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Retrograde Femoral Nailing

Retrograde Femoral Nailing is a fixation method for fractures of the distal femur and offers an alternative method to antegrade nailing for femoral shaft.

Advantages of retrograde nailing include:

  1. avoiding use of a fracture table and traction,
  2. easier patient positioning and nail insertion,
  3. shorter operating times with less blood loss.
  4. The entry site is easier to access because of less soft-tissue dissection, especially in large patients.
  5. Furthermore, there is no muscle dissection and less exposure to radiation, especially to pelvic organs.

Retrograde Femoral Nailing Indications

Indications for performing retrograde nailing for treating femoral shaft fractures include:

  1. Multisystem injury
  2. Femoral shaft fractures
  3. Hip soft-tissue injury
  4. Trauma involving multiple extremity fractures
  5. Morbid obesity
  6. Pregnancy
  7. Surgeon preference.
See Also: Intramedullary Femoral Nailing

Retrograde Femoral Nailing Procedures Steps

  • Place the patient on a radiolucent flattop operating room table. A small bolster can be positioned under the ipsilateral hip to prevent external rotation of the proximal femur. Surgical preparation and draping must include the hip girdle and lower flank.
  • Position the leg over a sterile bump or triangle. Tibial traction may be used and affixed to the traction bow holder.
  • Make an incision through the lateral parapatellar, medial parapatellar, or transpatellar tendon based on surgeon preference. The retropatellar fat pad must be incised, and an arthrotomy performed. Insert a 3.2-mm guidewire into the intercondylar notch. Position the pin directed centrally into the medullary canal on anteroposterior imaging. Confirm its position and trajectory on lateral imaging; the pin placement should be in line with the medullary canal at the anterior extent of Blumensaat’s line.
  • Advance the guidewire into the distal femoral metaphysis. Place the soft tissue protection sleeve over the guidewire for protection of the articular surfaces and patellar tendon.
  • Similar to the antegrade technique, a multiple-pin “honeycomb” insert can aid in perfecting the guidepin placement. If this is used, remove the honeycomb insert and place the cannulated entry reamer over the initial guidewire.
  • Advance into the femur until the reamer is within the distal femur, taking special care to maintain the soft tissue protection sleeve in place to avoid iatrogenic intraarticular injury. (Do not use the channel reamer and entry reamer connector for this procedure.)
  • Take care to ensure appropriate trajectory of the pin in the distal segment, particularly with fractures involving the distal femoral metaphysis. Otherwise, coronal and sagittal plane malalignments can result secondary to nail-canal mismatch. Blocking screws may be indicated to maintain alignment.
  • Remove the reamer and guidewire, and insert a 3-mm bead-tipped guidewire into the distal fragment.
  • Reduce the fracture and advance the guidewire into the proximal segment to the level of the lesser trochanter. A cannulated reduction tool or external devices, such as a large distractor, can be used for reduction maneuvers in combination with axial traction. Small bumps or bolsters can be placed along the posterior surface of the thigh as determined by fluoroscopy to aid in sagittal plane reduction.
  • Prepare the medullary canal by introducing cannulated reamers over the guidewire to a diameter 1.0 to 1.5 mm larger than the nail to be used.
  • Recheck the position of the guidewire to confirm its position at the lesser trochanter.
  • Apply traction to the leg to ensure proper length. Measure for the appropriate length of the nail with a ruler placed over the guidewire. Check to ensure the ruler is countersunk. This is most easily performed on the lateral image plane.
  • Remove the entry portal tool and insert the nail attached to the targeting guide, seating it to the level of the lesser trochanter.
  • Maintain traction on the leg to avoid shortening. Check the lateral image to ensure the nail is properly inset.
  • When the nail is at the proper level, remove the guidewire.
  • Proceed with distal locking of the nail using the guide. Insert the drill sleeve and trocar through the targeting guide, and dimple the skin. Make a stab wound at the site, and enlarge the hole with blunt dissection to bone. Reinsert the drill guide to bone. Advance the drill until the far cortex is encountered, and read the measurement off the drill bit calibrations for length approximation. Complete the penetration of the cortex.
  • Insert the screw by hand until fully seated.
  • Check the length and position of the screws with anteroposterior and lateral imaging.
  • Repeat this procedure until the desired number of interlocking screws have been positioned.
  • Recheck the alignment and length of the femur using a Bovie cord from the anterior superior iliac crest, middle of the femoral head, middle of the knee, and middle of the tibial plafond. Check the lateral reduction.
  • When the final reduction and length are acceptable, move to the proximal locking hole, which should be placed in the anteroposterior plane at the level of the lesser trochanter to avoid nerve and vessel injury. Identify the hole by the perfect circle technique.
  • Using the image intensifier, localize the interlocking holes proximally because this will assist in placement of the incision. Make a longitudinal skin incision, sharply dividing the subcutaneous tissue and deep fascia, and bluntly dissect to bone. Avoid damage to the branches of the femoral nerve.
  • Drill into the femur when the position is acceptable by the perfect circle technique.
  • Use the same technique to determine the screw length as described previously.
  • Place the interlocking screw using the captured screwdriver.
  • Recheck the alignment and reduction with multiple anteroposterior and lateral views.
  • Image the hip in full fluoroscopic mode with internal and external rotation and push-pull to check for an occult femoral neck fracture.
  • Close the wounds in a standard layered fashion and apply a dressing.
Retrograde Femoral Nailing procedures
Retrograde nailing of femoral fractures


  • Postoperative retrograde femoral nailing rehabilitation depends on the stability of fixation, and the fracture pattern and must be individualized for each patient. 
  • All patients are initially placed in a knee immobilizer. 
  • Patients with stable fixation can be started on a continuous passive motion program in the first 24 to 48 hours after surgery. 
  • Fractures with less secure fixation may require hinged bracing. 
  • Initial weight bearing depends on fracture stability after fixation. 
  • Patients with intercondylar fractures or supracondylar fractures require protected weight bearing until radiographic progression permits advancement of weight bearing (usually between 10 and 12 weeks).

References & More

  1. Neubauer T, Ritter E, Potschka T, Karlbauer A, Wagner M. Retrograde nailing of femoral fractures. Acta Chir Orthop Traumatol Cech. 2008 Jun;75(3):158-66. PMID: 18601812. Pubmed
  2. Campbel’s Operative Orthopaedics 12th edition Book.
  3. Sanders R, Koval KJ, DiPasquale T, Helfe DL, Frankle M. Retrograde reamed femoral nailing. J Orthop Trauma. 2014 Aug;28 Suppl 8:S15-24. doi: 10.1097/01.bot.0000452786.80923.a7. PMID: 25046411. Pubmed
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