 

^{If the subtrochanteric fracture has proximal extension, including either the lesser trochanter or piriformis fossa, or both, then proximal interlocking screw fixation of the retrograde nail would be compromised and alternative fracture fixation methods should be considered.}

 

^{Retrograde femoral nailing may be considered in certain supracondylar distal femoral fractures. We find}

^{that Muller's AO classification system of distal femoral fractures16 best elucidates which of these fractures can be addressed with retrograde femoral nailing ( FIG 5).}

 

^{Consideration for retrograde femoral nailing can be given for all extra-articular (A subgroup) fractures.}

 

^{It is important to know the distance between the distal interlocking screw holes and the tip of the nail in the retrograde nail system available in your hospital.}

 

^{We recommend being able to obtain at least two bicortical interlocking screws below the most distal fracture line for distal fractures.}

 

^{Nails with oblique distal interlocking options can be advantageous because of increased stability and potentially less screw head prominence.}

 

 

 

^{FIG 4 • Russell-Taylor classification system of subtrochanteric femur fractures,25 with fracture patterns amenable to retrograde femoral nailing highlighted.}

 

 

^P.441

 

 

 

^{FIG 5 • Muller's AO classification system of distal femoral fractures,16 with fracture patterns amenable to retrograde femoral nailing highlighted.}

 

 

 

 

^{FIG 6 • A. Diagram of lateral aspect of distal femur, with potential sites for intra-articular screw fixation out of the path of the retrograde femoral nail identified. B. Diagram of distal femur end on, with potential sites for intra-articular screw fixation out of the path of the retrograde femoral nail identified. C. Intraoperative lateral radiograph of a supracondylar, intracondylar (C1) distal femur fracture with intra-articular screw fixation and retrograde nail in place.}

 

^{Consideration for retrograde femoral nailing can be given to simple transverse articular fracture patterns (C-1 and C-2 subgroups).}

^{This should be performed with an open medial or lateral parapatellar approach to the knee in lieu of a percutaneous approach. Articular reduction must first be obtained and then maintained with bicortical screw fixation placed outside of the planned path for the retrograde nail (FIG 6).}

^{Partial articular fractures (all B subgroups) and complex articular fractures (C-3 subgroups) should not be considered for retrograde femoral nailing.}

^{Patients with osteoporotic distal fractures may be best treated with some of the newer fixed-angle plate devices, owing to concerns of distal interlocking screw purchase.}

^{Alternatively, nails designed with multiaxial screws or the use of supplemental blocking screws may help with augmenting fixation.}

 

^{Contraindications}

^{Preoperative knee stiffness preventing 40 to 60 degrees of flexion Active knee sepsis}

^{Grossly contaminated soft tissue wounds about the knee remain a contraindication but recent literature has shown that retrograde nailing of open fractures does not increase the incidence of postoperative knee sepsis.22}

^{Skeletally immature patients}

 

 

^{Preoperative Planning}

 

^{AP and lateral radiographs are used to measure the diameter of the femoral canal isthmus and thus determine the approximate nail diameter. Most intramedullary nail systems come in diameters ranging from 10 to 13 mm.}

 

 

^P.442

 

^{Nail lengths are often determined intraoperatively but can be ascertained by imaging the contralateral femur.}

 

^{Radiographs are evaluated to determine the location and morphology of the fracture; they should be scrutinized for nondisplaced secondary fracture lines that could become displaced during operative treatment.}

 

 

^{Occasionally, fracture fragments may be stuck in the canal and may need to be pulled out.}

 

^{In the case of fractures that show significant shortening preoperatively, it may be difficult to restore length off the fracture table.}

 

 

^{A trial reduction should be performed under fluoroscopy before the start of the procedure; the patient must be paralyzed for the procedure.}

 

^{If length is difficult to restore manually, then a femoral distractor should be used for the procedure. Placement of the femoral distractor is described in the section on Fracture Reduction.}

 

^{Before preparing and draping the injured limb, the surgeon should examine the contralateral extremity to determine the patient's normal leg length and rotation.}

 

 

