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Retrograde intramedullary nailing of comminuted intra-articular distal femur fractures results in high union rate



Retrograde intramedullary nailing of intra-articular distal femur fractures with metaphyseal and/or epiphyseal comminution is controversial and considered a contraindication to nailing. The purpose of this study was to report union rate, complications, and secondary procedures after open reduction and retrograde intramedullary nailing of comminuted, intra-articular, distal femur fractures.

Materials and methods

A retrospective review performed at an urban level one trauma center identified 16 patients AO/Orthopedic Trauma Association (OTA) 33-C2 and 33-C3 femur fractures treated with open reduction, lag screws, and retrograde intramedullary nail fixation. Radiographic union, complications, secondary operations were reviewed.


At the 3-month follow-up 12 (86%) of the 14 patients with radiographs had healed. At last follow-up, all 16 femur fractures achieved radiographic union after the index procedure. No patient required a revision procedure for delayed union or nonunion. Complications occurred in 6 (38%) patients, including failed distal interlocking screws (n = 2), knee arthrofibrosis (n = 3), superficial wound infection (n = 1), and wound dehiscence (n = 1). Three (19%) patients required secondary procedures, which included knee manipulation under anesthesia (n = 3), distal interlocking screw removal (n = 2), and closure of a wound dehiscence (n = 1).


Comminuted intra-articular distal femur fractures that can be successfully treated with retrograde IMN fixation will reliably go on to union with a complication rate that is favorable to that reported for plate fixation.

Level of Evidence:

Level IV, retrospective case-series.

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Corresponding author

Correspondence to Joshua A. Parry.

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Conflict of interest

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no specific disclosures related to this study.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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The institutional review board approved this study. Due to the retrospective nature of this work, informed consent was waived.

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Nino, S., Parry, J.A., Avilucea, F.R. et al. Retrograde intramedullary nailing of comminuted intra-articular distal femur fractures results in high union rate. Eur J Orthop Surg Traumatol (2021).

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  • Retrograde nail fixation
  • Intraarticular distal femur fractures
  • AO/OTA 33C
  • Union
  • Nonunion
  • Comminuted
  • Extreme nailing