Infrapatellar approach (medial parapatellar or transpatellar tendon) for distal-third shaft and selected diaphyseal femur fractures · intermediate
- Retrograde is chosen over antegrade for distal-third shaft fractures, ipsilateral femoral neck plus shaft injuries, polytrauma needing supine access, obesity where trochanteric entry is difficult, and bilateral femoral fractures — not for a union advantage.
- The entry point is the single most critical technical decision: centre of the intercondylar notch in the coronal plane, 1 cm anterior to the PCL insertion, and anterior to Blumensaat's line on the lateral view.
- Anterior knee pain affects 20 to 40 percent of patients — the dominant complication — and a proud nail tip in the notch is a preventable cause.
- The distal fragment must seat at least two locking screws (three if short), needing roughly 4 to 5 cm of bone; less than that usually means a locking plate instead.
- Lock distal first (jig-guided), then proximal freehand with the perfect-circle technique: static locking for comminuted or unstable fractures, dynamic for simple transverse patterns.
When & Why
Indication. Retrograde femoral nailing stabilises fractures of the distal third of the femoral shaft and selected diaphyseal fractures through an infrapatellar approach. The decision to go retrograde rather than antegrade turns on the fracture location and the patient, not on union biology. Choose retrograde when the fracture sits in the distal third of the shaft; in an ipsilateral femoral neck plus shaft injury (a retrograde shaft nail leaves the neck free for separate fixation); in polytrauma where the supine position preserves access to the chest and abdomen; in obesity where trochanteric entry is difficult; and in bilateral femoral fractures, which can both be nailed without repositioning. The full "RETRO" memory aid is in the exam-focus section. Retrograde versus antegrade — the decision at a glance.
- Retrograde
- Intercondylar notch
- Antegrade
- Piriformis fossa or greater trochanter
- Retrograde
- Supine, knee flexed 30–40°
- Antegrade
- Lateral, or supine on a fracture table
- Retrograde
- Distal-third shaft fractures
- Antegrade
- Proximal and middle third fractures
- Retrograde
- Preferred — supine access to chest and abdomen
- Antegrade
- Requires lateral positioning
- Retrograde
- Easier entry
- Antegrade
- Trochanteric entry can be very difficult
- Retrograde
- Efficient — no repositioning
- Antegrade
- Requires repositioning
- Retrograde
- Anterior knee pain 20–40%
- Antegrade
- Minimal
- Retrograde
- Minimal
- Antegrade
- Abductor weakness, heterotopic bone
- Retrograde
- Needs at least 4–5 cm
- Antegrade
- Less critical
- Retrograde
- Freehand (harder)
- Antegrade
- Jig-guided (easier)
Distal-fragment requirements. Retrograde nailing needs enough distal fragment to seat at least two locking screws (three if the fragment is short) — roughly 4 to 5 cm minimum. The most distal screw should sit as close to the joint as possible, perpendicular to the nail. When the fragment is too short (less than about 4 cm), the alternatives are an antegrade nail with a long construct, a distal-femur locking plate (LISS), a blade plate or condylar screw, or a combined plate-plus-nail. An intra-articular extension is a relative contraindication — image with CT, and reduce and fix the articular block before nailing. Floating knee. An ipsilateral femoral and tibial fracture (a "floating knee") is a classic retrograde indication: nail the femur retrograde and the tibia antegradely in the same supine sitting, sometimes through a single extended infrapatellar incision (classification and outcomes are covered in Background). Consent specifically for anterior knee pain (20–40%), malunion (5–15%), nonunion (3–7%), hardware failure, deep infection (1–3%), and the small risk of cruciate-ligament injury. Setup. Supine on a radiolucent table, knee flexed 30–40° over a triangle or bolster, image intensifier on the opposite side. Confirm AP and lateral views of the whole femur (hip to knee) before prepping and draping.
The Operation
The goal is to stabilise the fracture with a load-sharing intramedullary device entered through the intercondylar notch, restoring length, alignment and rotation while protecting the popliteal artery and the cruciate ligaments. The exposure — a short infrapatellar approach that opens the knee and delivers the intercondylar notch — is laid out as the first steps below, because the entry point it provides is the single most important determinant of outcome.
Operative sequence
- Review AP and lateral radiographs (and CT where available) to assess the pattern, comminution and canal diameter; CT is especially useful for distal extension or intra-articular involvement.
