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

Joshua Goethals; Daniel R Cavazos; Marek Denisiuk; Ryan Bray; Kerellos Nasr; Rahul Vaidya

doi:10.7759/cureus.37108

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

Cureus. 2023 Apr 4;15(4):e37108. doi: 10.7759/cureus.37108. eCollection 2023 Apr.

Authors

Joshua Goethals¹, Daniel R Cavazos^{2

1}, Marek Denisiuk¹, Ryan Bray¹, Kerellos Nasr^{2

1}, Rahul Vaidya^{2

1}

Affiliations

¹ Orthopaedic Surgery, Detroit Medical Center, Detroit, USA.
² Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, USA.

Abstract

Objective: The goal of the study is to diagnose and accurately correct malrotation of femur fractures after intramedullary (IM) nailing.

Materials and methods: An institutional review board (IRB) approved prospective study that was performed at a U.S. level 1 trauma center. After IM nailing of comminuted femur fractures, a computed tomography (CT) scanogram was routinely performed to detect the difference in the postoperative femoral version. Patients with malalignment greater than 15 degrees compared to the contralateral side were informed about the discrepancy and offered to have it acutely corrected. A four-pin technique was used: two Schanz pins were used for measuring angles and two different pins were used to turn and correct the malalignment. The pin in the distal fragment is placed directly under the nail to prevent shortening in comminuted fractures. The nail was unlocked either proximally for retrograde nails or distally for antegrade nails. The Bonesetter Angle application was used as a digital protractor to intraoperatively measure the two reference pins and correct the malrotation. Alternate holes were used for relocking the nail. All patients received a CT scanogram after correction.

Results: 19/128 patients with comminuted femoral fractures over five years with malrotations between 18 and 47 degrees were included in the study with an average malrotation of 24.7 + 8 degrees. All patients were corrected to an average of 4.0 +/- 2.1 degrees difference, as compared to the contralateral side (range 0-8). No patients required further surgeries to correct malrotation.

Conclusion: Comminuted fractures with malrotation >15 degrees after femoral nailing have an incidence of 15% at our institution. This technique provides an efficient and accurate correction method with the use of an intraoperative digital protractor, avoiding the need for revision IM nailing or osteotomies.

Keywords: ct scanogram; femoral anteversion; femoral malrotation; iatrogenic lld; inherent anteversion; intramedullary nailing; low dose ct; prospect trial; retroversion; second generation nail.