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. MethodsPapers 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.
ObjectiveTo summarize the characteristics of posterior coronal banana-shaped fragments and its research progress in treatment of intertrochanteric femoral fracture with cephalomedullary nail, provide valuable reference for clinical practice. Methods Relevant domestic and foreign literature was extensively reviewed to summarize the history, anatomical structure of posterior coronal banana-shaped fragments, and the need for reduction and fixation, the influence on the stability of cephalomedullary nail, and the remedies. Results The posterior coronal banana-shaped fragments refers to the second level fracture line of the intertrochanteric femoral fracture, involving four anatomical structures, namely, the posterior part of the greater trochanter, the intertrochanteric crest, the lesser trochanter, and the posteromedial cortex. With the wide application of three-dimensional-CT in clinical practice, the posterior coronal banana-shaped fragments were more comprehensively understood. According to whether the anterior extension of the fracture line affects the integrity of the lateral entry of the head and neck implant, the posterior coronal banana-shaped fragments can be divided into small and large ones, of which the large single banana-shaped fragment account for about 20% of the AO/Orthopaedic Trauma Association (AO/OTA) type A2 fractures. If the large fragment involving the posteromedial wall (lesser trochanter) will increase the difficulty of the medial cortical contact reduction; or involving the posterolateral wall and resulting in rupture of the entry portal (type A2.4), which will cause sagittal swing of the nail in the femoral marrow cavity, thereby affecting the stability of the nail. There is no effective technique for reduction and fixation of the banana-shaped fragment nowadays. However, the adverse effects of posterior coronal banana-shaped fragment can be compensated by improving the quality of fracture reduction and choosing high filling cephalomedullary nail. ConclusionThe posterior coronal banana-shaped fragments can easily lead to the rupture of the entry portal of head-neck implants, cause the sagittal swing of the cephalomedulis nail, and then lead to the loss of fracture reduction and affect the treatment effect. Whether the entry portal rupture or not and its risk factors still need further clinical and basic research.
Objective To explore the effectiveness of proximal femoral nail antirotation (PFNA) combined with minimally invasive clamp reduction technique by Kocher pincers in the treatment of irreducible intertrochanteric femoral fracture in the elderly. Methods The clinical data of 35 elderly patients with irreducible intertrochanteric femoral fractures who were treated with PFNA combined with minimally invasive clamp reduction technique by Kocher pincers between January 2016 and December 2022 were retrospectively analysed. There were 16 males and 19 females, aged from 63 to 95 years (mean, 75.2 years). The causes of injury included traffic accident in 3 cases and falling in 32 cases. The time from injury to operation was 2-11 days (mean, 3.6 days). According to AO/Orthopaedic Trauma Association (AO/OTA) classification system for intertrochanteric fractures, there were 14 cases of type A1, 18 cases of type A2, and 3 cases of type A3. According to the displacement of fracture by intraoperative fluoroscopy, there were 5 cases with only coronal displacement, 17 cases with only sagittal displacement, and 13 cases with both coronal and sagittal displacement. The operation time, intraoperative blood loss, rate of hemoglobin decline at 1 day after operation, length of hospital stay, and fracture healing time were recorded. The reduction quality of fracture during operation was evaluated according to reduction quality criteria proposed by Chang et al. The Harris scoring system was used to evaluate the hip joint function at last follow-up. Results The operation time was 45-105 minutes (mean, 54.4 minutes); the intraoperative blood loss was 80-300 mL (mean, 116.3 mL). The reduction quality of fracture during operation was good in 22 cases (62.9%) and acceptable in 13 cases (37.1%). The rate of hemoglobin decline at 1 day after operation ranged from 6.2% to 18.6% (mean, 10.2%); the length of hospital stay was 5-18 days (mean, 7.2 days). One case died of respiratory failure due to pulmonary infection, 2 cases were lost to follow-up, and the remaining 32 cases were followed up 6-24 months (mean, 10.6 months). All 32 patients achieved bony union and the healing time was 3-9 months (mean, 3.6 months). There was no complication such as incision infection, internal fixation failure, or coxa varus during follow-up. At last follow-up, the Harris score of hip joint was 67-96 (mean, 88.9); among them, 19 cases were excellent, 10 cases were good, 2 cases were fair, and 1 case was poor, with an excellent and good rate of 90.6%. Conclusion For the elderly patients with irreducible intertrochanteric femoral fracture, the application of PFNA combined with minimally invasive clamp reduction technique by Kocher pincers can achieve high-quality fracture reduction, which has the advantages of simple reduction operation, less trauma, and can avoid the radiation exposure of operators during maintenance reduction.