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All issues Volume 12 (2026) SICOT-J, 12 (2026) 33 Full HTML
Open Access
Review
Issue
SICOT-J
Volume 12, 2026
Article Number 33
Number of page(s) 14
Section Lower Limb
DOI https://doi.org/10.1051/sicotj/2026030
Published online 26 May 2026

© The Authors, published by EDP Sciences, 2026

Licence Creative CommonsThis is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction

Distal femur fractures account for 0.4% of all fractures and 3–6% of femur fractures [1]. Its age distribution is bimodal, with young people (20–30 years old with high energy injuries such as road traffic accidents) and elderly women (approximately 70 years old, with low energy injuries such as falls from standing height) being the most common [2, 3]. The goals of surgical fixation for these fractures are relative stability for diaphyseal fractures to initiate early mobilization, anatomical articular reduction, and blood supply preservation [4]. The non-union rate is quoted as high as 18–20% [5].

Compared to an eccentrically positioned plate and screws construct, intramedullary nails are load-sharing devices that stay close to the femoral axis and have better stress distribution. Nailing also requires a shorter operating time, less perioperative blood loss, and early patient mobilization [6].

One proven treatment for these fractures is retrograde nailing [7]. Prior research on the results of patients treated with retrograde nailing frequently included both young individuals with high-energy fractures and older patients with osteoporotic fractures [8, 9]. Retrograde intramedullary nailing was first used by Green in 1988 to treat distal femur fractures [10]. Its benefits include indirect reduction and internal fixation, which prevent excessive soft tissue dissection, periosteal blood supply interruption, and provide high union rates [11, 12].

Antegrade intramedullary nailing of the femur is an effective treatment for diaphyseal fractures [13]. The antegrade approach to femoral nailing is the favored way of fixation for the majority of surgeons due to its relative simplicity of patient posture (supine position with or without ipsilateral traction) and obvious surgical starting locations (piriformis fossa or greater trochanter, depending on nail design) [14].

A key consideration in antegrade intramedullary nailing is protection of the femoral neck, particularly in older osteoporotic patients, in whom reduced bone mineral density increases the risk of iatrogenic femoral neck fracture during entry point creation, reaming, or nail insertion. Malposition of the entry point, excessive insertion force, and implant–canal mismatch may increase stress within the proximal femur, predisposing to fracture. Given the substantial biomechanical forces transmitted through the femoral neck, meticulous surgical technique, appropriate implant selection, and careful intraoperative imaging are essential to minimize this risk [5].

The two methods for treating distal femur fractures – antegrade and retrograde intramedullary nailing – are compared and contrasted in this systematic study.

Search strategy and study design

A study protocol was developed and agreed upon by all authors prior to commencement. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines [15]. A comprehensive electronic search was performed across MEDLINE (via PubMed), EMBASE, and the Cochrane Library, including the Cochrane Central Register of Controlled Trials.

Search terms were constructed using combinations of keywords and Medical Subject Headings (MeSH), including: (“femoral shaft fracture” OR “distal femur fracture”) AND (“antegrade intramedullary nailing” OR “retrograde intramedullary nailing”) AND (“union” OR “non-union” OR “revision” OR “malunion” OR “post-operative fracture”). Reference lists of included studies were manually screened to identify additional relevant articles.

Eligibility criteria

Studies were eligible for inclusion if they directly compared antegrade and retrograde intramedullary nailing for femoral shaft or distal femur fractures and reported at least one predefined clinical or radiological outcome. Both retrospective and prospective studies involving human participants were included. Exclusion criteria comprised biomechanical or cadaveric studies, case reports, narrative reviews, editorials, non-English publications, and studies lacking full-text availability.

Primary outcomes were fracture union, revision surgery, and refracture following index fixation. Secondary outcomes included operative time, mobility-related outcomes, and overall complication rates. The review was prospectively registered with PROSPERO (CRD420251274011).

Data extraction and quality assessment

Data extraction was independently undertaken by four reviewers (M.I.K., A.S., T.M., and N.S.) using a standardized extraction form. Extracted data were cross-checked by senior authors (K.R., K.A., and P.M.) to ensure accuracy. Information collected included study characteristics, patient demographics, fracture type, surgical technique, follow-up duration, and reported outcomes.

Risk of bias was assessed independently by two reviewers (K.R. and P.M.) using the ROBINS-I tool for non-randomized studies [16]. Discrepancies were resolved by consensus. Risk-of-bias visualization was generated using the ROBVIS tool [17].

