Standard radiographic images in cephalomedullary nailing fixation for intertrochanteric femoral fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

 CHANG Shimin ¹ , SUN Guixin ² , WANG Zhenhai ³ , ZHANG Li ⁴ , TIAN Kewei ⁵ , LIU Tao ⁶ , WANG Xin ⁷ , RUI Yunfeng ⁸

1. Department of Orthopedic Surgery, Yangpu Hospital, Tongji University, Shanghai, 200090, P. R. China;
2. Department of Trauma Surgery, Dongfang Hospital, Tongji University, Shanghai, 200120, P. R. China;
3. Department of Traumatic Orthopedic Surgery, Yantaishan Hospital, Yantai Shandong, 264001, P. R. China;
4. Department of Orthopedic Surgery, Guangxi Nanxishan Hospital, Guilin Guangxi, 541002, P. R. China;
5. No.1 Department of Hip Injury and Disease, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471002, P. R. China;
6. Department of Orthopedic Trauma Surgery, Qilu Hospital of Shandong University (Qingdao), Shandong Qingdao, 266035, P. R. China;
7. Department of Orthopedic Surgery, Tongji Hospital, Tongji University, Shanghai, 200069, P. R. China;
8. Department of Orthopedic Trauma, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P. R. China;

Corresponding author：

CHANG Shimin, Email: shiminchang11@aliyun.com

Keywords：

Intertrochanteric femoral fracture; cephalomedullary nail; radiographic images

DOI：

10.7507/1002-1892.202405004

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Objective To review and summarize the projections of radiographic images during cephalomedullary nailing fixation for intertrochanteric femoral fractures, and to propose a set of three projections as standard requirement in immediate postoperative fluoroscopy. Methods Papers on intertrochanteric femoral fractures treated with cephalomedullary nailing fixation that published in a three-year period of 2021—2023 in four leading English orthopedic trauma journals were searched in PubMed. The presented radiographic pictures were identified and scrutinized as whether they were in standard anteroposterior and/or lateral projections of the implanted nails. The nonstandard presence percentage was calculated. Combined with clinical experience, the standard anteroposterior and lateral perspective images of femoral neck, the current situation of radiographic imaging in the operation of cephalomedullary nails, the literature analysis of nonstandard images, the impact of limb rotation on image interpretation, and the characteristics of anteromedial 30° oblique perspective were summarized and analyzed. Results The presence of nonstandard radiographic pictures is 32.1% in anteroposterior view and 69.2% in lateral view in leading orthopedic trauma journals. In cephalomedullary nailing fixation operation of intertrochanteric femoral fractures, it is reasonable to use the radiographic images of the implanted nails to represent the fractured head-neck, as the head-neck implant (lag screw or helical blade) is aimed to put into centrally in femoral head in lateral projection. Limb rotation or nonstandard projections produced distortion of images, which interfers the surgeons’ judgement of fracture reduction quality and the measurement of implant position parameters in femoral head (such as neck-shaft angle and tip-apex distance), and finally lead to a meaningless comparison with the accurate normal value. The 30° anteromedial oblique view from the true lateral (set as 0°) is a tangential projection of the cortices at the anteromedial inferior corner, which gives a clear profile for the determination of cortical apposition status and mechanical support. It is essential to get firstly the true standard lateral fluoroscopy of the nail (shown as a line), then rotate the C-arm to 90° and 30° to get anteroposterior and anteromedial oblique views, and use these three immediate postoperative radiographies as the baseline for evaluation of operative quality and follow-up comparisons. Conclusion As for real-time monitoring of surgical steps, intraoperative fluoroscopy follows the “Enough is Good” principle, but as for immediate postoperative data storage and basis for operative quality evaluation and baseline for follow-up comparison, it is recommended to obtain a set of three standard radiographic pictures in anteroposterior, true lateral, and 30° anteromedial oblique fluoroscopic projections.

