Clinical versus radiological method for adjusting rotational alignment during femoral shaft fractures intramedullary nailing and the malrotation impact on the functional outcomes: early results from a prospective cohort study

OBJECTIVES: The primary objective of the current study is to assess which is better for obtaining the proper femoral rotation during IMN of femoral fractures, the radiological or clinical method. The secondary objectives were to document malrotation's incidence and its effect on the hip and knee functional outcomes. METHODS: Thirty-three patients with unilateral femoral shaft fractures were treated using intramedullary nails (IMN) on a usual radiolucent operative table. Intraoperative rotation adjustment was performed using a radiological method (relying on the contralateral lesser trochanter profile) in 16 patients (group A), while in 17 patients, a clinical method was used (group B). Postoperative assessment of malrotation was performed using a CT scan, and 15 degrees was the cutoff value where below is an acceptable rotation (group I) and above is true malrotation (group II). Functional assessment was performed using the Harris hip score (HHS), the Tegner Lysholm Knee Scoring Scale (TLKSS), and the Neer score. RESULTS: The patients' mean age was 30.7 ± 9.3 years; 81.8% were males, and the left side was injured in 63.6% of patients. After a mean follow up of 18.2 ± 6.9 months, all fractures were united, and the overall mean amount of rotational difference between the fractured and the contralateral side was 14.7° ± 6.0 (3–29.4), 84.8% were in external rotation. No difference in the mean rotational deformity in group A compared to group B. Measurements were 13.9 ± 6.7 and 15.7 ± 5.5, respectively (p = 0.47). Seventeen (51.5%) patients in group I with a mean deformity of 9.8 ± 3.4 (3–14.7), while group II consisted of 16 (48.5%) patients with a mean deformity of 19.6 ± 3.7 (15.3–29.4). There was no difference in the functional scores between group I and group II; HHS was 89.4 ± 7.4 versus 87.7 ± 8.9 (p = 0.54), TLKSS was 84.6 ± 9.6 versus 80.4 ± 13.9 (p = 0.32), and Neer score was 87.9 ± 9.5 versus 83 ± 12.5 (p = 0.21) for group I and group II, respectively. CONCLUSION: There was no difference in malrotation incidence after unilateral femoral fractures IMN with either an intraoperative clinical or radiological method for rotational adjustment; furthermore, malrotation did not affect the functional outcomes.