Journal of Orthopaedic Surgery 2012;20(1):48-54

Antegrade interlocking nailing for distal

femoral fractures
Sunil Govind Kulkarni, Ankit Varshneya, Govind Shivram Kulkarni, Milind Govind Kulkarni, Vidisha Sunil Kulkarni,
Ruta Milind Kulkarni
Department of Orthopaedic Surgery, Post Graduate Institute of Swasthiyog Pratishthan, Miraj, Maharashtra, India

assessed using the modified knee-rating scale of the

Hospital for Special Surgery.
ABSTRACT Results. The mean time to bone union was 13.1
(range, 10–18) weeks. The mean follow-up period
Purpose. To assess outcomes of antegrade interlocking was 18.8 (range, 11–30) months. Three patients
nailing for supracondylar or intercondylar fractures were lost to follow-up; outcomes in the remaining
of the distal femur. patients were excellent in 20 and good in 7. The mean
Methods. Records of 10 women and 20 men aged 20 range of knee flexion was 106º (range, 90º–120º).
to 70 (mean, 48.7) years who underwent antegrade One patient developed a flexion deformity of 10º.
interlocking nailing for distal femoral fractures were All patients attained full quadriceps strength. No
reviewed. 23 patients had closed fractures and 7 patient had ligamentous instability, nerve injuries,
had open fractures; 6 had associated fractures of the superficial or deep infections, or implant failure.
forearm or tibia. According to the AO/ASIF system, Three patients had malunion, which was located in
fractures were classified as types A1 (n=13), A2 (n=6), the meta-diaphyseal segment and not in the intra-
A3 (n=3), and C1 (n=8). The affected leg was put in articular segment. Hence, there was no functional
an extension shoe for traction, and reduction was problem or shortening. The mechanical axis was not
achieved with the help of percutaneous lag screws. deviated.
The nail was inserted from the tip of the greater Conclusion. Antegrade interlocking nailing achieved
trochanter and centred in both anteroposterior and good-to-excellent outcomes for distal femoral
lateral planes. The nail was modified to have 3 screw fractures
slots in the mediolateral plane and one screw slot in the
anteroposterior plane distally for stability in multiple Key words: femoral fractures; fracture fixation,
directions. Postoperatively early mobilisation and intramedullary; treatment outcome
partial weight bearing were allowed. Patients were

Address correspondence and reprint requests to: Dr Sunil Govind Kulkarni, Department of Orthopaedic Surgery, Post Graduate
Institute of Swasthiyog Pratishthan Miraj, Maharashtra, India. E-mail: [email protected]
Vol. 20 No. 1, April 2012 Antegrade interlocking nailing for distal femoral fractures 49

