Distal Femur Extraarticular fracture, wedge

Closed reduction internal fixation (CRIF); retrograde nailing

MIO - retrograde nailing

Indication summary: Closed fractures, Gustilo types I & II open fractures, stable polytrauma. “Floating knee” injury, bilateral lower extremity fractures. Pregnancy. Obesity. Ipsilateral femoral neck fracture. Concomitant ipsilateral acetabular / pelvic ring fractures. Fracture below hip prosthesis.

Skill: Highly experienced and skilled surgeon
Equipment: Full specialized surgical and imaging resources

The introduction of a retrograde femoral intramedullary nail may need to be considered in certain circumstances. It has to be recognized that this procedure violates the knee joint and has the potential for iatrogenic compromise of later knee function.

Indications

  • Selected closed and open fractures
  • Where a closed reduction is possible
  • “Floating knee” injury
  • Pregnancy
  • Obesity
  • Concomitant ipsilateral acetabular/pelvic ring fractures
  • Fractures below stemmed hip prostheses

Contraindications

  • Polytrauma patient in unstable condition
  • Medically unfit for surgery 
  • Accompanying severe pulmonary trauma if reaming is planned
  • Narrow intramedullary canal or existing implant which does not allow for an intramedullary implant
  • Stiff knee joint which does not allow the flexion necessary for intramedullary nail insertion
  • Patella baja
  • Image intensifier unavailable
  • Local soft-tissue compromise

Advantages

  • Less invasive procedure
  • Fracture reduction
  • High union rates
  • Definitive procedure
  • Good biomechanical properties
  • Minimizes secondary soft-tissue damage
  • Fracture stabilization allows early patient mobilization
  • Good cosmetic results

Disadvantages

  • Closed reduction is more difficult than open reduction
  • Higher rate of malreduction 
  • Technically demanding procedure
  • Risk of infection
  • Risk of iatrogenic intraarticular damage to the knee joint
  • Risk of damage to the posterior cruciate ligament
  • Difficult control of distal femoral fracture fragment
  • Risk of damage to the patellar tendon
  • Risk of chronic knee pain
  • Risk of retropatellar damage (nail too long)
  • Risk of loss of fixation in osteoporotic bone
  • Implant-related pain (e.g. around distal interlocking screws)
  • Frequent use of image intensifier – risk of increased ionizing radiation exposure

Legend

*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

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v1.0 2008-12-03