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Xie W, Shi L, Zhang C, Cui X, Chen X, Xie T, Zhang S, Chen H, Rui Y. Anteromedial cortical support reduction of intertrochanteric fractures-A review. Injury 2024; 55:111926. [PMID: 39388744 DOI: 10.1016/j.injury.2024.111926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 09/19/2024] [Accepted: 09/21/2024] [Indexed: 10/12/2024]
Abstract
The intertrochanteric fracture is a common fragility fracture typically resulting from low-energy falls. The functional outcome of intertrochanteric fractures is closely linked to the patient's underlying physical condition, intraoperative procedures, and postoperative complications. In terms of surgery, while timely surgery and appropriate internal fixation have demonstrated favorable outcomes, attention to intraoperative reduction is crucial. In recent years, there have been further developments in the evaluation of reduction of intertrochanteric fractures, particularly in the anteromedial cortical reduction, and these advances have been further scientifically elucidated in terms of their ability to provide stable fracture reduction and resist loss of reduction. In order to gain a comprehensive understanding of the anteromedial cortex theory, this article reviewed the anatomy, related theoretical progress, and controversies in recent years.
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Affiliation(s)
- Wenjun Xie
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Liu Shi
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Cheng Zhang
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Xueliang Cui
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Xiangxu Chen
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Tian Xie
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Sheng Zhang
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Yunfeng Rui
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
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Patel VJ, Patel NB, Tank PM, Upadhyay KA, Ashwin KK. The Role of Computed Tomography and Radiographs in the Management of Intertrochanteric Fractures. Malays Orthop J 2023; 17:17-25. [PMID: 38107350 PMCID: PMC10723008 DOI: 10.5704/moj.2311.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 04/19/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction The Intertrochanteric fracture is a common hip trauma encountered in elderly patients. There is a lack of general agreement regarding its surgical management and choice of implant. Purpose of this study to conclude the final decision matrix regarding surgical management of intertrochanteric fractures based on parameters assessed on plain radiographs and CT scan. Materials and methods We have retrospectively evaluated 55 patients with intertrochanteric fractures presented to our institute after informed consent with radiographs and CT scans between July 2017 to July 2018. Assessment of various parameters regarding fracture geometry and classification as well as measurement was done. Results Mean lateral wall thickness in present study was 20.76mm. Incidence of coronal fragments was 90.9% and absence of coronal fragment in 5 patients. We noted the cases with anterior comminution had also a posterior comminution rendered the fracture unstable in almost 20 % cases. Conclusion Better understanding of fracture geometry by combined used of radiograph and CT scan enhanced preoperative planning, choice of suitable implant, helps in reduction manoeuvre and improving quality of osteosynthesis.
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Affiliation(s)
- V J Patel
- Department of Orthopaedics, Narendra Modi Medical College, Ahmedabad, India
| | - N B Patel
- Department of Orthopaedics, Smt. NHL Municipal Medical College, Ahmedabad, India
| | - P M Tank
- Department of Orthopaedics, Smt. NHL Municipal Medical College, Ahmedabad, India
| | - K A Upadhyay
- Department of Orthopaedics, Smt. NHL Municipal Medical College, Ahmedabad, India
| | - K K Ashwin
- Department of Orthopaedics, Smt. NHL Municipal Medical College, Ahmedabad, India
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Yang L, Gao S, Li P, Shi J, Zhou F. Recognition and Segmentation of Individual Bone Fragments with a Deep Learning Approach in CT Scans of Complex Intertrochanteric Fractures: A Retrospective Study. J Digit Imaging 2022; 35:1681-1689. [PMID: 35711073 PMCID: PMC9712885 DOI: 10.1007/s10278-022-00669-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 05/04/2022] [Accepted: 06/07/2022] [Indexed: 10/18/2022] Open
Abstract
The characteristics of bone fragments are the main influencing factors for the choice of treatment in intertrochanteric fractures. This study aimed to develop a deep learning algorithm for recognizing and segmenting individual fragments in CT images of complex intertrochanteric fractures for orthopedic surgeons. This study was based on 160 hip CT scans (43,510 images) of complex fractures of three types based on the Evans-Jensen classification (40 cases of type 3 (IIA) fractures, 80 cases of type 4 (IIB)fractures, and 40 cases of type 5 (III)fractures) retrospectively. The images were randomly split into two groups to construct a training set of 120 CT scans (32,045 images) and a testing set of 40 CT scans (11,465 images). A deep learning model was built into a cascaded architecture composed by a convolutional neural network (CNN) for location of the fracture ROI and another CNN for recognition and segmentation of individual fragments within the ROI. The accuracy of object detection and dice coefficient of segmentation of individual fragments were used to evaluate model performance. The model yielded an average accuracy of 89.4% for individual fragment recognition and an average dice coefficient of 90.5% for segmentation in CT images. The results demonstrated the feasibility of recognition and segmentation of individual fragments in complex intertrochanteric fractures with a deep learning approach. Altogether, these promising results suggest the potential of our model to be applied to many clinical scenarios.