INTRODUCTION (mean, 48.7) years who underwent antegrade

interlocking nailing between 2008 and 2011 for distal
Supracondylar femoral fractures occur in the distal 9 femoral fractures within 9 cm from the joint line
cm of the femur1 between the diaphyseal-metaphyseal were reviewed. The causes of injury included motor
junction and the femoral condyles. Extension of the vehicle accidents (n=27) and falls (n=3). 23 patients
fracture into the diaphyseal region is not uncommon had closed fractures and 7 had open fractures (6
in the high-energy injuries. Closed intramedullary grade I and one grade II according to the Gustilo
nailing is the treatment of choice for femoral shaft Anderson classification). Six patients had associated
fractures.2–4 For displaced supracondylar and fractures of the forearm or tibia, which were fixed
intercondylar fractures of the distal femur, open with intramedullary nails or plates as required.
reduction and internal fixation is advocated, as it can According to the AO/ASIF system,19 fractures were
maintain alignment under the unbalanced pull of classified as types A1 (n=13), A2 (n=6), A3 (n=3), and
thigh and calf muscles.5–8 Nonetheless, bony purchase C1 (n=8) [Fig. 1].
of the distal fragment may not be adequate because Patients with open grade-I fractures underwent
of the lack of good cortical bone, and thus a non- nailing with antibiotic impregnated cement beads as
surgical approach is recommended.9 The treatment soon as their condition was stabilised. In one patient
goals are correction of axial alignment, leg length, with a grade-II fracture, fixation was delayed for
and rotation, restoration of range of motion, early 7 days after thorough debridement. Prophylactic
bone union, and return to normal function.10 Early antibiotics were given half an hour prior to surgery.
use of a hinged brace may be appropriate for non- No tourniquet was used. Under general or spinal
displaced supracondylar femoral fractures; range- anaesthesia, patients were placed in a supine position
of-motion exercises and ambulation can be initiated on a fracture table; the unaffected leg was flexed
when pain and swelling subside. Early conversion to 90º at the hip and placed abducted in a leg holder.
cast bracing after a period of traction achieves better The affected leg was put in an extension shoe for
outcomes than prolonged casting.11,12 traction; a steinnman pin or femoral distracter was
Fixation with a lateral condylar blade plate,
dynamic condylar screws, or locking compression
plates for intra-articular fractures enables early
A1 A2 A3 C1
mobilisation of the knee joint.13–15 However, all these
techniques involve opening the fracture site and
draining of the haematoma. This results in excessive soft-
tissue disruption, blood loss, and operating time, and
may also require periosteal stripping. Delayed union/
non-union, bone grafting, and infection may ensue.13–18
Closed intramedullary nailing minimises the
extent of soft-tissue dissection and devitalisation,
and the fracture haematoma is not disturbed. Early
fracture healing is predictable because of abundant Figure 1 Fracture classification according to the AO system.
callus formation, and complications are few.
Retrograde nailing for distal femoral fractures
is associated with stiffness and infection of the
knee. Antegrade interlocking nailing avoids these
complications. As the canal at the metaphyseal
diaphyseal junction widens suddenly, the nail is
modified in the form of multiple, multi-directional
locking bolts at the distal end. This provides
extra stability and enables early mobilisation. We
assessed the outcomes of 30 patients who underwent
antegrade interlocking nailing for supracondylar or
intercondylar fractures of the distal femur.

MATERIALS AND METHODS

Figure 2 Entry point of the nail on the tip of the greater
Records of 10 women and 20 men aged 20 to 70 trochanter.
50 SG Kulkarni et al. Journal of Orthopaedic Surgery

used if necessary. Reduction was confirmed using confirmed under a C-arm after palpating the tip of
a C-arm. In patients with an intercondylar fracture, the greater trochanter (Fig. 2). The medullary canal
the intra-articular component was first reduced was prepared, and the reamer guide and nail guide
by traction and then the fracture fragments were were passed across the fracture site and centred in
held by percutaneous application of reduction both anteroposterior and lateral planes. The canal
forceps. Two 6.5 mm cancellous screws were then was over-reamed 0.5 to 1 mm more than the diameter
inserted percutaneously. The screws were positioned of the selected nail.
anteriorly or posteriorly away from the anticipated The nail was mounted on a targeting device that
path of the interlocking nail. had to be rotated approximately 90º during insertion,
The skin 70 mm proximal to the tip of the greater owing to the anatomic shape. This could avoid stress
trochanter was incised. A guide pin was inserted and peaks in the bone. The nail and targeting device were

(a)

(b)

(c)

Figure 3 Closed antegrade interlocking nailing for (a) ipsilateral segmental and supracondylar femoral fractures in a 40-year-
old woman, (b) a spiral oblique fracture extending into the supracondylar area in a 67-year-old man with osteoporosis, and (c)
a supracondylar femoral fracture in a 30-year-old man. All patients achieve good bone union.
Vol. 20 No. 1, April 2012 Antegrade interlocking nailing for distal femoral fractures 51