Citation： CHANG Shimin, SUN Guixin, WANG Zhenhai, ZHANG Li, TIAN Kewei, LIU Tao, WANG Xin, RUI Yunfeng. Standard radiographic images in cephalomedullary nailing fixation for intertrochanteric femoral fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2024, 38(9): 1130-1137. doi: 10.7507/1002-1892.202405004 Copy

1.	Baumgaertner MR, Curtin SL, Lindskog DM, et al. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg (Am), 1995, 77(7): 1058-1064.
2.	Chang SM, Zhang YQ, Ma Z, et al. Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg, 2015, 135(6): 811-818.
3.	Marchand LS, Jacobson LG, Stuart AR, et al. Assessing femoral rotation: A survey comparison of techniques. J Orthop Trauma, 2020, 34(3): e96-e101.
4.	Ivanov DV, Welby JP, Khanna A, et al. Evaluation of intraoperative fluoroscopic techniques to estimate femoral rotation: A cadaveric study. J Orthop Trauma, 2024, 38(5): 279-284.
5.	Marchand LS, Todd DC, Kellam P, et al. Is the lesser trochanter profile a reliable means of restoring anatomic rotation after femur fracture fixation? Clin Orthop Relat Res, 2018, 476(6): 1253-1261.
6.	Ju B, Moon YJ, Lee KB. Use of lesser trochanter profile as a rotational alignment guide in intramedullary nailing for femoral shaft fracture. J Bone Joint Surg (Am), 2021, 103(22): e89. doi: 10.2106/JBJS.21.00105.
7.	Jang ES, Davignon R, Geller JA, et al. Accuracy of the lesser trochanter profile as a marker of femoral rotation: Computed tomography-based study of 1, 722 femora. J Bone Joint Surg (Am), 2024, 106(10): 912-918.
8.	Chang SM, Hou ZY, Hu SJ, et al. Intertrochanteric femur fracture treatment in Asia: What we know and what the world can learn. Orthop Clin North Am, 2020, 51(2): 189-205.
9.	Marmor M, Guenthner G, Rezaei A, et al. Reporting on quality of reduction and fixation of intertrochanteric fractures—A systematic review. Injury, 2021, 52(3): 324-329.
10.	Li S, Chang SM, Niu WX, et al. Comparison of tip apex distance and cut-out complications between helical blades and lag screws in intertrochanteric fractures among the elderly: a meta-analysis. J Orthop Sci, 2015, 20(6): 1062-1069.
11.	Yam M, Chawla A, Kwek E. Rewriting the tip apex distance for the proximal femoral nail anti-rotation. Injury, 2017, 48(8): 1843-1847.
12.	Ng M, Shah NS, Golub I, et al. No difference between lag screw and helical blade for cephalomedullary nail cut-out a systematic review and meta-analysis. Eur J Orthop Surg Traumatol, 2022, 32(8): 1617-1625.
13.	Reis JPG, Lopes AL, Branco RJ, et al. Trochanteric fractures: Tip-apex distance, calcar tip-apex distance, and chang criteria—A multiple variable analysis. Arch Orthop Trauma Surg, 2023, 143(12): 7035-7041.
14.	张殿英. 重新认识尖顶距学说指导股骨转子间骨折治疗的价值. 中华创伤杂志, 2023, 39(2): 121-126.
15.	Fisher ND, Parola R, Anil U, et al. A good tip-apex distance does not make up for a poor reduction in intertrochanteric hip fractures treated with an cephalomedullary nail: The utility of the neck-shaft angle in preventing fixation failure. J Am Acad Orthop Surg, 2024, 32(2): 83-91.
16.	Kay RM, Jaki KA, Skaggs DL. The effect of femoral rotation on the projected femoral neck-shaft angle. J Pediatr Orthop, 2000, 20(6): 736-739.
17.	Lee C, Kelley B, Gurbani A, et al. Strategies for pertrochanteric fracture reduction and intramedullary nail placement: Technical tips and tricks. J Am Acad Orthop Surg, 2022, 30(18): 867-878.
18.	Mao W, Hong CC, Chang SM. Strategies for pertrochanteric fracture reduction and intramedullary nail placement: technical tips and tricks. J Am Acad Orthop Surg, 2024, 32(6): e267-e268.
