Injury, Int. J.

Care Injured 46S4 (2015) S88–S92

Contents lists available at ScienceDirect

Injury
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / i n j u r y

Femoral offset following trochanteric femoral fractures: a prospective

observational study
Benjamin Bueckinga, Christoph Kolja Boesea,b, Vinzenz Seiferta, Steffen Ruchholtza, Michael Frinka,
Philipp Lechlera,*
a
Center for Orthopaedics and Trauma Surgery, University of Giessen and Marburg, Marburg, Germany
b
Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Cologne, Germany

K E Y W O R D S A B S T R A C T

femoral offset Background:  Reconstruction of the femoral offset reportedly improves outcome following total hip
femoroacetabular impingement arthroplasty, but little is known of its influence following hip fractures. We aimed to establish the effect
hip biomechanics of the femoral offset on the medium-term functional outcome in elderly patients who had sustained
hip fracture
trochanteric fractures requiring proximal femoral nailing.
proximal femoral nailing
Patients and Methods:  We measured the rotation corrected femoral offset (FORC) and relative femoral
List of abbreviations: offset (FORL) on plain anteroposterior radiographs of the hip in 188 patients (58 male, 130 female) with
AP – anteroposterior a trochanteric fracture who underwent proximal femoral nailing at our institution. The primary out-
ASA - American society of anaesthesiologists come measure was the Harris hip score (HSS) 6 and 12 months postoperatively; the Barthel index was
CCD - caput-collum-diaphyseal assessed as a secondary outcome.
FH – femoral head circumference Results:  The mean FORC after surgery was 58 mm (±11 mm), while the mean FORL was 1.21 (±0.22). At
FO - femoral offset final follow up, we found significant inverse relationships (Spearman’s rank correlation coefficient, ρ)
FOP – projected femoral offset
between FORC and FORL and the functional outcome assessed by the HSS (FORC: ρ = -0.207, p = 0.036; FORL:
FORC - rotation-corrected femoral offset
ρ = -0.247, p = 0.012), and FORL and the Barthel index (FORC: ρ = -147, p = 0.129; FORL: ρ = -0.192, p = 0.046).
HR - hip rotation
MMSE - mini–mental state examination A consistent trend was observed after adjustment for confounding variables.
RCF - rotation-correction-factor as assessed Conclusions:  Our results underline the biomechanical importance of the femoral offset for medium-term
by the tangent function outcomes in elderly patients with trochanteric fractures. In contrast with the published findings on total
THA – total hip arthroplasty hip arthroplasty, we found an inverse correlation between functional outcome and the extent of the
γp – projected gamma angle of the implant reconstructed femoral offset.
γI – gamma angle of the implant Level of Evidence:
Level I – Prognostic study.
© 2015 Elsevier Ltd. All rights reserved.

Introduction
The incidence of hip fracture in elderly patients is expected to
double by 2050 [1]; the management of hip fracture presents a
key challenge to clinicians and healthcare providers now and in
the future [2]. There has been a strong focus on the reduction of
short- to medium-term mortality rates over the last decades [3],
but more recently there is growing clinical and scientific interest
in optimizing functional outcome following these injuries.
The importance of the reconstruction of hip anatomy has
been proven for elective total hip arthroplasty (THA) [4]; how-
ever, the biomechanical factors determining the functional
outcome following internal fixation of hip fractures remain
The study has been performed at the Center for Orthopaedics and Trauma
Surgery, University of Giessen and Marburg, Marburg, Germany.
* Corresponding author at: Center for Orthopaedics and Trauma Surgery,
University of Giessen and Marburg, Baldingerstraße, 35043 Marburg, Germany.
Tel.: +06421/58-61741; fax.: +06421/58-66721.
E-mail address: lechler@med.uni-marburg.de (Philipp Lechler).
unclear [5]. Femoral offset, defined as the distance from the cen-
ter of rotation of the femoral head to a line bisecting the long axis
of the femur, represents the biomechanical lever arm of the hip
abductor muscles [6]. The restoration of the correct length of the
femoral offset in THA reportedly correlates with reduced rates of
postoperative limping, impingement, leg length discrepancy and
dislocation [7].
The aim of this prospective observational study was to exam-
ine the influence of postoperative femoral offset on the func-
tional outcome of patients treated for a trochanteric fracture.
Patients and methods
We prospectively enrolled 188 consecutive patients who had
sustained a trochanteric fracture and were treated by proximal
femoral nailing in our level one trauma center (a university hospi-
tal) between April 1, 2009 and September 30, 2011. Exclusion cri-
teria were multiple trauma and malignancy-associated fractures.
The patients underwent surgery on a traction table in the supine
position under general anesthesia performed by experienced

