Anteromedial cortical support reduction in unstable pertrochanteric fractures: a comparison of intra-operative fluoroscopy and post-operative three dimensional computerised tomography reconstruction.

PURPOSE: Anteromedial cortical support reduction is favourable for secondary stability after limited sliding in unstable pertrochanteric fractures. The aim of this study was to compare the accuracy and agreement between intra-operative fluoroscopy and post-operative 3D reconstruction.

MATERIALS AND METHODS: A retrospective analysis of 28 patients (mean 81.6 years) treated with short cephalomedullary nails was performed. All patients had full sets of intra-operative fluoroscopy and post-operative 3D CT images. Observation was focused on the position of the anteromedial cortices of the inferior corner between the head-neck fragment and femoral shaft, and their relationship was categorised into three types: positive, neutral and negative. The percentage of subsequent changes in cortical reduction quality between fluoroscopy and 3D CT was calculated and compared.

RESULTS: There were 24 positive (85.7%), four neutral and no negative positions in the anteroposterior (AP) view and one positive, 20 neutral (71.4%) and seven negative positions in the lateral view from fluoroscopy. On post-operative 3D CT images with a full range of rotation, definitive anteromedial cortical contact (positive and neutral support) was observed in 18 cases (64.3%). Ten cases lost the anteromedial cortical buttress. With the posteromedial region of the lesser trochanter detached, a positive AP cortical position combined with a positive/neutral lateral position on fluoroscopy (17 cases) was highly predictive of reliable, definitive cortical support (15 cases, 88.2%) on 3D CT. A negative lateral position on fluoroscopy (seven cases), regardless of the combination in the AP view, was likely to predict the final loss of cortical support (six cases, 85.7%) on 3D CT; a positive/neutral lateral position (21 cases) was only associated with loss of support in four cases (19.1%) (p < 0.05).

CONCLUSIONS: A lateral negative position of the anterior cortex on fluoroscopy for unstable pertrochanteric fractures may be highly predictive of post-operative final loss of the anteromedial cortical buttress, which should be avoided during operation.