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Affiliation(s)
- Lv Yang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Shan Gao
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Pengfei Li
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Jiancheng Shi
- Department of Radiology, Peking University Third Hospital, Yanqing Hospital, Beijing, China
| | - Fang Zhou
- Department of Orthopedics, Peking University Third Hospital, Beijing, China.
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Cordero-Ampuero J, Peix C, Marcos S, Cordero G-G E. Influence of surgical quality (according to postoperative radiography) on mortality, complications and recovery of walking ability in 1425 hip fracture patients. Injury 2021; 52 Suppl 4:S32-S36. [PMID: 33642085 DOI: 10.1016/j.injury.2021.02.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/13/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the influence of surgical quality (as evaluated in the post-surgical radiographic control) on mortality, complications and recovery of walking ability in patients older than 64 years with hip fracture. PATIENTS AND METHODS Retrospective observational study of a single-center, consecutive cohort of 1425 patients operated from December/2012 to March/2018. Average age was 85.66±7.13 (65-108) years and 966 (67.86%) were female. Extracapsular fractures (811 cases, 56.91%) were fixed with trochanteric nails (Affixus-DePuy / PFNA-Synthes) (795 cases) or sliding-hip-screw-plates (Biomet) (16 patients). Intracapsular fractures (614, 43.09%) were treated with cannulated screws (Smith-Nephew) (134 cases) or with arthroplasty (472 bipolar and 8 total hip, Furlong-JRI or Exeter-Stryker). Postoperative radiographs were used to determine surgical quality (reduction, compression, screw position, tip-apex, stem position, Voss, intraoperative fracture). Patients were followed clinically and radiographically in outpatient clinic after 1, 3, 6, and 12 months. STATISTICAL ANALYSIS Bivariate analysis (Pearson, Fischer, Mann-Whitney, Wilcoxon) was applied to study statistically significant relations, and Relative Risks (RR) were calculated. RESULTS 196 patients (13.75%) died along follow-up, and poor reduction was found to be a risk factor for mortality both in trochanteric nail group (p=0.0495) (RR 1.510, 1.01-2.26) and in cannulated screw group (p=0.0023) (RR 6.48, 2.40-17.53); this is a previously non-published risk factor. Surgical complications included 33 infections (2.36%), 12 non-unions (1.27%), 12 cut-outs (1.47%), 7 broken nails (0.86%), 21 hemiarthroplasty dislocations (4.37%), and 8 ischemic necrosis of the femoral head (5.97%). The significant risk factors were: poor reduction for trochanteric nail breakage (p=0.041) (RR 4.47, 1.13-17.67), poor reduction for non-union in cannulated screws (p=0.035) (RR 10.91, 1.70-70.09), as well as "tip-apex distance" over 25mm in trochanteric fractures for "cut-out" type of fixation failure (p=0.0159) (RR 3.84, 1.19-12.40). Previous walking ability was restored in 564 patients (39.58%) and worsened in 581 (40.77%), but statistical relationships were not found, although follow-up data were inadequate in 212 cases (14.88%). CONCLUSIONS Appropriate reduction of hip fractures is a significant step to reduce mortality, nail breakage and non-union. Adequate position of sliding screw (avoiding tip-apex distances over 25mm) is important to reduce "cut-out" in trochanteric fractures.