^{Femoral length can be evaluated by using a radiographic ruler and intraoperative fluoroscopy (FIG 7A).}

 

^{Normal rotation can be determined by flexing the hip and knee and checking the patient's normal internal and external rotation of the hip and by examining the normal resting position of the foot as the patient lies supine on the operating room table (FIG 7B).}

 

 

 

^{FIG 7 • A. Schematic lateral view of a patient on a radiolucent operating room table, depicting how to use a radiopaque ruler and fluoroscopy to determine femoral length. B. Schematic anterior view of a patient on the operating room with the uninjured hip and knee flexed, checking the patient's normal internal and external rotation of the hip.}

 

^Positioning

 

^{The patient is positioned supine on a radiolucent diving board or flat-top table with no bump under the hip.}

 

^{The surgeon should ensure that the entire femur, from hip to knee, can be imaged on AP and lateral fluoroscopy.}

 

^{The extremity should be draped free from the anterior superior iliac spine to the ankle. The entire hip should be included in the preparation in case any femoral neck fractures are identified after treatment of the femoral shaft fracture.}

 

^{Radiolucent sterile towels, sheets, or a radiolucent triangle are used to create a bump under the knee, allowing for about 40 degrees of knee flexion and placing the patella anterior for correct rotational alignment.1, 15}

 

^{Intraoperative fluoroscopy should come in from the contralateral side.}

 

^Approach

 

^{The knee should be flexed about 40 degrees to avoid injury to the proximal tibia and the patella.15}

 

 

^P.443

 

^{Intraoperative fluoroscopy is used to obtain a perfect lateral of the knee. The line of Blumensaat should be clearly identified (see FIG 1C).}

 

^{A radiopaque guidewire can be used to identify the center of the long axis of the femur in order to determine the correct level of the skin incision.}

 

^{The guide pin is used to center a 1.5- to 2.5-cm incision just medial to the midline.}

 

^{A medial flap is created using subcutaneous dissection. A medial peritendinous arthrotomy is then made to allow entrance of the initial starting guidewire into the intracondylar notch.}

 

 

^TECHNIQUES

• ^{Placing the Guidewire}

  ^{The surgeon confirms the correct placement of the initial starting guidewire on the AP and lateral fluoroscopic radiographs.}

  ^{On the lateral image, the initial starting guidewire should be situated at the apex of the line of Blumensaat, in line with the femoral shaft (see FIG 1C).}

  ^{On the AP image, the guidewire should be centered or just medial to the midline in the trochlear groove, in line with the femoral shaft (see FIG 1B).}

  ^{On the AP image, the fluoroscope is moved proximally to be certain the guidewire is directed at the center of the canal.}

  ^{When starting to drill the initial guidewire, the surgeon's hand should drop slightly to prevent the wire from falling into the posterior cruciate ligament insertion; the hand is raised once the wire enters the cortex, so as to be in line with the femoral shaft.}

  ^{Once the initial starting guidewire is centered on the AP and lateral images, the wire is passed into the distal femoral shaft.}

  ^{A soft tissue retractor is placed over the initial starting guidewire to protect the patellar tendon during reaming.}

• ^{Creating and Reaming the Starting Hole}

  ^{The initial starting reamer is used to create the starting hole. (Alternatively, an awl or a step drill can be used to make the starting hole using the principles described earlier.)}

  ^{Once the starting hole has been made, a beaded-tip guidewire is passed to the level of the fracture.}

• ^{Fracture Reduction}

  ^{Traction is used to restore length. The surgeon must ensure that adequate anesthesia (full paralysis) is employed.}

  ^{There are many deforming muscle forces, depending on the level of the fracture. If the fracture cannot be reduced by manual traction, use of bumps, pulling with sheets wrapped around the proximal or distal thigh, or pushing with mallets are some options.}

  ^{The abductor muscles will abduct and externally rotate the proximal femur after high subtrochanteric and}

  ^{proximal shaft fractures. Inserting a unicortical 5-mm Schanz pin through a percutaneous incision in the lateral cortex just above the fracture or in the greater trochanter can gain excellent control of the proximal fracture fragment.}

   