inserted over the guide wire into the medullary canal Table 1
by hand using light pressure with the targeting device The modified knee-rating scale* of the Hospital for Special
Surgery20
oriented anteriorly. As the patient was in a supine
position, the targeting device was pointed upwards. Item Scores
After passage through the proximal metaphysis, the Pain (30 points)
targeting device was rotated slowly by pushing the During walking
nail further down into the medullary canal. At the None 15
end of the insertion, the targeting device was rotated Mild 10
Moderate 5
approximately 90º and to lie in a lateral direction. Severe 0
The guide wire was removed, and the nail position At rest
confirmed by fluoroscopy in anteroposterior and None 15
Mild 10
lateral planes (Fig. 3). Moderate 5
As the canal in the distal femur was widened, Severe 0
extra screws were inserted to attain stability in Function (22 points)
multiple directions. The nail was modified to have 3 Walking and standing
Unlimited 12
screw slots in the mediolateral plane and one screw 5–10 blocks, standing >30 mins 10
slot in the anteroposterior plane distally. Using a free- 1–5 blocks, standing 15–30 mins 8
hand technique and under a C-arm, stab incisions <1 block 4
Cannot walk 0
were made on the lateral side, and 3 locking bolts were Stairs
inserted after drilling. The knee was flexed to relax the Normal 5
quadriceps while locking the anteroposterior screw. With support 2
Muscle entanglement between the screw head and Transfer
Normal 5
the bone was avoided while the bolt was tightened With support 2
to prevent possible flexion problems. Two proximal Range of motion (15 points)
locking screws (either both static or one static and one 80º 10
dynamic) were then inserted. 90º 11
100º 12
Postoperatively, the leg was kept in 90º flexion. 110º 14
Suction drains were removed on day 2. Active and 120º 15
passive range-of-motion exercises were then started. Muscle strength (15 points)
Grade 5 15
Immediate weight bearing was allowed for fractures Grade 4 12
proximal to the joint. For fractures communicating Grade 3 9
with the joint or metaphysis, full weight bearing Grade 2 6
was allowed after bridging callus was seen on Grade 1 3
Grade 0 0
radiographs. The antibiotic beads were removed Flexion deformity (10 points)
under local anaesthesia after 4 to 6 weeks. Patients None 10
were assessed using the modified knee-rating 0º–10º 8
10º–20º 5
scale of the Hospital for Special Surgery (Table 1),20 >20º 0
which places more emphasis on motor strength than Instability (5 points)
ligamentous instability, because instability of the None 5
knee is not common after distal femoral fractures. 0º–5º 4
6º–15º 2
>15º 0
Total (97 points) -
RESULTS Subtractions
Walking aid
One cane 1
The mean operating time was 2.5 (range, 2–4) One crutch 2
hours, which included the time for other procedures Two crutches 3
performed under anaesthesia. All fractures were Extension lag
5º 2
reduced by the closed technique, and no bone grafting 10º 3
was required. The mean non–weight-bearing period 15º 5
was 7 (range, 4–10) weeks. The mean time to bone Deformity (5º=1 point)
union (formation of circumferential bridging callus Varus -
Valgus -
across the fracture) was 13.1 (range, 10–18) weeks.
The mean follow-up period was 18.8 (range, 11-30) * Scores ≥85 are excellent, 70–84 good, 60–69 fair, and <60
months. poor
52 SG Kulkarni et al. Journal of Orthopaedic Surgery

Three patients were lost to follow-up; outcomes DISCUSSION

for the remaining patients were excellent in 20 and
good in 7 (Table 2). The mean range of knee flexion The standard treatment for distal femoral fractures
was 106º (range, 90º–120º); 5 patients had 90º, 10 had with or without intra-articular involvement is open
100º, 5 had 110º, and 7 had ≥120º of knee flexion. reduction and internal fixation with plates and
One patient developed a flexion deformity of 10º; all screws.21–26 This necessitates extensive exposure and
others achieved full extension. All patients attained may lead to non-union or infection.21,24–27 Fixation
full quadriceps strength. No patient had ligamentous using plates and screws has the inherent drawback
instability, nerve injuries, superficial or deep of producing a load-shielding device. The resultant
infections, or implant failure. Only one patient had osteopenia creates a substantial risk of re-fracture
the implant removed. proximal to the plate, particularly in elderly patients
Three patients had malunion, which was located who have osteoporotic bones.
in the meta-diaphyseal segment and not in the intra- Closed intramedullary antegrade nailing with
articular segment. Hence, there was no functional or without supplemental internal fixation is the
problem or shortening. The mechanical axis was treatment of choice for femoral shaft fractures,
not deviated. All fractures healed with minimum regardless of the extent of comminution.23,27,28
deformity and no patient had incongruity of the Modification of the interlocking nails distally (3
weight-bearing articular surface. locking slots for lateromedial locking and one for