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trauma surgeons. In 153 cases a proximal femoral nail with a

caput-collum-diaphyseal (CCD) angle of 130° (Zimmer Natural
Nail System, Cephalo-medullary Nail, Zimmer, Inc., Warsaw, IN,
USA) was implanted according to the manufacturer’s instruc-
tions. Thirty-five patients were implanted with a proximal femo-
ral nail with a CCD of 125° (Trochanteric Gamma3TM Locking Nail,
Stryker Corporate, Kalamazoo, MI, USA) using the same operative
technique. The correct positioning of the lag screw in the cen-
ter of the femoral neck was confirmed by fluoroscopy focused
at 1,000 mm (Siremobil compact GE OEC 9900 C-arm, Siemens
Medical Solutions, Erlangen, Germany). Full weight-bearing
was allowed immediately postoperatively, and all patients were
treated according to a standardized postoperative therapeutic
protocol. Peri- and postoperative surgical complications and
requirement for revision surgery were recorded. Functional out-
come was assessed 6 and 12 months postoperatively by means of
the Harris hip score (HHS) and the Barthel index. Details of the
follow-up protocol are shown in Fig. 1.

Measurement of femoral offset

Following mobilization, standardized postoperative antero-

posterior (AP) and axial radiographs of the hip were obtained
in the supine position with a tube-to-film distance of 1,150 mm
(see Fig. 2). Improved views were obtained if radiographs were
judged to have an unacceptable degree of hip extension or flex-
ion. Radiographs were calibrated by calculating the ratio between
the true diameter of the head of the femoral nail (15.5 mm) and
its projected diameter. Pictures were archived and analyzed
using IMPAX and IMPAX EE software (AGFA HealthCare GmbH,
Bonn, Germany). Femoral offset was defined as the perpendic-
ular distance from the center of rotation of the femoral head to
Fig. 2. Measurement of femoral offset on plain anteroposterior radiographs
following proximal femoral nailing. FH – femoral head, FS – proximal femoral shaft
axis, FOP – projected femoral offset, LS – leg screw axis, γP – projected gamma angle
of the implant.
the long axis of the femoral shaft on AP radiographs, and rotation
correction was performed as previously described [5]. Briefly,
hip rotation leads to a variation in the projected CCD angle of
the implanted femoral nail. Rotation around the femoral axis
increases the projected gamma angle of the implant (γP). As the
true gamma angle (γI) of the implant is known, the hip rotation
(HR) can be calculated thus:

HR = arcos (tan (γP) / tan (γI))

To correct for the rotation of the projected femoral offset

(FOP), the rotation-correction factor (RCF) is calculated from the
following formula:

RCF = (tan (γI) / tan (γP))

The rotation-corrected femoral offset (FORC) is the product of

FOP and the RCF:

FORC = FOP • RCF

To further correct for the size of the patient and the dimen-
sions of their hip, the relative femoral offset (FORL) is the ratio
between the rotation-corrected femoral offset (FORC) and the cir-
cumference of the femoral head (FH):

