J Islamabad Med Dental Coll 2022  82 

Open Access 

  
Functional Outcome of Distal Femur Fracture Treated with 

Retrograde Nailing Technique 
 

Muhammad Azfar Khanzada1, Muhammad Tahir Lakho2, Zulfiqar Ali Memon3, Syed Alam Zeb4, Bashir Ahmed5, 
Rajesh Kumar6 

1,4Specialist, Department of Orthopedic Surgery, AlHabib Hospital, Riyadh, Kingdom of Saudi Arabia 
2Assistant Professor, Department of Orthopedic Surgery, Dr. Ruth K. M. Pfau, Civil Hospital, Karachi 

3Senior Registrar, Department of Orthopedic Surgery, Liaquat University of Medical and Health Sciences, Jamshoro 
5Surgeon, Department of Orthopedic Surgery, Jinnah Postgraduate Medical Center, Karachi 

6Medical Officer, Dr. Ruth K. M. Pfau, Civil Hospital, Karachi 

A B S T R A C T  

Background: Management of distal femur fractures is always challenging for the surgeons. Retrograde interlocking 
nailing is one of the effective methods with minimal complications for treatment of such fractures. The objective of the 
study was to evaluate the functional outcome of retrograde interlocking nailing technique in patients with distal femur 
fractures. 
Methodology: This interventional study was conducted at the department of orthopedic surgery, Liaquat University 
Hospital, Hyderabad from March 2017 to December 2019. Patients of either gender, between 30 to 65 years age, who 
presented with acute fracture of distal femur, as a result of trauma within 12-96 hours, requiring surgical intervention 
were included. Lysholm Scoring System was used to evaluate the functional outcome of patients treated with retrograde 
interlocking nailing technique. Data was analyzed using SPSS version 24. 
Results: Total 102 patients gave consent of participation. The mean age of study participants was 43.50±7.26 with the 
age range from 40-65 years. Male patients were 76.47% and female 23.53%. In majority (63.73%) of cases, mode of 
injury was road traffic accidents. Statistically significant difference in functional mobility score between the age groups 
and gender (p < 0.05) was found. Statistically significant (p < 0.05) decline in mean Lysholm score was observed in 
participants who had been bearing full weight for 3 months. Excellent functional outcome was achieved by 49.02% 
patients while 34.31% patients achieved good functional outcome. 
Conclusion: Retrograde interlocking nailing for fracture of distal femur is an effective fixation surgical technique with 
minimal complications and excellent to good functional outcome. 
Key words:  Accidents, Femur Fractures, Fracture Fixation, Functional Performance 

Authors’ Contribution: 
1Conception; Literature research; 
manuscript design and drafting; 2,3 Critical 
analysis and manuscript review; 4Data 
analysis; 5,6Manuscript Editing. 

Correspondence: 
Zulfiqar Ali Memon  
Email: memon.zulfi9326@gmail.com 

Article info: 
Received: February 26, 2021 
Accepted: May 17, 2022 

Cite this article.  Khanzada MA, Lakho MT, Memon ZA, Zeb SA, Ahmed B, Kumar R. Functional 
Outcome of Distal Femur Fracture Treated with Retrograde Nailing Technique. J Islamabad Med 
Dental Coll. 2022; 11(2):82-88.  DOI: https://doi.org/10.35787/jimdc.v11i2.687 

  
 
 

Funding Source: Nil 
Conflict of Interest: Nil 

I n t r o d u c t i o n  
 

Distal femur fractures (DFF) are the fractures that 

occur upto 15cm from the articular surface of distal 

femur. These are infrequently occurring fractures 

O R I G I N A L  A R T I C L E  



J Islamabad Med Dental Coll 2022  83 

that constitute around 4-6% of all femur fractures.1 

Globally, the DFF usually results from high energy 

trauma such as motor vehicle accidents, frequently 

seen in males between their 15 to 50 years of age. 

