The positive, neutral, and negative cortex relationship in fracture reduction of per/inter-trochanteric femur fractures
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LETTER TO THE EDITOR
The positive, neutral, and negative cortex relationship in fracture reduction of per/inter-trochanteric femur fractures Ke-Wei Tian 1 & Lei-lei Zhang 1 & Chao Liu 1 & Xian-tao Chen 1 & Ke Chen 1 Received: 4 June 2020 / Accepted: 9 June 2020 # SICOT aisbl 2020
Dear Editor, We read with great interest the article “The accuracy of intra-operative fluoroscopy in evaluating the reduction quality of intertrochanteric hip fractures” in your June 2020 journal. The author Jia confirms that after reduction of inter-trochanteric fractures, it is necessary to achieve “positive support” in the both anteroposterior [AP] and lateral position during fluoroscopy, but he did not accept the anatomical reduction in the lateral position and classified the neutral support in the lateral view as a poor reduction group. This academic view is clearly different from Chang et al. We want to comment on some points. Fracture reduction quality is the first prerequisite for the treatment success in per/inter-trochanteric femur fractures. Clinically, the reduction quality is assessed by fluoroscopy intra-operatively and by radiography, CT scanning, and 3-D reconstruction post-operatively. Fracture reduction quality is evaluated by two aspects, i.e., garden alignment and fragment displacement (cortical apposition). As the posteromedial lesser trochanter fragment is detached and usually not reduced and fixed in unstable A2 fractures, Chang et al. [1] in 2015 proposed the concept of anteromedial cortex-to-cortex support reduction, which is a non-anatomic pattern of functional buttress reduction and is specific for the proximal femur as it relates to the neck-shaft angle and when various implant devices with sliding mechanisms are
* Ke Chen [email protected] 1
Luoyang Orthopedic Hospital of Henan Province, Orthopedics Hospital of Henan Province, Luoyang, China
used for fixation. Controlled fracture impaction via limited telescoping provides secondary axial and torsional stability between the head-neck fragment and the shaft of the femur [2]. Clinical case series demonstrated that patients in a true cortical support reduction group had the least loss in neck-shaft angle and neck length and got ground walking much earlier than no cortical support group, with good functional outcomes and less hipthigh pain presence [3]. Whether to accept or not accept a fluoroscopic neutral position is still controversial. In the study by Chang et al. [4] in 2018, neutral positions in both the AP and lateral views are acceptable. In Chang’s group, 20 cases showed neutral position in lateral fluoroscopy and finally, 16 cases (80%) showed in 3D CT achieved true cortex-to-cortex buttress at the anteromedial corner, while 6 cases showed neutral position in AP view and finally, 4 (66.7%) lost true cortical support. For the most frequent combination of positive/neutral position, 14 in 16 cases (87.5%) obtained final cortical support (Table 1). However, in the study by Jia et al. [5] in 2020, neutral positions are not acceptable. In Jia’s group, they
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