Retrograde nailing of fractures of the femoral shaft

Abstract

The technique of antegrade nailing of femoral shaft fractures has changed only incrementally over the last 60 years. Kuntscher's original method using a straight nail through an entry portal in the greater trochanter or piriform fossa evolved slowly. Introduction of a closed technique for insertion necessitated fluoroscopy, guide pins, and a change in the cross-sectional geometry of the nail. More recent technical changes have focused on nails with various interlocking screw designs. Retrograde nailing of femoral fractures through a site in the distal femur has a shorter and more active history. In 1970, Kuntscher described a retrograde nailing technique through the medial femoral condyle for fixation of pertrochanteric fractures. 1 Subsequently, a variety of retrograde nails popularized by Enders, Harris, Zickel, and others were advocated for elastic fixation of metaphyseal fractures of the proximal and distal femur. 24 Fracture stability was afforded by the use of multiple contoured nails inserted either medially or laterally to the condylar joint surface. In 1984, Swiontkowski proposed the use of a single standard Kuntscher nail through an extraarticular portal for fixation of the shaft component of ipsilateral femoral neck/shaft fractures. 5 Several intraoperative manoeuvres were developed for nail insertion out of line with the longitudinal axis of the medullary canal. Sanders attempted to avoid some of the technical problems of the Swiontkowski method by using tibial nails but malreductions remained problematic. 6