19.	Lazzarini F, Paoli T, Cozzi Lepri A, et al. Accuracy of radiographic projections to guide cephalic screw position in pertrochanteric fracture: a cadaveric study. Eur J Orthop Surg Traumatol, 2024, 34(1): 479-487.
20.	Xiong WF, Zhang YQ, Chang SM, et al. Lesser trochanteric fragments in unstable pertrochanteric hip fractures: A morphological study using three-dimensional computed tomography (3-D CT) reconstruction. Med Sci Monit, 2019, 25: 2049-2057.
21.	王晓旭, 张世民, 胡孙君, 等. 沿股骨转子间线环周皮质的CT影像学测量及临床意义. 同济大学学报 (医学版), 2023, 44(6): 829-834.
22.	Chang SM, Zhang YQ, Du SC, et al. Anteromedial cortical support reduction in unstable pertrochanteric fractures: a comparison of intra-operative fluoroscopy and post-operative three dimensional computerised tomography reconstruction. Int Orthop, 2018, 42(1): 183-189.
23.	Mao W, Liu CD, Chang SM, et al. Anteromedial cortical support in reduction of trochanteric hip fractures: from definition to application. J Bone Joint Surg (Am), 2024, 106(11): 1008-1018.
24.	Chen SY, Chang SM, Tuladhar R, et al. A new fluoroscopic view for evaluation of anteromedial cortex reduction quality during cephalomedullary nailing for intertrochanteric femur fractures: the 30° oblique tangential projection. BMC Musculoskelet Disord, 2020, 21(1): 719. doi: 10.1186/s12891-020-03668-6.
25.	陈时益, 张世民, 熊文峰, 等. 股骨转子间骨折前方骨折线对髓内钉术后前侧皮质复位丢失的影响. 中国修复重建外科杂志, 2024, 38(4): 391-397.
26.	Inui T, Watanabe Y, Suzuki T, et al. Anterior malreduction is associated with lag screw cutout after internal fixation of intertrochanteric fractures. Clin Orthop Relat Res, 2024, 482(3): 536-545.
27.	Chen SY, Li HT, Chang SM. Letter to the editor: Anterior malreduction is associated with lag screw cutout after internal fixation of intertrochanteric fractures. Clin Orthop Relat Res, 2024, 482(2): 402-404.
28.	Yamamoto N, Tsujimoto Y, Yokoo S, et al. Association between immediate postoperative radiographic findings and failed internal fixation for trochanteric fractures: Systematic review and meta-analysis. J Clin Med, 2022, 11(16): 4879. doi: 10.3390/jcm11164879.
29.	Rikli D, Goldhahn S, Blauth M, et al. Optimizing intraoperative imaging during proximal femoral fracture fixation-a performance improvement program for surgeons. Injury, 2018, 49(2): 339-344.
30.	Michalowski AK, Puzzitiello RN, Ryan SP. How to place a cephalomedullary screw when visualization is obscured by the jig in peritrochanteric hip fractures using “peek radiographs”. J Clin Orthop Trauma, 2023, 42: 102208. doi: 10.1016/j.jcot.2023.102208.
31.	Cancio-Bello AM, Karam MD, Jahangir AA, et al. Winquist view of the femoral neck: Ideal visualization of femoral neck fixation. Iowa Orthop J, 2023, 43(1): 191-194.
32.	Elbahi A, Thomas O, Dungey M, et al. Factors associated with increased radiation exposure in the fixation of proximal femoral fractures. Ann R Coll Surg Engl, 2024. doi: 10.1308/rcsann.2023.0092.
33.	Ramanoudjame M, Guillon P, Dauzac C, et al. CT evaluation of torsional malalignment after intertrochanteric fracture fixation. Orthop Traumatol Surg Res, 2010, 96(8): 844-848.
34.	Kim TY, Lee YB, Chang JD, et al. Torsional malalignment, how much significant in the trochanteric fractures? Injury, 2015, 46(11): 2196-2200.
35.	杜守超, 熊文峰, 张世民, 等. 股骨转子间骨折头髓钉固定术后头颈骨块旋转角度的测量及其临床意义. 中国修复重建外科杂志, 2019, 33(10): 1228-1233.
36.	辛大江, 张成成, 李文亮, 等. 股骨转子间骨折中头颈骨块“鸟嘴样”向前翘起的形态特征及复位技巧. 中国修复重建外科杂志, 2024, 38(6): 710-715.

