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Treatment with Locking Intramedullary Nailing for Intertrochanteric Fracture of the Femur Utilizing a New Awl with a Distal Positioner
Published on: June 6, 2025
Incidence and Functional Impact of Malrotation after Intramedullary Nailing of Femoral Shaft Fractures: A Prospective
Nitish Kumar1, Navdeep Singh Keer2, Loveneesh G Krishna1
1Central Institute of Orthopaedics, VMMC and Safdarjung Hospital, New Delhi, India.
Introduction:
Rotational malalignment is a frequently overlooked yet clinically significant complication following closed intramedullary nailing (IMN) of femoral shaft fractures. Malrotation may result in functional impairment, altered gait biomechanics, and patient dissatisfaction. Computed tomography (CT) remains the most accurate modality for quantifying femoral torsion. This study aimed to determine the incidence, degree, and functional consequences of malrotation following IMN in diaphyseal and diaphyseo-metaphyseal femur fractures using CT-based assessment.
Materials And Methods:
This prospective observational study was conducted at a tertiary trauma center in Delhi over 18 months. Thirty skeletally mature patients with closed diaphyseal or diaphyseo-metaphyseal femur fractures treated with closed antegrade IMN were included. Post-operative femoral torsion was assessed through axial CT scans using the method described by Jeanmart. Lower extremity functional scale (LEFS) scores were recorded preoperatively and at 6 weeks, 12 weeks, and 6 months postoperatively. Correlation analyses were performed between malrotation magnitude, fracture comminution, timing of surgery, and functional outcomes. Significant malrotation (defined as >10° difference compared to the contralateral limb) was observed in 20% of patients. Internal rotation deformities (mean: 12.6°) and external rotation deformities (mean: 8°) occurred in equal proportion. Malrotation >10° was significantly associated with lower LEFS scores at 6-month follow-up (P < 0.05). Fracture comminution and delay in surgical fixation (>10 days) were independently correlated with greater degrees of malrotation and worse functional recovery (P < 0.001 and P = 0.0086, respectively). All patients eventually achieved radiological union by 6 months.
Conclusion:
CT-based assessment revealed a notable incidence of malrotation following IMN of femoral shaft fractures, with deformities >10° adversely affecting functional outcomes. Intraoperative vigilance in fracture reduction and early fixation may reduce the risk of malalignment. Routine CT evaluation in selected patients may be warranted to detect clinically relevant torsional deformities.