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Affiliation(s)
- José Cordero-Ampuero
- Department of Orthopaedic Surgery, University Hospital La Princesa, Universidad Autónoma de Madrid, c/Diego de León 62, 28006 Madrid, Spain.
| | - Claudio Peix
- Department of Orthopaedic Surgery, University Hospital La Princesa, Universidad Autónoma de Madrid, c/Diego de León 62, 28006 Madrid, Spain
| | - Sergio Marcos
- Department of Orthopaedic Surgery, University Hospital La Princesa, Universidad Autónoma de Madrid, c/Diego de León 62, 28006 Madrid, Spain
| | - Enrique Cordero G-G
- Department of Orthopaedic Surgery, University Hospital La Princesa, Universidad Autónoma de Madrid, c/Diego de León 62, 28006 Madrid, Spain
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Yamamoto N, Tamura R, Inoue T, Noda T, Nagano H, Ozaki T. Radiological findings and outcomes of anterior wall fractures in pertrochanteric fractures. J Orthop Sci 2021; 26:247-253. [PMID: 32241602 DOI: 10.1016/j.jos.2020.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 02/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Anterior wall fractures with comminution at the anterior cortex in pertrochanteric fractures are relatively rare. We aimed to investigate the prevalence and clinical findings of anterior wall fractures in this comparative cohort study. METHODS We reviewed 516 consecutive patients who underwent internal fixation. Anterior wall fractures were classified into three types: proximal, distal, and proximal/distal. Outcome measures included demographic data, residual anterior cortex length, fracture reduction, tip-apex distance (TAD), sliding distance, bone union, and revision surgery. We compared radiological outcomes between patients with anterior wall fractures and posterior comminuted fractures without an anterior wall fracture. The groups were matched for age and sex. RESULTS Anterior wall fractures were noted in 44 patients (8.5%). Residual anterior cortex length was shorter for the proximal/distal type. The distal type was the most common, was the most difficult to achieve an acceptable reduction status for, and was associated with the longest sliding distance. The proportion of unacceptable reduction status was higher for anterior wall fractures. However, there were no statistically significant differences between anterior wall fractures and posterior comminuted fractures without an anterior wall fracture in terms of TAD, sliding distance, bone union, and revision rate. CONCLUSIONS This study suggests that anterior wall fracture is not a significant predictor of over-sliding distance.
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Affiliation(s)
- Norio Yamamoto
- Department of Orthopaedic Surgery, Unnan City Hospital, Shimane, Japan.
| | - Ryu Tamura
- Department of Orthopaedic Surgery, Kochi Health Sciences Center, Kochi, Japan
| | - Tomoo Inoue
- Department of Orthopaedic Surgery, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Tomoyuki Noda
- Department of Musculoskeletal Traumatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Nagano
- Department of Orthopaedic Surgery, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Zhang Y, Sun Y, Liao S, Chang S. Three-Dimensional Mapping of Medial Wall in Unstable Pertrochanteric Fractures. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8428407. [PMID: 32596385 PMCID: PMC7285401 DOI: 10.1155/2020/8428407] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/18/2020] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Unstable pertrochanteric fractures are usually treated with internal fixation, and the integrity of the anteromedial cortex is an important factor for stability and healing. In this study, we described and analyzed the three-dimensional mapping technology and morphological characteristics of pertrochanteric fractures. METHODS Fifty-nine pertrochanteric fractures (OTA/AO 2007 types 31A2) were retrospectively reviewed. Computed tomographic (CT) images for all fractures were superimposed on a standard template. Medial wall integrity was analyzed, and three-dimensional fracture maps were created. RESULTS Pertrochanteric fractures always have a posterior defect in the medial cortex. The mean width of the defect, in our study, was 21.5 mm (SD: 6.1 mm, range: 10-40 mm), 56.3% (SD: 13.7%, range: 27.5-100%). Bone segments that contact by the anteromedial cortex were 16.5 mm (SD: 5.3 mm, range: 0-29 mm). CONCLUSION The integrity of the anteromedial cortex should be considered during internal fixation of femoral trochanteric fractures. These morphological characteristics could be used to form postoperative cortical contact and improve stability of the fixation. Three-dimensional mapping technology can help establish a typical fracture model, thereby improving doctors' understanding of fracture characteristics.