  ^{The iliopsoas muscle will flex and internally rotate proximalthird femoral shaft fractures by its pull on the lesser trochanter. Again, inserting a unicortical 5-mm Schanz pin through a percutaneous incision in the lateral cortex just above the fracture or in the greater trochanter can gain excellent control of the proximal fracture fragment.}

   

  ^{The adductor muscles span most shaft fractures and exert a strong axial and adduction force. Sometimes, midshaft transverse fractures can be the most difficult to reduce. Inserting a unicortical 5-mm Schanz pin through a percutaneous incision in the lateral cortex just above and just below the fracture can gain excellent control of the proximal and distal fracture fragments.}

   

  ^{Distal fractures tend to angulate into recurvatum through the pull of the gastrocnemius muscle. Bumps placed under the knee to flex the knee can help relax the gastrocnemius muscle. One can also use blocking screws in distal fractures to surgically create a narrow “canal” in the metaphyseal region in line with the canal of the femoral shaft so that the intramedullary nail can help with reduction of the fracture.}

   

  ^{Alternatively, a femoral distractor can assist with obtaining and maintaining fracture reduction for a fracture at any level. It can be placed laterally, inserted proximally at the greater trochanter, and distally in either the posterior aspect of the femoral condyle or in the proximal tibia. Alternatively, some surgeons recommend anterior placement to avoid potential posterior angulation of distal fracture patterns.}

   

  ^{Lastly, some fractures require opening of the fracture site to obtain reduction, with the finding of the muscle interposed within the fracture. We recommend laterally based incisions unless otherwise dictated by an open fracture wound.}

   

   

  ^{Restoration of length and correct rotation can be assessed clinically as well as radiographically by closely scrutinizing the diameter of the medial and lateral femoral cortex, ensuring they are of equal diameter proximal and distal to the fracture.}

   

• ^{Passing the Guidewire}

  ^P.444

   

  ^{Once the fracture is reduced on the AP and lateral images, the surgeon passes the guidewire to end just below the level of the piriformis fossa.}

   

  ^{This is done to ensure that reaming is performed past the level of the lesser trochanter because the reamers stop at the beaded portion of the guidewire.}

• ^Reaming

   

  ^{Reaming should begin with an end-cutting reamer (typically size 8 mm or 9 mm in diameter).}

   

   

  ^{Fracture reduction must be maintained throughout the reaming process to minimize eccentric reaming. Reaming should be performed slowly and in 0.5-mm increments to prevent thermal necrosis.}

   

  ^{The approximate nail diameter is selected based on the preoperative measurement of the femoral isthmus. The final nail diameter should be selected based on the size of the reamer that provides the initial cortical chatter.}

   

   

  ^{The canal is reamed to 1.0 to 1.5 mm over the selected nail diameter. Nail length can be determined multiple ways:}

   

  ^{A radiolucent ruler can be placed on the anterior aspect of the femur. The nail should end above the level of the lesser trochanter on the AP radiograph and should be measured so that it is deep to the apex of the line of Blumensaat on the lateral view (see FIG 1C).}

   

   

   

  ^{TECH FIG 1 • Schematic diagram of a lateral view of the knee, obtaining femoral length measurement using the twoguidewire technique. The amount of guidewire B (asterisk) indicated by the bracket equals the amount of guidewire A in the femoral canal.}

   

   

  ^{Alternatively, a second guidewire of the same length can be inserted into the knee to end just deep to the apex of the line of Blumensaat on the lateral fluoroscopic image.}

   

  ^{This additional guidewire is clamped at the level of the guidewire already in place.}

   

  ^{The portion distal to the guidewire in place is measured to equal the amount of guidewire in the femoral canal (TECH FIG 1).}

   

  ^{In addition, many nailing systems have system-specific measurement guides that are outlined in their technique manuals.}

   

  ^{If the measurement is between nail sizes, the shorter nail is selected. Length can be added with an end cap if required.}

• ^{Placing the Nail}

   

  ^{Once the nail size is selected, the nail is inserted over the guidewire.}

   

