CT analysis of femoral malrotation after intramedullary nailing of trochanteric fractures

Maléř, J; Džupa, Valér; Buk, Michal; Michna, Martin; Marvan, Jiří; Skála-Rosenbaum, J

doi:10.1007/s00402-021-03902-3

Cited by 5 publications

(11 citation statements)

References 29 publications

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“…1,6 While methods using computed navigation and CT scanning can reliably estimate anatomic anteversion, these techniques cannot easily be implemented intraoperatively. 1,11,12,16 The fluoroscopic methods assessed in this study have been proposed as less burdensome alternatives to CT-based methods and have a high acceptance among orthopaedic surgeons. 17,18 Utilizing the TL method, Tornetta et al 4 reported an average of 5 degrees rotational error and no cases of malrotation .15 degrees.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of Intraoperative Fluoroscopic Techniques to Estimate Femoral Rotation: A Cadaveric Study

Ivanov,

Welby,

Khanna

et al. 2024

Journal of Orthopaedic Trauma

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Objectives: To compare three fluoroscopic methods for determining femoral rotation. Methods: Native femoral version was measured by computed tomography in 20 intact femurs from 10 cadaveric specimens. Two Steinmann pins were placed into each left femur above and below a planned transverse osteotomy which was completed through the diaphysis. Four surgeons utilized the true lateral (TL), neck-horizontal angle (NH), and lesser trochanter profile (LTP) techniques to correct the injured femur’s rotation using the intact right femur as reference, yielding 120 measurements. Accuracy was assessed by comparing the angle subtended by the two Steinmann pins before and after manipulation and comparing against version measurements of the right femur. Results: Absolute mean rotational error in the fractured femur compared to its uninjured state was 6.0° (95% CI, 4.6-7.5), 6.6° (95% CI, 5.0-8.2), and 8.5° (95% CI, 6.5-10.6) for the TL, NH, and LTP techniques, respectively, without significant difference between techniques (p=0.100). Compared to the right femur, absolute mean rotational error was 6.6° (95% CI, 1.0-12.2), 6.4° (95% CI, 0.1-12.6), and 8.9° (95% CI, 0.8-17.0) for the TL, NH, and LTP techniques, respectively, without significant difference (p=0.180). Significantly more femurs were malrotated by >15° using the LTP method compared to the TL and NH methods (20.0% vs 2.5% and 5.0%, p=0.030). Absolute mean error in estimating femoral rotation of the intact femur using the TL and NH methods compared to CT was 6.6° (95% confidence interval [CI], 5.1-8.2) and 4.4° (95% CI, 3.4-5.4), respectively, with significant difference between the two methods (p=0.020). Conclusions: The true lateral (TL), neck-horizontal angle (NH), and the lesser trochanter profile (LTP) techniques performed similarly in correcting rotation of the fractured femur, but significantly more femurs were malrotated by >15° using the LTP technique. This supports preferential use of the TL or NH methods for determining femoral version intraoperatively.

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Section: Discussionmentioning

confidence: 99%

Evaluation of Intraoperative Fluoroscopic Techniques to Estimate Femoral Rotation: A Cadaveric Study

Ivanov,

Welby,

Khanna

et al. 2024

Journal of Orthopaedic Trauma

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“…In general, any malrotation of the femur comes with impairment in patient outcomes, regardless of location, when considering osteosynthesis. While issues with malrotation in the femoral shaft are described [11,12,17,[21][22][23][24][25], Male ´ř et al report a doubling of cutout rate when malrotation exceeds 15˚in the intertrochanteric region, showing the need for anatomic reduction [26]. Fractures of the basicervical femoral neck are treated with osteosynthesis.…”

Section: Discussionmentioning

confidence: 99%

Validation of direct CT measurement of malrotation in femoral neck fractures: A bone model study

