Intramedullary Nailing Of Femoral Fractures Research Articles

CT scanogram for limb length discrepancy in comminuted femoral shaft fractures following IM nailing

IntroductionLeg length discrepancy (LLD) following intramedullary nailing of femoral fractures is not uncommon. We designed a prospective study to evaluate the efficacy of routine postoperative computed tomography (CT) scanograms for evaluation of limb length discrepancy in patients with comminuted Winquist III or IV femoral shaft fractures treated with intramedullary nailing. MethodsThe study consisted of 15 patients with Winquist III and 13 with a Winquist IV femoral shaft fracture pattern with an average age of 37 years. The mechanisms of injury were motor vehicle collision (13), gunshot wound (12) and falls (three). All patients were treated with a statically locked intramedullary femoral nail (18 antegrade and 10 retrograde). A CT scanogram evaluated limb length in all patients. A discrepancy of greater than 20mm was considered for correction during the same admission. An LLD of 15–20mm was discussed with the patient extensively for correction. ResultsIn the 28 patients included in our study, the average limb length discrepancy was 9.1mm with a range of −43.5mm short to 10.3mm long. The LLD was less than 10mm in 18 patients (64%), 10–15mm in four patients (14%), 15–20mm in three patients (11%) and more than 20mm in three patients (11%). Measurement of discrepancy as small as 0.5mm showed that 18 patients were fixed with shortening and in 10 patients the operated femur was longer. Tibia lengths were also evaluated separately. Though none of the tibiae had a previous fracture, only three patients (10%) had tibiae of equal length. In 13 patients, an unequal tibia partially corrected the LLD whilst in 12 it added to the discrepancy. Five patients with LLD of greater than 15mm underwent correction. ConclusionsA postoperative scanogram in patients with comminuted femoral shaft fractures treated with intramedullary nailing is useful to evaluate LLD and allows for early intervention. The ideal length where correction is necessary remains unclear.

Accuracy of measurement of femoral anteversion in femoral shaft fractures using a computer imaging software: a cadaveric study

Rotational malalignment after intramedullary nailing of femoral fractures remains an unresolved problem. Various techniques have been described to address this problem, with limited success. In this cadaveric study, we describe the determination of the femoral anteversion (FAV) angle utilizing a new imaging software program which allows us to generate and manipulate reformatted virtual images from standard DICOM (Digital Imaging and Communications in Medicine) images. Eleven intact femoral specimens were scanned by CT before and after fracture induction in standardized fashion. The obtained DICOM image datasets were uploaded to the new software tool. From this, we obtained reformatted virtual fracture fragment images, which enabled us to reconstruct the femoral anatomy and determine FAV measurements. We then compared FAV measurements before and after fracture induction to determine if there were any statistically significant differences. Fracture induction generated 5 AO type A and 6 AO type B fractures. In the specimens prior to fracture induction, we were able to determine the mean FAV to be 17.94° ± 4.48°. Additionally, analysis of the fractured femoral specimens revealed the new mean FAV to be 16.26° ± 4.83°. Statistical analysis of these two measurement groups did not demonstrate statistical significance. When a sub-analysis was performed of the FAV measurements between the two different AO fracture types, there also were no statistically significant differences. Through new imaging software that allows us to reformat standard DICOM images and generate virtual fracture fragments, we were able to determine the appropriate FAV. We feel that this technique can potentially be integrated into the imaging algorithm for femoral shaft fractures in the future, and can potentially optimize clinical outcomes by allowing the orthopaedic surgeon to determine precisely the appropriate native FAV.