  ^{Most current systems allow the beaded-tip guidewire to pass through the cannulated nail. If an older system is being used, then the beaded-tip guidewire must be exchanged for a smoothtip guidewire using an exchange tube.}

   

  ^{If guidewire exchange is required, the surgeon ensures correct placement of the smooth-tip guidewire on the AP and lateral images before nail insertion.}

   

  ^{The nail is inserted over the guidewire and should pass relatively easily.}

   

  ^{If the nail does not advance easily, the surgeon performs a careful AP and lateral fluoroscopic assessment of the fracture reduction and nail placement.}

   

  ^{Nail insertion depth is assessed on the lateral knee radiograph.}

   

  ^{The nail should end proximal to the apex of the line of Blumensaat to ensure subchondral placement (TECH FIG 2A).}

   

  ^{The surgeon confirms that fracture length and alignment have been restored on the AP and lateral radiographs.}

   

  ^{The surgeon confirms that the nail length selected puts the proximal tip of the nail ending at or above the level of the lesser trochanter (TECH FIG 2B).}

   

   

  ^{The nail is advanced if the proximal tip does not end at or above the level of the lesser trochanter. If this leaves the nail countersunk, end caps can be selected to gain nail length.}

   

  ^{Care must be taken to remain below the piriformis fossa to avoid proximal nail protrusion.}

   

  ^{The nail is locked distally using the distal interlocking guides.}

   

  ^{We typically use one lateral to medial distal interlocking screw for transverse midshaft femoral fractures, and a second anterolateral to posteromedial distal interlocking screw for comminuted or distal femoral fractures.}

   

  ^{Using live fluoroscopy, the fluoroscopic machine is rotated about the knee to assess the length of the interlocking}

   

  ^P.445

  ^{screws. Because of the trapezoidal shape of the distal femur, screws are often prominent but not well recognized on the AP radiograph.}

   

   

   

  ^{TECH FIG 2 • A. Postoperative lateral radiograph of the knee, showing correct retrograde femoral nail insertion depth deep to the line of Blumensaat (BL). B. Postoperative AP radiograph of the hip, showing correct retrograde femoral nail insertion depth above the lesser trochanter of the femur but below the radiographic landmark for the piriformis fossa (PF).}

   

   

  ^{The surgeon should consider using washers, a medial locking nut, or a locking end cap (which locks the most distal interlocking screw to the nail) as options for osteoporotic bone.}

   

  ^{Once distal interlocking screw fixation is complete, the surgeon reassesses the fracture reduction fluoroscopically.}

   

  ^{If any shortening has occurred, length can be regained by manual traction or by backslapping the nail with the insertion guide nail removal attachment (the surgeon must exercise caution when using this technique in patients with osteoporotic bone).}

• ^{Screw Fixation}

   

  ^{Proximal interlocking screw fixation is performed in the anterior to posterior plane using the freehand perfect circle technique.7}

   

  ^{First, a magnified AP image of the proximal femur is obtained.}

   

  ^{The fluoroscopy machine is rotated until the proximal interlocking hole is seen as a “perfect circle” (also discussed in Chap. 44, Antegrade Intramedullary Nailing of the Femur; Tech Fig 4, Distal interlocking screw placement).}

   

  ^{A 1-cm incision is made in the proximal aspect of the thigh, anteriorly centered over the proximal interlocking hole, as visualized on the AP radiograph.}

   

  ^{Careful blunt dissection exposes the anterior femur.}

   

  ^{The proximal femur's dense cortical bone makes it difficult to start a hole using a standard drill bit. The pointed soft tissue guides from large external fixation systems or a pointed drill bit can be used to prevent slipping off of the anterior cortex.}

   

  ^{The femoral artery lies 1 cm medial to the femur at the level of the lesser trochanter, so the surgeon must avoid slipping off the femur medially.}

   

  ^{Once the drill passes through the first cortex, it is removed from the drill bit to confirm radiographically that it will pass though the nail by the appearance of a perfect circle within the proximal interlocking hole.}

   

  ^{Small changes in the drill angle can be made to ensure correct passage through the interlocking hole.}

   

  ^{With a mallet, the drill bit can be gently tapped through the nail hole. The drill is then reattached to complete drilling through the posterior aspect of the proximal femur.}

