Session IV - Femur

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

B. Liebrand, MD; Victor A. de Ridder, MD; S. De Lange, MD; C. Ulrich, MD; F. Hermans, BS, Westeinde Hospital, Va Den Haag, Holland

Purpose: In this study the clinical relevance of the rotational deformities after the femoral shaft fracture treated with intramedullary osteosynthesis was evaluated. Symptoms and physical examination were compared with the amount of the malrotation measured by CT. We also measured anteversion angles of fifteen healthy volunteers (control group) by CT and compared these results with the patient group.

Methods: In a retrospective study interviews and physical examinations were possible in thirty-four patients with thirty-four fractures. From these patients were also noted fracture type, additional fractures from pelvis and the homolateral leg, timing of operation, operation technique, nail type and fixation. Patients' complaints were classified in four categories: none, little, moderate, and severe. Physical examination was performed in two ways, in prone and in supine position, using the neutral-0-method. The complaints and measurements obtained from these patients were related to a CT-analysis according to Mesgarzadeh , a method accurate to ±1°.

Results: Eleven patients did have additional fractures from the pelvis and/or homolateral leg. In most cases the timing of the operation was within twenty-four hours after injury. In five cases the operation was postponed or treatment was initially elsewhere and reoperation was done in this hospital. Normally a closed reposition on an extension table was performed, in five cases in a lateral position on a standard table. The quality of the reduction of the fracture was very good in nineteen cases, moderate in four cases and not described in eleven cases. Most patients were treated with the Grosse-Kempf interlocking nail. Four patients received a Kuntscher-nail and four patients an unreamed femoral nail. In nineteen patients the locking was static and in fifteen patients locking was performed in another way. During the interviews nine patients had no complaints, ten patients had little complaints, ten patients had moderate complaints and five had severe complaints. When the complaints and the amount of the malrotation are compared no association is shown between them. 44% of the patients with malrotations less than 10° had moderate or severe complaints. Three patients with severe complaints belong to this group and only one patient with severe complaints had an endorotation of over 20°.

Physical examination in the prone position measured malrotations between 0-10° in sixteen patients, between 10-20° in ten patients and over 20° in seven patients. When patients were examined in the supine position, malrotation between 0-10° were measured in twenty-four patients, between 10-20° in seven patients and over 20° in two patients. 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 physical examination in prone position and CT-measurements were related and p=0.55 when physical examination in supine position and CT-measurements were related.

In the control group the differences between the left and right femur were in ten cases less than 10°. In five cases the difference was over 10° (12.6°, 13.3°, 18.1°, 18.6° and 23.4°).

Discussion: This research shows a poor comparison between patients' complaints, physical examination and the amount of the malrotation as determined by CT. Most patients with severe complaints had limited malrotations and only one patient with daily symptoms had a malrotation above 20°. The average deviation between physical examination and CT was more than 10° and in ten cases more than 15°. Also if left-right differences of 20° are found in a normal population, we could question whether the finding of a rotational malrotation of 20° is a malrotation after all.

Conclusion: According to this study the amount of the malformation after intramedullary osteosynthesis does not correspond with patients' complaints and physical examination, so the clinical relevance of rotational deformity seems to be limited.