RIA reamings and hip aspirate: A comparative evaluation of osteoprogenitor and endothelial progenitor cells

Autologous bone grafting represents the gold standard modality to treat atrophic non-unions by virtue of its osteoinductive and osteoconductive properties. The common harvest site is the iliac crest, but there are major concerns due to limited volume and considerable donor site morbidity. Alternative autologous bone graft can be harvested from the femoral bone cavity using a newly developed ‘Reamer Irrigator Aspirator’ (RIA). Osseous aspirated particles can be recovered with a filter and used as auto-graft. The purpose of this study was to compare the concentration and differentiation potential of mesenchymal stem cells (MSC) and endothelial progenitor cells (EPC) harvested with the RIA technique or from the iliac crest, respectively. RIA aspirate was collected from 26 patients undergoing intramedullary nailing of femur fractures. Iliac crest aspirate was collected from 38 patients undergoing bone graft transplantation. Concentration of MSC and EPC were assessed by means of the MSC colony assay, EPC culture assay and flowcytometry (CD34, CD133, VEGF-R2), respectively. Osteogenic differentiation of MSC's was measured by von Kossa staining. Patients in both groups did not significantly differ regarding their age, gender or pre-existing health conditions. In comparison to aspirates obtained from iliac crest the RIA aspirates from the femur contained a significantly higher percentage of CD34+ progenitor cells, a significantly higher concentration of MSC and a significantly higher concentration of early EPC. The percentage of late EPC did not differ between both sites. Moreover, the capability of MSC for calcium deposition was significantly enhanced in MSC obtained with RIA. Our results show that RIA aspirate is a rich source for different types of autologous progenitor cells, which can be used to accelerate healing of bone and other musculoskeletal tissues.

Clinical Results of Retrograde Femoral Intramedullary Nail for Femoral Fracture

Clinical Results of Retrograde Femoral Intramedullary Nail for Femoral Fracture

Pulmonary fat embolism after reamed and unreamed nailing of femoral fractures

BackgroundTo determine whether reamed or unreamed intramedullary nailing of femoral fractures results in higher incidence of pulmonary fat embolism, three different methods of intramedullary nailing were compared in sheep. To analyze the presence of bone marrow fat embolism in pulmonary arteries, histological evaluation was undertaken using a quantitative computer-assisted measurement system. MethodsIn this experimental model of 27 female Swiss alpine sheep, an osteotomy of the proximal femur was conducted in each animal. Then, the animals were divided into three groups according to the method of treatment: two different reamed intramedullary nailing techniques and an unreamed nailing technique were used.In the first group “ER” (experimental reamer; n=9), the nail was inserted after reaming with an experimental reamer; in the second group “CR” (conventional reamer; n=7), the intramedullary nail was inserted after reaming with the conventional AO-reamer. In the third group “UN” (unreamed; n=8) unreamed nailing was performed. During the operation procedure intramedullary pressure was measured in the distal fragment.After sacrificing the animals, quantitative histological analyses of bone marrow fat embolism in pulmonary arteries were done using osmium tetroxide fixation and staining of the fat. ResultsThe measurement of intramedullary pressure showed significantly lower values for reamed nailing than for the unreamed technique. The quantitative histological evaluation of lung vessels concerning bone marrow fat embolism revealed a statistically significant difference between reamed and unreamed insertion of the nail: 7.77%±6.93 (ER) and 6.66%±5.61 (CR) vs. 16.25%±10.05 (UN) (p<0.05) of the assessed lung vessels were filled with fat emboli. However, no difference was found between the traditional and experimental reamer. ConclusionsIntramedullary nailing after reaming is a safe procedure with low systemic embolisation when compared to the unreamed insertion of the nail.