   

  ^{Because of the proximity of the sciatic nerve, care should be taken to ensure that the drill is not advanced too far past the posterior cortex.}

   

  ^{Before removing the drill, the surgeon must reconfirm correct rotational alignment by flexing the hip and knee and assessing the hip's internal and external rotation profile.}

   

  ^{It is compared with the normal internal and external rotation of the contralateral uninjured hip that was examined preoperatively.}

   

  ^{Screw length measurement can be confirmed with a frog-leg lateral or a true lateral view with flexing of the hip to clear the contralateral leg.}

   

  ^P.446

   

  ^{A single proximal interlocking screw is all that is needed for most fractures.}

   

  ^{The usual length of the proximal interlocking screw is 25 to 35 mm.}

   

  ^{A second proximal interlocking screw may be selected for more proximal fracture patterns.}

   

  ^{A locking screwdriver should be used to avoid losing the screw in the proximal soft tissues. Alternatively, a suture can be tied around the head of the screw for retrieval if necessary.}

   

  ^{An internally rotated magnified view of the hip is obtained to critically reassess for the presence of a femoral neck fracture.}

• ^{Wound Closure}

 

^{After wound irrigation, the knee fascial layer is closed with a 0 or 1-0 absorbable suture. The subcutaneous layer is then closed with 2-0 absorbable suture. The skin can then be closed with surgical staples.}

 

^{The interlocking screw incisions can be closed with 2-0 absorbable subcutaneous sutures and skin staples.}

 

^{Soft dressings are applied.}

 

^{Once the limb is undraped but before moving the patient off the operating table, it is critical to assess the}

^{achieved length and rotation compared to the contralateral limb. If any leg length discrepancy or rotational}

^{deformity is appreciated, the limb should be reprepared, draped, and corrected by changing the proximal interlocking screw or screws.}

^{A repeat examination of knee stability is performed before leaving the operating room.}

 

 

PEARLS AND PITFALLS
	Fracture ▪ The surgeon should request full relaxation with anesthesia to facilitate length reduction restoration. The surgeon should beware of the potential for shortening of the femur with retrograde insertion. Before placing the proximal interlocking screws, the surgeon should scrutinize the intraoperative radiographs of the fracture site to ensure that correct length has been obtained. Length may be regained by using the femoral distractor, or by using the guide to backslap the nail after distal interlocking screw placement, or by manual traction.     Nail ▪ The surgeon should ensure that the initial starting guidewire is centered in line with insertion: the femoral shaft on the AP and lateral images. Due to the overhang of the posterior avoiding condyles, there is a tendency to err too far posterior; because of the normal valgus of poor the distal end of the femur, there is a tendency to aim too medial, and a varus starting deformity can be created. direction     Nail ▪ When starting to drill the initial guidewire, the surgeon should drop his or her hand insertion: slightly to prevent the wire from falling into the posterior cruciate ligament insertion; avoiding the hand is raised once the surgeon enters the cortex, so as to be in line with the slipping off femoral shaft.     Nail ▪ Before inserting the distal interlocking screws, the surgeon should confirm the insertion: subchondral position of the nail on the lateral intraoperative radiograph just deep to avoiding the apex of the line at Blumensaat (see TECH FIG 2A). distal nail prominence     Nail ▪ The proximal femoral cortex is thick and strong. It is easy to strip proximal locking insertion: screws during their insertion. If difficulties are encountered on insertion, the surgeon problems should replace it with a new screw. This can help avoid significant issues if screw or with nail removal is ever required. proximal locking screws     Use of ▪ Some systems have a locking distal end cap that can lock the most distal screw in distal end place; this is a useful feature for osteoporotic bone. cap ▪ End cap insertion can facilitate intramedullary nail removal if a reamed exchanged nailing for femoral delayed union or nonunion occurs.

