Fluoroscopic reduction during intertrochanteric fracture surgery, which one is more reliable, the anteroposterior or the lateral view?

Intertrochanteric fracture is the most common clinical hip fracture and one of the three major osteoporotic fractures in the elderly. Conservative treatment requires long-term bed rest, and the risk of bedsores, lung infection, pulmonary embolism, and deep vein thrombosis is extremely high. , nursing is difficult and the recovery period is long, which brings a heavy burden to society and families. Therefore, early surgical treatment as tolerated is the key to achieving good functional outcomes in hip fractures.

Currently, PFNA (proximal femoral nail antirotation system) internal fixation is the gold standard for surgical treatment of hip fractures, and intraoperative reduction of hip fractures to positive support is the key to allowing early functional exercise (about positive and negative supports for hip fractures Problem. The intraoperative fluoroscopic field is evaluated in the anteroposterior (AP) and lateral (Lateral) positions to evaluate the reduction of the anteromedial cortex of the femur. However, conflicts between the two fluoroscopy methods during the operation are inevitable. (i.e. positive in lateral position but not positive in upright position, or non-positive in lateral position and positive in upright position). In this case, how to evaluate whether the reduction is acceptable and whether reduction adjustment is needed is a problem that troubles clinicians. To this end, domestic scholars from Oriental Hospital and Zhongshan Hospital analyzed the accuracy of evaluating negative and positive supports in the anteroposterior and lateral views under intraoperative fluoroscopy, using postoperative three-dimensional CT as the standard.01

Picture shows the positive support (a), neutral support (b) and negative support (c) models of hip fracture in the orthopedic position.



Figure shows the positive support (d), neutral support (e) and negative support (f) patterns of hip fracture in the lateral position.

The article included case data of 128 patients with hip fractures. The intraoperative anteroposterior and lateral radiographs were given to two doctors (lower seniority and seniority) to evaluate positive support or non-positive support. Two months after the initial evaluation, they were evaluated again. Evaluate. The postoperative CT images were given to an experienced professor to evaluate whether the case was positive or non-positive, which was used as a standard to evaluate whether the imaging evaluation by the first two doctors was accurate. The article mainly compares: (1) Between the two evaluations before and after, is there a statistical difference between the evaluation results of junior doctors or senior doctors? As well as the consistency between the low-seniority and seniority groups between the two assessments, and the intra-group consistency between the two assessments.

Using the CT gold standard as a reference, which one is more reliable when evaluating the quality of reduction in the lateral or anteroposterior position? Research result:

1. In the two rounds of evaluation, using CT as the reference standard, there was no statistical difference in the sensitivity, specificity, false positive rate, and false negative rate between two doctors with different seniority in assessing the quality of reduction based on intraoperative X-rays.


2. In terms of reset quality assessment, take the first assessment as an example:


If the anteroposterior and lateral assessments are consistent (both positive or both non-positive), the reliability of predicting the quality of reduction on CT is 100%.


If the anteroposterior and lateral assessments are inconsistent, the lateral assessment criteria are more reliable in predicting the quality of reduction on CT.


Illustrated in the anterior view, it shows a positive support, and in the lateral view, it shows a non-positive support. That is, the evaluation results of the anteroposterior and lateral positions are inconsistent.



Three-dimensional CT reconstruction can obtain multi-angle observation images, which can be used as a standard for evaluation of reduction quality.

In the previous reduction standards for intertrochanteric fractures, in addition to negative and positive supports, there is also the concept of “neutral” support, that is, anatomical reduction. However, due to issues with perspective resolution and human eye recognition, the true “anatomical reduction” theory The above does not exist, there is a slight “positive” or “negative” reset. Zhang Shimin’s team at Shanghai Yangpu Hospital once published an article: It is possible that intertrochanteric fractures can achieve positive support and have better functional results than anatomical reduction.

Therefore, based on this article, we should try our best to achieve positive support for the intertrochanteric fracture during the operation. If it is achieved in both the anteroposterior and lateral positions, the reduction is optimal. If the positive support is achieved in the lateral position and the anteroposterior reduction is unsatisfactory, then it may not be necessary. Make “non-essential” readjustments.

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Post time: May-31-2024