Use of Inherent Anteversion of an Intramedullary Nail to Avoid Malrotation in Comminuted Femur Fractures: A Prospective Case– Control Study

Abstract

Objectives: To (1) evaluate using the inherent anteversion of a second or third generation femoral nail to set the version of the femur during locked intramedullary nailing of comminuted femoral shaft fractures (Espinosa Technique [ET]) and compare it with our traditional method (traditional group [TG]) and (2) assess the variation of anteversion because of the inherent play in the nail itself. Design: A prospective IRB-approved study. Setting: Academic US Level 1 Trauma Center. Patients: Fifty-two consecutive patients with comminuted femur fractures all completed the study. Intervention: The first 27 patients had the anteversion determined using the patellar shadow and lesser trochanter (TG), and the next 25 patients were treated by ET. Main Outcome Measure: Computed tomography scanogram for femoral anteversion and length in the normal versus operated femur. Results: A >15 degree difference from native to operated legs was found in 8/27 TG (29%, 95% CI 15.3%–54.2%), with a mean difference of 11.6 ± 10.2 degrees (95% CI 8.8–16.17) verses 1/25 in the ET group (2.5%, 95% CI 0%–15.3%), with a mean difference of 4.8 ± 6.2 degrees (95% CI 1.38–8.9) (P = 0.0068). There was a 5 degree variability in our ability to center the proximal locking screw in the femoral head and 5 degrees variation in distal locking. Conclusions: The inherent anteversion of a second generation nail can be used to minimize malrotation of the femur after comminuted fractures during locked intramedullary nailing in patients with normal anteversion and is superior to our present fluoroscopic technique. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acute Correction of Femoral Malrotation After Intramedullary Nailing Using an Intraoperative Digital Protractor

“…Malrotation of the femur after IM nailing is a difficult issue for orthopedic surgeons and is the most common complication following this procedure, with a prevalence of 19%-56% [1,5,7,[10][11][12][13][14]. The normal anteversion in healthy individuals without deformity has been shown to be between 9 and 14 degrees [4,7].…”

“…These techniques have pitfalls that make them unreliable because of differences in fracture morphology and variation in normal anatomy [ 5 , 10 ]. The literature has described a technique that uses the inherent anteversion of second-generation antegrade femoral nails (11-12 degrees) to avoid malrotation [ 12 , 14 ]. This technique can reliably align the femur to the 11-12 degrees of anteversion which is built into the nail +/- 5 degrees.…”

“…The gold standard of treatment for these injuries is locked intramedullary (IM) nailing which has resulted in high union rates. One of the most common complications of locked IM nailing is femoral malrotation with an incidence of 19%-56% [2][3][4][5][6][7][8][9][10][11][12][13][14], which is especially prevalent in highly comminuted fractures and transverse fractures due to a lack of osseous integration at the fracture site to assist in anatomic alignment [2][3][4][5][6][7][8][9]. Malrotation of greater than 15 degrees results in functional complaints such as anterior knee pain with demanding activities such as running, climbing stairs, and sports.…”

“…Several techniques have been proposed to avoid femoral malrotation intraoperatively; unfortunately, femoral malrotation during IM nailing still occurs [11][12][13][14][15][16][17]. To the best of our knowledge, no technique has been described to correct malrotation early during the initial hospitalization and before bony healing occurred [18].…”

Staged treatment of a comminuted femoral fracture with Masquelet technique and 3D printed reposition guides

“…Moreover, besides malrotation, varus or valgus malalignment also results in altered knee kinematics and can cause early posttraumatic osteoarthritis [4] . The reason for this high malalignment rate is the absence of bony references during surgery [5] . Therefore, the surgeon can only approximate correct rotation, length and axis.…”