Archives of Orthopaedic and Trauma Surgery

, Volume 129, Issue 5, pp 671–677 | Cite as

Navigated femoral anteversion measurements: general precision and registration options

  • Mustafa Citak
  • Daniel Kendoff
  • Andrew D. Pearle
  • Padhraig F. O’Loughlin
  • Christian Krettek
  • Tobias Hüfner
  • Musa Citak
Trauma Surgery



Intraoperative reduction of femoral fractures can result in rotational malalignment. Navigation modules allow fluoroscopy-based femoral anteversion (AV) measurements; however, their clinical feasibility has not been fully evaluated. An important technical consideration when obtaining navigated femoral rotational alignment is the necessity for orthogonal navigated fluoroscopic images.


The current investigators hypothesized that there would be a critical imaging angle between the fluoroscopic images which optimized the acquisition of accurate rotational measurements. Following initial testing in plastic femora, 14 intact human cadaveric femora were subjected to CT and navigated fluoroscopic assessment of AV. The navigated registration process included the following test series: Standard perpendicular AP and lateral imaging at a 90° angle; planar rotation of the lateral fluoroscopy position perpendicular to the axis of femoral neck and angled to the AP position at 75°, 60°, and 50°; inlet and outlet imaging of the axis of the femoral neck at angles of 10°, 20°, and 30°. For all setups, the difference between the AV angle of the navigation system and the CT-measured angle was calculated.


Results revealed no relevant differences between CT and navigated determination of plastic femora (1.5°). No significant deviations of cadaver femora with 90° angle imaging (mean 2.00°, range 0.00°–4.33°), 75° angle imaging (mean 1.95°, range 0.00°–3.33°) and 60° imaging (mean 2.00°, range 0.00°–3.33°) were found. However, significant deviations were found for the navigated 50° angled imaging technique (mean 5.02°, range 2.33°–7.67°).


These data demonstrated that the femoral AV angle can be calculated accurately by using two navigated fluoroscopic images when a minimum angle of 60° is utilized between the angled fluoroscopic images for the registration process. A difference of <60° does not allow for accurate navigated measurements.


Femoral anteversion Measurement CT Navigation system Validation Fluoroscopy Accuracy 


