A Derotational Corrective Osteotomy in a Torsional Malaligned Femoral Shaft Fracture Around a Prior Stuck Intramedullary Nail

Background: Femoral torsional malunion following trauma fixed with intramedullary (IM) nailing can necessitate femoral derotational osteotomy based on the symptomatic limitations of the patient. There is a paucity of studies discussing the utility and methods of femoral derotational osteotomy following post-traumatic femoral torsional malunion fixed with IM nailing that is not removable. Methods: We report a surgical technique in a patient treated with a femoral derotational osteotomy who sustained significant rotational deformity after a femoral shaft fracture initially treated with antegrade IM nailing. A standard inferior patellar approach was performed. The distal interlocking screws of the nail were removed, and a trephine was placed up through the distal femoral canal around the nail to free the nail from the surrounding bone to allow for mobility of the distal femur following osteotomy. Parallel K-wires were placed above and below the cut level for rotational control. A dynamic compression plate was then placed in compression mode on the lateral aspect of the femur, and the distal interlocking screws were placed to lock the IM nail. Conclusions: We recommend this technique only be used in cases where the nail is centric in the intramedullary canal and in line with the trochlea to be able to pass the trephine through the knee. We believe this technique to be an effective surgical option to treat post-traumatic torsional deformities of the femur where hardware cannot be removed.