Femur fractures, particularly extra-articular supracondylar fractures, are a common & challenging orthopedic problem, typically caused by high-energy trauma such as road traffic accidents, falls, or sports injuries[1]. These fractures can significantly impact a patient's functional status, leading to long-term disability if not appropriately managed. The surgical management of these fractures is often complex & requires careful consideration of the most appropriate fixation technique. One promising approach for treating extra-articular supracondylar femur fractures is retrograde intramedullary nailing (RIMN) [2].

Retrograde nailing is known for its minimal approach to soft tissue disruption, early weight-bearing ability, & good alignment of the fractured femur. This study evaluates the functional outcomes of 32 patients who underwent retrograde nailing for extra-articular supracondylar femur fractures[3-5].

The distal third femoral fractures constitute 6% of all femoral fractures .Approximately 5% to 10% of distal femur fractures are open injuries. The mechanism of injury for most supracondylar fracture is thought to be axial loading with varus, valgus, or rotational forces.These fractures occur in bi-modal distribution as high energy trauma in younger age group & low energy fractures  due to osteoporosis in the elder age group.

The orthodox management of distal third femur fractures described by Watson Jones & John Charnley comprised of skeletal traction, manipulation of fracture & external immobilization in the form of casts & braces. This method was associated with deformity, shortening, fibrous ankylosis of the knee, knee joint incongruity, malunion, quadriceps wasting, knee instability, & early knee osteoarthritis[6]. The complications with these treatment methods led to the development of newer techniques of fracture management. The distal third femoral fractures are best treated with open/closed reduction & surgical stabilisation with load sharing or load-bearing implants[7].

The current method of open reduction & internal fixation has become evident in the recent years with good results being obtained with the AO fixed-angle blade plate, dynamic condylar screw,intramedullary supracondylar nail & locking compression plate. The intramedullary nailing act as a load sharing device which gives good results with minimal soft tissue dissection & good stability[8]. The goals of treatment are anatomic reduction of the articular surface,restoration of limb alignment,length, & stable fixation that allows for early mobilization.

Aim

To analyse the functional outcome of Retrograde nailing in the management of extra articular supracondylar femur fractures. 

Department of Orthopaedics, District hospital, Tumkur, Patients belonging to both the sexes having closed supracondylar femur fractures of age group between 18-60 years.Admitted in district hospital,Tumkur during the study period of 2023-2024 will be included. This study will be done over a period of one year from June 2023 to May 2024, consisting of follow up period at interval of  6 weeks, 3 months & 6 months.

Inclusion criteria:

1. Closed supracondylar femur fractures.
2. Open type A & B Supracondylar fractures of femur.

Exclusion criteria:

1. Stiff knee joint, which does not allow for flexion of knee necessary for intramedullary nail insertion.
2. Intra-articular Supracondylar femur Fractures
3. Supracondylar Open Fractures type IIIC
4. Infection around the knee joint
5. Abnormally low lying patella,which is associated with restricted range of motion,crepitations & retropatellar pain.

Sample Size calculation:

Outcome variable of interest                                       : Mean Knee Flexion at 1  

                                                                                 Year follow up

Where Z at 95% Confidence Interval                         : 1.96

σ (Standard deviation)                                                                : 11.87

d (Margin of Error)                                                                      : 4.09

Minimum Required Sample size is (n) = 32

With 10% non-response rate sample is =36

Data Collection Methods:

Cases admitted in District hospital having closed supracondylar femur fractures & open type 1,type 2 fractures who are undergoing for surgical management with retrograde nailing will be included in this study.

Statistical Methods:

The data will be entered in Excel spread sheet & analyzed using SPSS (version 20 software). Categorical variables will be expressed by frequency & percentages & matrix data will be expressed by mean & standard deviation

Table No. 1: Demographic Characteristics

A total of 32 patients were included in the study, with the following distribution:

Table No. 2: Radiographic Healing & Union Time

The average time for radiographic union was 16 weeks (range 12–22 weeks). The following table outlines the fracture union data:

Table No. 3: Functional Outcome

The Knee Society Score (KSS) & Lower Extremity Functional Scale (LEFS) were used to evaluate knee function & overall mobility.