- Template nail length on the contralateral femur (subtract 2–3 cm) and plan a diameter 1–1.5 mm smaller than the reamed canal.
- Radiolucent table, image intensifier on the opposite side; confirm both AP and lateral femur views (including hip and knee) are obtainable before prep and drape.
- Supine, knee flexed 30–40° over a radiolucent triangle or bolster placed at the fracture level — this opens the posterior cortex distally and assists reduction.
- 30–40° is optimal: less than 30° makes the entry difficult, and more than 45° risks posterior cortex perforation during insertion.
- Hip neutral; pad the knee to protect the common peroneal nerve.
- 3–4 cm longitudinal infrapatellar incision from the inferior pole of the patella, either medial parapatellar (retract the tendon laterally) or transpatellar (split the tendon in the midline).
- Deepen through the fat pad and excise a triangular portion to visualise the intercondylar notch entrance.
- Medial parapatellar preserves the tendon but gives a slightly off-centre entry; transpatellar gives a central entry but needs a meticulous repair. If the tendon is split, place stay sutures for a later Krackow repair.
- At risk in this layer: the infrapatellar branch of the saphenous nerve medially, and the patellar tendon itself with aggressive retraction.
- Visualise the intercondylar notch directly. On the AP view the entry is the centre of the notch (equidistant from the medial and lateral walls); on the lateral view it is 1 cm anterior to the PCL insertion and anterior to Blumensaat's line.
- Mark and create the start with an awl in the subchondral bone. Too posterior damages the PCL and drives the nail anterior (an apex-anterior deformity); too anterior causes notch impingement and patellofemoral symptoms.
- Pass a ball-tipped guidewire through the entry under live fluoroscopy; the ball-tip prevents the wire being lost in the soft tissues.
- Advance centrally down the canal on both AP and lateral views and across the fracture; if the wire runs eccentric, withdraw and redirect rather than force it.
- Reduction must be achieved before reaming — reaming an unreduced fracture causes eccentric canal preparation, cortical perforation and locked-in malreduction.
- Acceptable limits: less than 5° angulation, less than 1 cm shortening, rotation matched to the contralateral side (compare the lesser-trochanter profile on the AP view).
- Use closed manipulation, percutaneous pointed clamps, or a mini-open lateral approach at the fracture if closed methods fail.
- Over the guidewire, use a cannulated awl or entry reamer to open the distal-femur portal, starting small and enlarging gradually.
- Confirm the position is intramedullary on fluoro. Use gentle, controlled force — excessive force risks condyle fracture, fracture displacement, or guidewire advancement.
- Ream over the ball-tipped guidewire in 0.5–1 mm increments, starting 1–1.5 mm below the planned nail size and reaming to 1–1.5 mm larger than the nail.
- Feel for cortical chatter and watch for eccentric reaming. Stop if resistance is excessive — the risk is posterior cortex perforation and popliteal-artery injury.
- Mount the templated nail on the jig and insert over the guidewire with gentle rotatory movements; rotatory insertion prevents incarceration.
- Advance until the tip lies 5–10 mm above the lesser trochanter. Too short gives inadequate proximal purchase; too long causes trochanteric pain and difficult proximal locking.
- Full AP and lateral fluoro before locking: fracture reduction acceptable, nail central throughout, no cortical perforation, distal tip seated in the notch, proximal tip appropriately placed.
- Check varus and valgus on the AP (mechanical axis) and flexion and extension on the lateral; rotation is the hardest to assess — compare with the contralateral limb.
- Lock the distal end first (the opposite sequence to antegrade nailing), using the jig attached to the nail: stab incision, tissue protector, drill near-cortex then nail then far-cortex, measure, and insert a screw 5 mm longer than the measurement for bicortical purchase.
- Use a minimum of two distal screws (three if the fragment is short), with the most distal screw as close to the joint as possible. Confirm on fluoro that no screw penetrates the joint.
- The jig cannot reach the proximal femur, so use the freehand perfect-circle technique: rotate the C-arm until the screw hole is a perfect circle, make a stab incision centred on it, and drill centred on both orthogonal views.
- Static locking (screws in all holes) for comminuted or unstable fractures to prevent shortening; dynamic locking (slot hole) for simple transverse patterns to allow compression. Protect the thyroid and eyes from radiation.