Dynamic Compression Plate and Cancellous Bone Graft for Aseptic Nonunion After Intramedullary Nailing of Femoral Fracture

We evaluated the effect of revision with dynamic compression plate and cancellous bone graft for aseptic nonunion after intramedullary nailing of femoral shaft fracture. Fifty patients with aseptic nonunion of femoral shaft fracture after intramedullary nailing were reviewed and analyzed retrospectively between 1996 and 2007. There were 40 men and 10 women with an average age of 44 years (range, 19-76 years). Thirty-five were diaphyseal fractures, 8 were distal fractures, and 7 were proximal fractures. Twenty-eight fractures were defined as atrophic nonunion, 13 fractures were hypertrophic nonunion, and 9 fractures could not be defined clearly. All fractures were managed by retaining previous implants, open reduction and internal fixation with dynamic compression plate, and supplementation by cancellous bone graft. The average follow-up period was 76 months (range, 24-128 months). Functional evaluations were done by Harris Hip score and Hospital for Special Surgery knee score. All nonunions united on average at 24 weeks (range, 18-32 weeks). One superficial wound infection occurred. At follow-up, each patient was evaluated to have satisfactory function results, with near normal hip/knee functions without noticeable pain, and full return to preinjury activities/work without pain.Augmentative dynamic compression plate with cancellous bone graft is a reliable and effective treatment for revision of aseptic nonunion of femoral shaft fracture after intramedullary nailing.

Computer-assisted Femur Fracture Reduction.

When using intramedullary nailing of femur fractures false axis alignment or malrotation is the greatest deterrent to successful reduction often causing extended x-ray exposure and the need to revert to an open procedure. The aim of this study was to demonstrate the advantages of using a trauma navigation system during intramedullary nailing of femur fractures. A fluoroscopic navigation unit was used and successful closed fracture reduction, x-ray exposure, and operation time were measured. Between 2004 and 2007 19 patients receiving intramedullary nailing of femur fractures using a Stryker trauma navigation system were included in the study. The results were compared to 10 conventionally operated femur fractures between 2003 and 2006. The study demonstrated an important reduction of radiation time and less needs for reverting to open reduction. Based on these findings we conclude that the use of a trauma navigation system during fracture reduction has clear advantages. These are based primarily on its ability to provide 3-dimensional viewing of the fracture during the reduction procedure. This eliminates the need for multiple positioning adjustments of the x-ray C-arm from horizontal to vertical for better viewing and in doing so reduced radiation time and needs for open reduction.

Techniques of Obtaining and Maintaining Reduction During Nailing of Femur Fractures

Several techniques and tools are useful for achieving fracture reduction during antegrade intramedullary nailing of femur fractures.

Rotational stability of femoral osteosynthesis in femoral fractures – Navigated measurements

Rotational malalignment after intramedullary nailing of femoral fractures is common, and symptoms occur when malrotation reaches 15 degrees . Intraoperative measurement of rotation remains difficult, and multiple techniques have been described to address this. Regardless of the method used, rotational toggling may occur between the interlocking screws and the screw holes. We hypothesized that a clinically significant amount of rotation may occur with standard statically locked intramedullary nails. Mid-shaft diaphyseal fractures were created in 24 cadaveric femurs. Specimens were divided into 4 groups, and were stabilized with a statically locked intramedullary nail, a dynamically locked intramedullary nail, a compression plate, and a locking plate. Six additional femurs were kept intact as a control group. Specimens were mounted in a custom holding jig, which stabilized the constructs proximally and allowed free rotation distally. A computer navigation system was applied, and the femoral anteversion was measured. 4 N-m of internal and external torque was applied, and the change in version was measured. The statically locked nails rotated 14.2 degrees , and the dynamically locked group rotated 15.7 degrees . Both intramedullary nail groups showed significantly greater rotation than the plated groups. The compression plate specimens rotated 6.5 degrees on average, and the locked plate group rotated 3.8 degrees . Intramedullary femoral nailing with static or dynamic interlocking allows 15 degrees of rotation of the femur around the nail under physiologic load. This may exacerbate intraoperative errors in determining and setting rotation. Angular stable plates or nails may minimize this problem.