Statistical analysis

Meta-analyses were conducted using Review Manager (RevMan version 5.4). Dichotomous variables were pooled using odds ratios (ORs), while continuous outcomes were analyzed using weighted mean differences, both reported with 95% confidence intervals. Statistical heterogeneity was evaluated using the Chi-square test and quantified with the I2 statistic, with values exceeding 50% indicating substantial heterogeneity. Publication bias was assessed through funnel plot analysis and Egger’s regression test.

Results

In the initial database search, 1127 items were found; 163 of them were removed due to duplication. Following abstract screening and the application of the exclusion criteria, 941 of the remaining ones were eliminated. Eighteen were deleted after the entire texts were evaluated to determine their relevance to the review subject. The final evaluation had five papers in total. A PRISMA-style graphic depicting the book selection procedure is shown in Figure 1 [15].

Thumbnail: Figure 1 Refer to the following caption and surrounding text. Figure 1

PRISMA: Preferred reporting items for systematic reviews and meta-analyses.

Five hundred and eighty-five of the five studies used retrograde intramedullary nailing, whereas 894 used antegrade intramedullary nailing [18–22]. The research comprised populations from Sweden, Turkey, Malaysia, Nigeria, and the United States [18–22].

Study characteristics are demonstrated in Table 1 [18–22].

Table 1

Study characteristics of included studies.

Clinical and radiological findings are summarized in Table 2 [18–22].

Table 2

Clinical and radiological outcomes (Retrograde vs Antegrade).

Qualitative findings are summarized in Table 3 [18–22].

Table 3

Qualitative data (Retrograde vs Antegrade).

Refracture after primary operation

According to our research, the antegrade approach had a significantly lower rate of fracture after primary fixation compared to the retrograde approach, with a moderate heterogeneity (OR 31.41; CI – 4.45 – 221.80; p = 0.0.0005; I2 – 28%) as seen in Figure 2.

Thumbnail: Figure 2 Refer to the following caption and surrounding text. Figure 2

Demonstrates forrest graph for refracture after primary operation.

The funnel plot and Egger’s test (p = 0.005), as shown in Figure 3, suggest significant publication bias. A meta-analysis of I2 – 28% shows Moderate heterogeneity.

Thumbnail: Figure 3 Refer to the following caption and surrounding text. Figure 3

Demonstrates Funnel plot and Egger’s test for refracture after primary fixation. Predictor – Standard error Z = −2.632, p = 0.008 CI: −5.470 to −0.801.

Revision

According to our research, the antegrade approach had a significantly lower rate of revision after primary fixation compared to the retrograde approach, with a moderate heterogeneity (OR 1.76; CI – 1.21 – 2.58; p = 0.0.003; I2 – 31%) as seen in Figure 4.

Thumbnail: Figure 4 Refer to the following caption and surrounding text. Figure 4

Demonstrates forrest graph for revision after primary fixation.

The funnel plot and Egger’s test (p = 0.109), as shown in Figure 5, suggest no significant publication bias. A meta-analysis of I2 31% shows Moderate heterogeneity.

Thumbnail: Figure 5 Refer to the following caption and surrounding text. Figure 5

Demonstrates Funnel plot and Egger’s test for revision after primary fixation. Predictor – Standard error Z = −1.602, p = 0.109 CI: −0.970 – 0.098.

Union

According to our research, the antegrade approach had a lower rate of union after primary fixation compared to the retrograde approach (OR 2.06; CI – 0.86 – 4.90; p = 0.10; I2 – 54%) as seen in Figure 6.

Thumbnail: Figure 6 Refer to the following caption and surrounding text. Figure 6

Demonstrates forrest graph for union after primary fixation.

The funnel plot and Egger’s test (p = 0.716), as shown in Figure 7, suggest no significant publication bias. A meta-analysis of I2 – 54% shows Substantial heterogeneity.

Thumbnail: Figure 7 Refer to the following caption and surrounding text. Figure 7

Demonstrates Funnel plot and Egger’s test for union after primary fixation. Predictor – Standard error Z = −0.364, p = 0.716 CI: −0.410 – 0.282.

Malunion

According to our research, the antegrade approach had a higher rate of malunion after primary fixation compared to the retrograde approach (OR 0.85; CI – 0.36 – 2.04; p = 0.72; I2 – N/A) as seen in Figure 8.

Thumbnail: Figure 8 Refer to the following caption and surrounding text. Figure 8

Demonstrates forrest graph for malunion after primary fixation.