1. Baumgaertner MR, Curtin SL, Lindskog DM, et al. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg (Am), 1995, 77(7): 1058-1064.
2. Chang SM, Zhang YQ, Ma Z, et al. Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg, 2015, 135(6): 811-818.
3. Marchand LS, Jacobson LG, Stuart AR, et al. Assessing femoral rotation: A survey comparison of techniques. J Orthop Trauma, 2020, 34(3): e96-e101.
4. Ivanov DV, Welby JP, Khanna A, et al. Evaluation of intraoperative fluoroscopic techniques to estimate femoral rotation: A cadaveric study. J Orthop Trauma, 2024, 38(5): 279-284.
5. Marchand LS, Todd DC, Kellam P, et al. Is the lesser trochanter profile a reliable means of restoring anatomic rotation after femur fracture fixation? Clin Orthop Relat Res, 2018, 476(6): 1253-1261.
6. Ju B, Moon YJ, Lee KB. Use of lesser trochanter profile as a rotational alignment guide in intramedullary nailing for femoral shaft fracture. J Bone Joint Surg (Am), 2021, 103(22): e89. doi: 10.2106/JBJS.21.00105.
7. Jang ES, Davignon R, Geller JA, et al. Accuracy of the lesser trochanter profile as a marker of femoral rotation: Computed tomography-based study of 1, 722 femora. J Bone Joint Surg (Am), 2024, 106(10): 912-918.
8. Chang SM, Hou ZY, Hu SJ, et al. Intertrochanteric femur fracture treatment in Asia: What we know and what the world can learn. Orthop Clin North Am, 2020, 51(2): 189-205.
9. Marmor M, Guenthner G, Rezaei A, et al. Reporting on quality of reduction and fixation of intertrochanteric fractures—A systematic review. Injury, 2021, 52(3): 324-329.
10. Li S, Chang SM, Niu WX, et al. Comparison of tip apex distance and cut-out complications between helical blades and lag screws in intertrochanteric fractures among the elderly: a meta-analysis. J Orthop Sci, 2015, 20(6): 1062-1069.
11. Yam M, Chawla A, Kwek E. Rewriting the tip apex distance for the proximal femoral nail anti-rotation. Injury, 2017, 48(8): 1843-1847.
12. Ng M, Shah NS, Golub I, et al. No difference between lag screw and helical blade for cephalomedullary nail cut-out a systematic review and meta-analysis. Eur J Orthop Surg Traumatol, 2022, 32(8): 1617-1625.
13. Reis JPG, Lopes AL, Branco RJ, et al. Trochanteric fractures: Tip-apex distance, calcar tip-apex distance, and chang criteria—A multiple variable analysis. Arch Orthop Trauma Surg, 2023, 143(12): 7035-7041.
14. 张殿英. 重新认识尖顶距学说指导股骨转子间骨折治疗的价值. 中华创伤杂志, 2023, 39(2): 121-126.
15. Fisher ND, Parola R, Anil U, et al. A good tip-apex distance does not make up for a poor reduction in intertrochanteric hip fractures treated with an cephalomedullary nail: The utility of the neck-shaft angle in preventing fixation failure. J Am Acad Orthop Surg, 2024, 32(2): 83-91.
16. Kay RM, Jaki KA, Skaggs DL. The effect of femoral rotation on the projected femoral neck-shaft angle. J Pediatr Orthop, 2000, 20(6): 736-739.
17. Lee C, Kelley B, Gurbani A, et al. Strategies for pertrochanteric fracture reduction and intramedullary nail placement: Technical tips and tricks. J Am Acad Orthop Surg, 2022, 30(18): 867-878.
18. Mao W, Hong CC, Chang SM. Strategies for pertrochanteric fracture reduction and intramedullary nail placement: technical tips and tricks. J Am Acad Orthop Surg, 2024, 32(6): e267-e268.
19. Lazzarini F, Paoli T, Cozzi Lepri A, et al. Accuracy of radiographic projections to guide cephalic screw position in pertrochanteric fracture: a cadaveric study. Eur J Orthop Surg Traumatol, 2024, 34(1): 479-487.
