Intramedullary Nailing Versus Plate Fixation for Femoral Derotational Osteotomy in Adolescents: A Randomized Controlled Trial

BACKGROUND: Persistent increased femoral anteversion (IFA) in adolescents can cause in-toeing, pain, and functional limitations. Femoral derotational osteotomy is the only effective treatment for symptomatic cases, but the optimal fixation method remains unclear. This randomized controlled trial compared intramedullary nailing with plate fixation, hypothesizing that intramedullary nailing would be noninferior in achieving the intended rotational correction. METHODS: Adolescents aged 10 to 18 years with symptomatic IFA were randomized to FDO stabilized either with a proximal femoral plate or an intramedullary nail. The primary outcome was correction accuracy, defined as the difference between planned and achieved derotation measured on postoperative CT. Secondary outcomes included hip rotation, radiographic healing, complications, operative metrics, patient-reported outcome measures (CHOHES, KOOS-child, KIDSCREEN-27), and patient satisfaction. Follow-up assessments were performed at 6, 12, 26, and 52 weeks. RESULTS: Thirty-one adolescents (49 osteotomies) with a mean age of 13.4±1.8 were analyzed. Intramedullary nailing was noninferior to plate fixation, with a mean deviation from the intended correction of 6.6±4.9 degrees and an intergroup difference of 0.7 degrees (P=0.586). All osteotomies healed within 6 months, and no cases of avascular necrosis occurred. Both groups demonstrated significant improvements in hip rotation and patient-reported outcomes at 1 year, without significant differences between techniques. Operative time was slightly longer with intramedullary nailing, whereas this group achieved full weight bearing slightly earlier. CONCLUSIONS: Intramedullary nailing achieves rotational correction accuracy comparable to plate fixation, with reliable healing and similar functional outcomes. Given its minimally invasive nature and allowance for immediate postoperative weight bearing, it represents an effective alternative for adolescents undergoing femoral derotational osteotomy. LEVELS OF EVIDENCE: Level I-randomized controlled trial.