The funnel plot and Egger’s test (p = 0.793), as shown in Figure 9, suggest no significant publication bias.

Thumbnail: Figure 9 Refer to the following caption and surrounding text. Figure 9

Demonstrates Funnel plot and Egger’s test for malunion after primary fixation. Predictor – Standard error Z = −2.63, p = 0.793 CI: −0.716 – 0.938.

Delayed union

According to our research, the antegrade approach had a higher rate of delayed union after primary fixation compared to the retrograde approach (OR 0.89; CI – 0.32 – 2.47; p = 0.83; I2 – 64%) as seen in Figure 10.

Thumbnail: Figure 10 Refer to the following caption and surrounding text. Figure 10

Demonstrates forrest graph for delayed union after primary fixation.

The funnel plot and Egger’s test (p = 0.914), as shown in Figure 11, suggest no significant publication bias. A meta-analysis, I2 = 54% shows Substantial heterogeneity.

Thumbnail: Figure 11 Refer to the following caption and surrounding text. Figure 11

Demonstrates Funnel plot and Egger’s test for delayed union after primary fixation. Predictor – Standard error Z = 0.108, p = 0.914 CI: −1.510 – 1.687.

Non-union

According to our research, the antegrade approach had a higher rate of non-union after primary fixation compared to the retrograde approach (OR 0.86; CI – 0.33 – 2.24; p=0.75; I2 – 0%) as seen in Figure 12.

Thumbnail: Figure 12 Refer to the following caption and surrounding text. Figure 12

Demonstrates forrest graph for non-union after primary fixation.

The funnel plot and Egger’s test (p = 0.947), as shown in Figure 13, suggest no significant publication bias. A meta-analysis of I2 – 0%.

Thumbnail: Figure 13 Refer to the following caption and surrounding text. Figure 13

Demonstrates Funnel plot and Egger’s test for non-union after primary fixation. Predictor – Standard error Z = 0.066, p = 0.947 CI: −0.934 – 0.999.

Operation time

According to our research, the antegrade approach had similar operative time compared to the retrograde approach (OR 1.48; CI: −3.82 to 6.78; p = 0.58; I2 – 96%) as seen in Figure 14.

Thumbnail: Figure 14 Refer to the following caption and surrounding text. Figure 14

Demonstrates forrest graph for mean operative time.

The funnel plot and Egger’s test (p = 0.869), as shown in Figure 15, suggest no significant publication bias. A meta-analysis of I2 – 96%.

Thumbnail: Figure 15 Refer to the following caption and surrounding text. Figure 15

Demonstrates Funnel plot and Egger's test for mean operative time. Predictor. Standard error Z = 0.165, p = 0.869 CI: −1.175 – 1.391.

Complications

According to our research, the antegrade approach had a lower incidence of complications after primary fixation compared to the retrograde approach (OR 1.10; CI – 0.73 – 1.65; p = 0.65; I2 – 77%) as seen in Figure 16.

Thumbnail: Figure 16 Refer to the following caption and surrounding text. Figure 16

Demonstrates forrest graph for complications after primary fixation.

The funnel plot and Egger’s test (p = 0.742), as shown in Figure 17, suggest no significant publication bias. A meta-analysis of I2 – 77% – shows Considerable heterogeneity.

Thumbnail: Figure 17 Refer to the following caption and surrounding text. Figure 17

Demonstrates Funnel plot and Egger’s test for complications after primary fixation. Predictor – Standard error. Z = −0.330, p = 0.742 CI: −1.235 – 0.880.

Data quality

All of the included studies were either retrospective or prospective studies and were deemed to have a high overall risk of bias due to confounding. Each study included in the meta-analysis is evaluated separately in Figure 18.

Thumbnail: Figure 18 Refer to the following caption and surrounding text. Figure 18

ROBINS I ROBVIS tool – Each study included in the meta-analysis is evaluated separately in Figure 18.

Discussion

With an emphasis on important clinical outcomes such as post-operative fracture healing, revision surgery, nonunion, and malunion, this meta-analysis synthesizes comparative information on antegrade vs retrograde intramedullary nailing (IMN) for femoral shaft and distal femur fractures in older individuals.

Union and nonunion outcomes

Both antegrade and retrograde IMN approaches have shown good overall union rates without statistically significant differences in previous comparative investigations [20]. Retrograde and antegrade nails showed equal healing rates following the index treatment in traditional comparative cohort data, with similar nonunion incidence (about 6% in both groups) and eventual healing following additional surgeries in most patients [20].

