Chang Shimin, Sun Guixin, Wang Zhenhai, Zhang Li, Tian Kewei, Liu Tao, Wang Xin, Rui Yunfeng
Department of Orthopedic Surgery, Yangpu Hospital, Tongji University, Shanghai, 200090, P. R. China.
Department of Trauma Surgery, Dongfang Hospital, Tongji University, Shanghai, 200120, P. R. China.
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2024 Sep 15;38(9):1130-1137. doi: 10.7507/1002-1892.202405004.
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.
Papers 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.
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.
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.
回顾并总结股骨转子间骨折髓内钉固定术中X线影像的投照情况，提出一套三张投照影像作为术后即刻透视的标准要求。
在PubMed上检索2021年至2023年三年间在四本主要的英文骨科创伤杂志上发表的有关股骨转子间骨折髓内钉固定治疗的论文。对所呈现的X线影像进行识别和审查，看其是否为植入髓内钉的标准前后位和/或侧位投照。计算非标准影像的出现百分比。结合临床经验，总结分析股骨颈的标准前后位和侧位透视影像、髓内钉手术中X线成像的现状、非标准影像的文献分析、肢体旋转对影像解读的影响以及前内侧30°斜位透视的特点。
在主要的骨科创伤杂志中，非标准X线影像在前后位视图中的出现率为32.1%，在侧位视图中的出现率为69.2%。在股骨转子间骨折的髓内钉固定手术中，用植入髓内钉的X线影像来代表骨折的头颈部分是合理的，因为头颈植入物（拉力螺钉或螺旋刀片）在侧位投照时旨在置于股骨头中心。肢体旋转或非标准投照会产生影像失真，干扰外科医生对骨折复位质量的判断以及股骨头内植入物位置参数（如颈干角和尖顶距）的测量，最终导致与准确正常值的无意义比较。从真正的侧位（设为0°）开始的30°前内侧斜位视图是前内侧下角皮质的切线投影，能清晰显示皮质贴合状态和力学支撑情况。首先必须获得髓内钉真正标准的侧位透视影像（显示为一条线），然后将C型臂旋转90°和30°以获得前后位和前内侧斜位视图，并将这三张术后即刻X线影像作为评估手术质量和随访比较的基线。
对于手术步骤的实时监测，术中透视遵循“足够即可”原则，但对于术后即刻的数据存储以及手术质量评估的依据和随访比较的基线，建议获得一套包括前后位、真正侧位和30°前内侧斜位透视投照的三张标准X线影像。
