Rotational malalignment in femoral nailing: prevention, diagnosis and surgical correction

Rotational malalignment in femoral nailing: prevention, diagnosis and surgical correction

Authors

  • Luigi Branca Vergano U.O. Ortopedia e Traumatologia, Ospedale M. Bufalini, Cesena (FC)
  • Gianluca Coviello Ospedale M. Bufalini, Cesena (FC)
  • Mauro Monesi Ospedale M. Bufalini, Cesena (FC)

Keywords:

femoral nailing, malrotation, rotational malalignment, derotation

Abstract

Background and aim of the work: to review and discuss the literature about rotational malalignment during and after femoral nailing.

Methods: analysis of the literature on prevention and evaluation of rotation during femoral nailing, clinical and subjective consequences of malrotation and techniques used to correct the deformity, both in the acute and chronic phase.

Results: malrotation is very common after femoral nailing. The exact definition of a malrotated femur is controversial, but it is widely agreed that a rotational malalignment <10° is considered normal while >30° is a deformity which requires correction. The complaints of the patients with a malrotated femur can be various and can involve the hip, the knee or below the knee. The ability to compensate for the deformity while standing and walking may decrease the symptoms. Surgical correction is feasible with many techniques and devices: the procedure involving derotation, changing the locking screws and maintaining the nail is safe, reproducible and relatively easy.

Conclusions: prevention of malrotation during femoral nailing is the cornerstone of successful operation outcomes. If rotational malalignment is suspected, prompt diagnosis and adequate surgical treatment are mandatory to overcome this common complication.

References

Bucholz RW, Jones A. Fractures of the shaft of the femur. J Bone Joint Surg Am. 1991;73(10):1561-1566

Brumback RJ, Virkus WW. Intramedullary nailing of the femur: reamed versus nonreamed. J Am Acad Orthop Surg. 2000;8(2):83-90.

Wolinsky PR, McCarty E, Shyr Y, Johnson K. Reamed intramedullary nailing of the femur: 551 cases. J Trauma. 1999;46(3):392-399.

Swanson EA, Garrard EC, Bernstein DT, OʼConnor DP, Brinker MR. Results of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions. J Orthop Trauma. 2015;29(1):21-27

Winquist RA, Hansen ST Jr, Clawson DK. Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. 1984. J Bone Joint Surg Am. 2001;83(12):1912

Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R. Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma. 2001;15(3):161-169

Langer JS, Gardner MJ, Ricci WM. The cortical step sign as a tool for assessing and correcting rotational deformity in femoral shaft fractures. J Orthop Trauma. 2010;24(2):82-88

Jaarsma RL, Pakvis DF, Verdonschot N et al (2004) Rotational malalignment after intramedullary nailing of femoral fractures. J Orthop Trauma 18:403–409

Jaarsma RL, Verdonschot N, van der Venne R et al (2005) Avoiding rotational malalignment after fractures of the femur by using the profile of the lesser trochanter: an in vitro study. Arch Orthop Trauma Surg 125:184–187

Citak M, Suero EM, O'Loughlin PF, et al. Femoral malrotation following intramedullary nailing in bilateral femoral shaft fractures. Arch Orthop Trauma Surg. 2011;131(6):823-827

Sennerich T, Sutter P, Ritter G, Zapf S. Computertomographische Kontrolle des Antetorsionswinkels nach Oberschenkelschaftfrakturen des Erwachsenen [Computerized tomography follow-up of the ante-torsion angle after femoral shaft fractures in the adult]. Unfallchirurg. 1992;95(6):301-305.

Tornetta P 3rd, Ritz G, Kantor A. Femoral torsion after interlocked nailing of unstable femoral fractures. J Trauma. 1995;38(2):213-219.

Gugenheim JJ, Probe RA, Brinker MR. The effects of femoral shaft malrotation on lower extremity anatomy. J Orthop Trauma. 2004;18(10):658-664

Kent ME, Arora A, Owen PJ, Khanduja V. Assessment and correction of femoral malrotation following intramedullary nailing of the femur. Acta Orthop Belg.

Thoresen BO, Alho A, Ekeland A, Strømsøe K, Follerås G, Haukebø A. Interlocking intramedullary nailing in femoral shaft fractures. A report of forty-eight cases. J Bone Joint Surg Am. 1985;67(9):1313-1320

Karaman O, Ayhan E, Kesmezacar H, Seker A, Unlu MC, Aydingoz O. Rotational malalignment after closed intramedullary nailing of femoral shaft fractures and its influence on daily life. Eur J Orthop Surg Traumatol. 2014;24(7):1243-1247

Lindsey JD, Krieg JC. Femoral malrotation following intramedullary nail fixation. J Am Acad Orthop Surg. 2011;19(1):17-26

Stephen DJ, Kreder HJ, Schemitsch EH, Conlan LB, Wild L, McKee MD. Femoral intramedullary nailing: comparison of fracture-table and manual traction. a prospective, randomized study. J Bone Joint Surg Am. 2002;84(9):1514-1521.

Reikerås O, Høiseth A, Reigstad A, Fönstelien E. Femoral neck angles: a specimen study with special regard to bilateral differences. Acta Orthop Scand. 1982;53(5):775-779.

Kim JJ, Kim E, Kim KY. Predicting the rotationally neutral state of the femur by comparing the shape of the contralateral lesser trochanter. Orthopedics. 2001;24(11):1069-1070.