- Complete AP and lateral fluoro: all screws fully seated, bicortical and correct length; reduction maintained in alignment, length and rotation; no intra-articular penetration.
- The commonest error is intra-articular screw penetration — re-check the distal screws with the knee in flexion, extension and rotation, because the condyle profile changes with position. Aim for 5 mm of screw beyond the far cortex; unicortical purchase alone is inadequate.
- If the tendon was split, repair it with a number-2 non-absorbable suture using a Krackow (locking) technique — patellar tendon rupture is a devastating complication.
- Irrigate, close the retinaculum and subcutaneous tissue with absorbable suture and the skin; apply a bulky compressive dressing. A drain is not usually required.
The two structures that make or break a retrograde nail are the PCL (injured by an entry point that is too posterior, which also produces an apex-anterior deformity) and the popliteal artery (injured by posterior cortex perforation during reaming, tethered as it is at the adductor hiatus). Confirm the entry on the lateral view — 1 cm anterior to the PCL and anterior to Blumensaat's line — and keep the knee flexed 30–40° throughout. The nail tip must sit flush or 2 mm recessed within the notch; a proud tip causes impingement and the anterior knee pain that is this operation's signature complication.
Reduction must be achieved before reaming — reaming a displaced fracture produces an eccentric canal, cortical perforation and locked-in malreduction. Rotation is the hardest error to detect: match the lesser-trochanter profile and the cortical width on the AP view to the contralateral femur.
Retrograde nails are locked in the opposite order to antegrade nails — distal first (jig-guided and accurate), then proximal freehand with the perfect-circle technique. Static locking (all holes) for comminuted or unstable patterns prevents shortening; dynamic locking for simple transverse patterns allows compression. Protect your thyroid and eyes from the extra radiation of freehand drilling.
Aftercare & Complications
Rehabilitation. Weight-bearing is dictated by the fracture pattern and fixation stability, with knee range-of-motion begun immediately to prevent stiffness. | Pattern | Weight-bearing | Expected union | |---------|----------------|----------------| | Stable simple transverse or short oblique | Touch-down, advancing to partial then full over 6–12 weeks | 8–12 weeks | | Comminuted or unstable (static locked) | Non-weight-bearing for 6–8 weeks minimum | 12–16 weeks | - Begin knee range-of-motion exercises immediately; DVT prophylaxis per protocol (LMWH or a DOAC).
- Serial radiographs at 2, 6 and 12 weeks to assess union, alignment and hardware. Full activity is allowed once clinical and radiographic union is confirmed, typically at 3–6 months. Complications.
- Recognition
- Pain with kneeling, stairs, prolonged sitting; patellofemoral tenderness, may have crepitus
- Prevention
- Precise entry point anterior to Blumensaat's line, bury the nail tip flush or 2 mm recessed, meticulous tendon repair, minimise fat-pad trauma
- Management
- Physiotherapy, activity modification and NSAIDs initially; nail removal after union improves 60–80% of cases; MRI if revision is considered
- Recognition
- Clinical deformity, abnormal gait, adjacent joint symptoms; radiographic angulation or rotation beyond acceptable limits
- Prevention
- Correct entry point (prevents apex-anterior deformity), reduce before nailing, check alignment in all planes before locking, compare rotation with the contralateral side
- Management
- Acceptable limits: less than 5° varus or valgus, less than 10° flexion or extension, less than 10° rotation; symptomatic malunion needs a corrective osteotomy after union
- Recognition
- Persistent fracture-site pain beyond 6 months, hardware loosening, motion on stress views
- Prevention
- Static locking for unstable fractures, avoid excessive distraction, optimise biology (smoking cessation), appropriate weight-bearing progression
- Management
- Exchange nailing to a larger diameter, add iliac-crest autograft or BMP, address infection if present, dynamise if hypertrophic
- Recognition
- Sudden pain after an event, loss of reduction, a broken screw or nail on radiograph
- Prevention
- Adequate nail diameter (fill about 80% of the canal), static locking for unstable patterns, appropriate weight-bearing restrictions
- Management
- Usually indicates nonunion; revision with exchange nailing to a larger diameter, bone graft, and attention to biological factors
- Recognition
- Post-operative instability, positive Lachman or posterior drawer, MRI if suspected
- Prevention