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Affiliation(s)
- Yingqi Zhang
- Department of Orthopedic Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yeqing Sun
- Department of Orthopedic Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shenghui Liao
- School of Information Science and Engineering, Central South University, Changsha, China
| | - Shimin Chang
- Department of Orthopedic Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China
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Wada K, Mikami H, Amari R, Toki S, Takai M, Sairyo K. A novel three-dimensional classification system for intertrochanteric fractures based on computed tomography findings. THE JOURNAL OF MEDICAL INVESTIGATION 2019; 66:362-366. [PMID: 31656307 DOI: 10.2152/jmi.66.362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
A novel three-dimensional fragment-based classification system based on computed tomography findings was established to characterize femoral intertrochanteric fractures. The intertrochanteric bone fragments were defined as follows : neck, posterior portion of the greater trochanter, anterior portion of the greater trochanter, lesser trochanter, and shaft. Each type of fracture was classified as 2-, 3-, 4-, or 5-fragment according to the number of floating bone fragments. Following the description of the fracture type, each floating bone fragment was appended, with the exception of a fragment involving the shaft. Ninety-five intertrochanteric fractures were classified by the same surgeon. The fractures occurred in 14 men and 81 women with a mean age of 84.7 years. The frequency of each type of fracture was investigated. Thirty-one fractures (32.6%) were 2-fragment and 64 (67.4%) were ≥ 3-fragment. A fragment of the anterior portion of the greater trochanter, which cannot be classified using conventional systems, was included in 29 cases (30.5%). A 5-fragment fracture was detected in two cases (2.1%). Using this fragment-based classification system, intertrochanteric fractures can be evaluated in more detail than is possible using conventional classification systems. J. Med. Invest. 66 : 362-366, August, 2019.
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Affiliation(s)
- Keizo Wada
- Department of Orthopedics, Institute of Biomedical Science, Tokushima University Graduate School, Tokushima, Japan
| | - Hiroshi Mikami
- Department of Orthopaedic Surgery, Yoshinogawa Medical Center, Tokushima, Japan
| | - Rui Amari
- Department of Orthopedics, Institute of Biomedical Science, Tokushima University Graduate School, Tokushima, Japan
| | - Shunichi Toki
- Department of Orthopedics, Institute of Biomedical Science, Tokushima University Graduate School, Tokushima, Japan
| | - Michihiro Takai
- Department of Orthopaedic Surgery, Yoshinogawa Medical Center, Tokushima, Japan
| | - Koichi Sairyo
- Department of Orthopedics, Institute of Biomedical Science, Tokushima University Graduate School, Tokushima, Japan
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Wang X, Zhang Y, Zhang S, Du S, Chen K, Wang Z. [Image study of anteromedial cortical morphology of intertrochanteric fractures]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:1260-1264. [PMID: 31544436 DOI: 10.7507/1002-1892.201905100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To study the anteromedial cortical morphology of intertrochanteric fracture with CT three-dimensional reconstruction technique, and to provide a reference for further study of cortical buttress reduction theory. Methods CT data of 75 patients with unstable intertrochanteric fracture with complete imaging data treated between January 2016 and January 2019 were retrospectively analyzed, including 32 males and 43 females, aged 65-98 years (mean, 79.8 years). According to AO/Orthopaedic Trauma Association typing of 2018 edition, there were 46 cases of 31-A2.2 type and 29 cases of 31-A2.3 type. The image processing techniques such as segmentation modeling and virtual reset were performed. The thickness of the cortex at the anteromedial corner, the angle between the anterior wall fracture line and the coronal horizontal line, the angle between the medial wall fracture line and the sagittal horizontal line, the width of the cortex supported by the medial wall were measured, and the morphology of the cortical bone at the anteromedial corner were observed. Results The angle between the anterior wall fracture line and the coronal horizontal line was 51.8-72.6°, with an average of 62.4°; the angle between the medial wall fracture line and the sagittal horizontal line ranged from 17.6° to -47.3°, with an average of -15.8°; the thickness of the cortex at the anteromedial angle was 3.6-6.1 mm, with an average of 4.4 mm; and the width of the cortex supported by the medial wall was 14.3-21.2 mm, with an average of 16.8 mm. The morphology of the cortical bone at the anteromedial corner had 3 forms: angle with femoral neck axis >90°, 57 cases (76.0%); perpendicular to femoral neck axis, 7 cases (9.3%); angle with femoral neck axis <90° (including reverse angle), 11 cases (14.7%). Conclusion CT three-dimensional reconstruction can clearly show the cortical morphology and the direction of the fracture line of intertrochanteric fracture, which can indicate the stability of the intertrochanteric fracture after reduction, and has a good guiding on the form of cortical buttress reduction.
