24 Retrograde Femoral Nailing

10.1055/b-0040-174147

24 Retrograde Femoral Nailing

Stephen Maraccio

Summary

Femoral shaft fractures are a common traumatic orthopedic injury. Often, these are the result of high-energy trauma (motor vehicle collision), in young patients, or lower-energy trauma (fall from standing), in the elderly population. The standard of care for femoral shaft fractures is intramedullary fixation with either an anterograde or retrograde intramedullary nail. Whereas anterograde intramedullary femoral nails are more commonly performed, retrograde femoral nails are especially useful in specific situations, such as femoral shaft fractures with ipsilateral femoral neck fractures, “floating knees” (ipsilateral tibial shaft fracture—can use same incision), bilateral femoral shaft fractures (do not have to reposition patient), morbid obesity, and polytrauma situations (can create more space for teams operating in abdomen). This chapter will explore the process of the retrograde intramedullary femoral nailing.

24.1 Preop

Imaging available. Make sure images of fracture are available for intraoperative referencing.
Surgical table. Radiolucent flat-top table
Intraop imaging. C-arm is available for intraoperative imaging; best when entering field from contralateral side, perpendicular to bed (take AP and lateral of femoral neck preop).
Patient positioning. Supine, small bump placed under ipsilateral thigh
If traction pin in place, you can remove prior to prep and drape process.
Prep. Prep and drape entire leg through ipsilateral iliac crest.

24.2 Approach

24.2.1 Anterior Knee Approach

Using radiolucent triangle, place ipsilateral knee in approximately 30 degrees of flexion (also aids in preventing further flexion of distal fragment by releasing tension on gasctrocnemius complex).
Mark knee anatomy. Using sterile marking pen, mark inferior pole of the patella, borders of patella tendon, joint line, and tibial tubercle.
Expose intercondylar notch by either trans-tendinous or parapatellar approach.
- Trans-tendinous. 2-cm incision from inferior pole of patella distally, then perform tenotomy and sharply dissect through patellar tendon.
  - Suction out synovial fluid, then remove fat pad (minimizes interference with guidepin).
- Parapatellar. After making a 2-cm incision along the medial third of the patellar tendon, retract the tendon laterally to insert self-retainer.

24.2.2 Guidewire Entry

Starting point. Center of the intercondylar notch (superior to Blumensaat’s line)
Begin with entry reamer (be sure to use soft tissue protector).
Insert guidepin to the level of distal metaphysis, making sure that guidepin is in the center of the intramedullary canal (can use C-arm to identify/confirm location).
Remove the starting pin and reamer; then, place balltip guidewire into canal (can use T-handle).
- Lightly bend tip of balltip wire; then, manually push to distal aspect of fracture site (using C-arm to guide distance).