Retrograde Femoral Rodding

Retrograde femoral rodding is a technique that has recently been used with increasing frequency for the management of supracondylar and femoral shaft fractures. A review of the literature reveals that this technique may have advantages over other fixation techniques in certain clinical situations. Retrograde femoral rodding allows the surgeon to treat bilateral lower extremity injuries simultaneously without the use of a fracture table. It has been shown to be a valuable technique in the management of ipsilateral femoral neck and shaft fractures, ipsilateral femoral and pelvic or acetabular fractures, and ipsilateral femoral and tibial fractures. The preferred entry portal, the intercondylar notch, can be reached quickly and effectively by a variety of methods. There are potential problems with retrograde rodding, specifically, the concern of intra-articular sepsis, synovial metallosis, patellofemoral arthritis, quadriceps atrophy, and knee stiffness. The literature has not verified these concerns. However, more long-term follow-up is needed, particularly for the evaluation of potential patellofemoral arthritis. This article should assist the surgeon in deciding whether a particular clinical situation merits the use of a retrograde femoral rod. This technique has offered solutions to challenging orthopaedic problems such as ipsilateral femoral neck and shaft fractures. Although long-term follow-up is lacking, the literature reveals that retrograde femoral rodding is a valuable addition to the orthopaedic surgeon’s armamentarium for the management of supracondylar and femoral shaft fractures. Introduction and History Intramedullary femoral nailing has classically been performed in an antegrade fashion, with a starting point in the piriformis fossa. This antegrade technique has had tremendous success. Winquist et al. [34] had a 99.1% union rate with postoperative knee range of motion averaging 130 degrees and a 0.9% infection rate in a series of 520 femur fractures. Since antegrade rodding has been so successful in treating femur fractures, there has been some resistance to accepting newer techniques. In 1950, Dr. Lezius [17] introduced a form of retrograde femoral rodding to treat subtrochanteric and intertrochanteric femur fractures. A curved nail was introduced through the medial femoral condyle and passed up through the fracture site. In 1970, Küntscher [16] described condylocephalic nailing utilizing a medial femoral condyle starting portal for the management of intertrochanteric hip fractures. Since then, better methods for fixation of subtrochanteric and intertrochanteric femur fractures have been developed. Later, Swiontkowski et al. [32] began treating ipsilateral femoral neck and shaft fractures by stabilizing the femoral neck with multiple cancellous screws, followed by retrograde rodding of the shaft fracture. In this series, the retrograde rods were inserted extra-articularly from a medial femoral condylar starting point. The disadvantage of the medial condylar starting point was that it required the use of a flexible femoral nail or a reversed tibial nail. The tibial nail has no anterior bow and may cause varus malalignment in distal one-third femur fractures. Reversed tibial rods also tend to be smaller in diameter and weaker than larger diameter femoral rods. Subsequently, an intercondylar starting point was developed for retrograde rodding of femoral shaft fractures in order to avoid the varus malalignment associated with the medial femoral condyle starting point [10,24]. Patterson et al. [24] were the first to report on this intercondylar approach after they performed the procedure in 14 patients. Indications for Retrograde Femoral Rodding Retrograde femoral rodding may have an advantage over other techniques. Specific advantages include decreased setup time in the operating room [21,22]; decreased operative time in certain situations [21,22]; no significant postoperative abductor weakness; no postsurgical heterotopic ossification in the region of the hip; simultaneous treatment of bilateral lower extremity injuries [6,21–24]; effective treatment of ipsilateral femoral shaft and femoral neck fractures [6,10,21–23,32]; no risk of pudendal nerve palsy (which is as high as 17% in antegrade femoral rodding on a fracture table) [2,3,15]; no risk of position-induced well-leg compartment syndrome; rapid access to the intended starting portal in patients with traumatic arthrotomies to the knee [26]; and the ability to treat thoracic and/or abdominal injuries and orthopaedic injuries simultaneously or sequentially without having to change operating tables. Several authors [6,10,21–23] have advocated retrograde femoral rodding to treat bilateral femur fractures. Both fractures can be rodded simultaneously, thus minimizing operative time and blood loss. Obese patients can be operated on more efficiently and with greater ease using a retrograde technique [5,10,23]. Patients with poor skin quality in the region of antegrade starting points should also be considered candidates for retrograde femoral rodding [6,24]. Ipsilateral femoral neck and shaft fractures can be stabilized using this technique [6,10,21–23,32]. Since there is no diFrom the Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA. Address correspondence to William G. DeLong, Jr., M.D., Department of Orthopaedic Surgery, 3400 Spruce Street, Philadelphia, PA 19104. The University of Pennsylvania Orthopaedic Journal 12: 57–65, 1999 © 1999 The University of Pennsylvania Orthopaedic Journal