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Where Is the True Location of the Femoral Piriform Fossa?

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Where Is the True Location of the Femoral Piriform Fossa? Injury, Int. J. Care Injured 47 (2016) 2749–2754 Contents lists available at ScienceDirect Injury journal homepage: www.elsevier.com/locate/injury Where is the true location of the femoral piriform fossa? a,b, c Pedro José Labronici, PhD, Professor *, Fernando Claudino dos Santos Filho, Physician , d e Robinson Esteves Santos Pires, MSc , André Wajnsztejn, Staff Physician , f g José Otávio Soares Hungria, Assistant , Vinicius Schott Gameiro, PhD, Professor , h Luiz Henrique Penteado da Silva, Staff Physician a Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil b Faculdade de Medicina de Petrópolis (FMP), Petrópolis, RJ, Brazil c Department of Orthopedics and Trauma, Hospital Santa Teresa, Petrópolis, RJ, Brazil d Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil e Trauma and Walk-in Clinic Team, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil f Trauma Team, Department of Orthopedics and Trauma, Irmandade de Misericórdia da Santa Casa de São Paulo, São Paulo, SP, Brazil g UFF, Niterói, RJ, Brazil h Department of Trauma, Member of Pelvic and Hip Surgery Team, Instituto de Ortopedia e Traumatologia (IOT), Hospital do Trauma, Hospital Escola São Vicente Paula, Passo Fundo, RS, Brazil A R T I C L E I N F O A B S T R A C T Article history: Objective: To analyze knowledge of the anatomic location of the piriform fossa using a questionnaire with Accepted 17 October 2016 anatomic figures. Materials and methods: Participants taking AO Trauma Brasil courses were requested to complete a Keywords: questionnaire containing a photograph of the superior surface and a photograph of the lateral surface of Piriform fossa the femur and answer a question asking which of four numbered points corresponded to the piriform Trochanteric fossa fossa. Point of entry Results: Just 4.5% of respondents correctly chose point 2 (the piriform fossa) in both images, while 75.4% Proximal femur of respondents chose point 4 (the trochanteric fossa) as the correct anatomic structure. The subset of 4th- year residents’ answers was significantly different from those of the other subsets, with 7.5% of correct answers. Conclusions: The low rate of correct answers indicates a tendency for the respondents to be influenced by illustrations in text books or examples in scientific publications that indicate the site of the piriform fossa incorrectly. Interest in the specialty of traumatology is possibly the reason why the subset of 4th-year residents had a better- than-average rate of correct answers. ã 2016 Elsevier Ltd. All rights reserved. Introduction including complications such as comminuted fractures, eccentric reaming of the medial cortex and varus deformity [7–12]. Antegrade intramedullary nailing is currently the first-choice Despite the importance of the correct insertion point to procedure for treatment of fractures of the neck and shaft of the surgeons who perform anterograde intramedullary nailing pro- femur [1–6]. Use of an intramedullary nail was originally cedures, the literature lacks clarity and consensus on terminology. introduced by Küntscher, who proposed that the point of entry Anatomic references employed include “tip of the greater for straight nails should be the greater trochanter. Later, Winquist trochanter,” “piriform fossa,” “trochanteric fossa,” “digital fossa” recommended that the piriform fossa was a better point of entry in and “junction of femoral neck and trochanter”1, [13–16]. The order to avoid problems attributed to insertion via the trochanter, majority of articles recommend the “piriform fossa” as the site for insertion of the anterograde intramedullary nail. However, their illustrations show the “trochanteric fossa” [1,7–9,17–26]. The objective of this study was to analyze anatomic knowledge * Corresponding author at: Av. Roberto Silveira, 187/601 25685-040, Petrópolis, about the piriform fossa in a sample of participants taking trauma RJ, Brazil. courses, using an illustrated questionnaire. E-mail address: [email protected] (P.J. Labronici). http://dx.doi.org/10.1016/j.injury.2016.10.016 0020-1383/ã 2016 Elsevier Ltd. All rights reserved. 2750 P.J. Labronici et al. / Injury, Int. J. Care Injured 47 (2016) 2749–2754 Materials and methods Results Between January and December of 2014, during Basic Principles Analysis of the relationships between respondents’ answers for and Advanced courses run by AO Trauma Brasil, course participants the image showing the superior view of the trochanter and the were requested to complete a questionnaire with the following type of respondent (shown in Table 3) revealed that for all subsets information, age; and year of residency, or, if not a resident, the the percentage of respondents who correctly answered point 2 (the time since qualification; and to indicate the location of the piriform piriform fossa) was small and that the majority chose point 4 (the fossa on two illustrations. These figures consisted of one trochanteric