While DFF resulting from low energy trauma like 

simple fall commonly occurs in females more than 

50 years of age. Moreover, patients suffering from 

osteoporosis and/or having previous knee 

arthroplasties are at higher risk of these fractures.2,3  

Globally, in elderly people, DFF are the second most 

common cause of mortality after hip fractures.3 

Fractures of distal femur are usually treated by using 

different surgical techniques like; internal fixation by 

95 degree angle blade plate, cancellous screws, 

dynamic condylar screw and plate, condylar buttress 

plates, distal femoral locking plate and retrograde 

intramedullary nail.3,4 

While conservative methods include traction and 

plaster immobilization of joint, the ultimate goal of 

restoration of alignment is to preserve the function 

of extremity which is a crucial step in the definitive 

treatment of distal femur fracture.4 

In addition to this, early knee range of motion (ROM) 

is the key to achieve acceptable outcomes. Whereas, 

loss of knee ROM and subsequent stiffness of the 

knee joint may result in immobilization and often 

contribute to poor outcome. Understanding the 

characteristics, principles and challenges in the 

management of DFF is important in optimizing their 

outcomes.5,6 

Closed Intramedullary implants not only respect soft 

tissue envelope and periosteum but can achieve this 

goal without increasing the risk of infection and 

prolonged immobilization. Retrograde interlocking 

nail is associated with swift recovery, early union 

and lesser complications.6 This implant is preferable 

to plate and screws because it is load sharing, 

minimum soft tissue dissection and periosteal 

stripping is done during its application, chances of 

union are more and patient is mobilized earlier.(5, 7) 

While some very minimal complications like knee 

pain, nonunion, and arthrofibrosis are also 

associated with this technique. 

The current interventional study was designed to 

evaluate the functional outcome of retrograde 

interlocking nailing technique in patients with distal 

femur fracture presented in Liaquat University 

Hospital Hyderabad. The findings of the present 

study can help in formulating the standard 

guidelines for the effective and efficient surgical 

technique for DFF. 

 

M e t h o d o l o g y  

 

The interventional study was conducted at the 

orthopedic surgery unit of Liaquat University 

Hospital, Jamshoro, Hyderabad from March 2017 to 

December 2019. All the patients of either gender, 

between ages 40 to 65 years, who presented with 

acute fracture of distal femur close extra-articular 

and intra-articular fractures (diagnosed by 

radiograph) resulting from the trauma within 12– 96 

hours, requiring surgical intervention were included. 

While patients, presenting with gunshot injury, 

previous knee injury, fracture involving nerve, 

vascular and/or head injury, poly trauma of other 

bones of same side, previous interventional femoral 

surgery of same side, having evidence of infected 

wound or existence of purulent discharge on 

examination and with lost follow-up were excluded 

from the study. 

The sample size of 102 was calculated by setting 

confidence interval at 95%, margin of error at 8% 

and taking 23% of anticipated proportion knee range 

pain using Open Epi. Online calculator.8,9 

Non-random consecutive sampling technique was 

applied for selection of the participants.  Ethical 

approval was sought from the Ethical Review Board 

of Liaquat University of Medical and Health Sciences, 

Jamshoro. An informed consent was taken from the 

patients after briefing them about the risks and 

benefits, as well as purpose of the study.  

A predesigned written proforma was used to collect 

the detailed information of all the participants 

relating to the age, sex and occupation, mode of 



J Islamabad Med Dental Coll 2022  84 

injury, past and associated medical illness.10 After 

collection of information, all the patients were 

assessed and treated for any life-threatening 

conditions. Detailed physical examination was done 

in all the patients to observe the condition of skin, 

any swelling or edema, vascular involvement etc.  

Upon arrival, patients were kept on skeletal pin 

traction or below knee skin traction application and 

limb put over bohler-braun cradle till the time of 

operation while in some cases, a skin traction or a 

long slab was applied. X-ray of the affected limb was 

taken in anterior-posterior and lateral views at the 

time of admission. Distal femur fracture was 

classified according to the Arbeitsgemeinschaft für 

Osteosynthesefragen (AO) classification system.11 

All surgeries were performed under general or spinal 

anesthesia on radiolucent traction table. 