FORL = FORC / FH

Statistical analysis

For descriptive analysis, absolute mean values and standard

Fig. 1. Flow chart depicting the follow up of 188 patients with trochanteric femoral
fractures.
deviations are reported. Normality of the distribution of the data
was tested using the Kolmogorov-Smirnov test. The relationship
between FORC and FORL was demonstrated in a scatterplot and
Spearman’s correlation coefficient was calculated. To detect a
correlation between femoral offset and the primary and second-
ary outcome measures, Spearman’s correlation coefficient was
calculated using a bivariate technique. To adjust for confounding
variables, a multivariate analysis was undertaken that included

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Table 1
Demographic and clinical characteristics, femoral offset and functional outcome
of 188 patients with trochanteric femoral fractures. At 6 month 127 patients, at 12
month 108 patients were available for functional follow up. Abbreviations: ASA -
American society of anaesthesiologists, MMSE - mini–mental state examination.

Age in years (mean ± SD) 82 ± 8 (median 83, range 60-99)

Gender
female 130 (69%)
male 58 (31%)

ASA Score 2.9 ± 0.6; median 3; range 1-4

I 2 (1%)
II 32 (17%)
III 136 (72%)
IV 18 (10%)

Pre-fracture Barthel index 82 ± 23; median 90; range 0-100

MMSE on admission 21 ± 9.0; median 24; range 0-30

27-30 (normal) 61 (33%)
20-26 (mild dementia) 70 (37%)
10-19 (moderate dementia) 29 (15%)
<10 (severe dementia) 28 (15%)

Rotation corrected femoral offset in mm 57 ± 11; median 56; range 35-95

Relative femoral offset 1.21 ± 0.22; median 1.19; range 0.78-1.87 Fig. 3. Scatter blot depicting the correlation between rotation corrected femoral
offset and relative femoral offset.
Harris hip score
6 month FU 64 ± 19; median 64; range 8-100
12 month FU 68 ± 18; median 67; range 8-99
Table 2
Barthel index Correlation between femoral offset and functional outcome. At 6 month 127 patients,
6 month FU 69 ± 30; median 80; range 0-100 at 12 month 108 patients were available for functional follow up. Abbreviations:
12 month FU 70 ± 32; median 80; range 0-100 FORC - rotation corrected femoral offset, FORL – relative femoral offset, FU – follow up.

FORC Relative femoral offset

Patients’ Spearmen’s p-value Spearmen’s p-value

the femoral offset as an independent variable along with sex, functional coefficient coefficient
age, American Society of Anesthesiologists (ASA) physical sta- outcome
tus score, mini-mental state examination (MMSE) on admission Harris hip score
and pre-fracture Barthel Index as dependent variables. Results 6 month FU -0.112 0.221 -0.128 0.161
with p-values <0.05 were considered to be statistically signif- 12 month FU -0.207 0.036 -0.247 0.012
icant. Data were entered into a database (FileMaker Inc., Santa Barthel index
Clara, CA, USA), and double entry with a plausibility check was 6 month FU -0.176 0.048 -0.219 0.013
performed to monitor for data quality. IBM SPSS statistics 22 12 month FU -0.147 0.129 -0.192 0.046
(Statistical Package for the Social Science, IBM Cooperation,
Armonk, NY, USA) was used for all statistical analyses.
(±0.22). The strength of the correlation between FORC and FORL
Sample size calculation was ρ = 0.893 (Fig. 3).

