Plate and retrograde nailing

Intramedullary nailing usually provides stable fixation for early weight-bearing, but occasionally in severe osteoporosis additional fixation can help prevent construct failure. 
Nailing is usually performed first and supplemented with a plate that is carefully fitted around the nail using what cortical bone is available for fixation. 
In the setting of interprosthetic fracture, a supplementary plate might be utilized to bridge between the intramedullary nail and the total hip stem.

A variety of plate options exists, but variable angle systems have an advantage. Variable angle locking screws can be directed around the nail to get purchasing in the available bone.

Plate selection can often only be finalized after completion of the intramedullary nailing. A new assessment of the deforming forces and bone available for fixation should be performed after nailing is completed.

Because the nail takes up the space in the intramedullary canal, only the cortical bone in the periphery is available for fixation.

Each fracture is different, and a variety of plating options exist. The plates that are used include: surgeon contoured LCPs, and precontoured plates. Occasionally medial buttress plating will help prevent varus collapse, but generally surgeons are more familiar with lateral fixation and precontoured lateral plate options.

A medial plate is applied through a medial approach to the distal femur according the standard principles, as illustrated in the distal femur section of the AO Surgery Reference. Medial plate will often be in buttress mode and length might be restricted such that only 2 screws above and below the fracture will be possible.

A lateral plate should be of sufficient length to provide at least three bicortical points of fixation proximally and as much cancellous fixation distally as possible.

Because more screws are used with the lateral plate, variable angle systems have an advantage in being able to direct variable angle locking screws towards the limited bone available for fixation.

The lateral plate often sits on top of the lateral entry point of the spiral blade and distal locking screw.

The lateral plate can be inserted using an open or MIO technique.

Nail and plate fixation permit early full weight bearing postoperatively.

Knee bracing is not essential and should be considered optional for patient comfort.