Evaluation of reduction quality and implant positioning in intertrochanteric fracture fixation: A review of key radiographic parameters

Table 1 Baumgaertner Reduction Quality Criteria

I Alignment

a: AP view: Normal or slight valgus NSA

b: Lateral view: Less than 20° of angulation

II Displacement

a: AP view: Less than 4 mm of displacement of any fragments

b: Lateral view: Less than 4 mm of displacement of any fragments

Reduction quality:

Good: Both main criteria met

Acceptable: Only one main criterion met

Poor: Neither main criterion met

AP: Anteroposterior; NSA: Neck shaft angle.

Table 2 Chang Reduction Quality Criteria

I Alignment

a: AP view: Normal or slight valgus NSA

b: Lateral view: Less than 20° of angulation

II Displacement

a: AP view: Neutral or positive medial cortical support

b: Lateral view: Smooth anterior cortical contact

Reduction quality:

Excellent: All four sub criteria met

Acceptable: Two or three sub criteria met

Poor: One or no sub criterion met

AP: Anteroposterior; NSA: Neck shaft angle.

Table 3 Summary of the key radiographic parameters used to assess quality of reduction and implant positioning

Parameter	Imaging modality	Strengths	Limitations	Recommendation
Parameters for quality of reduction
Neck shaft angle	AP X-ray	Simple, familiar measure; side-to-side comparison possible	Affected by femoral rotation and traction; intraoperative leg positioning alters measurement; side-to-side variation exists naturally	NSA best compared to uninjured side; not reliably accurate without pre-injury imaging; avoid varus malreduction
Greater trochanter orthogonal line	AP X-ray	Easy intraoperative estimation; correlates with NSA; uses anatomical landmarks	Influenced by abduction/adduction; population-based average has wide range	Use as a rough intraoperative guide; more useful with contralateral comparison
Anterior cortical line	Lateral X-ray	Consistent mean correlation with femoral anteversion; helps identify rotational issues	Affected by limb rotation; broad range around mean; limited individual specificity	Can assist intraoperatively when other landmarks are limited
Calcar Displacement	AP and lateral X-ray	Highlights medial cortical support; distinguishes positive/neutral/negative support	Requires high-quality views; subjective classification	Positive or neutral support (AP) + reduced/anterior displacement (lateral) associated with better outcomes
Wedge Effect signs (Medialized GT, Cross Wire Sign)	Fluoroscopy (Intraoperative)	Identifies iatrogenic varus malreduction during nail insertion	Requires saved pre- and post-insertion images for comparison	Avoid medialization and improper entry; contributes to varus malalignment
Baumgaertner Reduction Quality Criteria	AP and lateral X-ray	Simple alignment/displacement criteria	Less interobserver reliability; not predictive after multivariate analysis	Achieving 'good' BRQC predicts fewer mechanical complications, but CRQC is preferred
Chang Reduction Quality Criteria	AP and lateral X-ray	Includes medial cortical support; better interobserver reliability; predictive of outcomes	Slightly more complex; requires careful assessment of cortical contact	Recommended over BRQC; better predictor of complications and reduction quality
Parameters for implant positioning
TAD	AP and lateral X-ray	Easy to measure; well-established cut-off; widely used	Influenced by positioning; variability in measurement	TAD > 25 mm associated with increased cut-out risk; aim for < 25 mm
Calcar-Referenced TAD	AP and lateral X-ray	Accounts for stronger calcar bone; inferior placement favoured	Cut-off values vary; some studies show limited superiority over TAD	CalTAD > 25 mm linked to cut-out; may be more predictive than TAD, but not conclusively superior
Cleveland zones	AP and lateral X-ray	Standardized 9-zone grid; easy to visualize component position	No direct distance measurement; qualitative zone allocation	Centre-centre and central-inferior positions have lowest cut-out risk
Parker’s ratio index	AP and lateral X-ray	Quantitative position assessment; applicable in both planes	Calculation required; multiple cut-off values proposed (58–65)	Higher index (superior/anterior) linked to increased complications; lower index < 60 (posterior/inferior) preferred

AP: Anteroposterior; NSA: Neck shaft angle; TAD: Tip-apex distance; BRQC: Baumgaertner Reduction Quality Criteria; CRQC: Chang Reduction Quality Criteria; CalTAD: Calcar-Referenced tip-apex distance.