 

 

	As with any nail insertion, if an end cap is used, it should be specifically mentioned in the operative note for review in the event of future screw or nail removal.     Avoiding ▪ Before removing the insertion jig, the distal femur is rotated under live fluoroscopy distal to evaluate the length of the distal interlocking screws. Screw length changes are interlocking made if necessary. screw ▪ Accurate measurement for locking screws minimizes postoperative hardware prominence irritation. Off-axis screws are used when the option is available.     Associated ▪ The surgeon should always check the preoperative images and intraoperative C-injuries arm images for ipsilateral fractures of the femoral neck. The surgeon should remember to do a knee ligamentous examination after the femoral fracture is stabilized. When using a hip screw side plate implant, the surgeon should try to overlap proximal hardware for improved mechanical properties.11     Specific ▪ Table 2 lists alternative techniques patterns. fracture

 

 

 

 

^P.447

 

 

^{Table 2 Alternative Techniques}

 

Fracture Type

Pros

Cons

Technique

 

^{Ipsilateral femoral shaft and neck fractures}

^{Optimal fixation for each fracture pattern}

^{Two separate surgical procedures and implants}

^{Stabilize hip fracture first, using cannulated screws or dynamic hip screw. Select four-hole side plate to overlap nail placement. Do not fill distal three holes until after femoral nail is placed. Select femoral nail length to end at}

^{or above lesser trochanter.21}

 

^{Subtrochanteric femoral shaft fractures}

^{Percutaneous treatment compared to plating techniques. Lower incidence of malunion than antegrade nailing}

^{technique.9,19}

^{Less stable proximal fixation}

^{Use small lateral incisions at the level of the fracture to place pointed reduction clamps without muscle stripping in fracture reduction. Place two proximal interlocking screws.}

 

^{Periprosthetic fractures below a hip stem}

^{Percutaneous treatment compared to plating techniques}

^{Stress riser created between}

^{Standard technique except for shorter nail insertion}

 

^{end of hip stem and nail}

 

^{Supracondylar femur fractures}

^{Percutaneous treatment compared to plating techniques}

^{Longer times to union Less stable implants than with current locking plate}

^{Judicious use of blocking screws to ensure center placement of guidewire, reamer, and nail. Important to maintain alignment during reaming.}

 

^{Supracondylar femur fractures with a simple sagittal fracture}

^{Percutaneous treatment compared to plating techniques}

^{Longer times to union Less stable implants than with current locking plate}

^{As above, with an open parapatellar approach to knee to ensure anatomic knee reduction. (Refer to FIG 6 for screw placement.)}

 

^{Periprosthetic fractures above a total knee}

^{Percutaneous treatment compared to plating techniques}

^{Limited points of distal fixation}

^{Preoperatively determine if femoral component has open box design. Routine nail insertion technique}

 

^{Ipsilateral femoral shaft and tibial shaft fractures (“floating knee injuries”)}

^{Single approach and incision for treatment of both injuries}

^{None Routine insertion technique}

 

^{POSTOPERATIVE CARE}

 

^{Physical therapy for active and passive knee range of motion may be started on the first postoperative day, as can ambulation, prescribed based on the fracture pattern and associated injuries.}

 

^{For most femoral shaft fractures, even those with comminution, weight bearing as tolerated can be safely initiated in the immediate postoperative period.}

 

^{Routine postoperative deep vein thrombosis prophylaxis, such as low-molecular-weight heparin, may be safely resumed on postoperative day 1 and prescribed for 6 weeks thereafter.}

 

^{Twenty-four hours of antibiotic prophylaxis is standard for closed fractures. Patients with open fractures remain on antibiotics for 48 hours after the final intraoperative débridement has been performed.}

 

 

^OUTCOMES

^{The long-term effects of retrograde nailing on knee function are not known, but recent literature reports that knee function following retrograde and antegrade nailing to stabilize femoral shaft fractures was}

^comparable.2

^{Two prospective, randomized trials comparing reamed antegrade and retrograde nailing of femoral shaft fractures showed no difference in knee pain or knee function at time of fracture union.19, 30 As expected, early postoperative knee pain was higher in the retrograde femoral nailing groups, but by the time of union,}

^{there was no significant difference between the two approaches.}

^{Fracture healing rates seem to be equivalent except in the more distal supracondylar femur fractures, which have taken longer to achieve union. The retrograde nailing technique appears to produce slightly higher malunion rates, with external rotation, shortening, and distal varus malalignment being the most}

