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Intramedullary Nailing of Diaphyseal Femur Fractures Secondary to Gunshot Wounds: Predictors of Postoperative Malrotation

Patel, Neeraj M. MD, MPH, MBS*; Yoon, Richard S. MD*; Cantlon, Matthew B. MD*; Koerner, John D. MD; Donegan, Derek J. MD; Liporace, Frank A. MD*

doi: 10.1097/BOT.0000000000000124
Original Article

Objectives: The purpose of this study was to determine significant factors that may impact the postoperative differences in femoral version (DFV) and differences in femoral length (DFL) between the fixed and uninjured sides after intramedullary nailing (IMN) secondary to gunshot wounds.

Design: Retrospective data registry study.

Setting: Academic level I trauma center.

Patients: Over a 10-year period, 417 patients underwent IMN of a diaphyseal femur fracture (OTA/AO 32A-C). Of these, 57 patients sustained fractures caused by gunshots and had a postoperative computed tomographic scanogram.

Main Outcome Measures: DFV and DFL. The effect of the following variables on DFV and DFL were determined through univariate and stepwise multivariate regression analyses: age, sex, body mass index, trauma fellowship-trained versus nontrauma surgeon, daytime versus nighttime surgery, antegrade versus retrograde nail insertion, use of traction, type of operating table, and AO and Winquist classifications.

Results: The mean postoperative DFV for all patients was 8.62 degrees (±6.67 degrees). Postoperative DFV greater than 15 degrees was found in 12.3% of all patients. After IMN, no significant differences in DFV were found with increasing complexity of AO/OTA or Winquist fracture classification. None of the aforementioned independent variables were significantly predictive of postoperative DFV in univariate or multivariate analyses. The mean postoperative DFL for all patients was 5.25 mm (±4.36 mm). In a multivariate model, classification as Winquist type 3 or 4 was weakly (adjusted R2 = 0.075) but significantly predictive of less DFL than categorization as type 1 or 2 (P = 0.027).

Conclusions: Although gunshot-associated femur fractures may present surgical challenges for treatment through IMN, acceptable femoral rotation and length are obtainable regardless of the fracture complexity or a variety of demographic and surgically-related variables.

Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

*Department of Orthopaedic Surgery, Division of Orthopaedic Trauma, NYU Hospital for Joint Diseases, New York, NY;

Department of Orthopaedic Surgery, Division of Orthopaedic Trauma, Jefferson Medical Center, Rothman Institute, Philadelphia, PA; and

Department of Orthopaedic Surgery, Division of Orthopaedic Trauma, Hospital of the University of Pennsylvania, Philadelphia, PA.

Reprints: Frank A. Liporace, MD, Department of Orthopaedic Surgery, Division of Orthopaedic Trauma, Orthopaedic Trauma Research, NYU Hospital for Joint Diseases, 301 E. 17th St, Suite 1402, New York, NY 10003 (e-mail:

The authors report no conflict of interest.

Institutional Review Board approval was obtained prior to the completion of this article.

Accepted March 27, 2014

© 2014 by Lippincott Williams & Wilkins