Retrograde Intramedullary Nail

Chad P Coles M.D., FRCSC
Assistant Professor
Division of Orthopaedics, Department of Surgery
Dalhousie University
Halifax, NS

First popularized in the 1990's, retrograde intramedullary nailing of supracondylar femur fractures remains a standard form of treatment for these fractures today. While not suited to every distal femur fracture, retrograde nailing offers certain advantages which maintain its position in the armamentarium of treatment options for these challenging fractures.

Retrograde intramedullary nailing offers the most truly percutaneous, minimally invasive fracture fixation, without disruption of the periosteal blood supply or fracture hematoma. Insertion is through a small, two cm arthrotomy, with an ideal starting point anterior to the posterior cruciate ligament attachment, and just medial to the intercondylar groove, having minimal impact on patellofemoral contact area1.

Unlike more rigid constructs, intramedullary devices offer relative stability, leading to secondary bone healing through callus formation. Implant design allows for multiple targeted screws in the metaphyseal region, interference fit in the diaphysis, and freehand proximal locking to maintain length and rotation. Full length nails have shown superior fracture stability over shorter, supracondylar designs2, and a single proximal locking screw should be above the level of the lesser trochanter to minimize stress riser and potential fracture3.

Retrograde intramedullary nailing is best suited to supracondylar femur fractures in the metadiaphyseal region (AO/OTA type A), those with shaft extension or simple intra-articular extension (AO/OTA type C1), and periprosthetic fractures above cruciate retaining total knee arthroplasties.

Figure 1. Independent lag screws anterior and posterior to retrograde nail.














Fractures with intra-articular extension must be reduced and clamped prior to reaming and nail insertion. Independent lag screws anterior and posterior to the nail provide additional fixation (Figure 1). It is crucial that fracture alignment be achieved prior to and maintained during reaming and nail insertion to avoid mal-alignment. The mismatch in canal dimensions relative to nail in the metaphysis can lend to instability and mal-reduction in the coronal plane. The use of Poller (blocking) screws4 can be helpful in this situation (Figure 2).

Fractures above total knee arthroplasties require special attention. The housing of cruciate sacrificing (posterior stabilized) designs does not permit passage of a retrograde nail. The notch in most cruciate retaining prostheses is of sufficient width to permit nail placement, although sometimes more limiting is the posterior position of the notch, forcing extension deformity at the fracture site5. Good mid-term results have been shown with retrograde nailing around stable knee components6. In comparison with the Less Invasive Stabilization System (LISS), retrograde intramedullary nailing may provide greater stability in these periprosthetic fractures.7

Figure 2. Poller blocking screw to reduce relative canal dimensions and prevent valgus malalignment.















Retrograde intramedullary nailing has been shown to give similar clinical results, with less blood loss and shorter operating times when compared to the dynamic condylar screw (DCS)8. Retrograde nailing has also been shown to resist varus deformation as well as an angled blade plate9. The limitation of retrograde intramedullary nailing remains the distal fixation in osteoporotic bone. Although good results have been shown in the treatment of these fractures in the geriatric population10, newer fixed-angled devices such as the LISS may provide better fixation in osteoporotic bone and short distal segments11. Similar complications and one-year clinical outcomes have been shown with both LISS and retrograde nail12. Newer nail designs with locked distal screws may improve distal fixation, but this has yet to be proven clinically3.

Retrograde intramedullary nailing continues to provide a minimally invasive, relative stability option for fixation of these challenging fractures. Appropriate case selection, attention to insertion technique, and an understanding of potential implant limitations can lead to excellent clinical results.


  1. Carmack D.B., Moed B.R., Kingston C., Zmurko M., Watson J.T. Richardson M. Identification of the optimal intercondylar starting point for retrograde femoral nailing: an anatomic study. J Trauma. 2003 Oct;55(4):692-5.
  2. Sears B.R., Ostrum R.F., Litsky A.S. A mechanical study of gap motion in cadaveric femurs using short and long supracondylar nails. J Orthop Trauma. 2004 Jul;18(6):354-60.
  3. Tejwani N.C., Park S., Iesaka K., Kummer F. The effect of locked distal screws in retrograde nailing of osteoporotic distal femur fractures: a laboratory study using cadaver femurs. J Orthop Trauma. 2005 Jul;19(6):380-3.
  4. Krettek C., Rudolf J., Schandelmaier P., Guy P., Konemann B., Tscherne H. Unreamed intramedullary nailing of femoral shaft fractures: operative technique and early clinical experience with the standard locking option. Injury. 1996 May;27(4):233-54.
  5. Currall V.A., Kulkarni M., Harries W.J. Retrograde nailing for supracondylar fracture around total knee replacement: A compatibility study using the Trigen supracondylar nail. Knee. 2007 Feb 6 (Epub ahead of print).
  6. Gliatis J., Megas P., Panagiotopoulos E., Lambiris E. Midterm results of treatment with a retrograde nail for supracondylar periprosthetic fractures of the femur following total knee arthroplasty. J Orthop Trauma. 2005 Mar;19(3):164-70.
  7. Bong M.R., Egol K.A., Koval K.J., Kummer F.J., Su E.T., Iesaka K., Bayer J., Di Cesare P.E. Comparison of the LISS and a retrograde-inserted supracondylar intramedullary nail for fixation of a periprosthetic distal femur fracture proximal to a total knee arthroplasty. J Arthroplasty. 2002 Oct;17(7):876-81.
  8. Christodoulou A., Terzidis I., Ploumis A., Metsovitis S., Koukoulidis A., Toptsis C. Supracondylar femoral fractures in elderly patients treated with the dynamic condylar screw and the retrograde intramedullary nail: a comparative study of the two methods. Arch Orthop Trauma Surg. 2005 Mar;125(2):73-9.
  9. Firoozbakhsh K., Behzadi K., DeCoster T.A., Moneim M.S., Naraghi F.F. Mechanics of retrograde nail versus plate fixation for supracondylar femur fractures. J Orthop Trauma. 1995 Apr;9(2):152-7.
  10. Armstrong R., Milliren A., Schrantz W., Zeliger K. Retrograde interlocked intramedullary nailing of supracondylar distal femur fractures in an average 76-year-old patient population. Orthopedics. 2003 Jun;26(6):627-9.
  11. Zlowodzki M., Williamson S., Cole P.A., Zardiackas L.D., Kregor P.J. Biomechanical evaluation of the less invasive stabilization system, angled blade plate, and retrograde intramedullary nail for the internal fixation of distal femur fractures. J Orthop Trauma. 2004 Sep;18(8):494-502.
  12. Markmiller M., Konrad G., Sudkamp N. Femur-LISS and distal femoral nail for fixation of distal femoral fractures: are there differences in outcome and complications? Clin Orthop Relat Res. 2004 Sep;(426):252-7.

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