- Precise entry point (fluoro anterior to Blumensaat's line, 10 mm anterior to the PCL), direct notch visualisation, avoid eccentric entry
- Management
- PCL: most tolerated non-operatively; ACL: consider reconstruction after fracture healing if symptomatic instability persists
- Recognition
- Wound erythema, drainage, fever, CRP and ESR elevated beyond the expected timeframe, positive cultures
- Prevention
- Pre-operative IV cephazolin 2 g, minimise soft-tissue trauma, limit surgical time, meticulous haemostasis
- Management
- Early (less than 3 weeks): debridement, retain hardware, IV antibiotics for 6 weeks; late: staged removal, debridement, antibiotic spacer, definitive fixation after eradication
Viva & Exam Focus
RETRORETRO — indications for retrograde nailing
ENTRYENTRY — the entry-point landmarks
- Location
- Inserts on the posterior intercondylar roof
- At risk when
- Entry point too posterior — damages the PCL and creates an apex-anterior deformity
- Protection
- Entry 1 cm anterior to the PCL, confirmed anterior to Blumensaat's line on the lateral view
- Location
- Anterolateral intercondylar notch
- At risk when
- Eccentric entry or reaming, or a proud nail impinging in the notch
- Protection
- Central coronal entry, direct notch visualisation, bury the nail tip
- Location
- Posterior to the distal femur, tethered at the adductor hiatus
- At risk when
- Posterior cortex perforation during reaming, retractor placement, or fracture displacement
- Protection
- Keep the knee flexed 30–40°, use a ball-tipped guidewire, monitor on AP and lateral fluoro
- Location
- Wraps around the fibular neck
- At risk when
- Compression from positioning or a lateral retractor
- Protection
- Pad the knee, avoid valgus stress, careful lateral screw placement
- Location
- Crosses medially 1–2 cm below the patella, variable course
- At risk when
- Medial parapatellar approach divides branches
- Protection
- Longitudinal incision in line with the tibial tuberosity, minimise medial dissection, counsel re infrapatellar numbness
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 45-year-old polytrauma patient has bilateral femoral shaft fractures with associated chest and abdominal injuries. How would you manage the femoral fractures and what approach would you use?”
“During retrograde nailing of a distal femoral shaft fracture, you are having difficulty achieving reduction and the guidewire keeps exiting posteriorly at the fracture site. What is your approach?”
“You have completed a retrograde femoral nail and the patient develops anterior knee pain at 3 months that limits rehabilitation. The fracture is healing well. What is your assessment and management?”
Indications (RETRO)
- Rescue: ipsilateral femoral neck plus shaft fracture (leaves the neck free)
- Extremity — bilateral: supine positioning is efficient for bilateral femurs
- Third — distal third: distal-third shaft fractures (better distal purchase)
- Resuscitation: polytrauma needing supine access to chest and abdomen
- Obesity: antegrade trochanteric entry is difficult
Entry point (ENTRY)
- Exactly 1 cm anterior to the PCL insertion on the lateral view
- Notch centre in the coronal plane (equidistant from the condyle walls)
- Two cortices anterior to Blumensaat's line (roof of the notch)
- Recessed nail tip (flush or 2 mm deep, to avoid impingement)
- whY — check fluoro in both planes before proceeding
Critical numbers
- Knee flexion 30–40° over a bolster
- Minimum distal fragment 4–5 cm for two or more screws
- Nail tip 5–10 mm above the lesser trochanter
- Ream 1–1.5 mm larger than the nail diameter
- Anterior knee pain incidence 20–40%
Danger zones
- PCL: an entry too posterior damages the PCL and creates an apex-anterior deformity
- ACL: eccentric entry or a proud nail causes impingement or injury
- Popliteal artery: posterior cortex perforation during reaming
- Common peroneal nerve: lateral knee, protect with positioning
- Infrapatellar branch of the saphenous nerve: medial parapatellar approach
Static versus dynamic locking
- Static: comminuted, segmental or unstable fractures — prevents shortening
- Dynamic: simple transverse or short oblique — allows compression with loading
- Lock distal first (jig-guided), then proximal freehand
- Perfect-circle technique for freehand proximal locking
- Minimum two distal screws (three if short); one to two proximal screws
Background & Evidence
Classification. The fractures suited to retrograde nailing are distal-third femoral shaft and extra-articular distal femur fractures (AO/OTA 33A, and selected simple intra-articular 33C patterns when the condylar block can be reduced and fixed first). When the same injury includes an ipsilateral tibial fracture, it is a "floating knee". Floating-knee classification (Fraser).
