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Vol 7, No 4, July/August 1999 209 Antegrade interlocked intramedullary (IM) nailing with reaming has been shown to be an effective method for the management of fractures of the femoral shaft. 1-4 Considered the treatment of choice for most of these fractures, its advantages include a rate of fracture union approximating 98%, infrequent malunion, and a low prevalence of infection. 1-6 How- ever, this technique is not without its disadvantages. These include limited applicability in the treatment of common ipsilateral fracture combinations, such as femoral shaft fracture occurring in association with ipsilateral femoral neck, acetabular, pelvic, and/or tibial shaft fractures, as well as the risk of postoperative heterotopic ossification about the hip. 7-10 If a fracture table is used for fracture reduction, additional potential problems include the risk of pudendal nerve palsy, increased operating room setup time, and logistic problems in managing patients with multiple injuries who may require simultaneous or sequential operative procedures. 8,11,12 Postoperative hip dysfunction is another important concern. The procedure was initially thought not to adversely affect function. How- ever, in one series, 13 antegrade nailing was shown to be associated with trochanteric pain (40% of patients), thigh pain (10%), stiffness (38%), limp (13%), reduced walking distance (12.5%), and difficulty with stairs related to hip abductor muscle weakness (10%). In another series, 14 limited walking, standing, or stair-climbing ability was noted in 39% of patients, with 37% having some pain or discomfort. The concept of retrograde femoral shaft fracture fixation was developed in an attempt to over- come these limitations of antegrade nailing. 8,10 This article will review the clinical and experimental literature regarding retrograde nailing and summarize the current indications and contraindications for its use (Table 1). Dr. Moed is Professor, Department of Orthopaedic Surgery, Wayne State University, Detroit, Michigan; and Chief, Department of Orthopaedic Surgery, Detroit Receiving Hospital. Dr. Watson is Professor, Department of Orthopaedic Surgery, Wayne State University; and Vice-Chief, Department of Orthopaedic Surgery, Detroit Receiving Hospital. Reprint requests: Dr. Moed, Department of Orthopaedic Surgery, University Health Center, Suite 7C, 4201 St. Antoine Boulevard, Detroit, MI 48201. Copyright 1999 by the American Academy of Orthopaedic Surgeons. Abstract Retrograde intramedullary nailing of fractures of the femoral shaft with use of a distal intercondylar intra-articular entry portal is a relatively new surgical technique. This method of nailing represents a modification of the previously described procedure in which an extra-articular entry portal in the medial femoral condyle was used. The earlier procedure was plagued by technical difficulties, which limited its use; these problems were mainly related to the fact that the entry portal was not in line with the intramedullary canal, as well as to the fact that purpose-specific implants and instrumentation were not available. Modification of this technique, by using the intercondylar entry portal and a nail designed for retrograde insertion, has proved very effective in clinical studies. There have been theoretical concerns regarding postoperative knee function and intraoperative injury to important anatomic structures, such as branches of the femoral nerve; however, laboratory and clinical findings have dispelled many of these concerns and have provided firm support for continued use of the technique. Nonetheless, further study is required to delineate the long-term outcome of knee joint function. Current indications for use of this technique include multisystem injuries, multiple fractures (including ipsilateral lower- limb combination injuries), ipsilateral vascular injuries, periprosthetic fractures, and morbid obesity. J Am Acad Orthop Surg 1999;7:209-216 Retrograde Nailing of the Femoral Shaft Berton R. Moed, MD, and J. Tracy Watson, MD Perspectives on Modern Orthopaedics Historical Perspective Retrograde IM femoral fracture fixation has long been recognized as a technique with many potential advantages, including ease of implant insertion and applicability to patients with multisystem injuries, those with ipsilateral femoral neck and shaft fractures, and those with multiple fractures. However, complications, such as angular malalignment and knee joint stiffness, have limited its general use. The flexible IM pin developed by Rush during the 1930s and 1940s was intended for retrograde insertion via an extra-articular condylar entry portal for the stabilization of distal-third femoral shaft and condylar fractures. 