Intraoperative Imaging in Proximal Femur Fractures

Ladies and gentlemen, dear colleagues, I would like to extend a warm welcome to everybody at the screen. Today we will talk about intraoperative imaging and treatment of proximal femur fractures. I would like to introduce the faculty to you on my left side, Eric Mandalika. My name is John Franco. We are trauma surgeons at the bigger trauma center in Ludwigshafen, Germany. What can you expect from our presentation? We will talk about the standard projections at the proximal femur. We will show you how you can achieve these standard projections. We will talk about the radiological. Anatomical landmarks and the criteria how to assess fracture reduction in the two standard projections. Now I would like to explain the two standard views of the proximal femur to you and the anatomic electronical landmarks that you should detect later in these two standard views. We have. The so-called AP view. And more or less perpendicular to it, the so-called lateral or axial view. In the AP view, you see the femoral head, the femoral neck with the so-called calca or medial line. You have the crater Troke and the lesser troke. In the axial view, you have the femoral head, you have the greater troke. The lesser troke you have the posterior line and the anterior line. Now we will show you how to achieve the two standard projections A and lateral. There are different types of positioning of the patient in treatment of proximal femur fractures. Here we've chosen the. Positioning in the traction table. The traction table has the advantage that you can reduce the fracture under fluoroscopy and the traction table holds your fracture reduction. During your implant positioning, if you look at a model of the proximal femur, everybody knows that we have an anti version of the femoral neck to the shaft from around about 15 degrees. So the first thing. That you have to apply if you want to reduce such a fracture is traction and internal rotation. With the internal rotation the 15 degrees of anteversion. Are equalized so that you can in general achieve a good AP view with the Central X-ray beam perpendicular to the shaft axis. X-ray, please. So now I will turn it for you. So this is a nice AP view. Of the proximal femur. You see the femoral head? The creator troke. The lesser troke. And the so-called Cal Kaline. In case. Of a fracture after fracture reduction, you should consider. Different criteria for good reduction result. This is a continuity of the Calca line and no Varus or valgus deformity. For the lateral view, you have to rotate the C arm in a position like that. And then we'll make the first image. So we can achieve a better one. Please rotate a little bit more. I will tell you the criterias for good letter image soon. Again. Yeah, a little bit better, but maybe we can achieve. And you can do it. With pulse fluoroscopy or single shots like we will do it or you can do it under dynamic fluoroscopy, it's up to you. In this case we use single shots. OK. That's not bad. OK, now we have a good lateral view of the proximal femur you can see. The femoral head. The creator troke. The lesser troke. The entire line. And the posterior line and the criteria for a good fracture reduction are? The neck and shaft axis in one axis. A harmonic harmonic. And fuel line and the harmonic. Posture line. Now we have learned that the two standard fuse at the proximal femur are the AP few and the axial view. With these two views, you can assess your fracture reduction and in a lot of cases your implant placement. But I want to point out one important thing. If we're talking about implant placement in the proximal femur, one of the first steps is in a lot of cases, for example in nailing or if you use the DHS to place. OK, wire in the center, center position. Center Center in a femoral neck and a femoral head. And then you replace your screw or what else you plate. If you place. Your implant. Really in the real center center position? Then you can see the tip of for example the K wire in the AP view. If it is penetrating the cortical bone, this means it's intraarticular what it should not be. So it's easy to detect, but you have to take care because you have a. Convex joint surface in every direction. So if you place a K wire in this position and the tip. Of the KY penetrates here. Round about two or three millimeters it is not possible to detect this penetration in the AP. Or in the letter of you. Because there is all the, the tip of the KY is always covered by bone, so in this case you should use or to check. To exclude if there is a intra articular implant displacement you should use pulse fluoroscopy in different angles. Or what I do in most cases is a short dynamic fluoroscopy to be. Pretty sure that there is no intra articular implant misplacement. Maybe you're interested in the future of interactive imaging? In future we will have several new tools that can assist or support you during your procedure. For example this application. It's called target pointer. Target Pointer finds a linear object in the field of view and draws you a line along the axis of this. For example, implant like I have KY here so that you can imagine where your KY will run to if your treat proximal femur fractures. In most of the procedures one of the key step is to place the kvar in center center position. But the way from what the distance from the entry point at the bone to the center of the femoral head is around about 11:50 centimeters, so. It is sometimes not really so easy to place the K wire in the right position and this application can help you. I will show you how it works. I placed the kyer here. At the proximal femur. And now let's make an image. And what I can do? I can use it under fluoroscopy 2 fluoro. And you see, so I can aim in. Stop. And only a few seconds I found the right way. To place my K wire in this projection. Now we are at the end of our presentation, I would like to summarize the take home messages for you. At the proximal femur we have two standard views, the AP view and the letter of view. The Radiological anatomical landmarks in the app you are the femoral head, the crater troke, the lesser troke and the so-called kalkar or medial line. In the letter review, the landmarks are the femoral head. The greater troke, the lesser troke, the posterior line, and the anterior line. The very important criteria after reduction of approximate femur fracture are in the AP view. Or harmonic calcarine and no varus or valgus deformity and in the axial fuel. Should be the neck and the shaft axis in line and. You should take care about a harmonic and your line and the harmonic posterior line. Thank you very much for your attention.

Intraoperative imaging in proximal femur fractures With the 2D/3D C-arm Cios Spin PD Dr. med. Jochen Franke 3GU clinic, Ludwigshafen, Germany SIEMENS Standard projections of proximal femur 3D Healthineers Target P Target Pointer Take-home messages SIFMENS SIEME Please note that the learning material is for training purposes only. For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively "Operator Manual") issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of the training. The Operator Manual shall be used as your main reference, in particular for relevant safety information like warnings and cautions. Please note: Some functions shown in this material are optional and might not be part of your system. Certain products, product related claims or functionalities (hereinafter collectively "Functionality") may not (yet) be commercially available in your country. Due to regulatory requirements, the future availability of said Functionalities in any specific country is not guaranteed. Please contact your local Siemens Healthineers sales representative for the most current information. The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages. All names and data of patients, parameters and configuration dependent designations are fictional and examples only. All rights, including rights created by patent grant or registration of a utility model or design, are reserved. Siemens Healthcare GmbH 2022