- Definition
- Extra-articular — femoral and tibial shaft fractures
- Note
- Both fractures away from the knee joint
- Definition
- The knee joint is involved
- Note
- Intra-articular extension on the femoral or tibial side
- Definition
- A distant joint (hip or ankle) is involved
- Note
- Open fracture pattern is common
- Definition
- Both the knee and a distant joint are involved
- Note
- Highest-energy pattern
Floating-knee management. Nail the femur retrograde and the tibia antegradely in the same supine sitting; stabilise the more unstable fracture first, and use damage-control external fixation if the patient is physiologically unstable. Outcomes carry a high complication burden — infection around 5–10 percent and nonunion around 10 percent — with knee stiffness common, so early range of motion is essential and a vascular check is mandatory. Static versus dynamic locking.
- Static locking
- Screws in all holes (proximal and distal)
- Dynamic locking
- An oval or slot hole allows sliding
- Static locking
- Comminuted, segmental, unstable
- Dynamic locking
- Simple transverse or short oblique
- Static locking
- Maintains length, prevents rotation
- Dynamic locking
- Allows fracture compression with loading
- Static locking
- Protected until healing
- Dynamic locking
- Can advance as tolerated
- Static locking
- Same
- Dynamic locking
- May be slightly faster
- Static locking
- May remove a proximal screw at 8–12 weeks if delayed union
- Dynamic locking
- Already dynamic
- Static locking
- Prevented
- Dynamic locking
- Possible if comminution is missed
- Static locking
- Excellent
- Dynamic locking
- Excellent
Entry-point errors and their consequences.
- Consequence
- PCL injury; the nail exits anterior (an apex-anterior deformity)
- Prevention
- Keep the entry anterior to Blumensaat's line on the lateral view
- Consequence
- Difficult nail insertion, notch impingement, patellofemoral symptoms
- Prevention
- 1 cm anterior to the PCL only — no further
- Consequence
- Lateral-condyle abutment, valgus malreduction
- Prevention
- Centre in the notch on the AP view
- Consequence
- Medial-condyle abutment, varus malreduction
- Prevention
- Centre in the notch on the AP view
- Consequence
- Notch impingement, anterior knee pain, ACL irritation
- Prevention
- Bury the tip flush or 2 mm recessed
- Consequence
- Loss of fixation, condyle-fracture risk
- Prevention
- Enlarge the entry gradually, match the nail
Key evidence. Retrograde and antegrade nailing give equivalent union — the trade-off is anatomical, not biological. Ricci (2001) found no difference in union or malunion in 281 fractures, but knee pain was far more common after retrograde nailing (36 versus 9 percent) while hip pain was more common after antegrade nailing. Tornetta and Tiburzi's randomised trial (2000) confirmed equivalent operating time, blood loss and union, with more problems controlling length and rotation on a radiolucent table — malreduction, not nonunion, is the technique-specific risk. Papadokostakis's systematic review (2005) showed retrograde nailing is most reliable for distal femoral fractures (union 96.9 percent, knee pain 16.5 percent) and slightly less so for diaphyseal fractures (union 94.2 percent, knee pain 24.5 percent), with overall infection of just 1.1 percent. For extra-articular and simple intra-articular distal femur fractures, Aggarwal's meta-analysis (2022) found a retrograde nail and a lateral locking plate broadly equivalent, the nail offering fewer nonunions and infections while the plate may preserve knee motion. In periprosthetic distal femur fractures above a total knee replacement (Quinzi, 2021), a retrograde nail is valid only when the femoral component has a nail-compatible open intercondylar box and the distal fragment is long enough — confirm the implant geometry pre-operatively, as malunion risk is higher than with plating.