  1. 1.
    Braten M, Terjesen T, Rossvoll I (1993) Torsional deformity after intramedullary nailing of femoral shaft fractures. Measurement of anteversion angles in 110 patients. J Bone Joint Surg Br 75(5):799–803PubMedGoogle Scholar
  2. 2.
    Grutzner PA, Suhm N (2004) Computer aided long bone fracture treatment. Injury 35(Suppl 1):S-A57–S-A64Google Scholar
  3. 3.
    Hankemeier S, Hufner T, Wang G, Kendoff D, Zheng G, Richter M, Gosling T, Nolte L, Krettek C (2005) Navigated intraoperative analysis of lower limb alignment. Arch Orthop Trauma Surg 125(8):531–535. doi:10.1007/s00402-005-0038-9 PubMedCrossRefGoogle Scholar
  4. 4.
    Hilgert RE, Ohrendorf K, Schafer FK, Schafer PJ, Muller M, Trompetter R, Egbers HJ (2006) Unfallchirurg 109(10):855–861 (preventing malrotation during intramedullary nailing of femoral fractures). doi:10.1007/s00113-006-1093-6 Google Scholar
  5. 5.
    Hoaglund FT, Low WD (1980) Anatomy of the femoral neck and head, with comparative data from Caucasians and Hong Kong Chinese. Clin Orthop Relat Res (152):10–16Google Scholar
  6. 6.
    Jaarsma RL, Pakvis DF, Verdonschot N, Biert J, van Kampen A (2004) Rotational malalignment after intramedullary nailing of femoral fractures. J Orthop Trauma 18(7):403–409. doi:10.1097/00005131-200408000-00002 PubMedCrossRefGoogle Scholar
  7. 7.
    Jaarsma RL, Verdonschot N, van der Venne R, van Kampen A (2005) Avoiding rotational malalignment after fractures of the femur by using the profile of the lesser trochanter: an in vitro study. Arch Orthop Trauma Surg 125(3):184–187. doi:10.1007/s00402-004-0790-2 PubMedCrossRefGoogle Scholar
  8. 8.
    Jend HH (1986) Computed tomographic determination of the anteversion angle. Premises and possibilities. Rofo 144(4):447–452PubMedGoogle Scholar
  9. 9.
    Kendoff D, Bogojevic A, Citak M, Citak M, Maier C, Maier G, Krettek C, Hufner T (2007) Experimental validation of noninvasive referencing in navigated procedures on long bones. J Orthop Res 25(2):201–207. doi:10.1002/jor.20318 PubMedCrossRefGoogle Scholar
  10. 10.
    Kettelkamp DB, Hillberry BM, Murrish DE, Heck DA (1988) Degenerative arthritis of the knee secondary to fracture malunion. Clin Orthop Relat Res (234):159–169Google Scholar
  11. 11.
    Krettek C, Miclau T, Grun O, Schandelmaier P, Tscherne H (1998) Intraoperative control of axes, rotation and length in femoral and tibial fractures (technical note). Injury 29(Suppl 3):C29–C39. doi:10.1016/S0020-1383(98)95006-9 PubMedCrossRefGoogle Scholar
  12. 12.
    Kuo TY, Skedros JG, Bloebaum RD (2003) Measurement of femoral anteversion by biplane radiography and computed tomography imaging: comparison with an anatomic reference. Invest Radiol 38(4):221–229. doi:10.1097/00004424-200304000-00006 PubMedCrossRefGoogle Scholar
  13. 13.
    Mosheiff R, Weil Y, Peleg E, Liebergall M (2005) Computerised navigation for closed reduction during femoral intramedullary nailing. Injury 36(7):866–870. doi:10.1016/j.injury.2004.12.036 PubMedCrossRefGoogle Scholar
  14. 14.
    Ricci WM, Bellabarba C, Lewis R, Evanoff B, Herscovici D, Dipasquale T, Sanders R (2001) Angular malalignment after intramedullary nailing of femoral shaft fractures. J Orthop Trauma 15(2):90–95. doi:10.1097/00005131-200102000-00003 PubMedCrossRefGoogle Scholar
  15. 15.
    Sharma L, Song J, Felson DT, Cahue S, Shamiyeh E, Dunlop DD (2001) The role of knee alignment in disease progression and functional decline in knee osteoarthritis. JAMA 286(2):188–195. doi:10.1001/jama.286.2.188 PubMedCrossRefGoogle Scholar
  16. 16.
    Tornetta P 3rd, Ritz G, Kantor A (1995) Femoral torsion after interlocked nailing of unstable femoral fractures. J Trauma 38(2):213–219. doi:10.1097/00005373-199502000-00011 PubMedCrossRefGoogle Scholar
  17. 17.
    van der Schoot DK, Den Outer AJ, Bode PJ, Obermann WR, van Vugt AB (1996) Degenerative changes at the knee and ankle related to malunion of tibial fractures. 15-year follow-up of 88 patients. J Bone Joint Surg Br 78(5):722–725PubMedGoogle Scholar
  18. 18.
    Weil YA, Gardner MJ, Helfet DL, Pearle AD (2007) Computer navigation allows for accurate reduction of femoral fractures. Clin Orthop Relat Res 460:185–191PubMedGoogle Scholar
  19. 19.
    Weiner DS, Cook AJ, Hoyt WA Jr, Oravec CE (1978) Computed tomography in the measurement of femoral anteversion. Orthopedics 1(4):299–306. doi:10.1007/BF00572255 PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Mustafa Citak
    • 1
  • Daniel Kendoff
    • 2
  • Andrew D. Pearle
    • 2
  • Padhraig F. O’Loughlin
    • 2
  • Christian Krettek
    • 1
  • Tobias Hüfner
    • 1
  • Musa Citak
    • 1
  1. 1.Trauma DepartmentHannover Medical SchoolHannoverGermany
  2. 2.Orthopaedic DepartmentHospital for Special SurgeryNew YorkUSA

Personalised recommendations