Postoperative Malrotation After Closed Reduction and Intramedullary Nailing of Femoral Shaft Fractures

Closed reduction and intramedullary nailing is an established procedure in the treatment of diaphyseal femoral fractures. Postoperative malrotation of the femur is a complication that can be assessed with computed tomography (CT). A rotational difference >15° to the contralateral side appears in 17 to 35% of literature reports, and correlates with a reduced clinical outcome. Hence, an anatomical reduction of the femur plays an important role.
One-hundred and seven cases of unilateral femoral shaft fractures were investigated. All fractures were treated with closed reduction and intramedullary nailing. All patients underwent computed tomography postoperatively, analyzing rotational differences. In cases with a rotational difference of > 15°, an indication of revision surgery was posed. Twenty-three patients were female and 84 male. The average age was 32.5 ± 14.4 years. The age ranged from 14 to 94 years.
In the postoperative CT scan, according to Waidelich, an average femoral malrotation of 11° ± 9.16° to the healthy side was determined. In 16 cases (14.9 %), 11 males (13.1%) and 5 females (23.81%), a femoral malrotation larger than 15° (average: 23.23° ± 6.02°) was detected.
Femoral malrotation after closed reduction and intramedullary nailing is a delicate topic and occurs commonly. Postoperative computed tomography could in addition to the clinical examination identify critical postoperative deviations and lead to a correction of femoral malrotation in a revision surgery. Despite extensive efforts, an intraoperative adjustment of the rotation could not be achieved anatomically in more than 10% of all cases. As a consequence, after closed reduction and femoral nailing, a postoperative CT scan to detect femoral malrotation is recommended.