Femoral Derotation for the Acutely Malrotated Femur Following Intramedullary Nail Fixation

Clinically significant malrotation is one of the common complications following intramedullary treatment of femoral shaft fractures. We provide our experience revising an acutely malrotated femoral shaft fracture treated by intramedullary nail fixation. Following clinical examination, radiographic evaluation must include computed tomography scan for evaluation of femoral torsion. Derotation should be pursued after discussion of risks and benefits with the patient, if the malrotation exceeds 15 degrees in comparison with the uninjured limb. Revision surgery must include careful intraoperative clinical examination, as well as bilateral fluoroscopic imaging to confirm improved total femoral neck version. Our preferred technique includes proximal and distal Schanz pins in parallel, which can be used as "joysticks" for performing derotation as well as a measurement tool to evaluate the adjustment angle. A sterile goniometer is required to confirm that adequate derotation has been obtained, before replacing distal interlock screws. Confirmatory imaging and examination is then performed as a second check before waking the patient.