References
References 1. Ricci WM, Bellabarba C, Evanoff B, et al. Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma. 2001;15(3):161-169. 2. Tornetta P 3rd, Tiburzi D. Antegrade or retrograde reamed femoral nailing: a prospective, randomised trial. J Bone Joint Surg Br. 2000;82(5):652-654. 3. Herrera-Soto JA, Price CT. Retrograde intramedullary nailing of the femur. J Am Acad Orthop Surg. 2009;17(11):687-696. 4. Papadokostakis G, Papakostidis C, Dimitriou R, Giannoudis PV. The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature. Injury. 2005;36(7):813-822. 5. Ostrum RF, Agarwal A, Lakatos R, Poka A. Prospective comparison of retrograde and antegrade femoral intramedullary nailing. J Orthop Trauma. 2000;14(7):496-501. 6. Moed BR, Watson JT. Retrograde nailing of the femoral shaft. J Am Acad Orthop Surg. 1999;7(4):209-216. 7. Bong MR, Kummer FJ, Koval KJ, Egol KA. Intramedullary nailing of the lower extremity: biomechanics and biology. J Am Acad Orthop Surg. 2007;15(2):97-106. 8. Canadian Orthopaedic Trauma Society. Reamed versus unreamed intramedullary nailing of the femur: comparison of the rate of ARDS in multiple injured patients. J Orthop Trauma. 2006;20(6):384-387. 9. Lepore S, Capuano N, Romano G. Retrograde nailing of femoral shaft fractures in patients with hip arthroplasty. Arch Orthop Trauma Surg. 1999;119(5-6):286-289. 10. Handolin L, Pajarinen J, Lindahl J, Hirvensalo E. Retrograde intramedullary nailing in distal femoral fractures — results in a series of 46 consecutive operations. Injury. 2004;35(5):517-522. 11. Aggarwal S, Rajnish RK, Kumar P, et al. Comparison of outcomes of retrograde intramedullary nailing versus locking plate fixation in distal femur fractures: a systematic review and meta-analysis of 936 patients in 16 studies. J Orthop. 2022;36:36-48. PMID: 36591439. 12. Quinzi DA, Ramirez G, Kaplan NB, et al. Early complications and reoperation rates are similar amongst open reduction internal fixation, intramedullary nail, and distal femoral replacement for periprosthetic distal femur fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg. 2021;141(6):997-1006. PMID: 33743062.
Retrograde versus antegrade nailing of femoral shaft fractures
- 281 femoral shaft fractures (134 retrograde, 147 antegrade) at a Level I trauma centre; groups matched for age, comminution and locking mode
- No significant difference in union or malunion: healing after index procedure 88 percent retrograde vs 89 percent antegrade, ultimate union 96 vs 99 percent
- Knee pain significantly more common after retrograde nailing (36 percent vs 9 percent, p less than 0.001) when ipsilateral knee injuries excluded
- Hip pain significantly more common after antegrade nailing (10 percent vs 4 percent, p less than 0.05)
Antegrade or retrograde reamed femoral nailing: a prospective, randomised trial
- 68 patients with 69 femoral shaft fractures randomised to antegrade (fracture table) or retrograde (radiolucent table) reamed nailing
- No difference in operating time, blood loss, nail or reamer size, or transfusion requirement
- All fractures in both groups united with no difference in time to union
- More problems with length and rotation occurred with the retrograde technique on a radiolucent table than with antegrade nailing on a fracture table
The role and efficacy of retrograde nailing for diaphyseal and distal femoral fractures: a systematic review
- Systematic review of 24 studies, 914 patients, 963 distal and diaphyseal femoral fractures (mean age 48.8 years)
- Distal femoral fractures: union rate 96.9 percent, knee pain 16.5 percent, malunion 5.2 percent
- Diaphyseal fractures: union rate 94.2 percent, knee pain 24.5 percent, malunion 7.4 percent
- Overall infection 1.1 percent, septic arthritis of the knee 0.18 percent
Retrograde intramedullary nailing versus locking plate fixation in distal femur fractures: systematic review and meta-analysis
- 936 patients across 16 studies (6 randomised controlled trials), 467 retrograde nail vs 477 locking plate, AO/OTA 33A/B/C
- No significant difference in union time, overall complications, implant-related complications, reoperation rate or operative duration
- Retrograde nail group had significantly fewer nonunions and fewer infections than locking plate
- Locking plate group achieved better post-operative knee range of motion
Early complications and reoperation rates are similar amongst ORIF, intramedullary nail and distal femoral replacement for periprosthetic distal femur fractures
- Systematic review and meta-analysis of 52 studies: ORIF (1205 cases), retrograde nail (272), distal femoral replacement (353)
- No significant difference in major complication or reoperation rates between the three strategies
- Malunion rates were higher with intramedullary nail than ORIF (p = 0.02)
- Requires a knee-replacement femoral component with an open box and adequate distal fragment for the nail to pass