Authors of section


Florian Gebhard, Phil Kregor, Chris Oliver

Executive Editor

Chris Colton

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Retrograde nailing approach

1. Principles

Anatomical structures

Care should be taken with the approach for retrograde nailing as several anatomical structures are at risk. The most important potential hazard is damage to the posterior cruciate ligament. In addition, cartilage from the weight bearing zone may be damaged if the wrong approach is selected. This can also lead to a failure to reduce the fracture properly, resulting in a varus/valgus malposition of the distal main fragment.

The anatomical landmark is the Blumensaat’s line, which corresponds to the roof of the intercondylar notch.

Prophylactic antibiotics

Antibiotics are administered according to local antibiotic policy and specific patient requirements.

Many surgeons use gram-positive prophylactic antibiotic cover for closed fractures, adding gram-negative prophylactic cover for open fractures. Always remember that antibiotic therapy will never compensate for poor surgical technique.

Anatomical structuresRetrograde nailing approach

2. Skin incision

Make a longitudinal 2 cm skin incision, just distal to the inferior patellar pole, over the midline of the patellar tendon.

Retrograde nailing approach

3. Soft-tissue handling

Spread the medial parapatellar soft tissues longitudinally with scissors. Retract the patellar tendon gently to allow for guide-wire insertion.

The approach may alternatively involve splitting of the patellar tendon.

Retrograde nailing approach

4. Wound closure

Before closure, irrigate wounds copiously with warm Ringer lactate solution. Close the joint capsule and the fascia with absorbable sutures. The use of a suction drain may be considered. Close the skin meticulously with nonabsorbable sutures.