^{common deformities.20, 23, 30}

 

 

^{COMPLICATIONS}

^{The most common complications can often be prevented with meticulous surgical techniques.}

^{Paying close attention to the proper nail insertion starting point and ensuring that the distal portion of the nail remains subchondral are two key technical points to avoiding potential knee problems.}

^{Distal interlocking screw prominence is common, and a relatively high percentage of patients elect to have these removed as a secondary procedure.19, 20, 23}

^{Malunions can be avoided when blocking screws are used judiciously for the more distal fracture patterns, and close attention is paid to ensure that the fracture reduction is first obtained and then maintained during the entire reaming process.}

^{Shortening and malrotation can be readily assessed at the end of the procedure and corrected immediately by revising placement of the proximal interlocking screw or screws.}

^{Selecting larger diameter nails based on feedback of cortical chatter during reaming seems to improve union rates when the retrograde nailing technique is used.}

 

 

^REFERENCES

1. ^{Aglietti P, Insall JN, Walker PS, et al. A new patella prosthesis: design and application. Clin Orthop Relat Res 1975;107:175-187.}

    

    

2. ^{Andrzejewski K, Panasiuk M, Grzegorzewski A. Comparison of knee function in patients with a healed fracture of the femoral shaft fixed with retrograde and antegrade intramedullary nailing. Ortop Traumatol Rehabil 2013;15(5):395-405.}

    

    

3. ^{Arneson TJ, Melton LJ III, Lewallen DG, et al. Epidemiology of diaphyseal and distal femoral fractures in Rochester, Minnesota, 1965-1984. Clin Orthop Relat Res 1988;234:188-194.}

    

    

   ^P.448

    

4. ^{Britton JM, Dunkerley DR. Closed nailing of a femoral fracture followed by sciatic nerve palsy. J Bone Joint}

   ^{Surg Br 1990;72B:318.}

    

    

5. ^{Carmack DB, Moed BR, Kingston C, et al. Identification of the optimal intercondylar starting point for retrograde femoral nailing: an anatomic study. J Trauma 2003;55:692-695.}

    

    

6. ^{Christie J, Court-Brown C, Kinninmonth AW, et al. Intramedullary locking nails in the management of femoral shaft fractures. J Bone Joint Surg Br 1988;70B:206-210.}

    

    

7. ^{Court-Brown CM. Femoral diaphyseal fractures. In: Browner B, Jupiter JB, Levine A, et al, eds. Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 3. Philadelphia: Saunders, 2003:1879-1956.}

    

    

8. ^{Court-Brown CM, Rimmer S, Prakash U, et al. The epidemiology of open long bone fractures. Injury 1998;29:529-534.}

    

    

9. ^{French BG, Tornetta P III. Use of an interlocked cephalomedullary nail for subtrochanteric fracture stabilization. Clin Orthop Relat Res 1998;348:95-100.}

    

    

10. ^{Gregory P, DiCicco J, Karpik K, et al. Ipsilateral fractures of the femur and tibia: treatment with retrograde femoral nailing and unreamed tibial nailing. J Orthop Trauma 1996;10:309-316.}

     

     

11. ^{Harris T, Ruth JT, Szivek J, et al. The effect of implant overlap on the mechanical properties of the femur. J Trauma 2003;54:930-935.}

     

     

12. ^{Herscovici D Jr, Whiteman KW. Retrograde nailing of the femur using an intercondylar approach. Clin Orthop Relat Res 1996;332:98-104.}

     

     

13. ^{Moed BR, Watson JT. Retrograde intramedullary nailing, without reaming, of fractures of the femoral shaft in multiply injured patients. J Bone Joint Surg Am 1995;77A:1520-1527.}

     

     

14. ^{Moed BR, Watson JT, Cramer KE, et al. Unreamed retrograde intramedullary nailing of fractures of the femoral shaft. J Orthop Trauma 1998;12:334-342.}

     

     

