Skeletal Radiology

, Volume 48, Issue 3, pp 421–428 | Cite as

Anatomy-based MRI assessment of the iliopsoas muscle complex after pertrochanteric femoral fracture

  • Malwina KaniewskaEmail author
  • Matthias Schenkel
  • Karim Eid
  • Tobias Bühler
  • Rahel A. Kubik-Huch
  • Suzanne E. Anderson
Scientific Article



To evaluate the quality of the iliopsoas muscle complex after pertrochanteric femoral fracture, using MRI; to propose an anatomy-based evaluation of the iliopsoas muscle complex; and to determine the inter-reader reliability of two classifications of fatty muscle degeneration.

Materials and methods

We included adult patients with a displaced lesser trochanter following pertrochanteric femoral fracture. Muscle quality was evaluated using the Goutallier and Slabaugh classifications at three levels (L4/L5, L5/S1, and the anterior inferior iliac spine). Two radiologists independently reviewed the MRIs, and force measurement was performed on both hips. Linear mixed-effects models were used to determine the effect of fracture on muscle quality and strength, and Cohen’s kappa statistic was used to assess inter-reader agreement.


In the 18 patients included, the iliopsoas muscle complex showed higher grades of fatty muscle degeneration on the fractured side than on the non-fractured side. The mean difference between muscle strength on the fractured vs the non-fractured side was −12 N (p > 0.05). Inter-reader agreement for the Goutallier and Slabaugh classifications was good and very good respectively (weighted K = 0.78 and 0.85 respectively).


Fatty muscle degeneration of the iliopsoas muscle complex after pertrochanteric femoral fracture was evident using both classification systems; however, fatty muscle degeneration resulted in only a minimal reduction of muscle strength. To provide a thorough assessment of iliopsoas muscle complex quality, we suggest evaluating it at different anatomical levels. Regarding inter-reader agreement, the Slabaugh classification was superior to the Goutallier classification.


Hip Hip joint Muscle strength Femoral fractures Skeletal muscle Psoas muscle Magnetic resonance imaging Reproducibility 



We would like to thank the statistician, Andreas Schötzau Dipl.-Math. ( and the medical illustrator, Dr Piotr Golofit ( for their contributions to this study. We also thank Jane Charbonneau, DVM, from Edanz Group ( for editing a draft of this manuscript.


This radiology research was partially funded by a Young Researchers Grant awarded by the European Society of Musculoskeletal Radiology (ESSR) during the ESSR Annual Meeting in Bari, Italy, June 2017. This project has been accepted for the European Congress of Radiology 2018 (“Anatomy-based MR classification of the iliopsoas muscle complex after pertrochanteric femur fracture”, Control #: 1786, Session Date/Time: 3/1/2018 10:30:00 AM – 3/1/2018 12:00:00 PM).

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflicts of interest.