15 A similar flexible IM system described in 1970 by Ender and Simon-Weidner expanded the indications for retrograde insertion to include fractures along the entire femoral diaphysis. 16 Ret- rograde Ender-pin IM stabilization of the femoral diaphyseal compo- nent of concomitant ipsilateral hip and shaft fractures was reported in 1979 by Casey and Chapman. 17 However, the advantages of short operating times and minimal blood loss with flexible IM fixation were overshadowed by problems, such as inability to maintain length and alignment in axially unstable fractures and residual knee stiffness and pain. In 1984, Swiontkowski et al 10 reported the results in a series of seven patients with ipsilateral fractures of the femoral neck and shaft treated by using reamed retrograde IM nailing. The technique utilized a fracture table with an extra-articular entry portal via the medial femoral condyle at the junction between the distal femoral articular cartilage and the metaphyseal supracondylar flare. A standard KŸntscher nail with reaming was used. The results were encouraging but not impressive. Complications included varus malalignment in two patients and transient hypoxemia, knee contracture, and infection in one patient each. On the basis of these results, Sanders et al 8 revised the technique to minimize complications by using a radiolucent operating room table, except in the case of ipsilateral femoral neck and shaft fractures; by moving the entry portal medial- ly; and by utilizing an implant with interlocking capability. Initial difficulties with femoral nail insertion necessitated a change (after 11 cases) to a different implant, the AO/ASIF Universal Tibial Nail (Synthes, Paoli, Pa). The proximal interlocking holes of the tibial nail are ori- ented in an anteroposterior direc- tion, facilitating free-hand proximal locking. Expanded indications in that study included pregnancy, ipsilateral pelvic and/or acetabular fractures, multisystem injury, and multiple fractures. In that prospective series of 29 femoral shaft fractures, one procedure was aborted intraoperatively due to technical difficulties, and six closed fractures required use of an open technique to obtain an adequate reduction. Major loss of knee range of motion was noted in 3 of the 23 limbs that were evaluated, with knee flexion limited to less than 100 degrees. In all 3, the limitation was attributed to associated injuries. Of the 25 fractures with adequate follow-up, 23 (92%) healed. How- ever, there were 4 (16%) malunions. In a subsequent study, Patterson et al 18 reported the results in a retrospective series of 17 patients treated with a retrograde reamed interlocked nail inserted via either an extra-articular or an intercondylar entry portal. There were five nonunions, and postoperative com- Retrograde Nailing of the Femoral Shaft Journal of the American Academy of Orthopaedic Surgeons 210 Table 1 Current Indications and Contraindications for Retrograde Nailing of Fractures of the Femoral Shaft Indications Multisystem injury Trauma involving multiple extremity fractures including but not limited to: Ipsilateral hip and femoral shaft fractures Ipsilateral pelvic and femoral shaft fractures Ipsilateral femoral supracondylar and shaft fractures Ipsilateral tibial and femoral shaft fractures Bilateral femoral shaft fractures Ipsilateral vascular injury Isolated fracture above preexisting total knee arthroplasty Isolated fracture in the morbidly obese patient Relative indication Pregnancy (especially during the first trimester) Contraindications Skeletal immaturity History of knee joint sepsis Relative contraindications Preexisting limitation of knee flexion to less than 45 degrees Fractures located within 5 cm of the lesser trochanter Type IIIB open fractures Severe soft-tissue injury about the knee plications were common, including three cases of implant failure, one deep infection, and one instance of significant shortening. The authors attributed the poor results