Table 2
Fracture types and outcomes of the patients

Patient Sex/age Fracture type AO type Other injury Knee range of Outcome*
no. (years) motion
1 F/40 Closed A1 Ipsilateral segmental femoral fracture 120º Excellent
2 F/50 Closed C1 - 120º Excellent
3 M/30 Closed A1 - 120º Excellent
4 F/50 Closed A1 - 130º Excellent
5 F/50 Closed A1 - 110º Excellent
6 M/63 Open grade I A2 - 100º Excellent
7 M/35 Open grade I A3 Ipsilateral patellar & open grade I tibial 90º Good
fractures
8 M/70 Closed A2 Osteoarthritis of knee 100º Excellent
9 M/60 Closed C1 - 90º Good
10 M/63 Closed C1 - 100º Excellent
11 M/35 Closed A2 Ipsilateral hip dislocation & compound 100º Good
tibial fracture
12 M/45 Closed A1 - 110º Excellent
13 M/40 Closed C1 Open grade I proximal tibia fracture 90º Good
14 M/30 Open grade I A2 - 100º Excellent
15 M/30 Closed A3 Contralateral femoral shaft and ipsilateral 100º Good
tibial fractures
16 M/40 Open grade II A1 - 110º Excellent
17 M/20 Closed A1 Ipsilateral both bone forearm fractures 100º Excellent
18 M/45 Closed A1 - 120º Excellent
19 M/50 Closed A1 - 110º Excellent
20 M/49 Closed A2 - 90º Good
21 M/40 Open grade I A1 - 100º Excellent
22 F/55 Closed A2 - 90º Good
23 M/55 Closed A1 - 100º Excellent
24 F/60 Open grade I C1 - 100º Excellent
25 M/55 Closed A1 - 120º Excellent
26 M/67 Closed A1 - 130º Excellent
27 F/60 Open grade I C1 - 100º Excellent
28 F/70 Closed A3 - - Lost to follow-up
29 F/60 Closed C1 - - Lost to follow-up
30 F/45 Closed C1 - - Lost to follow-up

* Based on knee rating scale of the Hospital for Special Surgery

Vol. 20 No. 1, April 2012 Antegrade interlocking nailing for distal femoral fractures 53

anteroposterior locking) enables treatment for nailing promoted secondary bone healing, and the
supracondylar and some intercondylar femoral morselised bone from reaming extravasated into
fractures (types A and C1). The distance between 2 the fracture site and served as bone grafts. Angular
screws is 20 mm. The hole size is 5 mm to pass the malunion in either the coronal or sagital plane may
4.5 to 5 mm bolts, depending on the nail diameter. develop when displacement occurs during bone
As the proximal part is lateralised, the entry point of healing. Varus/valgus bending force is significantly
the nail can be from the tip of the greater trochanter reduced with intramedullary nailing than with
in a supine position, which requires less tissue lateral plating. Intramedullary positioning of the nail
dissection and fluoroscopic imaging. Entering from also provided 3-point fixation to prevent flexion/
the piriform fossa in a supine position requires more extension displacement of the distal fragment. Early
exposure and fluoroscopic imaging. If the patient is bone union and stable fixation effectively reduced the
placed in a lateral position, there is a chance of valgus risks of angular malunion.
angulation.29 Distally the nail should be centred in Three patients developed malunion, but had no
both anteroposterior and lateral planes, with the help functional problems. The intra-articular segment
of blocking pins and fixation of the distal fragments was reduced anatomically by lag screws, whereas
with multiple, multilevel, multiplanar screws to the multi-fragmented fractures were reduced non-
provide extra stability. anatomically by the closed method. The big butterfly
Outcomes in our series were comparable to fragment was fixed by a lag screw. All these fixations
those of others using other modalities.13,15,30 Closed minimised soft-tissue interposition and the risk of
reduction facilitated passage of the guide wire and malunion or even nonunion. Antegrade interlocking
resulted in no injury to other soft tissues, especially nailing minimises soft-tissue disruption and provides
the periosteum and fracture haematoma persisted. good purchase of the distal fragment through extra
The load-sharing mechanism of intramedullary locking screws.

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