J Korean Fract Soc.  2016 Jan;29(1):1-11. 10.12671/jkfs.2016.29.1.1.

Assessment of Coronal Plane Malalignment Following Reduction of Trochanteric Fractures-Simple Intraoperative Guideline Using Greater Trochanter Orthogonal Line

Affiliations
  • 1Department of Orthopaedic Surgery, Korea University Guro Hospital, Seoul, Korea. jeus1103@gmail.com
  • 2Trauma Center, Gacheon University Gil Medical Center, Incheon, Korea.

Abstract

PURPOSE
There is no consensus on a clear intraoperative guideline for judging the coronal plane alignment following reduction of trochanteric fractures. Complex angular measurements using fluoroscope monitors are tedious. Therefore the relation of the horizontal line from the tip of the greater trochanter (GT orthogonal) and femur head center (HC orthogonal) was studied to define this line as a criterion for predicting varus-valgus malalignment.
MATERIALS AND METHODS
We studied this relation in 200 standing orthoradiograms which included 100 males and 100 females. The images were digitally analyzed using the picture archiving and communication system. GT orthogonal line and HC orthogonal line were evaluated. The distance of these lines was measured as trochanter center distance (TCD) and its correlation with angular parameters like neck shaft angle, medial proximal femoral angle with reference to anatomical axis (aMPFA) and lateral proximal femoral angle with reference to mechanical axis (mLPFA) were analyzed.
RESULTS
In all patients, the GT orthogonal line passed either at or above the center of the head. Overall mean of TCD was 7.22 mm, ranging from 0 to 17.57 mm. TCD was found to show strong correlation with angular parameters like aMPFA, mLPFA and neck shaft angle. TCD was less than one fourth of the corresponding head diameter in around 90%. Therefore following reduction of trochanteric fractures, the GT orthogonal line should pass through the superior juxta central quadrant of the femoral head.
CONCLUSION
This line can be represented by a guide wire with fluoroscopy during surgery. The GT orthogonal line can be used intraoperatively as a simplified tool for prediction of varus/valgus malalignment following the reduction of trochanteric fractures.

Keyword

Hip fractures; Reduction; Trochanter center distance; GT orthogonal line

MeSH Terms

Axis, Cervical Vertebra
Consensus
Female
Femur Head
Femur*
Fluoroscopy
Head
Hip Fractures
Humans
Male
Neck

Figure

  • Fig. 1 Line diagram showing a summary of the measurements. A: Medial proximal femoral angle with reference to the anatomical axis (aMPFA), B: Lateral proximal femoral angle with reference to the mechanical axis (mLPFA), C: Neck shaft angle (NSA), TCD: Trochanter center distance, GT: Greater trochanter, HC: Head center.

  • Fig. 2 (A) The greater trochanter (GT) orthogonal line passed through the superior juxta-central quadrant (II) in approximately 90% of the patients. Quadrant division in femoral head (I-IV). (B) A guide wire representing the GT orthogonal line during surgery. The perpendicular relation of this line can be reproduced by marking the anatomic axis and the GT orthogonal line on the skin before draping.

  • Fig. 3 Correlation between the trochanter center distance (TCD; mm) and MPFA. aMPFA: Medial proximal femoral angle with reference to the anatomical axis.

  • Fig. 4 Correlation between the trochanter center distance (TCD; mm) and lateral proximal femoral angle (LPFA).

  • Fig. 5 Cervico-trochanteric trigone. This is a small triangle formed by the radiographic lines of the medial surface of the greater trochanter and the superior neck margin.

  • Fig. 6 Clinical location of the cervico-trochanteric trigone. (A) Posterior aspect of the proximal femur showing the trigone distal to the insertion of piriformis. (B) It is marked out in the posterior aspect because the neck trochanter junction is slightly distal posteriorly which represented the radiological trigone.

  • Fig. 7 Scatter plot of the trochanter center distance (TCD) and the neck shaft angle (NSA). The range of the NSA based on the recommended TCD values is highlighted. x axis: TCD.

  • Fig. 8 Efficacy of the greater trochanter (GT) orthogonal line in identifying coronal malalignment (arrows). (A) Anatomical reduction illustrated after traction. (B) Loss of reduction leading to subtle varus malalignment. (C) GT orthogonal line while in anatomic reduction as in Fig. 8A. (D) GT orthogonal line in subtle varus malalignment as in Fig. 8B. However, it passes within the recommended range. Intraoperative representation of this line is shown in Fig. 2B.

  • Fig. 9 Neck web contributing to the deviation of the femur head center from the trigone. (A) Normal neck anatomy. (B) Broad neck with web. Note both images are taken in similar rotation.


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