to the severity of the initial injury rather than the technique of nailing. They concluded that the retrograde technique should be reserved for patients with very severe injuries. Although the authors commented on the technical difficulty of plac- ing interlocking screws through the femoral nails, they also noted the advantage of the intercondylar entry portal (Fig. 1). They concluded that the intercondylar starting point had a minimal adverse effect on knee function and was optimally used in a patient with a traumatic knee dislocation and an ipsilateral femoral shaft fracture. In summary, the early results following retrograde femoral nailing were disappointing. High rates of malunion (primarily related to use of an entry portal in the medial femoral condyle), nonunion, implant-related technical difficulties, and knee joint problems precluded a recommendation for routine use. Current Clinical Experience A resurgence of interest in retrograde nailing of femoral shaft fractures was stimulated by the 1995 report by Moed and Watson. 19 Using a revised method incorporat- ing changes suggested by previous studies, they treated 20 consecutive multiply injured patients with 22 femoral shaft fractures. Nailing was performed on a radiolucent operating room table with the leg draped free. Their technique incorporated a customized interlocking titanium alloy nail modified to allow free- hand, anterior-to-posterior proximal locking-screw insertion; creation of an entry portal through the intercondylar notch of the knee; and an aggressive postoperative knee reha- bilitation program geared toward regaining knee function. At the time of that study, many reports ques- tioned the advisability of reaming the femoral canal in patients with multiple injuries; therefore, nailing was performed without reaming. 20-23 The results were very different from those in previous studies. There were no infections, no nail or screw failures, and only one (rota- tional) malunion. Normal knee motion was regained in all patients except one with an ipsilateral knee dislocation. The operative time for nailing averaged only 75 minutes and was associated with minimal blood loss. Fracture union occurred at an average of 15 weeks. How- ever, there were three nonunions. Pa- tient follow-up averaged 13 months (range, 6 to 24 months). The authors concluded that retrograde nailing is a safe and effective technique for femoral stabilization of the multiply injured patient. In a follow-up study in which the indications were expanded to include any femoral shaft fracture amenable to IM nailing, changes were incorporated to minimize injury to the patellofemoral joint and to maximize bone union. 24 The authors used a new implant that had dynamization capability to pro- mote bone union and that was designed specifically for retrograde insertion through the intercondylar notch of the knee with appropriate instrumentation (Fig. 2). To further minimize potential injury to the knee extensor mechanism and the patellofemoral joint, the surgical approach to the distal femur involved splitting of the patellar tendon, except in the presence of an associated fracture of the ipsilateral proximal tibia, patella, or distal femur. Functional outcome was as- sessed by using the Knee Society clinical rating system. Thirty-four patients with 35 fractures were examined. Follow-up averaged 10 months (range, 5 to 20 months). There were only two nonunions in this series (a rate of 6%, compared with 14% in the previously reported series) and a shorter time to union (12.6 vs 15 weeks). There were no infections or malunions. Postoperative complaints of knee pain were minimal (average score, 98 of a possible 100 points), and knee function was excellent (average score, 97 points). Although not advocated as a replacement for other techniques, nonreamed retrograde nailing was recommended as a safe and effective method of fracture fixation that should be added to the orthopaedic surgeonÕs treatment armamentarium. Berton R. Moed, MD, and J. Tracy Watson, MD Vol 7, No 4, July/August 1999 211 Fig. 1 The main advantage of the intercondylar entry portal over the medial condylar extra-articular entry portal is that it is in line with the axis of the femoral canal. Medial condylar extra-articular portal Intercondylar portal Early nail dynamization and early weight bearing were noted to be important in