股骨转子间骨折头髓钉内固定手术的标准化放射影像

Standard radiographic images in cephalomedullary nailing fixation for intertrochanteric femoral fractures

目的总结股骨转子间骨折头髓钉内固定术中放射影像,提出术毕即刻标准化3件套影像,为评价手术质量和术后随访测量提供基线资料。方法在PubMed数据库查阅4本国际著名创伤骨科杂志2021年—2023年发表的股骨转子间骨折相关文献,观察其头髓钉内固定物正侧位影像是否符合标准的投射角度,计算不标准影像出现的百分比。另结合临床经验,从股骨颈标准正侧位透视影像、头髓钉手术中放射影像现状、影像不标准的文献分析、肢体旋转对图像判读的影响、前内侧30°斜位透视特点等方面进行总结分析。结果在国际著名创伤骨科杂志文献中,头髓钉正位图像不标准占32.1%,侧位图像不标准占69.2%。在股骨转子间骨折内固定手术中,由于头颈内固定物以打入侧位股骨头正中为目标,因此临床常以内固定物的正侧位影像为基准,代表骨折复位内固定后的股骨颈正侧位影像。肢体旋转或投射角度不正导致的影像扭曲,会干扰对骨折复位质量和股骨头内固定物位置的准确判断和参数测量(如颈干角和尖顶距),使其失去与正常标准值比较的基础。前内侧30°斜位能清晰显示皮质切线位轮廓影像,有利于判断前内下角皮质对位状况。建议在术毕即刻先透视出标准侧位,再将C臂X线机旋转90°和30°分别透视出标准正位和前内侧斜位,以此3件套影像作为评价手术质量和随访对比的基线。结论在股骨转子间骨折的头髓钉内固定手术中,作为监视手术步骤的术中透视图像应以“够用即可”为原则,但作为术毕即刻资料留存和观测评价对比的基线,推荐获取标准规范的正、侧和前内侧30°斜位3张放射影像。

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.Methods 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.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.