Systemic Inflammatory Response After Extremity or Truncal Fracture Operations

The purpose of this study was to assess proinflammatory markers in blunt trauma patients regarding the relationship of these and blood loss and duration of surgery in different fracture locations. Prospective, multicenter, nonrandomized cohort study. Three level I trauma centers. Sixty-eight blunt trauma patients, who did not require emergency operations and had sustained truncal or extremity fractures, were included. In two index patient groups, patients with spinal fractures (group SF, n = 24) and pelvic and acetabular fractures (group PAF, n = 21) underwent fixation of their fractures and were compared with a group of patients with isolated fractures (group FF, n = 28). Ten healthy volunteers served as controls. Internal fixation of pelvic, acetabular and spinal fractures, intramedullary nailing of femoral fractures, measurement of proinflammatory cytokines. From serially sampled central venous blood, the perioperative concentrations of interleukin-6 (IL-6) and IL-8 were evaluated during a 24-hour period and set into relation with the duration of surgery and the degree of blood loss. Intramedullary instrumentation for isolated PAF caused a significant perioperative increase in the concentrations of IL-6 (preoperative: 16 pg/mL +/- 12 pg/mL, 7 hours: 89 pg/mL +/- 15 pg/mL, and 24 hours: 107 pg/mL +/- 27 pg/mL, p < 0.05). This increase was comparable with the isolated femoral fracture (group FF: IL-6 preoperative, 52 pg/mL +/- 12 pg/mL; 7 hours, 78 pg/mL +/- 14 pg/mL; and 24 hours, 120 pg/mL +/- 23 pg/mL, p = 0.02). The changes observed after spinal fracture fixations (group SF) were considerably lower (IL-6 preoperative: 11 pg/mL +/- 6 pg/mL, 7 hours: 16 pg/mL +/- 11 pg/mL, and 24 hours: 56 pg/mL +/- 19 pg/mL). The percent change of baseline IL-6 and IL-8 concentrations, and the blood loss in group PAF at 24 hours were positively correlated (IL-6 r = 0.72, p < 0.03, IL-8 0.67, p = 004) after insertion. No correlation with the duration of surgery was found. The release of proinflammatory cytokines was higher in patients when their pelvic fractures were operated than in patients with spine fracture fixations, and was associated with the degree of blood loss. A higher increase in cytokine levels occurred when they were performed early (day 1-2) across all patient groups. The level of the released markers seems to be related to the magnitude of surgery, rather than to the duration of the procedure. This study supports the value of immunologic markers in determining subclinical changes during and after orthopedic surgical procedures.

Does fixation of femoral fractures using retrograde intramedullary nailing cause long-term knee pain: a systematic review of the literature

To perform a systematic review of the literature to discover if knee pain was a common complication in patients who underwent retrograde intramedullary fixation for femoral fractures and whether the pain persisted beyond fracture union and soft tissue healing. The literature search revealed eight articles which fit the inclusion criteria. These series were then compared and articles critiqued to allow conclusions to be drawn. Three articles compared antegrade and retrograde nails and five articles reviewed results of retrograde fixation only. Retrograde intramedullary nailing produced knee pain in 40-53% of patients compared with 20% in antegrade fixations during follow-up. These figures however, dropped substantially by final follow-up to 23-24% for retrograde and 12.5% for antegrade. Thirty-seven per cent of knee pain post operatively was associated with prominent metal work the majority of which resolved if the metal was removed. Retrograde intramedullary nailing for femoral fractures is associated with higher rates of anterior knee pain than antegrade nailing. Many cases of knee pain can be prevented with proper technique avoiding prominent metal work and many more cases settle in time with no intervention.