minimizing the risk of nonunion after nonreamed nailing. The authors speculated that reamed retrograde nailing may be a better alternative, even in patients with multiple injuries. Reports from other investigators have corroborated the results from these two studies. Herscovici and Whiteman 25 reported a series of 45 fractures (in 41 patients) treated ac- cording to a protocol similar to that of Moed et al 24 and obtained similar results, with an average follow- up of 24 months (range, 9 to 73 months). There were two nonunions, one malrotation of the leg that necessitated a second anesthetic administration for correction, and no infections. Knee symptoms attributable to the femoral nailing were minimal. Of the 5 patients with significant residual knee pain, one had mild pain with some limitation of activities but not requiring analgesics, and the other 4 had related complex injuries. Differ- ences in their protocol included using lateral retraction of the patellar tendon (rather than a splitÐ patellar tendon approach) and reaming before nail insertion in a small number of patients. Ostrum et al 26 reported the results in a series of 61 consecutive femoral fractures treated with a reamed retrograde nail. Five fractures required nail dynamization to attain union, and there were three nonunions (5%). Sepsis developed in one knee joint 16 months after nailing of a closed fracture that also required thigh fasciotomy. There were no significant malunions, and excellent knee motion was noted in patients who did not have other ipsilateral lower-limb injuries. However, follow-up was fairly short in some cases (average, 10 months; range, 2 to 23 months). The authors attributed the excellent functional results to the use of an implant specifically designed for retrograde nailing and a relatively atraumatic surgical approach to the knee joint. In 1997, Decoster et al 27 reported the results of retrograde nailing in 38 patients. On the basis of their 1- to 10-year follow-up of knee motion, the authors noted the absence of any permanent knee joint impairment. 28 Laboratory Data There continues to be concern regarding knee joint function after retrograde IM nailing of femoral fractures, despite recent reports to the contrary. None of the previously described clinical studies has suf- Retrograde Nailing of the Femoral Shaft Journal of the American Academy of Orthopaedic Surgeons 212 A B C D E F Fig. 2 A 41-year-old man was involved in a motor vehicle accident as an unrestrained passenger and sustained a closed head injury and multiple extremity fractures, including a closed segmental left femoral shaft fracture and an ipsilateral open (type IIIA) tibial shaft fracture. Initial anteroposterior (on left) and lateral (on right) radiographs of the femoral shaft fracture (A) and ipsilateral tibial fracture (B). C and D, Radiographs obtained 2 weeks after emergent nonreamed nailing of both fractures. E and F, Radiographs obtained at 8-month follow-up examination show fracture union. Both fractures had been dynamized at 12 weeks. Knee motion was 0 to 125 degrees. (Reproduced with permission from Moed BR, Watson JT: Retrograde nailing of fractures of the femoral shaft. Orthop Traumatol 1998;6:193-204.) ficient long-term outcome data regarding knee function. There are two areas of concern. One is the potential for disruption of knee joint mechanics or injury to the articular cartilage as a consequence of creation of the intercondylar entry portal. The other is the possibility of ongoing articular cartilage injury from the intra-articular location of the retained implant (e.g., synovial metallosis 28,29 ). Recent experimental data have provided important infor- mation regarding these issues. In 1975, Aglietti et al 30 studied the normal patellofemoral contact areas (Fig. 3). With the knee in full exten- sion, the patella is completely cepha- lad to the femoral articular surface. At 30 degrees of flexion, the inferior aspect of the patella is in contact with the most superior aspect of the femoral condyles, with a contact area of 2.95 cm 2 . At 60 degrees, the femoral contact area is located at the femoral groove, slightly inferior to and encompassing a greater area (4.72 cm 2 ) than at 30 degrees. At 90 degrees, the femoral contact area is somewhat larger (5.0 cm 2 ) and is located at the femoral groove just above the notch. At 120 degrees, the patella