The Clinical Relevance of the Rotational Deformity after Femoral Shaft Fracture Treated with Intramedullary Nailing

Abstract

Objective: The clinical relevance of the rotational deformities after the femoral shaft fracture treated with intramedullary osteosynthesis was evaluated. Symptoms and the amount of the malrotation were compared. To obtain a better insight into the clinical relevance, the anteversion angles of fifteen healthy volunteers were measured by CT and compared with the results of the patient group.
Setting and Design: In a retrospective study, interviews and examinations were possible in thirty-four patients. Patient's complaints were classified in four categories: none, little, moderate, and severe. Physical examination was performed in the prone and supine positions, using the neutral-0-method. The measurements obtained from these patients were related to a CT analysis according to Mesgardzadeh, a method accurate to ± 1°.
Results: No association is shown between the complaints and the amount of the malrotation. Most patients with severe complaints had little malrotations and only one patient with daily symptoms had a malrotation above the 20° endorotation. Measurements in physical examination did not correspond to the amount of the malformation obtained by CT either. In a paired Student t-test p = 0.39 when the physical examination in the prone position and CT measurements were related and p = 0.55 when the physical examination in the supine position and CT measurements were related.
Conclusion: This study shows that the amount of the rotational deformity as determined by CT scan following an intramedullary nailing of the femur does not correlate well with a patient's complaints or physical examination. This finding lends to the support that intramedullary nailing of the femur has little clinical relevance.

