Three-Dimensional Evaluation of the Femoral Medullary Canal Center for Antegrade Femoral Nailing

Year 2025, Volume: 15 Issue: 4, 377 - 387, 20.12.2025

Pelin İsmailoğlu , Ali İhsan Soyluoğlu , Abdul Veli Ismailoglu , Mehmet Hakan Özsoy , Alp Bayramoğlu

https://doi.org/10.31832/smj.1721201

https://izlik.org/JA29YU37AW

Abstract

Objective: Antegrade intramedullary nailing is a commonly used method for the treatment of femoral shaft fractures. However, the optimal anatomical entry point for nail insertion on the proximal femur remains controversial. This study aimed to anatomically determine the projection of the femoral medullary cavity center on the proximal femur using three-dimensional computed tomography imaging.
Materials and Methods: Computed tomography scans from 51 adult individuals were retrospectively analyzed. A total of 102 femora (right and left) were reconstructed in 3D and evaluated using the Sectra IDS7 visualization system. The medullary cavity was identified in each femur, and its center was projected onto the superior surface of the proximal femur. The position of the trochanteric fossa and greater trochanter tip was also assessed in relation to the projected center.
Results: The center of the medullary cavity was located more anteromedially than the trochanteric fossa by 31.4% on the right and 39.2% on the left. No significant differences were found between genders. The tip of the greater trochanter rarely covered the center. If the trochanteric fossa was used as the entry point, the greater trochanteric tip overlapped with the entry zone in 66.7% (right) and 88.2% (left) of cases.
Conclusion: This study demonstrated that the center of the femoral medullary cavity projects anteromedially to the trochanteric fossa. The findings provide key anatomical references for identifying the optimal entry point during antegrade femoral nailing with straight nails. We believe these data may guide surgical planning, reduce complications, and improve surgical success.

Keywords

Medullary cavity , Intramedullary nailing , Trochanteric fossa

Ethical Statement

The study was approved by the Clinical Research Ethical Committee of Acıbadem University. The Acıbadem University Medical Research Evaluation Committee (ATADEK) reviewed the study in its meeting dated 20.08.2015 and approved it from a medical ethics standpoint with the decision number 2015-9/10.