Park J, Yang KH. Correction of malalignment in proximal femoral nailing--Reduction technique of displaced proximal fragment. Injury. 2010;41(6):634-638

Afsari A, Liporace F, Lindvall E, Infante A Jr, Sagi HC, Haidukewych GJ. Clamp-assisted reduction of high subtrochanteric fractures of the femur. J Bone Joint Surg Am. 2009;91(8):1913-1918

Ricci WM, Gallagher B, Haidukewych GJ. Intramedullary nailing of femoral shaft fractures: current concepts. J Am Acad Orthop Surg. 2009;17(5):296-305.

Hilgert RE, Ohrendorf K, Schäfer FK, et al. Bildwandlergestützte Vermeidung einer Torsionsabweichung zur Gegenseite bei der Oberschenkelmarknagelung [Preventing malrotation during intramedullary nailing of femoral fractures]. Unfallchirurg. 2006;109(10):855-861

Ao surgery reference: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/femoral-shaft/simple-transverse-middle-1-3-fractures/antegrade-nailing

Langer JS, Gardner MJ, Ricci WM. The cortical step sign as a tool for assessing and correcting rotational deformity in femoral shaft fractures. J Orthop Trauma. 2010;24(2):82-88

Gösling T, Oszwald M, Kendoff D, Citak M, Krettek C, Hufner T. Computer-assisted antetorsion control prevents malrotation in femoral nailing: an experimental study and preliminary clinical case series. Arch Orthop Trauma Surg. 2009;129(11):1521-1526.

Khoury A, Liebergall M, Weil Y, Mosheiff R. Computerized fluoroscopic-based navigation-assisted intramedullary nailing. Am J Orthop (Belle Mead NJ). 2007;36(11):582-585

Kendoff D, Citak M, Gardner MJ, Gösling T, Krettek C, Hüfner T. Navigated femoral nailing using noninvasive registration of the contralateral intact femur to restore anteversion. Technique and clinical use. J Orthop Trauma. 2007;21(10):725-730.

Bråten M, Terjesen T, Rossvoll I. Torsional deformity after intramedullary nailing of femoral shaft fractures. Measurement of anteversion angles in 110 patients. J Bone Joint Surg Br. 1993;75(5):799-803.

Yildirim AO, Aksahin E, Sakman B, et al. The effect of rotational deformity on patellofemoral parameters following the treatment of femoral shaft fracture. Arch Orthop Trauma Surg. 2013;133(5):641-648.

Gugala Z, Qaisi YT, Hipp JA, Lindsey RW. Long-term functional implications of the iatrogenic rotational malalignment of healed diaphyseal femur fractures following intramedullary nailing. Clin Biomech (Bristol, Avon). 2011;26(3):274-277.

Salem Kh, Maier D, Keppler p, Kinzl L, Gebhard F. Limb malalignment and functional outcome after antegrade versus retrograde intramedullary nailing in distal femoral fractures. J Trauma 2006 ; 61 : 375-381

Jeanmart L, Baert AL, Wackenheim A. Computer Tomography of Neck, Chest, Spine and Limbs. Atlas of Pathological Computer Tomography. Vol 3. Springer, Berlin, Heidelberg, New York. pp 171-177.

Eckhoff DG. Effect of limb malrotation on malalignment and osteoarthritis. Orthop Clin North Am. 1994;25(3):405-414

Jaarsma RL, Ongkiehong BF, Grüneberg C, Verdonschot N, Duysens J, van Kampen A. Compensation for rotational malalignment after intramedullary nailing for femoral shaft fractures. An analysis by plantar pressure measurements during gait. Injury. 2004;35(12):1270-1278.

Sloan, Matthew MD, MS; Lim, Daniel MD; Mehta, Samir MD Femoral Derotation for the Acutely Malrotated Femur Following Intramedullary Nail Fixation, Techniques in Orthopaedics: January 16, 2019

Jagernauth S, Tindall AJ, Kohli S, Allen P. New Technique: A Novel Femoral Derotation Osteotomy for Malrotation following Intramedullary Nailing. Case Rep Orthop

Samuel AW. Malrotation of the femur after intramedullary nailing. Injury 1996 ; 27(6) : 438-440.

Brinker MR, Gugenheim JJ, O'Connor DP, London JC. Ilizarov correction of malrotated femoral shaft fracture initially treated with an intramedullary nail: a case report. Am J Orthop (Belle Mead NJ). 2004;33(10):489-493

Chiodo CP, Jupiter JB, Alvarez G, Chandler HP. Oblique osteotomy for multiplanar correction of malunions of the femoral shaft. Clin Orthop Relat Res. 2003;(406):185-194.

Winquist RA. Closed intramedullary osteotomies of the femur. Clin Orthop Relat Res. 1986;(212):155-164

Stahl JP, Alt V, Kraus R, Hoerbelt R, Itoman M, Schnettler R. Derotation of post-traumatic femoral deformities by closed intramedullary sawing. Injury 2006;37(2):145-151.

Downloads

Published

30-12-2020

How to Cite

1.
Rotational malalignment in femoral nailing: prevention, diagnosis and surgical correction. Acta Biomed [Internet]. 2020 Dec. 30 [cited 2024 Mar. 29];91(14-S):e2020003. Available from: https://mattioli1885journals.com/index.php/actabiomedica/article/view/10725