What is the step-by-step procedure for treating a distal femur fracture with retrograde intramedullary (IM) nailing using a Closed Reduction Internal Fixation (CRIF) technique?

From the Guidelines

Retrograde intramedullary nailing for distal femur fractures using CRIF technique is the recommended approach, as it provides stable fixation while minimizing soft tissue damage and promoting biological healing. The procedure involves a systematic surgical approach, starting with patient positioning in a supine position on a radiolucent table with the knee flexed 30-40 degrees over a bump 1.

Preoperative Preparation

• The patient is positioned in a supine position on a radiolucent table with the knee flexed 30-40 degrees over a bump.
• Standard surgical preparation and draping are performed.
• A 4-5 cm midline incision is made from the inferior pole of the patella extending distally.

Surgical Approach

• The patellar tendon is split longitudinally to access the intercondylar notch.
• An entry point is established in the intercondylar notch, approximately 1 cm anterior to the femoral attachment of the posterior cruciate ligament.
• A guide wire is inserted through this entry point and advanced proximally across the fracture site under fluoroscopic guidance.

Implant Insertion

• Sequential reaming is performed over the guide wire until the appropriate diameter is reached (typically 1-2 mm larger than the intended nail diameter) 1.
• The selected intramedullary nail is then inserted over the guide wire and advanced until properly positioned.
• Distal interlocking screws are placed through the nail into the distal fragment, followed by proximal interlocking screws to provide rotational stability.

Postoperative Care

• Final fluoroscopic images are obtained to confirm proper reduction and hardware placement.
• The wound is irrigated and closed in layers.
• Postoperatively, patients typically begin early range of motion exercises and remain toe-touch weight bearing for 6-8 weeks, progressing to full weight bearing based on radiographic evidence of healing, as recommended by recent guidelines for the acute care of severe limb trauma patients 1.

This technique is preferred for distal femur fractures as it provides stable fixation while preserving the fracture hematoma and periosteal blood supply, which promotes biological healing with minimal soft tissue disruption, ultimately reducing morbidity and mortality 1.

From the Research

Procedure Overview

The procedure for treating a distal femur fracture with retrograde intramedullary (IM) nailing using a Closed Reduction Internal Fixation (CRIF) technique involves several steps:

• Preparation of the patient and the operating room
• Reduction of the fracture
• Insertion of the retrograde IM nail
• Distal interlocking screw placement
• Proximal interlocking screw placement (if necessary)

Step-by-Step Procedure

The step-by-step procedure for retrograde IM nailing of a distal femur fracture is as follows:

• The patient is positioned on a radiolucent table to allow for fluoroscopic imaging during the procedure 2.
• A small incision is made in the knee to allow for insertion of the retrograde IM nail 3.
• The fracture is reduced using a combination of manual manipulation and fluoroscopic imaging 4.
• The retrograde IM nail is inserted through the knee incision and advanced proximally into the femur 3.
• Distal interlocking screws are placed to secure the nail in place 5.
• Proximal interlocking screws may be placed if necessary to provide additional stability to the fracture 2.

Considerations and Complications

Several considerations and potential complications must be taken into account when performing retrograde IM nailing of a distal femur fracture:

• The risk of malunion or nonunion, particularly in comminuted or intra-articular fractures 6, 5.
• The potential for complications such as infection, nerve damage, or vascular injury 3.
• The importance of proper patient positioning and imaging to ensure accurate placement of the nail and interlocking screws 2.
• The need for careful preoperative planning and consideration of associated comorbidities or injuries 2.

Outcomes and Results

Studies have shown that retrograde IM nailing can be an effective treatment for distal femur fractures, with high union rates and low complication rates 4, 5, 3. However, the procedure may be more challenging in certain cases, such as comminuted or intra-articular fractures, and may require additional techniques or implants to achieve stable fixation 6, 5.