Preoperative prophylactic antibiotic (second 

generation cephalosporin) was administered to all 

the patients at the time of induction. All surgeries 

were performed in a standard and uniform manner. 

Open reduction and internal fixation were done 

using standard lateral approach. Patients were kept 

in supine position, on radiolucent table with knee in 

slight flexion. The femoral condyle was exposed 

through a central 5 cm incision starting from lower 

pole of patella and just medial to the patellar 

tendon. The inter condylar notch was palpated and 

under image intensifier (anterior-posterior and 

lateral fluoroscopy) proper entry point was made 

and guide wire was passed while maintaining 

reduction and alignment. A proper length and 

maximum diameter of nail was inserted closely and 

locked at both ends. The medullary canal was 

reamed and the nail of appropriate size was 

reinserted.  

To encourage the early range of motion of knee, 

physiotherapy was initiated on the first post-

operative day. Patients were called for follow up at 

2nd, 4th and 6th week initially and then monthly for 

one year. In each visit, patients were clinically 

assessed for knee range of motion, measured by 

goniometer and ability to tolerate weight. X- rays 

were done to evaluate the bony union. The 

functional outcome was assessed on the 36th week 

post-operatively with radiological healing through X 

ray AP/Lateral view and Lysholm Gillquist Scoring 

System (LGSS). The Lysholm knee scoring system 

comprise of eight components to measure: Pain, 

instability, limp, swelling, locking, squatting, support 

and stair climbing. For each question response, an 

arbitrary score has been assigned. The random LGSS 

has a maximum score of 100. The scores >90 is 

graded as excellent, while 84-90 considered as good, 

it is categorized as fair, if score is 65-83 and poor if 

the score is <65.12   

Data was entered and analyzed using SPSS ver. 24. 

The relationship between age of all participants (≤ 

45 and over 45 years), gender, the duration of 

immobilization (up to 6 and ≥ 6 weeks), time to start 

full weight-bearing (≤ 3 months and over 3 months) 

were also analyzed.13 Qualitative variables are 

presented as frequency and percentages while 

quantitative variables  demonstrated as means and 

standard deviation. Student’s t-test was applied for 

the statistical analysis of qualitative variables. 

Significance level was kept at p-value < 0.05. 

 

R e s u l t s  

 

Total 102 patients participated in the study. The 

mean age of study participants was 43.50±7.26 with 

the age range from 30-65 years. Male patients were 

78(76.47%) and female 24(23.53%).  According to 

stratified groups, 43(42.15%) patients were aged 

≤45years and 59(57.84%) patients were aged >45 

years. Mean age of patients aged ≤45 years was 

37.83±3.07 years and for patients aged >45 years the 

mean age was 53.42±3.14 years. 

Most of participants had right side of knee involved 

(61.76%) compared with left side (38.23%). In 

majority of cases, mode of injury was road traffic 

accidents (RTA) (63.73%) while second highest 

number of patients sustained fractures due to fall on 

ground. (36.27%) 



J Islamabad Med Dental Coll 2022  85 

On radiological examination, majority 36(35.30%) of 

patients had type A1, 26(25.50%) A2, 21(20.58%), 

A3 and 19(18.62%) patients had C1 type of femur 

fracture on AO classification. Total 48 (47.07%) 

patients underwent surgery within three days of 

admission while 39 (38.23%) patients underwent 

surgery in 3-7 days after initial stabilization and 15 

(14.70%) underwent surgery after 7 days of 

admission after extensive treatment for controlling 

infection. 

After completion of one year, out of total patients, 

≥110° flexion was achieved by 75 (73.53%) patients, 

91°-109° flexion achieved by 16(15.68%) patients 

and ≤ 90° of knee flexion was achieved by 11 

(10.78%) patients. The knee flexion was assessed for 

all the patients and the mean flexion at knee on 

different duration is mentioned in Table I. 