20. Xiong WF, Zhang YQ, Chang SM, et al. Lesser trochanteric fragments in unstable pertrochanteric hip fractures: A morphological study using three-dimensional computed tomography (3-D CT) reconstruction. Med Sci Monit, 2019, 25: 2049-2057.
21. 王晓旭, 张世民, 胡孙君, 等. 沿股骨转子间线环周皮质的CT影像学测量及临床意义. 同济大学学报 (医学版), 2023, 44(6): 829-834.
22. Chang SM, Zhang YQ, Du SC, et al. Anteromedial cortical support reduction in unstable pertrochanteric fractures: a comparison of intra-operative fluoroscopy and post-operative three dimensional computerised tomography reconstruction. Int Orthop, 2018, 42(1): 183-189.
23. Mao W, Liu CD, Chang SM, et al. Anteromedial cortical support in reduction of trochanteric hip fractures: from definition to application. J Bone Joint Surg (Am), 2024, 106(11): 1008-1018.
24. Chen SY, Chang SM, Tuladhar R, et al. A new fluoroscopic view for evaluation of anteromedial cortex reduction quality during cephalomedullary nailing for intertrochanteric femur fractures: the 30° oblique tangential projection. BMC Musculoskelet Disord, 2020, 21(1): 719. doi: 10.1186/s12891-020-03668-6.
25. 陈时益, 张世民, 熊文峰, 等. 股骨转子间骨折前方骨折线对髓内钉术后前侧皮质复位丢失的影响. 中国修复重建外科杂志, 2024, 38(4): 391-397.
26. Inui T, Watanabe Y, Suzuki T, et al. Anterior malreduction is associated with lag screw cutout after internal fixation of intertrochanteric fractures. Clin Orthop Relat Res, 2024, 482(3): 536-545.
27. Chen SY, Li HT, Chang SM. Letter to the editor: Anterior malreduction is associated with lag screw cutout after internal fixation of intertrochanteric fractures. Clin Orthop Relat Res, 2024, 482(2): 402-404.
28. Yamamoto N, Tsujimoto Y, Yokoo S, et al. Association between immediate postoperative radiographic findings and failed internal fixation for trochanteric fractures: Systematic review and meta-analysis. J Clin Med, 2022, 11(16): 4879. doi: 10.3390/jcm11164879.
29. Rikli D, Goldhahn S, Blauth M, et al. Optimizing intraoperative imaging during proximal femoral fracture fixation-a performance improvement program for surgeons. Injury, 2018, 49(2): 339-344.
30. Michalowski AK, Puzzitiello RN, Ryan SP. How to place a cephalomedullary screw when visualization is obscured by the jig in peritrochanteric hip fractures using “peek radiographs”. J Clin Orthop Trauma, 2023, 42: 102208. doi: 10.1016/j.jcot.2023.102208.
31. Cancio-Bello AM, Karam MD, Jahangir AA, et al. Winquist view of the femoral neck: Ideal visualization of femoral neck fixation. Iowa Orthop J, 2023, 43(1): 191-194.
32. Elbahi A, Thomas O, Dungey M, et al. Factors associated with increased radiation exposure in the fixation of proximal femoral fractures. Ann R Coll Surg Engl, 2024. doi: 10.1308/rcsann.2023.0092.
33. Ramanoudjame M, Guillon P, Dauzac C, et al. CT evaluation of torsional malalignment after intertrochanteric fracture fixation. Orthop Traumatol Surg Res, 2010, 96(8): 844-848.
34. Kim TY, Lee YB, Chang JD, et al. Torsional malalignment, how much significant in the trochanteric fractures? Injury, 2015, 46(11): 2196-2200.
35. 杜守超, 熊文峰, 张世民, 等. 股骨转子间骨折头髓钉固定术后头颈骨块旋转角度的测量及其临床意义. 中国修复重建外科杂志, 2019, 33(10): 1228-1233.
36. 辛大江, 张成成, 李文亮, 等. 股骨转子间骨折中头颈骨块“鸟嘴样”向前翘起的形态特征及复位技巧. 中国修复重建外科杂志, 2024, 38(6): 710-715.

Chinese Journal of Reparative and Reconstructive Surgery

Standard radiographic images in cephalomedullary nailing fixation for intertrochanteric femoral fractures

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