56% of patients (18 out of 32) achieved an excellent score of 85-100 on the KSS. This indicates that over half of the patients had a successful recovery, with minimal to no functional limitations in their knee after surgery.

31% of patients (10 out of 32) had a good score, ranging from 70 to 84. These patients demonstrated satisfactory knee function, though there may have been some residual mild pain or limitations in range of motion. 9% of patients (3 out of 32) scored in the fair category (55–69), which suggests moderate functional impairment. These patients likely experienced some difficulty with daily activities or had limitations in range of motion. 3% of patients (1 out of 32) had a poor score of less than 55, indicating severe functional deficits or knee stiffness. This patient may have had significant difficulty with activities of daily living, & their outcome was less favorable.

Table No. 4: Range of Motion (ROM)

The range of motion of the knee was measured at 12 months post-surgery.

A majority of patients (87%) had well to excellent knee flexion (>100°), suggesting that retrograde nailing does not significantly impair knee movement in the majority of cases. The fact that no patients had knee flexion below 80° highlights the overall success of the surgical technique in preserving or restoring knee function. The small percentage of patients (13%) with knee flexion between 80° & 99° could benefit from targeted rehabilitation or physical therapy to further improve their range of motion, though their functionality is still acceptable for most daily activities.

Table No. 5: Complications

Postoperative complications were limited. The most notable complications included:

In terms of fracture healing and functional outcomes, the retrograde nailing approach for extra articular supracondylar femur fractures has demonstrated encouraging results. Compared to other fixation procedures like plate and screw fixation, this technique is especially beneficial since it can prevent severe disturbance to soft tissues, allowing for earlier weight-bearing and faster rehabilitation. Fracture Union: By six months, 100% of fractures had unified, indicating a high overall fracture union rate. This is in line with earlier research showing how successful retrograde nailing is in providing a stable fixation [9–10]. Knee Function: Most patients' KSS and LEFS functional scores ranged from excellent to good, indicating that their knee function and mobility had been successfully restored. High rates of knee function recovery after retrograde nailing have been reported in the literature, which is consistent with the functional outcomes of our trial [11]. Range of Motion: Some patients experienced modest to severe limits, despite the fact that the majority of patients were able to reach complete knee extension and adequate knee flexion (mean 120°).

Soft tissue stiffness is probably the cause of this, and rehabilitation exercises can help with that.

Complications: This study had a low rate of complications.

A superficial wound infection only occurred in one patient, and it was managed conservatively. Anticoagulation treatment was successful in treating DVT in two patients [12].

Advantages of Retrograde Nailing:

1. Minimized Soft Tissue Injury: The retrograde approach minimizes the need for extensive soft tissue dissection, which reduces the risk of infection & improves postoperative recovery.
2. Stable Fixation: The intramedullary nail provides stable internal fixation, reducing the risk of malunion or nonunion.
3. Early Weight-Bearing: Most patients were able to begin partial weight-bearing within 2-4 weeks, which promotes faster functional recovery.

The effectiveness of retrograde nailing over lateral locked plating for full articular distal femur fractures was investigated by K Chandra et al. in 2022.In comparison to retrograde intramedullary nailing, the study showed a greater nonunion rate and coronal plane malalignment using Lateral Locking Plate. With a possible lower probability of nonunion, rIMN does seem to be a suitable treatment for full articular distal femur fractures, while prospective data is needed [13]. A study on the functional outcome of distal femur fractures treated with distal femur nailing was conducted by Tayade SR et al. in 2023.In 25 cases, distal femur nailing was used as a surgical procedure.The Lysholm knee grading method was used to assess the functional result [14].

The retrograde nailing technique for extra-articular supracondylar femur fractures provides excellent functional outcomes with high rates of fracture union & low complication rates. It offers a viable alternative to other methods of fixation, with the benefits of minimal soft tissue disruption, early weight-bearing, & good functional recovery. Given the promising results of this study, retrograde nailing should be considered as a primary treatment option for patients with these types of fractures, especially in younger, active individuals.

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