 

Table I: Mean flexion at knee joint on 
different follow-up visits 

Monthly Follow-ups Mean degree of flexion 

First           42.10° ± 5.26° 

Third 89.62° ± 10.81° 

Sixth 111.87° ± 9.21° 

Twelfth 120.50° ± 11.87° 

 

The findings of Functional outcome for all the 

patients is shown in the figure below. Majority of 

patients showed excellent functional outcome on 

LGSS. (Figure 1) 

 

 
Figure 1: Functional outcome on Lysholm Gillquist 

Scoring System (LGSS) 

Table II below is demonstrating the relationship 

between the age, gender, immobilization time and 

weight bearing time with functional scores of the 

patients. There was a statistically significant 

difference between the two age groups (< 45 and 

>45) and gender (P < 0.05), while no statistically 

significant difference between the affected side of 

the patients and functional outcomes. 

                            

Table II: Differences in mean lysholm knee scoring 
among study participants 

 LYSHOLM KNEE SCORING  

 Mean± SD P-value 

Age 

 ≤ 45 years 

 > 45 years 

 
90.71±7.34 
80.11±9.78 

 
0.0001* 

Gender 

 Male 

 Female 

 
91.24±6.45 
85.13±7.08 

 
0.0003* 

Immobilization Time 

 < 6 weeks 

 ≥ 6 weeks 

 
87.81±10.68 
81.32±13.22 

 
0.054 

Weight-bearing Time 

 ≤ 3 months 

 > 3 months 

 
87.54±13.27 
79.48±13.54 

 
0.010* 

 

Radio-graphical presentation of fracture of distal 

femur at the time of admission and after application 

of retrograde femoral nail.  

 

 
1a-Pre-operative radiographic scan 

 



J Islamabad Med Dental Coll 2022  86 

 
1b- Post-operative retrograde femoral nailing 

 

D i s c u s s i o n  

 

The patterns and spectrum of distal femur fractures 

are so diverse that no single treatment option has 

proven consistently successful. The management of 

DFF using surgical techniques with the ultimate goal 

of restoration of alignment is preservation of the 

function of extremity, promotion of early motion of 

knee and restoration of articular surfaces.5  

Moreover, preservation of soft–tissue envelope by 

durable fixation techniques allows the functional 

recovery throughout the bone healing.7,14 The 

present study was designed with an objective of the 

evaluation of functional outcome of DFF using 

retrograde nailing technique. The male to female 

ratio in our study is 3:1 while more patients belong 

to age > 45 years. The demographic profile of the 

present study participants is almost identical to 

those reported in previous studies by Shah et al and 

Prasanna et al.14, 15  

In this study, the retrograde nailing technique was 

being used. The advantages of closed intra-

medullary nailing act as a load sharing device range 

from providing the favorable intramedullary 

stability, early mobilization to lesser complications 

as compared to other treatment options. It is a 

closed treatment option without interrupting the 

fracture hematoma and leads to early callus 

formation.16  

In order to preserve the soft-tissue envelope and for 

achieving the closed indirect fracture reduction, the 

nail was inserted at a correct insertion point, so that 

it may leave the soft-tissue envelope intact. 

Moreover, the intramedullary fixation not only 

allows to achieve the multi-angle interlocking but 

also protects blood circulation around the fracture 

at the utmost extent.  

In our study, significantly higher union rate of DFF 

with minimal complications was achieved. Atef et al. 

