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Can Fluoroscopy-based Computer Navigation Improve Entry Point Selection for Intramedullary Nailing of Femur Fractures?

  • Symposium: Femur Fractures: Contemporary Treatment Approaches
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

The entry point is crucial to an accurate reduction in femoral nailing. Fluoroscopy-based navigation was developed to aid in reducing femur fractures and selecting entry points.

Questions/purposes

We asked: (1) Can the piriformis fossa (PF) and tip of the greater trochanter (TT) be identified with high reproducibility? (2) What is the range of nonneutral images clinically acceptable for entry point selection? (3) Does navigation improve accuracy and precision of landmarking the TT and PF? And (4) does off-angle fluoroscopy within the acceptable range affect landmark accuracy?

Methods

Three orthopaedic surgeons digitized the PF and TT under direct visualization on 10 cadaveric femurs, quantifying the reproducibility of the targeted PF and TT landmarks. Arcs of acceptable AP and lateral images of each femur were acquired in increments of 5° with a C-arm. An experienced orthopaedic surgeon rejected or accepted images for entry point selection by qualitatively assessing the relative positions and sizes of the greater trochanter, lesser trochanter, and femoral neck. Entry points were identified on each image using fluoroscopy and navigation. Hierarchical linear modeling was used to compare accuracy and precision between navigation and fluoroscopy and the effects of image angle.

Results

A 29° average arc of acceptable images was found. Reproducibility of the target landmarks for the PF and TT under direct visualization was excellent. Navigation had similar accuracy to fluoroscopy for PF localization but less for TT. Navigation increased precision compared to fluoroscopy for both PF and TT. Image angle affected accuracy of the PF and TT under fluoroscopy and navigation.

Conclusions

Nonorthogonal images reduce accuracy of PF and TT identification with both navigation and fluoroscopy. Navigation increased precision but decreased accuracy and cannot overcome inaccuracies induced by nonorthogonal images.

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Acknowldgments

We thank Dr. Yan Yan Wu and the Applied Health Research Centre of St Michael’s Hospital for statistical consultation. We also thank Dr. Barry Cayen of the Division of Orthopaedic Surgery at the Humber River Regional Hospital (Toronto, ON, Canada) and Dr. Ashesh Kumar of the Division of Orthopaedic Surgery at St Michael’s Hospital for their contribution by performing landmark selection in this study.

Author information

Authors and Affiliations

  1. Martin Orthopaedic Biomechanics Laboratory, St Michael’s Hospital, Li Ka Shing Institute, Room B116, 30 Bond Street, Toronto, ON, M5B 1W8, Canada

    Meghan C. Crookshank PhD, Michael Sellan MSc & Emil H. Schemitsch MD, FRCS(C)

  2. Orthopaedic Biomechanics Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    Meghan C. Crookshank PhD & Cari M. Whyne PhD

  3. Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada

    Meghan C. Crookshank PhD & Cari M. Whyne PhD

  4. Princess Royal University Hospital, South London Healthcare NHS Trust, Orpington, Kent, United Kingdom

    Max R. Edwards MD, FRCS(Tr&Ortho)

  5. Department of Surgery, University of Toronto, Toronto, ON, Canada

    Cari M. Whyne PhD

  6. Division of Orthopaedic Surgery, Department of Surgery, St Michael’s Hospital, University of Toronto, 800-55 Queen Street East, Toronto, ON, Canada

    Emil H. Schemitsch MD, FRCS(C)

Authors
  1. Meghan C. Crookshank PhD
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  2. Max R. Edwards MD, FRCS(Tr&Ortho)
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  3. Michael Sellan MSc
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  4. Cari M. Whyne PhD
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  5. Emil H. Schemitsch MD, FRCS(C)
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Corresponding author

Correspondence to Emil H. Schemitsch MD, FRCS(C).

Additional information

Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed in the Martin Orthopaedic Biomechanics Laboratory at St Michael’s Hospital, Toronto, ON, Canada.

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Crookshank, M.C., Edwards, M.R., Sellan, M. et al. Can Fluoroscopy-based Computer Navigation Improve Entry Point Selection for Intramedullary Nailing of Femur Fractures?. Clin Orthop Relat Res 472, 2720–2727 (2014). https://doi.org/10.1007/s11999-013-2878-x

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  • DOI: https://doi.org/10.1007/s11999-013-2878-x

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