et al. 2023

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Background While postoperative malrotation in the subtrochanteric region is a well-known problem, malrotation after osteosynthesis in proximal femoral fractures has not been extensively studied. In this context, many methods for perioperatively assessment of femoral torsion have been described, but none of them is applicable in the basicervical region of the proximal femur. As an important difference in femoral neck fractures, the discontinuous neck fails to serve as a significant “pointer” for measurements and malfunctions to be placed in relation to the condylar plane. Considering postoperative maltorsion at any location as a substantial negative effect on patients’ outcome and functional expectations, precise and patient-friendly rotation measurement standards in femoral neck fractures are desired in clinical practice. Recently, a novel computed tomography (CT) based geometric technique was described named “direct measurement” with promising results covering this diagnostic disparity, but still requires validation. Thus, we aimed to validate the previously described technique using a controlled range of displacement in a femoral neck fracture Sawbone® model. Methods and findings A goniometer was designed to set retro- and anteversion of the proximal femur in a reproducible manner. Prospectively, all femurs underwent a CT scan and were measured 3D for displacement. The interclass correlation between the CT measurements and the goniometer measurements was calculated and was found to be very high (1.00, 95% confidence interval: 0.99–1.00; p < 0.001). For the mean of all measurements, the Pearson’s correlation was 1.00 (p < 0.001). No significant differences in the measurements of both investigators were observed, with 20° of retroversion not significant (-1.20 ± 1.71; 95% confidence interval: -2.43–0.03; p = 0.054). Conclusion This CT-based 3D measurement technique may allow for perioperative malrotation assessment in basicervical femoral neck fractures and appears to be feasible in femoral neck fractures when it comes to rare cases of osteosynthesis. Further investigations are still needed to define the thresholds of malrotation provoking functional impairment after osteosynthesis in basicervical femoral neck fractures.

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“…The acceptable range of bilateral differences in the femoral rotation is ≤15° [ 1,2,[4][5][6][7]. The malrotation>15° has been found to be 17%-28% in femoral shaft fractures [1,2,[5][6][7] and 25.7%-40% in femoral trochanteric fractures [8][9][10][11]. The indicators of rotation are "cortical step sign," "lesser trochanter shape sign," and" hip lateral view difference," etc.…”

Section: Introductionmentioning

confidence: 99%

“…However, there is no indicator of rotation when treating trochanteric fractures during surgery. The incidence of malrotation of trochanteric fractures is not different between young surgeons and experienced surgeons [ 11 ]. The incidence of internal malrotation was higher than the incidence of external malrotation in trochanteric fractures [ 11 ].…”

Section: Introductionmentioning

confidence: 99%

“…The incidence of malrotation of trochanteric fractures is not different between young surgeons and experienced surgeons [ 11 ]. The incidence of internal malrotation was higher than the incidence of external malrotation in trochanteric fractures [ 11 ]. While treating trochanteric fractures using a cephalo-medullary nail, over-reduction of the proximal fragment of the distal cortex is recommended to prevent excessive sliding which causes fixation failure [ 16 , 17 ].…”

Section: Introductionmentioning

confidence: 99%

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Measurement of Lag-Screw Anteversion With an iPhone During Trochanteric Fracture Surgery

Kinami¹,

Hasei²

2022

Cureus

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IntroductionA useful way to easily evaluate femoral rotation during surgery for trochanteric fractures is not known. Hence, this pilot study aimed to develop an intraoperative indicator to evaluate anteversion in femoral trochanteric fractures. Material and methodsProspectively, from June 2021 to January 2022, all patients with femoral trochanteric fractures (Orthopaedic Trauma Association classification: 31A1-3) treated using a cephalo-medullary nail with a lag-screw neckshaft angle of 125° were included in this study. During surgery, lag-screw anteversion (LS-AV) was measured using the goniometer application in an iPhone with the fractured femur table-top-plane level with the traction table floor. Accuracy was analyzed by comparing axial-projected lag-screw anteversion (AxP-LS-AV) and three-dimensional computed tomography lag-screw anteversion (3DCT-LS-AV) measurements after surgery. ResultsFifty patients (14 males and 36 females) were included in the study. The mean age was 87 (range; 69-98) years; the Orthopaedic Trauma Association classifications were A1 (28 patients), A2 (18 patients), and A3 (4 patients). The mean LS-AV was 10.7° ± 6.9°, the mean AxP-LS-AV was 12.8° ± 8.3°, and the mean 3DCT-LS-AV was 13.1° ± 8.6°. The median difference between AxP-LS-AV and 3DCT-LS-AV was 3.0° (range: 0°-12°), and 40 (80%) patients had differences of ≤5° (Bland-Altman plot: inside of limit of agreement = 86%, paired t-test p = 0.7, Pearson correlation coefficient r = 0.817, p <0.001). ConclusionFemur malrotation is defined as a deformity of >15° relative to the normal contralateral limb. Intraoperative LS-AV iPhone measurement on table-top-plane standard had sufficient accuracy as an indicator of anteversion in femoral trochanteric fractures.

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CT analysis of femoral malrotation after intramedullary nailing of trochanteric fractures

Cited by 5 publications

References 29 publications

Evaluation of Intraoperative Fluoroscopic Techniques to Estimate Femoral Rotation: A Cadaveric Study

Evaluation of Intraoperative Fluoroscopic Techniques to Estimate Femoral Rotation: A Cadaveric Study

Validation of direct CT measurement of malrotation in femoral neck fractures: A bone model study

Measurement of Lag-Screw Anteversion With an iPhone During Trochanteric Fracture Surgery

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