Femoral Shaft Fractures Treated by Intramedullary Interlocked Nailing

To evaluate the results of femoral shaft fractures treated by closed interlocked nailing, throughout an analysis of clinical and radiological findings. Retrospective study of 150 consecutive patients (156 femoral fractures) treated by closed interlocked nailing, over a period of 15 years (1987-2002). Fractures were classified and studied, analyzing the timing and type of surgical intervention, as well as intraoperative and postoperative complications. We performed a clinical evaluation concerning pain and function, as well as a radiological multiobserver analysis regarding the time of healing, rotational malalignment and malunion. Most fractures occurred after motor vehicle accidents (86.6%), with a predominance of males (71%) and with a mean age of 26.9 years (range 14-85); 17% were open fractures. The average follow-up was 35.7 months (range 18-174). 67% of the cases presented with associated fractures. The most frequent complication was pain in the area where the nail was introduced (5.8%). Radiological consolidation was achieved in all cases. In 12 cases (7.7%) an additional surgical procedure was necessary for final consolidation. We can conclude that closed intramedullary nailing of femoral fractures permits excellent fracture healing, early patient recovery and few complications. Analizar el tratamiento de las fracturas diafisarias de fémur mediante enclavado intramedular encerrojado y los resultados obtenidos clínica y radiológicamente. Estudio retrospectivo de fracturas diafisarias de fémur tratadas mediante enclavado intramedular encerrojado: en 150 pacientes consecutivos (156 fracturas), intervenidos en el Hospital Universitario de Tarragona Joan XXIII durante un período de 15 años (1987-2002). Las fracturas han sido clasificadas y se han analizado el momento y el tipo de intervención quirúrgica y las complicaciones intra y postoperatorias. El tiempo medio de seguimiento fue de 35,7 meses (18-174). La valoración clínica final incluye el dolor y la función junto a un análisis radiológico multiobservador del tiempo de consolidación, posible consolidación en mala posición y dismetría. La mayoría de las fracturas se produjeron en accidentes de tráfico (86,6%), afectando con mayor frecuencia a varones (71%) y a jóvenes (edad media de 26,9 años [14-85]). Un 17% de las fracturas fueron abiertas y en el 67% de los casos presentaron lesiones asociadas. La complicación postoperatoria más frecuente fue el dolor enla zona de introducción del clavo (5,8%). En 12 casos (7,7%) fue necesaria la reintervención quirúrgica para obtener la consolidación definitiva, pero finalmente se obtuvo la consolidación clínica y radiológica en todos los pacientes. La intervención quirúrgica precoz, en pacientes estables, ha disminuido el índice de complicaciones inmediatas en nuestra serie. Con el tratamiento de las fracturas de fémur mediante enclavado intramedular encerrojado hemos obtenido buenos resultados clínicos y radiológicos con un reducido índice de complicaciones.

Early Unreamed Intramedullary Nailing of Femoral Fractures is Safe in Patients With Severe Thoracic Trauma

The timing of fixation of femoral fractures in multiply injured patients with severe thoracic trauma is discussed controversially. Some authors recommend damage control surgery, whereas other authors prefer early definitive treatment. The aim of our study was to investigate the effect of early definitive fixation of femoral fractures on outcomes in multiply injured patients with severe thoracic trauma. Between May 1, 1998 and December 31, 2004, 578 severely injured patients were admitted to our institution. Forty-five patients met the inclusion criteria for the study cohort (severe thoracic trauma and femoral fracture stabilized with unreamed intramedullary nailing [IMN] within the first 24 hours) and 107 patients were selected for the control cohort (severe thoracic trauma without any lower extremity fracture). Inclusion criteria for both cohorts were age 15 to 55 years with blunt trauma (e.g. motor vehicle collisions, falls) including severe thoracic trauma (Abbreviated Injury Scale [AIS] score >or=3) and Injury Severity Score (ISS) >or=18. For comparison between the cohorts data on patients status (Glasgow Coma Scale score at arrival, Revised Trauma Score, Trauma and Injury Severity Score survival prognosis, Simplified Acute Physiology Score II score), treatment (intubation rate, thoracic drainage, surgery), and outcomes (duration of intensive care unit stay and ventilation, rate of adult respiratory distress syndrome [ARDS], multiple organ failure syndrome [MOFS], and mortality) were selected from hospital databases. Dichotomous data were analyzed by chi test; continuous data were analyzed by Student's t test. Any values of p < 0.05 were considered significant for any test. Both cohorts were comparable with regard to demographic data, ISS, AIS score in the thoracic region, and incidence and severity of brain injury. There was no difference in dependent parameters in both cohorts. Rates of ARDS, MOFS, and mortality were not negatively influenced by early unreamed IMN. Early unreamed IMN of femoral fractures in multiply injured patients with severe thoracic trauma is a safe procedure and seems to be justified to achieve early definitive care.