fossa). There was a significant difference between the photograph of the superior surface and another of the lateral frequencies of answers between different subsets of respondents surface of a femur on which four regions had been labeled. The (chi-square test p-value = 0.010). Exclusion of the subset of 4th- labels corresponded to: 1- insertion of obturator and gemelli; 2- year residents resulted in the difference no longer achieving piriform fossa; 3- tip of the greater trochanter and 4- trochanteric significance (p-value = 0.312). It was therefore concluded that the fossa (Fig. 1A and B). The question was as follows, “Which of the 4th-year residents’ answers are significantly different from the numbers in the figures below corresponds to the piriform fossa?” other subsets’ answers. It can be observed from the frequencies (Fig. 2). shown in Table 3 that the subset of 4th-year residents had the The questionnaire was administered to a total of 670 people highest frequency of correct answers (7.5%) and had the lowest taking the courses, but 20 questionnaires were incomplete, so the frequency of respondents who chose point 4 (the trochanteric sample used for analysis comprised 650 valid questionnaires. fossa, 77.6%). Tables 1 and 2 list the data on experience and age, respectively, for For the lateral-view image, a greater percentage of respondents those who responded to the questionnaire. in all subsets correctly chose point 2 (piriform fossa) as can be observed from the results shown in Table 4. Notwithstanding, the percentage of participants who chose correctly was less than 11% in Statistical methods all subsets and 80.5% of all of the respondents chose point 4 (the trochanteric fossa). While the percentage of correct answers was The data collected were used to construct a database containing greater for the Post- residents subset (10.8%), the difference was the variables age, classification of respondent (2nd, 3rd, 4th-year not significant from a statistical point of view. The chi-square test resident or post-resident), post- residency experience, answer for did not detect significant differences between the answers from superior-view image and answer for lateral-view image. This the different subsets; p-value = 0.436. database was analyzed using SPSS (Statistical Package for the Social Table 5 shows the distribution of the answers for both images Science) version 22.0. taken together. Just 4.5% of respondents chose point 2 (piriform Data were synthesized using descriptive statistics, descriptive fossa) as the correct anatomic structure in both images. For both graphs, frequency distributions and contingency tables in order images, 75.4% of respondents chose point 4 (the trochanteric fossa) to characterize the sample and analyze the behavior of the as the correct anatomic structure. As had been expected, the variables. An inferential analysis of the significance of differences degree of agreement between images measured using the Kappa between percentages for distinct groups was conducted using the coefficient is not high. There is moderate agreement (0.48), chi-square test. Since distribution was not normal, independent indicating that the angle from which the image is taken interferes groups were compared using the Kruskal- Wallis nonparametric with the choice made, since 15.7% of the respondents chose test, with Tukey post-hoc analysis. Agreement between different points for the two different views. responses to the two images was assessed according to the Figs. 3 and 4 illustrate the percentages by group, showing the percentage of cases in which both answers were the same and analysis of both images. In all subsets, there was a higher frequency with the Kappa index, where possible. All analyses were of correct answers for the lateral- view image. The subset of 4th- conducted with a maximum cutoff for significance of 5%, i.e., year residents had the highest percentage of correct answers for the following decision rule was adopted for all tests: the null both images combined (6.0%) and the highest percentage of correct hypothesis was rejected whenever the p-value associated with a answers for the image taken from above (7.5%). The subset of post- test was less than 0.05. residents had the highest percentage of correct answers for the Fig. 1. A) lateral and B) superior views showing anatomic structures. P.J. Labronici et al. / Injury, Int. J. Care Injured 47 (2016) 2749–2754 2751 Fig. 2. Study questionnaire. image taken from the lateral (10.8%). For all groups, the most frequent answer was point 4 (the trochanteric fossa), and the Table 1 subset of Distribution of respondents, by experience. post-residents had the highest frequency of this choice (86.7% Frequency Percentage for the photograph taken from above, 83.1% for the lateral view and 2nd-year residents 134 20.6 80.7% for both images combined). 3rd-year residents 283 43.5 4th-year residents 67 10.3 Discussion Post-residents 166 25.5 “ ” fi Total 650 100 The piriform fossa is an anatomic structure that is dif cult to identify, particularly during orthopedic surgery to insert an 2752 P.J.
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