For the primary outcome measure a required sample size of
90 patients was calculated by employing an Altman nomogram
(data not shown). Power was set at 0.80, while a standardized
difference of 0.6 was assumed (required difference of the pri-
mary outcome measure: 10, standard deviation: 16.5).
Results
Clinical and treatment characteristics
Patients’ demographic and clinical characteristics are shown
in Table 1. Of the 188 patients enrolled, 127 (67.6%) were avail-
able for follow-up at 6 months, and 108 (57.4%) at 12 months.
The in-hospital mortality rate was 2.1% (n = 4). By 6 months 33
patients (17.6%) had died, increasing to 43 (22.9%) at 12 months.
Revision surgery was required in nine cases (4.8%): three due
to cutting out of the lag screw (1.6%), two to treat peri-implant
fracture (1.1%), two to evacuate a postoperative hematoma (1.1%),
two to address irritation of the iliotibial band (1.1%) and one to
treat deep infection (0.5%).
Post-traumatic femoral offset and functional outcome
Bivariate analysis of the influence of FORC on HSS showed
a significant inverse correlation 12 months postoperatively
(ρ = -0.207, p = 0.036); although a similar observation was made
at 6 months, this did not reach statistical significance (Table 2).
When adjusted for patient-specific hip joint dimensions (FORL),
an inverse correlation between femoral offset and HSS 12 months
postoperatively was confirmed (ρ = -0.247, p = 0.012). When we
examined the relationship between FORC and the postoperative
Barthel index, a more complex global measure of performance in
activities of daily living that does not focus solely on the hip, we
again identified a negative correlation at 6 months (ρ = -0.176,
p = 0.048), but this was not statistically significant at 12 months
(ρ = -0.147, p = 0.129). When adjusted for patient size (FORL), the
strength of the negative correlation was stronger at both time
points (6 months, ρ = -0.219, p = 0.013; 12 months, ρ = -0.192,
p = 0.046).
Adjustment for confounding variables

Femoral offset Multivariate analysis to adjust for potentially confounding

variables including sex, age, ASA physical status score, MMSE
The mean projected femoral offset was 50.2 mm (±7.1 mm), on admission and pre-fracture Barthel index found no correla-
while the mean rotation-corrected femoral offset (FORC) was tion between FORC and HSS at 12 months (ρ = -0.195, p = 0.221;
57.0 mm (±11.0 mm). Relative femoral offset (FORL) was 1.21 Table 3). Multivariate analysis of the relationships between FORC