Furthermore, when fixation is satisfactory and fracture reduction is adequate, systematic research indicates that nonunion rates are generally modest and not greatly impacted by the direction of nail entrance [23].

Our study reported that retrograde had a higher rate of union than antegrade.

Malunion and alignment

Comparative studies of femoral shaft fractures also show that malunion rates, which indicate the quality of alignment following repair, are generally similar among procedures. In a large retrospective series, for example, malunion was documented in 11% of retrograde and 13% of antegrade instances, with no significant difference between groups [20].

However, compared with retrograde procedures, antegrade nailing may represent a slightly higher risk of loss of coronal alignment in particular fracture subgroups, possibly because of mechanical leverage and entry site biomechanics, according to some data in the larger femoral fracture literature [24].

Our study showed antegrade nailing had a higher rate of malunion and delayed union, though none of our results showed a statistically significant difference.

Revisions and complications

In existing investigations of adult femur fractures, reoperation and revision rates – important indicators of early postoperative failure – do not seem to consistently favor one strategy over the other [25]. The general safety of both procedures for shaft fractures was highlighted by a recent systematic study that compared antegrade and retrograde treatments and found no significant difference in reoperation rates or the majority of secondary problems [25].

Interestingly, the pattern of problems seems to vary depending on the entrance method: anterior knee discomfort is more usually linked to retrograde nailing, while proximal thigh or hip pain is more frequently related to antegrade nailing [20].

Although antegrade intramedullary nailing has been associated with higher rates of malalignment or delayed union in certain fracture patterns, it may paradoxically demonstrate lower revision rates due to several biomechanical and technical factors. Antegrade nails provide a more central, load-sharing construct along the anatomical axis of the femur, which can enhance overall stability and promote sufficient callus formation even in the presence of minor malalignment. In addition, the entry point and proximal fixation allow for better control of femoral length and rotation in many shaft fractures, reducing the likelihood of gross mechanical failure requiring revision. Furthermore, delayed unions following antegrade nailing are often amenable to non-operative management or minor adjuncts (e.g., dynamization), whereas complications associated with alternative techniques may necessitate more complex reoperations [5]. These factors may explain the lower observed revision rates despite theoretical concerns regarding alignment and healing [5].

Our study showed the antegrade approach had a significantly lower rate of revisions and a lower incidence of complications after primary fixation.

Functional outcomes and older patients

Although they are less commonly recorded, functional outcomes in geriatrics that go beyond simple radiographic recovery, such as pain, mobility, and quality of life, are crucial. There are no discernible differences between antegrade and retrograde nails in adult populations according to long-term patient-reported outcomes (such as WOMAC and VAS), indicating that both approaches can produce satisfactory functional recovery [26].

Limitations and implications

The lack of large cohorts specifically targeting older populations (≥65 or ≥80 years) limits the generalisability of existing evidence to the management of geriatric fractures, where physiological reserve, bone quality, comorbidities, and functional demands differ substantially from those of younger cohorts. Many current studies report aggregated outcomes without adequate age stratification, potentially obscuring differences in healing rates, complication profiles, and tolerance to surgical interventions. In older patients, outcomes such as functional recovery, return to independence, mobility, and quality of life are often more clinically meaningful than radiographic union alone. Therefore, future research should prioritize adequately powered, age-stratified analyses and incorporate patient-centered outcome measures, including validated functional scores and health-related quality of life assessments, to better inform decision-making in this growing and high-risk population.

Conclusion

Our study shows that the antegrade approach has lower revision rates despite a higher incidence of malunion and delayed union. The antegrade approach has a lower complication rate, and both approaches have similar operation times. Our authors also suggest an additional advantage of antegrade nailing in elderly patients, as this allows protection of the femoral neck. This study can serve as a basis for further clinical trials in the future.

Funding

Funding is not received for this research.

Conflicts of interest

All authors declare no conflict of interest.

Data availability statement

Data is available upon request.

Author contribution statement

Author 1: Study selection, literature search, data extraction, quality assessment, meta-analysis, writing – original (introduction, methodology, results, and conclusion).

Authors 2, 3, 4, and 5: Study selection, literature search.

Author 6: Meta-analysis, writing – original (results and conclusion).

Author 7: Conceptualization, quality assessment, supervision, and Writing review.

Ethics approval

Ethical approval was not required for this study as it is a systematic review and meta-analysis based exclusively on previously published studies and did not involve direct patient contact or the use of identifiable individual patient data.