also endorsed these findings in his study and 

reported the 100% union rate of DFF in their study 

participants.12 A study by Dileep et al. reported that 

retrograde nailing is the reliable technique for DFF 

with higher rate of union, with very limited 

complications that don’t affect the movement of 

knee.17 Two other local studies by Habib et al and 

Shafiq et al also reported excellent functional 

outcome, union rate and minimal complications 

using retrograde nailing technique in DFF in majority 

of their study participants.7, 9 

Most 60(61.9%) of the participants in our study had 

right side of knee involved compared with left side 

37(38.1%). RTA was the most common mode of 

injury in this study as more than 60% patients 

suffered from RTA while 36.27% of patients 

sustained fractures due to fall on ground. Prasanna 

et al and Jillala et al also reported similar proportion 

of mode of injury in their study participants with RTA 

more predominant mode of injury.15, 18 

Several rating scales are available and have been 

used to determine the functional outcomes after 

surgical treatment of fractures of femur yet none of 

the scale is validated to be superior to other. The 

most commonly used rating scales for functional 

outcome assessment include; Lysholm Gillquist 

Scoring System (LGSS), Neer’s score, Schaztker and 

Lambert score, rand Knee Society Score (KSS) etc. In 

our study, we used Lysholm Gillquist Scoring System 

for the assessment of functional outcome of 

patients with DFF undergoing  retrograde 

intramedullary nailing technique.19  

In the present study, excellent functional outcome 

was demonstrated in 49.02%, good in 34.21% and 



J Islamabad Med Dental Coll 2022  87 

fair in 9.80% patients with DFF type A1, A2, A3 and 

C1 according to the Lysholm Knee Scoring System. 

Poor functional outcome due to non-union and 

breakage of nail was demonstrated in 6.86% 

patients in our study. Moreover, Prasanna et al also 

reported consistent findings as over two-third of 

their patients had excellent to good functional 

outcome using same technique and scoring 

system.(15) Shah et al. also reported an excellent to 

good functional outcome in majority of their study 

participants after retrograde nailing for DFF using 

Schatzker and Lambert criteria.14 

Few complications are observed in patients of the 

present study, the most common complication was 

anterior knee pain followed by superficial infection 

at the site of nail insertion and delayed union. 

Similar findings have been reported by Prasanna et 

al. While another study reported more serious 

complications including pulmonary embolism, knee 

stiffness and shortening of size of femur.15 

This study evaluated the functional outcome of 

intramedullary retrograde nailing technique for DFF, 

comparative analysis of different surgical techniques 

may provide more detailed information regarding 

effectiveness of the surgical techniques.  

 

C o n c l u s i o n  

 

Intramedullary retrograde nailing for fracture of 

distal femur is reliable and effective fixation surgical 

technique. Excellent to good functional outcome 

with minimal complications and disruption to the 

soft tissues, as well as higher union rate and fast 

recovery is achieved in distal femur fracture 

patients.  

 

R e f e r e n c e s  

 
  1.  Rathi NB, Solanki RA, Patel HA, Tank PJ. Study of 

retrograde intramedullary nailing in distal one third 
shaft femur fracture. Journal of Dental and Medical 
Sciences. 2016;15(4):18-23. 

2. Elsoe R, Ceccotti AA, Larsen P. Population-based 
epidemiology and incidence of distal femur fractures. 
International orthopaedics. 2018;42(1):191-6. doi: 
10.1007/s00264-017-3665-1. 

3. Meluzio M, Oliva M, Minutillo F, Ziranu A, 
Saccomanno M, Maccauro G. The use of knee mega-
prosthesis for the management of distal femoral 
fractures: A systematic review. Injury. 2020;51:S17-
S22. doi: 10.1016/j.injury.2019.08.011. 

4. Metwaly RG, Zakaria ZM. Single-incision double-
plating approach in the management of isolated, 
closed osteoporotic distal femoral fractures. Geriatric 
orthopaedic surgery & rehabilitation. 
2018;9:2151459318799856. 

5. Agrawal AK, Bansal A, Rawat S, Kapadiya S, Desai S, 
Golwala P. Surgical Management of Distal Femur 
Fracture Using Anatomical Locking Compression 
Plate. Int J Cur Res Rev| Vol. 2021;13(02):176. 

6. Albareda-Albareda J, Gabarre-Raso S, Rosell-Pradas J, 
Puértolas-Broto S, Ibarz-Montaner E, Redondo-
Trasobares B, et al. Biomechanical behavior of 
retrograde intramedullary nails in distal femoral 
fractures. Injury. 2021. 10.1016/j.injury.2021.01.052. 