Ethical approval

This radiological study is part of a prospective orthopaedic study that was approved by the Ethical Review Committee (EKNZ BASEC 2016-00612) of our institution.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;304:78–83.Google Scholar
  2. 2.
    Osti L, Buda M, Del Buono A. Fatty infiltration of the shoulder: diagnosis and reversibility. Muscles Ligaments Tendons J. 2013;3(4):351–4.PubMedGoogle Scholar
  3. 3.
    Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis: report of the European working group on sarcopenia in older people. Age Ageing. 2010;39(4):412–23.CrossRefGoogle Scholar
  4. 4.
    Kindler JM, Lewis RD, Hamrick MW. Skeletal muscle and pediatric bone development. Curr Opin Endocrinol Diabetes Obes. 2015;22(6):467–74.CrossRefGoogle Scholar
  5. 5.
    Komolka K, Albrecht E, Wimmers K, Michal JJ, Maak S. Molecular heterogeneities of adipose depots—potential effects on adipose-muscle cross-talk in humans, mice and farm animals. J Genomics. 2014;2:31–44.CrossRefGoogle Scholar
  6. 6.
    Rivas DA, McDonald DJ, Rice NP, Haran PH, Dolnikowski GG, Fielding RA. Diminished anabolic signaling response to insulin induced by intramuscular lipid accumulation is associated with inflammation in aging but not obesity. Am J Physiol Regul Integr Comp Physiol. 2016;310(7):R561–9.CrossRefGoogle Scholar
  7. 7.
    Chaudhury S, Dines JS, Delos D, Warren RF, Voigt C, Rodeo SA. Role of fatty infiltration in the pathophysiology and outcomes of rotator cuff tears. Arthritis Care Res. 2012;64(1):76–82.CrossRefGoogle Scholar
  8. 8.
    Goutallier D, Postel JM, Lavau L, Bernageau J. Impact of fatty degeneration of the supraspinatus and infraspinatus muscles on the prognosis of surgical repair of the rotator cuff. Rev Chir Orthop Reparatrice Appar Mot. 1999;85(7):668–76.PubMedGoogle Scholar
  9. 9.
    Aprato A, Lo Baido R, Crosio A, Matteotti R, Grosso E, Masse A. Does lesser trochanter implication affect hip flexion strength in proximal femur fracture? Eur J Trauma Emerg Surg. 2015;41(5):523–9.CrossRefGoogle Scholar
  10. 10.
    D’Arrigo C, Carcangiu A, Perugia D, Scapellato S, Alonzo R, Frontini S, et al. Intertrochanteric fractures: comparison between two different locking nails. Int Orthop. 2012;36(12):2545–51.CrossRefGoogle Scholar
  11. 11.
    Ehrnthaller C, Olivier AC, Gebhard F, Durselen L. The role of lesser trochanter fragment in unstable pertrochanteric A2 proximal femur fractures—is refixation of the lesser trochanter worth the effort? Clin Biomech (Bristol, Avon). 2016;42:31–7.CrossRefGoogle Scholar
  12. 12.
    Luo F, Shen J, Xu J, Dong S, Huang Q, Xie Z. Treatment of AO/OTA 31-A3 intertrochanteric femoral fractures with a percutaneous compression plate. Clinics. 2014;69(1):1–7.CrossRefGoogle Scholar
  13. 13.
    Pahor M, Manini T, Cesari M. Sarcopenia: clinical evaluation, biological markers and other evaluation tools. J Nutr Health Aging. 2009;13(8):724–8.CrossRefGoogle Scholar
  14. 14.
    Erlandson MC, Lorbergs AL, Mathur S, Cheung AM. Muscle analysis using pQCT, DXA and MRI. Eur J Radiol. 2016;85(8):1505–11.CrossRefGoogle Scholar
  15. 15.
    Wokke BH, van den Bergen JC, Versluis MJ, Niks EH, Milles J, Webb AG, et al. Quantitative MRI and strength measurements in the assessment of muscle quality in Duchenne muscular dystrophy. Neuromuscul Disord. 2014;24(5):409–16.CrossRefGoogle Scholar
  16. 16.
    De Jesus JO, Parker L, Frangos AJ, Nazarian LN. Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis. AJR Am J Roentgenol. 2009;192(6):1701–7.CrossRefGoogle Scholar
  17. 17.
    Fischer CA, Weber M-A, Neubecker C, Bruckner T, Tanner M, Zeifang F. Ultrasound vs. MRI in the assessment of rotator cuff structure prior to shoulder arthroplasty. J Orthop. 2015;12(1):23–30.CrossRefGoogle Scholar
  18. 18.
    Swigelaar R, Oschman Z, Laubscher H. Role of ultrasound in the evaluation of rotator cuff muscle quality: a review. Afr J Phys Health Educ Recreat Dance. 2012;18(2):293–8.Google Scholar
  19. 19.
    Schenkel M, Kaniewska M, Buhler T, Anderson S, Eid K (2018) No difference in flexion power despite iliopsoas fatty degeneration in healed hip fractures with large lesser trochanter displacement. Eur J Orthop Surg Traumatol.
  20. 20.
    Anderson PA, Chanoski CE, Devan DL, McMahon BL, Whelan EP. Normative study of grip and wrist flexion strength employing a BTE work simulator. J Hand Surg. 1990;15(3):420–5.CrossRefGoogle Scholar
  21. 21.
    Scott DA, Bond EQ, Sisto SA, Nadler SF. The intra- and interrater reliability of hip muscle strength assessments using a handheld versus a portable dynamometer anchoring station. Arch Phys Med Rehabil. 2004;85(4):598–603.CrossRefGoogle Scholar
  22. 22.
    Slabaugh MA, Friel NA, Karas V, Romeo AA, Verma NN, Cole BJ. Interobserver and intraobserver reliability of the Goutallier classification using magnetic resonance imaging: proposal of a simplified classification system to increase reliability. Am J Sports Med. 2012;40(8):1728–34.CrossRefGoogle Scholar
  23. 23.
    R Core Team. R: a language and environment for statistical computing. Vienna: R Foundation for Statistical Computing; 2014.Google Scholar
  24. 24.
    Hain KS, Blankenbaker DG, De Smet AA, Keene JS, del Rio AM. MR appearance and clinical significance of changes in the hip muscles and iliopsoas tendon after arthroscopic iliopsoas Tenotomy in symptomatic patients. HSS J. 2013;9(3):236–41.CrossRefGoogle Scholar
  25. 25.
    Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg. 1999;8(6):599–605.CrossRefGoogle Scholar
  26. 26.
    Lippe J, Spang JT, Leger RR, Arciero RA, Mazzocca AD, Shea KP. Inter-rater agreement of the Goutallier, Patte, and Warner classification scores using preoperative magnetic resonance imaging in patients with rotator cuff tears. Arthroscopy. 2012;28(2):154–9.CrossRefGoogle Scholar
  27. 27.
    Wolfgang GL. Surgical repair of tears of the rotator cuff of the shoulder: factors influencing the result. JBJS. 1974;56(1):14–26.CrossRefGoogle Scholar
  28. 28.
    Donovan PJ, Zerhouni EA, Siegelman SS. CT of the psoas compartment of the retroperitoneum. Semin Roentgenol. 1981;16:241–50.CrossRefGoogle Scholar
  29. 29.
    Van Dyke JA, Holley HC, Anderson SD. Review of iliopsoas anatomy and pathology. Radiographics. 1987;7(1):53–84.CrossRefGoogle Scholar
  30. 30.
    Weinreb JC, Cohen JM, Maravilla KR. Iliopsoas muscles: MR study of normal anatomy and disease. Radiology. 1985;156(2):435–40.CrossRefGoogle Scholar
  31. 31.
    Goutallier D, Postel JM, Gleyze P, Leguilloux P, Van Driessche S. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears. J Shoulder Elbow Surg. 2003;12(6):550–4.CrossRefGoogle Scholar

Copyright information

© ISS 2018

Authors and Affiliations

  1. 1.Institute of RadiologyKantonsspital BadenBadenSwitzerland
  2. 2.Chefarztsekretariat Radiologie Bea EngeliKantonsspital BadenBadenSwitzerland
  3. 3.Centre for Orthopaedic SurgeryKantonsspital Aarau und BadenBadenSwitzerland
  4. 4.The University of Notre Dame Australia, Sydney School of MedicineSydneyAustralia

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