Long-term outcome after middle third fractures of the femur shaft; a comparison between antegrade and retrograde nailing.

PURPOSE: This study compared patient-reported functional outcomes, range of motion, and radiological alignment in antegrade (AN) versus retrograde nailing (RN) for midshaft femur fractures (AO/OTA type 32). METHODS: A retrospective review of adult patients treated between January 1, 2001, and May 1, 2016, was conducted. Patients completed questionnaires and underwent physical exams to measure leg length, rotation, and hip/knee range of motion. Final radiographs assessed union alignment. RESULTS: A total of 162 patients with 173 fractures were included, with a median follow-up of 8.2 years. Of the 52 patients completing full follow-up, 8% showed rotational malalignment with a flexed hip, and 6% had > 15° malalignment with an extended hip. Knee flexion-extension range was slightly better in the AN group (130° vs. 125°; p = 0.019). Patients treated with AN also showed better results in the Lower Extremity Functional Scale (LKS) (83 vs. 61; p = 0.041) and the SMFA dysfunction index (13 vs. 29; p = 0.026) compared to RN. CONCLUSION: While both nailing techniques produced similar overall outcomes, AN demonstrated fewer complications, fewer rotational issues, and better patient-reported outcomes. Based on these findings, AN is preferred over RN for treating midshaft femoral fractures when technically feasible.