Background: Malrotation of the femur is a frequent complication in the management of a diaphyseal fracture. It is often responsible for pain and adverse functional results. Among these complications, contact stress effects on the patellofemoral joint are recognized as predictive factors of impaired results. The purpose of this study was to analyze the effect of malrotation on stress distribution on the patellofemoral joint, using radiological measurement and three-dimensional finite element models. Methods: Functional analysis of the patellofemoral joint was evaluated in eight knee pairs from patients with unilateral femoral fractures and subsequent femoral malrotation. A computed tomography-based protocol allowed patellofemoral joint analysis. A finite element model of the healthy (contralateral) knee was then created from 3D reconstruction at 30 flexion. In a finite element model, incremental rotational malalignment was simulated to observe changes in stress distribution on the patellar surface. Results: Femoral malrotation was associated with anomalies of patellofemoral joint rotational alignment. Internal rotation resulted in increased stress on the lateral side of the patella, and external rotation increased inferior medial side stress. Conclusions: Rotational disorders of the distal femur resulted in increased stress on the patellofemoral joint and alignment changes. Malrotation in internal and external rotation might cause patellofemoral pain syndrome from rotations <10 degrees Care should be taken especially for internal malrotation in the management of femoral shaft fracture. (C) 2018 Elsevier B.V. All rights reserved.