Informed consent

The study did not involve individual patient data.

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Cite this article as: Ravendran K, Khalil MI, Manoharan T, Alexander AA, Shahid N, Abdelghafour K & Mishra P (2026) Comparing outcomes for retrograde intramedullary nailing vs. antegrade intramedullary nailing for Femoral fractures – a systematic review and metaanalysis. SICOT-J 12, 33. https://doi.org/10.1051/sicotj/2026030.

All Tables

Table 1

Study characteristics of included studies.

In the text
Table 2

Clinical and radiological outcomes (Retrograde vs Antegrade).

In the text
Table 3

Qualitative data (Retrograde vs Antegrade).

In the text

All Figures

Thumbnail: Figure 1 Refer to the following caption and surrounding text. Figure 1

PRISMA: Preferred reporting items for systematic reviews and meta-analyses.
In the text
Thumbnail: Figure 2 Refer to the following caption and surrounding text. Figure 2

Demonstrates forrest graph for refracture after primary operation.
In the text
Thumbnail: Figure 3 Refer to the following caption and surrounding text. Figure 3

Demonstrates Funnel plot and Egger’s test for refracture after primary fixation. Predictor – Standard error Z = −2.632, p = 0.008 CI: −5.470 to −0.801.
In the text
Thumbnail: Figure 4 Refer to the following caption and surrounding text. Figure 4

Demonstrates forrest graph for revision after primary fixation.
In the text
Thumbnail: Figure 5 Refer to the following caption and surrounding text. Figure 5

Demonstrates Funnel plot and Egger’s test for revision after primary fixation. Predictor – Standard error Z = −1.602, p = 0.109 CI: −0.970 – 0.098.
In the text
Thumbnail: Figure 6 Refer to the following caption and surrounding text. Figure 6

Demonstrates forrest graph for union after primary fixation.
In the text
Thumbnail: Figure 7 Refer to the following caption and surrounding text. Figure 7

Demonstrates Funnel plot and Egger’s test for union after primary fixation. Predictor – Standard error Z = −0.364, p = 0.716 CI: −0.410 – 0.282.
In the text
Thumbnail: Figure 8 Refer to the following caption and surrounding text. Figure 8

Demonstrates forrest graph for malunion after primary fixation.
In the text
Thumbnail: Figure 9 Refer to the following caption and surrounding text. Figure 9

Demonstrates Funnel plot and Egger’s test for malunion after primary fixation. Predictor – Standard error Z = −2.63, p = 0.793 CI: −0.716 – 0.938.
In the text
Thumbnail: Figure 10 Refer to the following caption and surrounding text. Figure 10

Demonstrates forrest graph for delayed union after primary fixation.
In the text
Thumbnail: Figure 11 Refer to the following caption and surrounding text. Figure 11

Demonstrates Funnel plot and Egger’s test for delayed union after primary fixation. Predictor – Standard error Z = 0.108, p = 0.914 CI: −1.510 – 1.687.
In the text
Thumbnail: Figure 12 Refer to the following caption and surrounding text. Figure 12

Demonstrates forrest graph for non-union after primary fixation.
In the text
Thumbnail: Figure 13 Refer to the following caption and surrounding text. Figure 13

Demonstrates Funnel plot and Egger’s test for non-union after primary fixation. Predictor – Standard error Z = 0.066, p = 0.947 CI: −0.934 – 0.999.
In the text
Thumbnail: Figure 14 Refer to the following caption and surrounding text. Figure 14

Demonstrates forrest graph for mean operative time.
In the text
Thumbnail: Figure 15 Refer to the following caption and surrounding text. Figure 15

Demonstrates Funnel plot and Egger's test for mean operative time. Predictor. Standard error Z = 0.165, p = 0.869 CI: −1.175 – 1.391.
In the text
Thumbnail: Figure 16 Refer to the following caption and surrounding text. Figure 16

Demonstrates forrest graph for complications after primary fixation.
In the text
Thumbnail: Figure 17 Refer to the following caption and surrounding text. Figure 17

Demonstrates Funnel plot and Egger’s test for complications after primary fixation. Predictor – Standard error. Z = −0.330, p = 0.742 CI: −1.235 – 0.880.
In the text
Thumbnail: Figure 18 Refer to the following caption and surrounding text. Figure 18

ROBINS I ROBVIS tool – Each study included in the meta-analysis is evaluated separately in Figure 18.
In the text

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