is in contact with the femoral condyles on either side of the notch. Theoretically, the potential exists for an alteration in joint contact forces from slight encroachment of the patellofemoral contact area at 90 degrees or more of knee flexion by the hole drilled for the intercondylar entry portal. Morgan et al 31 recently studied the effect of retrograde nail insertion on these contact forces by using cadaveric knee specimens and pressure-sensitive film. Testing was performed at 90 and 120 degrees of knee flexion in intact knees and in knees in which the nail was recessed 3 mm below the articular cartilage, was flush with the cartilage, or protruded 1 mm beyond the articular surface. Patellofemoral contact areas were the same for all four groups. Patellofemoral contact pressure was adversely affected only in the protruding nail group. The authors concluded that with proper nail placement, patellofemoral biomechanics should re- main unaltered. Possible adverse effects on the knee joint following retrograde femoral nailing have recently been evaluated in an animal study. Stubbs et al 32 placed stainless steel implants in the intercondylar notch in 18 rabbits, approximating the clinical location for retrograde nail insertion; in each animal, the other knee served as the control. The ani- mals were sacrificed at 2, 6, and 12 months. Examination at that time revealed that all implant insertion sites were completely covered by fibrous tissue. Histologic analysis of the cartilage and synovium showed no differences between the experimental and control groups. There were no changes indicative of synovial metallosis. Clinical experience obtained by direct visual, arthroscopic, and biopsy examination of the articular cartilage around the entry portal at the time of nail removal is consistent with these findings. 19,24,27 Another point of concern has been the potential risk of injury to the femoral nerve or artery during the anterior-to-posterior insertion of the proximal locking screws used in retrograde femoral nailing systems. In an anatomic cadaver study, however, Riina et al 33 found the risk to the femoral artery to be extremely low when the screws were placed above the level of the lesser trochanter. The femoral artery lies medial to the femur throughout its course, and no branches of the femoral artery were found within 4 cm of the lesser trochanter. Some branches of the femoral nerve are at risk; however, these are small branches and should have only minimal functional impact even if injured. 33 There is, perhaps, more reason for concern if the nail ends distal to the lesser trochanter, requiring that the proximal locking screws be placed below the level of the lesser trochanter. However, previous anatomic study and substantial clinical experience, as reflected in Berton R. Moed, MD, and J. Tracy Watson, MD Vol 7, No 4, July/August 1999 213 120° 90° 60° 30° 30° 120° 90° 60° 0° Fig. 3 The normal contact areas of the distal femur (left) and the corresponding areas of the patella (right) at 0, 30, 60, 90, and 120 degrees of knee flexion. (Adapted with permission from Aglietti P, Insall JN, Walker PN, Trent P: A new patella prosthesis: Design and application. Clin Orthop 1975;107:175-187.) the literature on external fixation, indicate that there is minimal, if any, risk of injury to important structures along the entire proximal femur from locking screws inserted from anterior to posterior (Fig. 4). 34,35 Although the recent clinical experience with retrograde nailing with insertion of proximal locking screws below the level of the lesser trochanter is limited (9 of 35 fractures in one series 24 ), it does provide support for this con- tention. Current Indications and Contraindications Retrograde nailing has recently been advocated as a direct alternative to antegrade nailing, having only relative contraindications, such as type IIIB open fractures and subtrochanteric fractures, rather than specific indications. 