15. ^{Morgan E, Ostrum RF, DiCicco J, et al. Effects of retrograde femoral intramedullary nailing on the patellofemoral articulation. J Orthop Trauma 1999;13:13-16.}

     

     

16. ^{Muller ME, Nazarian S, Koch P, et al. The Comprehensive Classification of Fractures of Long Bones. Berlin/Heidelberg: Springer-Verlag, 1990.}

     

     

17. ^{Nork SE, Segina DN, Aflatoon K, et al. The association between supracondylar-intercondylar distal femoral fractures and coronal plane fractures. J Bone Joint Surg Am 2005;87A:564-569.}

     

     

18. ^{Ostrum RF. Retrograde femoral nailing: indications and techniques. Op Tech Orthop 2003;13:79-84.}

     

     

19. ^{Ostrum RF, Agarwal A, Lakatos R, et al. Prospective comparison of retrograde and antegrade femoral intramedullary nailing. J Orthop Trauma 2000;14:496-501.}

     

     

20. ^{Ostrum RF, DiCicco J, Lakatos R, et al. Retrograde intramedullary nailing of femoral diaphyseal fractures. J Orthop Trauma 1998;12:464-468.}

     

     

21. ^{Ostrum RF, Tornetta P III, Watson JT, et al. Ipsilateral proximal femur and shaft fractures treated with hip screws and a reamed retrograde intramedullary nail. Clin Orthop Relat Res 2013;472(9): 2751-2758.}

     

     

22. ^{O'Toole RV, Riche K, Cannada LK, et al. Analysis of postoperative knee sepsis after retrograde nail insertion of open femoral shaft fractures. Orthop Trauma 2010;24(11):677-682.}

     

     

23. ^{Ricci WM, Bellabarba C, Evanoff B, et al. Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma 2001;15: 161-169.}

     

     

24. ^{Riina J, Tornetta P III, Ritter C, et al. Neurologic and vascular structures at risk during anterior-posterior locking of retrograde femoral nails. J Orthop Trauma 1998;12:379-381.}

     

     

25. ^{Russell TA. Subtrochanteric fractures of the femur. In: Browner B, Jupiter JB, Levine A, et al, eds. Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 3. Philadelphia: Saunders, 2003:1832-1878.}

     

     

26. ^{Salminen ST, Pihlajamaki HK, Avikainen VJ, et al. Population-based epidemiologic and morphologic study of femoral shaft fractures. Clin Orthop Relat Res 2000;372:241-249.}

     

     

27. ^{Sanders R, Koval KJ, DiPasquale T, et al. Retrograde reamed femoral nailing. J Orthop Trauma 1993;7:293-302.}

     

     

28. ^{Schwartz JT Jr, Brumback RJ, Lakatos R, et al. Acute compartment syndrome of the thigh: a spectrum of injury. J Bone Joint Surg Am 1989;71A:392-400.}

     

     

29. ^{Tornetta P III, Kain MS, Creevy WR. Diagnosis of femoral neck fractures in patients with a femoral shaft fracture: improvement with a standard protocol. J Bone Joint Surg Am 2007;89A:39-43.}

     

     

30. ^{Tornetta P III, Tiburzi D. Antegrade or retrograde reamed femoral nailing: a prospective, randomised trial. J Bone Joint Surg Br 2000;82B:652-654.}

     

     

31. ^{Vangsness CT Jr, DeCampos J, Merritt PO, et al. Meniscal injury associated with femoral shaft fractures: an arthroscopic evaluation of incidence. J Bone Joint Surg Br 1993;75B:207-209.}

     

     

32. ^{Walling AK, Seradge H, Spiegel PG. Injuries to the knee ligaments with fractures of the femur. J Bone Joint Surg Am 1982;64A:1324-1327.}

     

     

33. ^{Winquist RA, Hansen ST, Clawson DK. Closed intramedullary nailing of femoral fractures: a report of 520 cases. J Bone Joint Surg Am 1984;66A:529-539.}

     

     

34. ^{Wiss DA, Brien WW, Stetson WB. Interlocked nailing for treatment of segmental fractures of the femur. J Bone Joint Surg Am 1990;72A: 724-728.}