Similar Central Hemodynamics but Increased Postoperative Oxygen Consumption in Unreamed Versus Reamed Intramedullary Nailing of Femoral Fractures

Patients undergoing intramedullary nailing of long bone fractures have pathologically altered pulmonary vascular tone, right heart strain, and transient impairment of pulmonary gas exchange. The purpose of this study was to examine the acute differences in cardiopulmonary variables between reamed and unreamed nailing techniques in 18 (9 + 9) healthy patients with unilateral femoral shaft fractures. Intramedullary nailing was performed under general anesthesia within 12 hours after the trauma. For blood sampling, recording, and measurements, the patients were cannulated with radial artery and pulmonary artery catheters. Changes in central hemodynamics and oxygenation were studied pre-, peri-, and postoperatively for 16 to 20 hours. Abnormally high pulmonary shunting (23 +/- 12% in the reamed and 27 +/- 11% in the unreamed group) was observed before the operation. The trends of all variables were very similar in both groups except for the last phase in which the mixed venous oxygen saturation tended to be lower (65 +/- 8 vs. 70 +/- 5%) and the oxygen consumption index was higher (186 +/- 21 vs. 151 +/- 20 mL/min/m) in the unreamed group than in the reamed group (p < 0.05). The timepoints most strenuous to the heart were at the end of operation and in the recovery room. The unreamed intramedullary nailing technique does not offer any advantage in cardiopulmonary variables over the reamed technique. In both groups, there was considerable deviation in over 10 cardiopulmonary variables from normal reference values during the study. We suggest the use of invasive monitoring on patients with a long bone fracture and poor preoperative oxygenation or a history of cardiopulmonary or cardiac disease.

Intramedullary Nailing of Femoral Fractures in Children Through the Lateral Aspect of the Greater Trochanter Using a Modified Rigid Humeral Intramedullary Nail: Preliminary Results of a New Technique in 15 Children

Intramedullary Nailing of Femoral Fractures in Children Through the Lateral Aspect of the Greater Trochanter Using a Modified Rigid Humeral Intramedullary Nail: Preliminary Results of a New Technique in 15 Children

Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases.

In the years encompassed by this study there were major advances in trauma care and the overall approach to patients with fractures of the femur changed accordingly. Early in the series there was concern over the possibility of fat embolism from intramedullary reaming and nailing which led to a delay in the nailing for five to seven days after injury. At the end of the study period, immediate internal fixation was performed in all patients with multiple long-bone fractures, including those with bilateral shaft fracture and concomitant injuries to the head, chest, or abdomen. The change to immediate internal fixation of all type-I and II open femoral fractures produced no increase in the number of infections and eased the care of the patients considerably.

Computerised navigation for closed reduction during femoral intramedullary nailing

Intramedullary nailing is the most commonly used technique for fixing femoral shaft fractures. 17 Winquist R.A. Hansen Jr., 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: 529-539 PubMed Google Scholar Use of a fluoroscopy based computerised navigation system can improve the nailing technique by locating the entry point of the nail, inserting locking and Poller screws and providing accurate nail and screw measurements. These tasks then can be performed with markedly reduced radiation exposure. 5 Kahler D.M. Virtual fluoroscopy, a tool for decreasing radiation exposure during femoral intramedullary Nailing. Stud Health Technol Inform. 2001; 81: 225-228 PubMed Google Scholar , 7 Khoury A, Liebergall M, Weil Y, Mosheiff R. Navigation assisted intramedullary nailing – the first generation. In: The 19th Annual Meeting of the Orthopaedic Trauma Association [abstract]. Salt Lake City, Utah, USA; 2003. p. 124. Google Scholar , 14 Suhm N. Messmer P. Zuna I. et al. Fluorsocopic guidance versus surgical navigation for distal locking of intramedullary implants. A prospective controlled clinical study. Injury. 2003; 35: 567-574 Abstract Full Text Full Text PDF Scopus (64) Google Scholar However, fracture reduction in vivo has not been achieved by computerised navigation systems, since dynamic imaging of two separate anatomic sites, such as fracture fragments, has not yet proved feasible.