Rotational deformity - Femoral fracture - Intramedullary nailing

References

• 1 Bland J M, Altman D G. Statistical methods for assessing agreement between two methods of clinical measurement.  The Lancet. 1986;  1 307-310
• 2 Bone L, Bucholz R. The management of fractures in the patient with multiple trauma.  J Bone Joint Surg [Am]. 1986;  68 945-949
• 3 Braten M, Terjesen T, Rossvoll I. Torsional deformity after intramedullary nailing of femoral shaft fractures. Measurement of anterversion angles in 110 patients.  J Bone Joint Surg [Br]. 1993;  75 799-803
• 4 Braten M, Terjesen T, Rossvoll I. Femoral anteversion in normal adults.  Acta Orthop Scand. 1992;  63 29-32
• 5 Brouwer K J, Molenaar J C, van Linge B. Rotational deformities after femoral shaft fractures. A retrospective study 27-32 years after the accident.  Acta Orthop Scand. 1981;  52 81-89
• 6 Brumback R J, Reilly J P, Poka A, Lakatos R P, Bathon G H, Burgess A R. Intramedullary nailing of femoral shaft fractures. Part I: decision-making errors with interlocking fixation.  J Bone Joint Surg [Am]. 1988;  70 1441-1452
• 7 Brumback R J, Reilly J P, Poka A, Lakatos R P, Bathon G H, Burgess A R. Intramedullary nailing of femoral shaft fractures. Part II: fracture-healing with static interlocking fixation.  J Bone Joint Surg [Am]. 1988;  70 1453-1462
• 8 Cristie J, Court-Brown C, Kinnimonth A WG, Howie C R. Intramedullary locking nails in the management of femoral shaft fractures.  J Bone Joint Surg [Br]. 1988;  70 206-210
• 9 Dugdale T W, Degnan G G, Turen C H. The use of computed tomographic scan to assess femoral malrotation after intramedullary nailing. A case report.  Clin Orthop. 1990;  279 258-262
• 10 Dunn D M. Anteversion of the neck of the femur.  J Bone Joint Surg [Br]. 1952;  34 181-189
• 11 Hanks G A, Foster W C, Cardea J A. Treatment of femoral shaft fractures with the Brooker-Wills interlocking intramedullary nail.  Clin Orthop. 1988;  226 206-218
• 12 Harper M C. Fractures of the femur treated by open and closed intramedullary nailing using the fluted rod.  J Bone Joint Surg [Am]. 1985;  67 699-708
• 13 Hogh J, Mikkelsen P. Hansen-Street nailing of fractures of the femoral shaft. A study of 70 consecutive cases.  Injury. 1983;  14 440-446
• 14 Hooper G J, Lyon D W. Closed unlocked nailing for comminuted femoral fractures.  J Bone Joint Surg [Br]. 1988;  70 619-621
• 15 Johnson K D, Cadambi A, Seibert G B. Incidence of adult respiratory distress syndrome in patients with multiple musculoskeletal injuries: effect of early operative stabilization of fractures.  J Trauma. 1985;  25 375-384
• 16 Kempf I, Grosse A, Beck G. Closed locked intramedullary nailing. Its application to comminuted fractures of the femur.  J Bone Joint Surg [Am]. 1985;  67 709-720
• 17 King K F, Rush J. Closed intramedullary nailing of femoral shaft fractures. A review of one hundred and twelve cases treated by the Küntscher technique.  J Bone Joint Surg [Am]. 1981;  63 1319-1323
• 18 Klemm K W, Borner M. Interlocking nailing of complex fractures of the femur and tibia.  Clin Orthop. 1986;  212 89-100
• 19 Krettek C, Rudolf J, Schandelmaier P, Guy P, Konemann B, Tscherne H. Unreamed intramedullary nailing of femoral shaft fractures: operative technique and early clinical experience with the standard locking option.  Injury. 1996;  27 233-254
• 20 Mesgarzadeh M, Revesz G, Bonakdarpour A. Femoral neck torsion angle measurement by computed tomography.  J Comput Assist Tomogr. 1987;  11 799-803
• 21 Murphy C P, D’Ambrosia R D, Dabezies E J, Acker J H, Shoji H, Chuinard R G. Complex femur fractures: treatment with the Wagner external fixation device of the Grosse-Kempf interlocking nail.  J Trauma. 1988;  28 1553-1560
• 22 Murphy S B, Simon S R, Kijewski P K, Wilkinson R H, Griscom N T. Femoral anteversion.  J Bone Joint Surg [Am]. 1987;  69 1169-1176
• 23 Murti G S, Ring P A. Closed medullary nailing of fractures of the femoral shaft using the AO-method.  Injury. 1983;  14 318-323
• 24 Reikeras O, Hoiseth A, Reigstad A, Fonstelien E. Femoral neck angles. A specimen study with special regard to bilateral differences.  Acta Ortop Scand. 1982;  52 775-779
• 25 Riske E B, Myllynen P. Fat embolism in patients with multiple injuries.  J Trauma. 1982;  22 891-894
• 26 Rothwell A G. Closed Küntscher nailing for comminuted femoral shaft fractures.  J Bone Joint Surg [Br]. 1982;  64 12-15
• 27 Ryder C T, Crane L. Measuring femoral anteversion: the problem and the method.  J Bone Joint Surg [Am]. 1953;  35 321-328
• 28 Sennerich T, Sutter P, Ritter G, Zapf S. Computertomographische Kontrolle des Antetorsionswinkels nach Oberschenkelschaftfrakturen des Erwachsenen.  Unfallchirurg. 1992;  95 301-305
• 29 Stockenhuber N, Hofer H P, Schweighofer F, Bratschitsch G, Szyszkowitz R. Erste Erfahrungen mit dem unaufgebohrten AO-Marknagel (UFN) in der Behandlung von Oberschenkelfrakturen.  Chirurg. 1997;  68 718-726
• 30 Thoresen B O, Alho A, Ekeland A, Stromsoe K, Folleras G, Haukebo A. Interlocking intramedullary nailing in femoral shaft fractures. A report of forty-eight cases.  J Bone Joint Surg [Am]. 1985;  67 1313-1320
• 31 Weiner D S, Cook A J, Hoyt W A, Oravec C E. Computed tomography in the measurement of femoral anteversion.  Orthopedics. 1978;  1 299-306
• 32 Winquist R A, Hansen S T, Clawson D K. Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases.  J Bone Joint Surg [Am]. 1984;  66 529-538
• 33 Wiss D A, Fleming C H, Matta J M, Clark D. Comminuted and rotational unstable fractures of the femur treated with an interlocking nail.  Clin Orthop Rel Research. 1986;  11 35-47
• 34 Wissing H, Spira G. Die Bestimmung von Rotationsfehler am Femur durch computertomographische Bestimmung des Antetorsionswinkels der Schenkelhalses.  Unfallchirurgie. 1986;  12 1-11
• 35 Wolf H, Schauwecker F, Tittel K. Rotationsfehler nach Marknagelung des Oberschenkels.  Unfallchirurgie. 1984;  10 133-136
• 36 Yang K H, Han D Y, Jahng J S, Shin D E, Park J H. Prevention of malrotation deformity in femoral shaft fracture.  Journal of Orthopaedic Trauma. 1998;  12 558-562