References

• Ansari Moein CM, Gerrits PD, ten Duis HJ. Trochanteric fossa or piriform fossa of the femur: Time for standardised terminology? Injury. 2013;44(6):722-725. doi:10.1016/j.injury.2012.08.049
• Brumback RJ, Reilly JP, Poka A, Lakatos RP. Intramedullary nailing of femoral shaft fractures. Part I: Decision-making errors with interlocking fixation. J Bone Joint Surg Am. 1988;70(10):1441-1452.
• Böstman O, Varjonen L, Vainionpää S, Majola A, Rokkanen P. Incidence of local complications after intramedullary nailing and after plate fixation of femoral shaft fractures. J Trauma. 1989;29(5):639-645. doi:10.1097/00005373-198905000-00019
• Kale SP, Patil N, Pilankar S, Karkhanis AR, Bagaria V. Correct anatomical location of entry point for antegrade femoral nailing. Injury. 2006;37(10):990-993. doi:10.1016/j.injury.2006.06.003
• Toogood PA, Skalak A, Cooperman DR. Proximal femoral anatomy in the normal human population. Clin Orthop Relat Res. 2009;467(4):876-85. doi:10.1007/s11999-008-0473-3
• Erçakmak Güneş B, Ilgaz HB, Çiledağ N, Özsoy H, Hayran M, Demiryürek D. Estimating the optimal entry point of the antegrade femoral nailing: Previous and novel morphometric measurements. Acta Orthop Traumatol Turc. 2022;56(2):81-87. doi:10.5152/j.aott.2022.21107
• Ansari Moein CM, Verhofstad MHJ, Bleys RLAW, van der Werken C. Soft tissue injury related to choice of entry point in antegrade femoral nailing: Piriform fossa or greater trochanter tip. Injury. 2005;36(10):1337-1342. doi:10.1016/j.injury.2004.07.052
• Byun YS, Jung GH. Three-dimensional correlation between trochanteric fossa and the ideal entry point for antegrade femoral nailing. Injury. 2016;47(12):2539-2543. doi:10.1016/j.injury.2016.09.026
• Labronici PJ, Galeno L, Teixeira TM, et al. Entry point for the antegrade femoral intramedullary nail: A cadaver study. Rev Bras Ortop (English Ed). 2015;50(5):539-544. doi:10.1016/s2255-4971(15)30145-2
• Lakhwani OP, Mittal PS, Naik DC. Piriformis fossa - an anatomical and orthopedics consideration. J Clin Diagn Res. 2014;8(3):96-97. doi:10.7860/JCDR/2014/6905.4118
• Papadakis SA, Shepherd L, Babourda EC, Papadakis S. Piriform and trochanteric fossae. A drawing mismatch or a terminology error? A review. Surg Radiol Anat. 2005;27(3):223-226. doi:10.1007/s00276-005-0316-9
• Gausepohl T, Pennig D, Koebke J, Harnoss S. Antegrade femoral nailing: An anatomical determination of the correct entry point. Injury. 2002;33(8):701-705. doi:10.1016/S0020-1383(02)00158-4
• Streubel PN, Wong AHW, Ricci WM, Gardner MJ. Is there a standard trochanteric entry site for nailing of subtrochanteric femur fractures? J Orthop Trauma. 2011;25(4):202-207. doi:10.1097/BOT.0b013e3181e93ce2
• Shi T, Jia X, Zhang K, et al. Anatomical structure of the medullary cavity of proximal femur with three-dimensional computed tomography. BMC Musculoskelet Disord. 2025;26(1):337. doi:10.1186/s12891-025-08588-x
• Dora C, Leunig M, Beck M, Rothenfluh D, Ganz R. Entry point soft tissue damage in antegrade femoral nailing: A cadaver study. J Orthop Trauma. 2001;15(7):488-493. doi:10.1097/00005131-200109000-00005
• Canale ST, Beaty JH. Campbell’s Operative Orthopaedics. 11th ed. İstanbul: Güneş Tıp Kitabevleri; 2013:3193-3217.
• McMaster WC, Prietto C, Rovner R. Closed treatment of femoral fractures with the fluted Sampson intramedullary rod. Orthop Clin North Am. 1980;11(3):593-606.
• Grechenig W, Pichler W, Clement H, Tesch NP, Grechenig S. Anatomy of the greater femoral trochanter: Clinical importance for intramedullary femoral nailing. Anatomic study of 100 cadaver specimens. Acta Orthop. 2006;77(6):899-901. doi:10.1080/17453670610013196
• Ozsoy MH, Basarir K, Bayramoglu A, Erdemli B, Tuccar E, Eksioglu MF. Risk of superior gluteal nerve and gluteus medius muscle injury during femoral nail insertion. J Bone Joint Surg Am. 2007;89(4):829-834. doi:10.2106/JBJS.F.00617
• Ito H, Song Y, Lindsey DP, Safran MR, Giori NJ. The proximal hip joint capsule and the zona orbicularis contribute to hip joint stability in distraction. J Orthop Res. 2009;27(8):989-995. doi:10.1002/jor.20852
• Brumback RJ, Uwagie-Ero S, Lakatos RP, Poka A, Bathon GH, Burgess AR. Intramedullary nailing of femoral shaft fractures. Part II: Fracture-healing with static interlocking fixation. J Bone Joint Surg Am. 1988;70(10):1453-1462. doi:10.2106/00004623-198870100-00003
• Atsumi T, Kuroki Y. Role of impairment of blood supply of the femoral head in the pathogenesis of idiopathic osteonecrosis. Clin Orthop Relat Res. 1992;(277):22-30.
• Buford D, Christensen K, Weatherall P. Intramedullary nailing of femoral fractures in adolescents. Clin Orthop Relat Res. 1998;(350):85-89. doi:10.1097/00003086-199805000-00012
• Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J Orthop Trauma. 2005;19:681-686. doi:10.1097/01.bot.0000184145.75201.1b
• Wu Q, Wang Q, Sun X, Li J, Zhao G, Yu P. Use of controlled nail dynamization technique for femoral shaft hypertrophic nonunion. J Orthop Surg Res. 2024;19(1):45. doi:10.3389/fsurg.2025.1547793
• Ulici A, Odagiu E, Haram O, et al. Poor prognostic factors of femoral shaft fractures in children treated by elastic intramedullary nailing. Exp Ther Med. 2020;24(3):563. doi:10.1051/sicotj/2020031