A Skeletal Traction on the Radiolucent Table in Closed Intramedullary nailing of Femoral Fracture

A Skeletal Traction on the Radiolucent Table in Closed Intramedullary nailing of Femoral Fracture

Intramedullary nailing of femoral fractures in children through the lateral aspect of the greater trochanter using a modified rigid humeral intramedullary nail: preliminary results of a new technique in 15 children.

To evaluate the clinical results of intramedullary nailing of femoral shaft fractures using a rigid intramedullary nail placed through the lateral aspect of the greater trochanter in older children and adolescents. A retrospective study was carried out evaluating all skeletally immature patients with femoral shaft fractures treated using a modified rigid humeral intramedullary nail. Fifteen children and adolescents with displaced femoral diaphyseal fractures and open physes. Femoral shaft fractures in children and adolescents were stabilized using a modified humeral intramedullary nail placed through the lateral aspect of the greater trochanter. Patients were evaluated to determine time to union, final fracture alignment, hospital stay, complications, clinical outcome, and proximal femoral changes including avascular necrosis or proximal femoral valgus with femoral neck narrowing. Fifteen patients were followed for a minimum of 1 year (range 70-157 weeks). The average age of the patients was 12 years and 5 months (range 8 years and 2 months-17 years and 1 month). All fractures healed at a mean of 7 weeks (range 5-14 weeks) after fracture. The average hospital stay for patients with isolated femur fractures (8/15) was 2.8 days (range 1-5 days). At an average follow-up of 141 weeks (range 70-326 weeks), no patient had developed avascular necrosis, femoral neck valgus, femoral neck narrowing, or other complications. The technique of intramedullary nailing in children through the lateral aspect of the greater trochanter seems to be safe, effective, and well tolerated by patients.

Rotational malalignment after intramedullary nailing of femoral fractures.

Intramedullary nailing has been accepted as the treatment of choice for femoral shaft fractures. The aim of our study was to determine the incidence and implications of rotational malalignment after intramedullary nailing using computed tomography measurements. Cohort study. Patients who postoperatively visited the orthopaedic outpatient and radiology clinics. Seventy-six patients, 59 men and 17 women, with a mean age of 28.4 years (15-88). Patients treated on a fracture table with an antegrade reamed AO nail (n = 46) or Grosse Kempf nail (n = 30) for a unilateral femoral shaft fracture between 1988 and 1998 were included in the study. Patients filled out a questionnaire concerning pain, daily activities, and sport. Oxford, Western Ontario and McMaster University osteoarthritis index, and Harris Hip and Knee Society scores were obtained. Physical exams and computed tomography measurements were established. Twenty-one patients (28%) were found to have a rotational malalignment of 15degrees or more. There was no significant difference in rotational deformity with either the AO or Grosse Kempf nail. The incidence of malrotation was independent of the fracture level. Patients with a torsional deformity had difficulties with more demanding activities like running, sports, and climbing stairs. Patients with an external rotational malalignment (n = 12) have more functional problems than patients with an internal rotational malalignment (n = 9). Clinically determined rotation differences are not accurate (+/-20degrees) compared with the established computed tomography measurements. Rotational malalignment after intramedullary nailing for femoral fractures is found in 28% of the patients in this study. These patients have difficulties with more demanding activities, especially when they have an external torsional deformity.