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Affiliation(s)
- Xin Wang
- Department of Orthopedics, Tongji Hospital of Tongji University, Shanghai, 200065, P.R.China
| | - Yingqi Zhang
- Department of Orthopedics, Tongji Hospital of Tongji University, Shanghai, 200065, P.R.China
| | - Shimin Zhang
- Department of Orthopedics, Yangpu Hospital, Tongji University, Shanghai, 200090,
| | - Shouchao Du
- Department of Orthopedics, Yangpu Hospital, Tongji University, Shanghai, 200090, P.R.China
| | - Kai Chen
- Department of Orthopedics, Tongji Hospital of Tongji University, Shanghai, 200065, P.R.China
| | - Zhiyuan Wang
- Department of Orthopedics, Tongji Hospital of Tongji University, Shanghai, 200065, P.R.China
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Anteromedial cortical support reduction in unstable pertrochanteric fractures: a comparison of intra-operative fluoroscopy and post-operative three dimensional computerised tomography reconstruction. INTERNATIONAL ORTHOPAEDICS 2017; 42:183-189. [PMID: 28891021 DOI: 10.1007/s00264-017-3623-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 08/15/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Anteromedial cortical support reduction is favourable for secondary stability after limited sliding in unstable pertrochanteric fractures. The aim of this study was to compare the accuracy and agreement between intra-operative fluoroscopy and post-operative 3D reconstruction. MATERIALS AND METHODS A retrospective analysis of 28 patients (mean 81.6 years) treated with short cephalomedullary nails was performed. All patients had full sets of intra-operative fluoroscopy and post-operative 3D CT images. Observation was focused on the position of the anteromedial cortices of the inferior corner between the head-neck fragment and femoral shaft, and their relationship was categorised into three types: positive, neutral and negative. The percentage of subsequent changes in cortical reduction quality between fluoroscopy and 3D CT was calculated and compared. RESULTS There were 24 positive (85.7%), four neutral and no negative positions in the anteroposterior (AP) view and one positive, 20 neutral (71.4%) and seven negative positions in the lateral view from fluoroscopy. On post-operative 3D CT images with a full range of rotation, definitive anteromedial cortical contact (positive and neutral support) was observed in 18 cases (64.3%). Ten cases lost the anteromedial cortical buttress. With the posteromedial region of the lesser trochanter detached, a positive AP cortical position combined with a positive/neutral lateral position on fluoroscopy (17 cases) was highly predictive of reliable, definitive cortical support (15 cases, 88.2%) on 3D CT. A negative lateral position on fluoroscopy (seven cases), regardless of the combination in the AP view, was likely to predict the final loss of cortical support (six cases, 85.7%) on 3D CT; a positive/neutral lateral position (21 cases) was only associated with loss of support in four cases (19.1%) (p < 0.05). CONCLUSIONS A lateral negative position of the anterior cortex on fluoroscopy for unstable pertrochanteric fractures may be highly predictive of post-operative final loss of the anteromedial cortical buttress, which should be avoided during operation.
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