7. Habib MK, Niazi A. Outcome of Retrograde 
Interlocking Nail in Supracondylar Femur Fracture. 
Journal of Pakistan Orthopaedic Association. 
2018;30(01):05-8. 

8. Sullivan KM, Dean A, Soe MM. On academics: 
OpenEpi: a web-based epidemiologic and statistical 
calculator for public health. Public health reports. 
2009;124(3):471-4. 

9. Shafiq M, Ahmed A, Akram R, Javed S, Aziz A. 
RETROGRADE FEMUR NAIL:OUTCOME OF 
RETROGRADE FEMUR NAIL, IS IT IMPLANT OF CHOICE 
FOR DISTAL SHAFT OF FEMUR FRACTURE? The 
Professional Medical Journal. 2018;25(03):364-70. 
DOI:https://doi.org/10.29309/TPMJ/2018.25.03.370 

10. Wang W, Liu L, Chang X, Jia Z, Zhao J, Xu W. Cross-
cultural translation of the Lysholm knee score in 
Chinese and its validation in patients with anterior 
cruciate ligament injury. BMC musculoskeletal 
disorders. 2016;17(1):1-8. DOI: 10.1186/s12891-016-
1283-5 

11. El Mwafy HM, Abd El Gawad MM, El Din AFS, Youssef 
WM. Surgical treatment of distal femoral fractures 
using a distal femoral locked plate versus a condylar 
buttress plate. Menoufia Medical Journal. 
2015;28(4):948. DOI: 10.4103/1110-2098.173681 

12. Atef M, Hamoda AI. Management of distal femoral 
fractures: A comparative study between open 
reduction and internal fixation by distal femur locked 
plate and retrograde nailing. Al-Azhar International 
Medical Journal. 2020;1(4):144-8. DOI: 
10.21608/AIMJ.2021.35593.1284 



J Islamabad Med Dental Coll 2022  88 

13. Ahmed B, Lakho MT, Khanzada MA, Memon ZA, 
Karim M, Bhatti A. Functional and radiological 
outcome of condylar buttress plate in patients with 
intra-articular distal femoral fracture. Rawal Medical 
Journal. 2021;46(1):98-101. 

14. Shah SGM, Ahmed A, Shaikh SA, Ahmed N, Jamali AR. 
Outcome of Fracture Distal Femur Treated with 
Retrograde Nailing. Journal of Pakistan Orthopaedic 
Association. 2019;31(4):149-52. 

15. Prasanna A, Jeyaraman M, Chaudhari K, Ajay S, 
Sabarish K. Prospective Study on Functional Outcome 
of Retrograde Femoral Nailing in Distal Third Femoral 
Fractures. J Clin Exp Orthop. 2019;5. DOI: 
10.36648/2471-8416.5.2.65 

16. Hoskins W, Sheehy R, Edwards E, Hau R, Bucknill A, 
Parsons N, et al. Nails or plates for fracture of the 
distal femur? Data from the Victoria Orthopaedic 
Trauma Outcomes Registry. The bone & joint journal. 

2016;98(6):846-50. doi: 10.1302/0301-
620X.98B6.36826. 

17. Dileep K, Mahesha K. Retrograde intramedullary 
nailing for fractures of distal femur: A prospective 
study. Int J Res Orthop. 2016;2(4):276-9. DOI: 
http://dx.doi.org/10.18203/issn.2455-
4510.IntJResOrthop20164003 

18. Jillala SR, Ahmed SW, Shruthi A, Gajul R, Katikitala A, 
Rakesh K. A Comparative Study of Supracondylar Nail 
versus Locking Compression Plate in Distal Femur 
Fractures. Annals of International Medical and Dental 
Research. 2017;3(4):35-41. 

19. Samuel AJ, Kanimozhi D. Outcome measures used in 
patient with knee osteoarthritis: with special 
importance on functional outcome measures. 
International journal of health sciences. 
2019;13(1):52. PMCID: PMC6392485 

        PMID: 30842718