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. 2020 Nov 5;21(1):719.
doi: 10.1186/s12891-020-03668-6.

A new fluoroscopic view for evaluation of anteromedial cortex reduction quality during cephalomedullary nailing for intertrochanteric femur fractures: the 30° oblique tangential projection

Shi-Yi Chen  1 , Shi-Min Chang  2 , Rujan Tuladhar  1 , Zhen Wei  1 , Wen-Feng Xiong  1 , Sun-Jun Hu  1 , Shou-Chao Du  1
Affiliations

A new fluoroscopic view for evaluation of anteromedial cortex reduction quality during cephalomedullary nailing for intertrochanteric femur fractures: the 30° oblique tangential projection

Shi-Yi Chen et al. BMC Musculoskelet Disord. .

Abstract

Background: Anteromedial cortex-to-cortex reduction is a key parameter for stable reconstruction of the fracture fragments during the intertrochanteric fracture fixation. This paper introduces the oblique fluoroscopic projection as a novel method to evaluate the quality of anteromedial cortical apposition.

Methods: Three proximal femur specimens were marked with steel wires along five anatomic landmarks: Greater trochanter, Lesser trochanter, Intertrochanteric line, Anterolateral tubercle and the Anteromedial cortical line. After obtaining the standard femoral neck AP and lateral fluoroscopic images, the C-arm was rotated by every 5°increments until a clear tangential view of the antero-medial-inferior corner cortex was observed. 98 cases of intertrochanteric hip fractures were enrolled from April 2018 to October 2019. After fixation with the nails, the intra-operative anteromedial cortex reduction quality was evaluated from the AP, the true lateral, and the new anteromedial oblique fluoroscopic images. The fluoroscopic results were compared with the post-operative 3D-CT reconstruction images.

Results: The specimen study showed that internal rotation of the C-arm to approximately 30 ° can remove all the obscure shadows and clearly display the antero-medial-inferior cortical tangent line. Clinically,the positive, neutral and negative apposition of different cortices via intra-operative fluoroscopic images showed79, 19 and 0 cases of medial cortical apposition in AP views; 2, 68 and 28 cases of anterior cortices in lateral views;and 22, 51 and 25cases of anteromedial cortical apposition in oblique views respectively. The post-operative 3D-CT reconstruction images revealed that the final anteromedial cortical contact was noted in 62 cases (63.3%), and lost in 36 cases (36.7%). The overall coincidence rate between intra-operative fluoroscopy and post-operative 3D-CT was 63.3% (62/98) in AP view,79.6% (78/98) in lateral view, and 86.7% (85/98) in oblique view(p < 0.001). Negative cortical apposition in oblique view was highly predictive of a final loss of cortical support on 3D CT (24/25 cases, 96%).And non-negative cortical apposition in oblique view was highly associated with true cortical support on 3D CT images (61/73 cases, 83.6%) (p < 0.001).

Conclusions: Besides the AP and lateral projections, an anteromedial oblique view of 30° certifies to be a very useful means for evaluation of the fracture reduction quality of anteromedial cortical apposition.

Keywords: 3D-CT; Anteromedial cortex; Cortical apposition; Fluoroscopy; Oblique view; Pertrochanteric fracture.

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Conflict of interest statement

The authors have no conflicts of interest to declare.

Figures

Fig. 1
Fig. 1
Schematic drawing to show three types of cortical appositions of the anteromedial cortices in oblique tangential view. a. Positive; b. Neutral; c. Negative
Fig. 2
Fig. 2
Intraoperative fluoroscopy of the 30 ° oblique view. a: Firstly, the standard lateral view (true sagittal) of the femoral neck was got i.e. the helical blade in the femoral head was aligned in a straight line with the nail in the femur medullary canal (set as 0°). b: The C-arm was rotated 30° lower to get the new anteromedial oblique tangential view
Fig. 3
Fig. 3
Fluoroscopy of proximal femur. a. APview; b. lateral view; c.30° anteromedial oblique view. Anatomical landmarks: 1. Anteromedial cortical tangent line, 2. Lesser trochanter, 3. Intertrochanteric line, 4. Greater trochanter, 5. Anterolateral tubercle
Fig. 4
Fig. 4
An 84 years old female with pertrochanteric femur fracture (AO/OTA-A2.3). a: Preoperative AP view; b: Intraoperative AP view; c: Lateral view; d: 30° anteromedial oblique view showed positive cortical support reduction pattern; e:Post-operative 3D-CT image revealed the anteromedial cortex achieved a true contact (positive support). f:A slightly flexed rotation of the head-neck fragment resulted in a minor forward shift of the inferior spike, and confirmed stable cortex-to-cortex contact of the anteromedial inferior corner
See this image and copyright information in PMC

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