Any intraoperative rotational malalignment during intramedullary nailing (IMN) of femoral shaft fractures will become permanent. We hypothesized that rotational malalignment of the femur and its compensatory biomechanics may induce problems in the hip, knee, patellofemoral and ankle joints. We purposed to clarify the influence of a femoral rotational malalignment of ≥10° on daily activities.

Twenty-four femoral shaft fracture patients treated with closed antegrade IMN were included. At last follow-up, to reveal any rotational malalignment, computerized tomography (CT) scans of both femurs (injured and uninjured sides) were examined. The patient groups with or without CT-detected true rotational malalignment ≥10° were compared with respect to the activity scores.

Ten of the 24 patients (41.7%) had a CT-detected true rotational malalignment of ≥10° compared with the unaffected side. The AOFAS scores were 100.00 for all of the patients. LKS, WOMAC knee, and WOMAC hip scores were significantly decreased in the patients with rotational malalignment compared to those without. Patients without rotational malalignment tolerated climbing stairs significantly better than those with rotational malalignment. Patients who could not tolerate climbing stairs were consistently complaining of anterior knee pain.

A femoral rotational malalignment of ≥10° is symptomatic for the patients, and the hip, knee, and patellofemoral joints were affected. Because of the possibly altered joint loadings and biomechanics, these could render patients prone to degenerative joint disease. In addition, due to the high rates of rotational malalignment after femoral shaft fracture and consequent malpractice claims, it is important for surgeons to be more aware of rotational alignment during surgery.

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