title: Femoral malrotation after unreamed intramedullary nailing: an evaluation of influencing operative factors.
abstract: OBJECTIVE
  The objective of this study was to determine which clinical factors influence the presence and extent of femoral malrotation during unreamed nail insertion performed without a fracture table.
  
  
  METHODS
  Retrospective chart review.
  
  
  METHODS
  Academic trauma center.
  
  
  METHODS
  Patients were treated statically locked femoral nails inserted without reaming in either a retrograde or antegrade manner without the use of a fracture table between April 1, 2000, and December 31, 2005. All patients received postoperative computed tomography scans. Institutional radiographic threshold for revision surgery was 15° of either internal or external rotation.
  
  
  METHODS
  Postoperative computed tomography measurements of rotation were compared with the opposite side. Patients were grouped by 1) Orthopaedic Trauma Association fracture classification; 2) closed versus mini open reduction; 3) surgeon experience; 4) antegrade versus retrograde femoral nail; and 5) time of day surgery performed (day shift versus night shift). The following parameters were measured from the chart and x-ray: rotational malalignment, x-ray time, and duration of surgery.
  
  
  RESULTS
  There were 82 femurs in 82 patients, 59 men and 23 women, with a mean age of 32 years (range, 17-83 years). Eighteen femurs (22%) showed a malrotation of greater than 15°. Seven were internally malrotated (mean, 23°; range 16°-32°), whereas 11 were externally malrotated (mean, 24.2°; range, 16°-39.7°). After clinical examination, only 11 of the 18 patients (61%) underwent revision surgery, six patients for external malrotation (mean, 27.47°; range, 21.9°-39.7°) and five for internal malrotation (mean, 23.6°; range, 16°-32°). Malrotation varied significantly with fracture severity with Type C averaging 19.4° (24 patients), Type B 9° (26 patients), and Type A 6.6° (32 patients). No difference was found between an open and closed technique nor the experience of surgeon or the type of implant. There was a significant difference depending on the time of surgery in which an average malrotation of 15.2° (14 patients) was found on the night shift and an average malrotation of 10.3° (68 patients) was found during the day.
  
  
  CONCLUSIONS
  Rotational malalignment greater than 15° was found in 22% of femurs treated in this study. Fracture comminution and time of day the surgery was performed had the greatest effect on the severity of malrotation.
authors.affiliation: Trauma Department, Hannover Medical School, Hannover, Germany.
authors.forename: Tobias
authors.initials: T
authors.lastname: Hüfner
authors.forename: Mustafa
authors.initials: M
authors.lastname: Citak
authors.forename: Eduardo M
authors.initials: EM
authors.lastname: Suero
authors.forename: Brian
authors.initials: B
authors.lastname: Miller
authors.forename: Daniel
authors.initials: D
authors.lastname: Kendoff
authors.forename: Christian
authors.initials: C
authors.lastname: Krettek
authors.forename: Musa
authors.initials: M
authors.lastname: Citak
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005264:Femoral Fractures / Q000150:complications* / Q000601:surgery*; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects*; D006801:Humans; D007593:Joint Instability / Q000000981:diagnostic imaging* / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012399:Rotation; D017211:Treatment Failure