26 However, most investigators have defined specific indications and relative contraindications, withhold- ing the recommendation for general use in a patient with an isolated femoral shaft fracture pending reports with larger numbers and longer follow-up. 19,24,25,27,36,37 Cur- rent indications and contraindications are listed in Table 1. Femoral shaft fractures often occur in combination with other injuries, and the patient can benefit if simultaneous or sequential surgical procedures can be performed with a single anesthetic induction. In the case of ipsilateral lower limb fractures, retrograde nailing facili- tates fixation of the associated injury (Fig. 2). In the case of ipsilateral pelvic and acetabular fractures, retrograde nailing avoids further compromise of the injured proximal soft tissues and possible additional delays or complications in surgical fracture management. Pregnancy is included as a relative indication because retrograde nailing limits proximal radiation expo- sure. 8 Summary The recent clinical and experimental literature supports the use of retrograde femoral nailing. Revised tech- Retrograde Nailing of the Femoral Shaft Journal of the American Academy of Orthopaedic Surgeons 214 Fig. 4 On the basis of experience gathered from the placement of proximal femoral external fixator pins (as illustrated in this drawing), safe corridors for insertion of locking screws in retrograde nails have been established. (Adapted with permission from Green SA: Complications of External Skeletal Fixation. Springfield, Ill: Charles C Thomas, 1981, pp 31-77.) 0° Anterior First perforating artery and vein Tuberosity of ischium Posterior femoral cutaneous nerve Sciatic nerve Inferior gluteal artery and vein Lateral femoral cutaneous nerve Greater saphenous vein Branch of obturator nerve 90° Lateral Branch of posterior obturator nerve Lateral femoral circumflex artery Femoral nerve and branches Superficial femoral artery and vein Deep femoral artery and vein niques and newer implants appear to have minimized the risk of major complications (i.e., nonunion, malunion, implant failure, infection, and knee joint functional impairment) while maintaining the perceived advantages of retrograde nailing. These include decreased operating time, decreased blood loss, and applicability to the patient with multisystem injury, multiple fractures, or other special problems. Attention to detail is very important in this procedure, which has been described else- where in detail. 19,24,36,37 Retrograde nailing is currently accepted as an excellent method for femoral shaft fracture fixation in selected patients. Its general use as an alternative to antegrade nailing also has its advo- cates. 26 However, additional clinical series with greater patient numbers and long-term functional outcome studies are required. Antegrade nailing with reaming remains the standard to which retrograde nailing must be compared. Berton R. Moed, MD, and J. Tracy Watson, MD Vol 7, No 4, July/August 1999 215 References 1.Brumback RJ, Uwagie-Ero S, Lakatos RP, Poka A, Bathon GH, Burgess AR: Intramedullary nailing of femoral shaft fractures: Part II. Fracture-heal- ing with static interlocking fixation. J Bone Joint Surg Am1988;70:1453-1462. 2.Hansen ST Jr, Winquist RA: Closed intramedullary nailing of the femur: KŸntscher technique with reaming. Clin Orthop1979;138:56-61. 3.Winquist RA, Hansen ST Jr, Clawson DK: Closed intramedullary nailing of femoral fractures: A report of five hun- dred and twenty cases. J Bone Joint Surg Am1984;66:529-539. 4.Wiss DA, Brien WW, Stetson WB: Interlocked nailing for treatment of segmental fractures of the femur. J Bone Joint Surg Am1990;72:724-728. 5.Johnson K: Femur: Trauma, in Frymoyer JW (ed): Orthopaedic Knowl- edge Update 4. Rosemont, Ill: American Academy of Orthopaedic Surgeons, 1993, pp 559-567. 6.Wiss DA, Fleming CH, Matta JM, Clark DC: Comminuted and rotation- ally unstable fractures of the femur treated with an interlocking nail. Clin Orthop1986;212:35-47. 7.Brumback RJ, Wells JD, Lakatos R, Poka A, Bathon GH, Burgess AR: Heterotopic ossification about the hip after intramedullary nailing for fractures of the femur. J Bone Joint Surg Am1990;72:1067-1073. 8.Sanders R, Koval KJ, DiPasquale T, Helfet DL, Frankle M: Retrograde reamed femoral nailing. J Orthop Trauma1993;7:293-302. 9.Steinberg GG, Hubbard C: Hetero- topic ossification after femoral intramedullary rodding. J Orthop Trauma 1993;7:536-542. 10.Swiontkowski MF, Hansen ST Jr, Kellam J: Ipsilateral fractures of the femoral neck and shaft: A treatment protocol. J Bone Joint Surg Am1984; 66:260-268. 11.Brumback RJ, Ellison TS, Molligan H, Molligan DJ, Mahaffey S, Schmid- hauser C: Pudendal nerve palsy com- plicating intramedullary nailing of the femur. J Bone Joint Surg Am1992;74: 1450-1455. 