The safety and accuracy of the fluoroscopic imaging during proximal femoral fixation: A computerized 3D reappraisal of the joint penetration risk.

Abstract

To assess the success of proximal cephalomedullary nailing operations for treating trochanteric fractures, surgeons utilize 2D fluoroscopy to observe the relative positions of the femoral head and the implant. One distance-based risk parameter, observed from the AP and Lateral projections, is the Tip-Surface Distance(TSD) that dictates how close to the outer cortex should the implant tip be residing to avoid post-surgical complications such as cut-out or joint penetration. In this study, the safety and the accuracy of the orthogonal fluoroscopic imaging were evaluated. A femoral head model was created and the risk zone was defined as a hemispherical shell of 5mm thickness beneath the subchondral cortex, which should not be violated during screw insertion. The remaining hemisphere beneath the risk zone was designated as the safe zone. To assess the effect of head size, each simulation was conducted for 34, 47, and 60mm diameter(Dfemur) femoral heads. The rate of safe zone violation was calculated for all possible screw endpoints with a TSD of at least 5mm on fluoroscopic orthogonal views (TSDAP and TSDLat). The minimum risk of joint penetration was achieved when the TSDAP/TSDLat ratio was 1. For Dfemur of 34mm there was a risk of 91.7% of the safe zone violation when each TSDAP and TSDLat were 5mm and 0% for 9mm. For Dfemur of 47mm, the risk was 92.2% for 5mm and 0% for 11mm. For Dfemur of 60mm, the risk was 92.3% for 5mm and 0% for 13mm. Safety maps were constructed for all possible TSD combinations for 34, 47, and 60mm femoral heads. Depending solely on the orthogonal fluoroscopic images is not a safe and accurate technique for assessing joint penetration risk during proximal femoral fixation due to the spherical geometry of the femoral head. The screw tip can lie completely outside of the femoral head even when it appears inside, in both orthogonal fluoroscopic views. Evidently, when using TSD, more stringent distance limits should be chosen, contrary to the recommended 5mm limit. Our safety maps for TSD combinations may be used to check the security of the implantation.