12.Kao JT, Burton D, Comstock C, McClellan RT, Carragee E: Pudendal nerve palsy after femoral intramedullary nailing. J Orthop Trauma1993;7: 58-63. 13.Bain GI, Zacest AC, Paterson DC, Middleton J, Pohl AP: Abduction strength following intramedullary nailing of the femur. J Orthop Trauma 1997;11:93-97. 14.Benirschke SK, Melder I, Henley MB, et al: Closed interlocking nailing of femoral shaft fractures: Assessment of technical complications and functional outcomes by comparison of a prospective database with retrospective review. J Orthop Trauma1993;7:118- 15.Rush LV: Dynamic intramedullary fracture-fixation of the femur: Reflections on the use of the round rod after 30 years. Clin Orthop1968;60:21- 27. 16.Eriksson E, Hovelius L: Ender nailing in fractures of the diaphysis of the femur. J Bone Joint Surg Am1979;61: 1175-1181. 17.Casey MJ, Chapman MW: Ipsilateral concomitant fractures of the hip and femoral shaft. J Bone Joint Surg Am 1979;61:503-509. 18.Patterson BM, Routt MLC Jr, Benirsch- ke SK, Hansen ST Jr: Retrograde nailing of femoral shaft fractures. J Trauma1995;38:38-43. 19.Moed BR, Watson JT: Retrograde intramedullary nailing, without reaming, of fractures of the femoral shaft in multiply injured patients. J Bone Joint Surg Am1995;77:1520-1527. 20.Pape HC, AufÕmÕKolk M, Paffrath T, Regel G, Sturm JA, Tscherne H: Pri- mary intramedullary femur fixation in multiple trauma patients with associated lung contusion: A cause of post- traumatic ARDS? J Trauma1993;34: 540-548. 21.Pape HC, Dwenger A, Grotz M, et al: Does the reamer type influence the degree of lung dysfunction after femoral nailing following severe trauma? An animal study. J Orthop Trauma 1994;8:300-309. 22.Pape HC, Dwenger A, Regel G, et al: Pulmonary damage after intramedullary femoral nailing in traumatized sheep: Is there an effect from different nailing methods? J Trauma1992;33: 574-581. 23. Wozasek GE, Simon P, Redl H, Schlag G: Fat embolism during intramedullary nailing. J Orthop Trauma1993;7: 156-157. 24.Moed BR, Watson JT, Cramer KE, Karges DE, Teefey JS: Unreamed retrograde intramedullary nailing of fractures of the femoral shaft. J Orthop Trauma1998;12:334-342. 25.Herscovici D Jr, Whiteman KW: Retrograde nailing of the femur using an intercondylar approach. Clin Orthop1996;332:98-104. 26.Ostrum RF, DiCicco J, Lakatos R, Poka A: Retrograde intramedullary nailing of femoral diaphyseal fractures. J Orthop Trauma1998;12:464-468. 27.DeCoster TA, Brown G, Robinson B: Retrograde nailing of femur shaft fractures for specific indications: Ten year experience. Orthop Trans1997-1998;21: 1353. 28.Johnson EE, Marroquin CE, Kossovsky N: Synovial metallosis resulting from intraarticular intramedullary nailing of a distal femoral nonunion. J Orthop Trauma1993;7:320-324. 29.Seligson D: In response to article by Johnson et al. J Orthop Trauma1993;7: 325-326. 30.Aglietti P, Insall JN, Walker PS, Trent P: A new patella prosthesis: Design and application. Clin Orthop1975;107:175-187. 31.Morgan E, Ostrum RF, DiCicco J, McElroy J, Poka A: Effects of retrograde femoral intramedullary nailing on the patellofemoral articulation. J Orthop Trauma1999;13:13-16. 32.Stubbs M, Zhang H, Vrahas MS, Baratta RV, Zieske A: The effect of intra-articular stainless steel implants on the health of the rabbit knee joint: An experimental study. Presented at the 44th Annual Meeting of the Louisiana Orthopaedic Association, New Orleans, November 20-23, 1997. 33.Riina J, Tornetta P III, Ritter C, Geller J: Neurologic and vascular structures at risk during anterior-posterior locking of retrograde femoral nails. J Orthop Trauma1998;12:379-381. 34.Green SA: Complications of External Skeletal Fixation. Springfield, Ill: Charles C Thomas, 1981, pp 31-77. 35.Cattaneo R, Catagni MA, Villa A, et al: Fractures of the femur, in Bianchi- Maiocchi A, Aronson J (eds): Operative Principles of Ilizarov: Fracture Treatment, Nonunion, Osteomyelitis, Lengthening, and Deformity Correction. Baltimore: Williams & Wilkins, 1991, pp 125-145. 36.Moed BR, Watson JT: Retrograde nailing of fractures of the femoral shaft. Orthop Traumatol1998;6:193-204. 37.Watson JT, Moed BR: Retrograde nailing of the femoral diaphysis. Tech- niques Orthop1998;13:38-50. Retrograde Nailing of the Femoral Shaft Journal of the American Academy of Orthopaedic Surgeons 216

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