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Table 3 study, femoral offset was not among the risk factors found to
Influence of rotation corrected femoral offset on functional outcome adjusted have influenced short-term outcome after hip fracture [17]. In
for gender, age, ASA score, MMSE and pre-fracture Barthel Index. At 6 month this study, however, hip-specific functional outcome measures
127 patients, at 12 month 108 patients were available for functional follow up.
Abbreviations: ASA - American society of anaesthesiologists, FORC - rotation
were not used, and the influence of hip rotation was not taken
corrected femoral offset, FU – follow up, MMSE - mini–mental state examination. into account when calculating the femoral offset [5]. It is critically
important to make a precise assessment of the femoral offset
FORC
with low standard errors to examine its influence on functional
Patients’ functional B β 95% CI of B p-value outcome when there are so many other potentially confounding
outcome
factors, including the wide range of pre-existing comorbidities
Harris hip score in patients who sustain hip fractures [27]. Attempting to obtain
6 month FU 0.044 0.026 -0.269; 0.357 0.780 highly standardized radiographs of the fractured hip in elderly
12 month FU -0.195 -0.098 -0.509; 0.119 0.221
patients to make an assessment of femoral offset is substantially
Barthel index complicated by pain, contractures and limited compliance. Even
6 month FU -0.097 -0.036 -0.456; 0.262 0.593
12 month FU -0.058 -0.020 -0.510; 0.393 0.798
if an optimal radiographic technique with a defined internal
rotation is applied, femoral ante- and retroversion and the con-
founding effects of the ankle and knee joints preclude the precise
and Barthel index, and FORL and functional outcomes yielded assessment of femoral offset [5,6]. Paul et al. corrected for hip
broadly comparable findings (Table 4). rotation by analyzing the lag screw length, but this technique has
been shown to be associated with a significant misinterpretation
Discussion of the true femoral offset [28]. Computed tomography remains
the most accurate method for the measurement of femoral offset,
The core principles of the operative treatment of trochanteric but its routine use for patients with proximal femoral fractures is
fractures are to stabilize the proximal femur allowing immedi- limited by high radiation exposure and costs [27]. The well-es-
ate mobilization and to minimize operative trauma, blood loss tablished mathematical method we used to correct for rotation
and the risk of revision for any reason [8-12]. Osteosynthesis when measuring femoral offset on plain radiographs is accurate
using intra- or extramedullary fixed-angle devices is the current and practical, and we recommend it for future investigations [5].
standard of treatment for hip fracture involving the trochanteric Our bivariate analysis found that a lower post-traumatic femo-
region [13,14]. While the majority of the previously published ral offset was associated with better functional outcome 6 months
studies focused on the effects of implant design and the opti- and 1 year after surgery. While this study was not designed to
mization of implant placement [15], few studies have examined identify the mechanisms underpinning this phenomenon, there
the influence of the reconstructed hip anatomy on postoperative are several possible explanations. The advantages of a non-an-
joint biomechanics and functional outcome [16,17]. atomical reduction of a trochanteric fracture with a slightly
The restoration of an adequate femoral offset has been identi- increased CCD and simultaneously reduced femoral offset has
fied as an important determinant of functional outcome following been reported previously [29]. Valgisation of the proximal femur
hip arthroplasty [18]. Besides its influences on the stability of the increases compression at the interface between the femoral neck
articulation [19], overall leg length [20] and polyethylene wear and shaft (i.e. the fracture site), potentially reducing the risk of
[21], its effects on impingement-free range of motion [22] and implant failure and cutting out [30,31], as well as a reduction in
postoperative abductor muscle biomechanics have been inves- micromovement and postoperative pain during rehabilitation.
tigated in depth. In contrast to its clearly characterized role in Moreover, a number of authors have reported the effectiveness
THA, the importance of the femoral offset following hip fractures of secondary operative valgisation for the treatment of nonunion
is not satisfactorily understood. As one of the first scientific con- following trochanteric fracture [32,33]. Thus, the suboptimal bio-
tributions to have examined the importance of post-traumatic mechanical characteristics of valgisation due to a reduced femoral
femoral offset after hip fracture, Weinrobe et al. reported that offset, and consequently a shorter lever arm of the hip abduc-
an initially inferior offset increased the risk of redisplacement of tors, could be clinically outweighed by superior early stability of
femoral neck fractures [23]. In 2001, the Bernese group published the fracture region. Interestingly, Liebs and colleagues recently
a case series of nine young patients with post-traumatic femoro- reported a similar negative correlation between the length of
acetabular impingement following femoral neck fracture [24], in femoral offset and outcome assessed by the Western Ontario and
which the deleterious effects of insufficient fracture reduction, McMaster Universities osteoarthritis index (WOMAC) pain sub-
resulting in decreased femoral CCD-angle and anterior femoral scale in a series of 362 patients following THA [34]. The authors
offset, were highlighted. Several subsequent clinical and biome- suggested increased tension in the abductor muscles or iliotibial
chanical studies described the relationship between the extent of band and greater bending moments at the proximal femur as pos-
the femoral offset and implant failure following hip fracture, but sible biomechanical explanations for their findings [34].
their findings were inconsistent [25,26]. In a recent retrospective Our study has some limitations. The identification of fac-
tors determining functional outcome in elderly patients with
Table 4 proximal femoral fractures is complicated by the prevalence of
Influence of relative femoral offset on functional outcome adjusted for gender, age, pre-existing morbidity and the relatively high incidence of peri-
ASA-Score, MMSE and pre fracture Barthel Index. At 6 month 127 patients, at 12 and postoperative complications in this frail population [35].
month 108 patients were available for functional follow up. Abbreviations: ASA - Although it is widely used and well understood, the HSS also has
American society of anaesthesiologists, FORL - relative femoral offset, FU – follow up,
MMSE - mini–mental state examination.
some methodological limitations: its major weakness is a ceiling
effect in younger patients following THA or operative treatment
FORL
of femoroacetabular impingement [36], but it is also susceptible
Patients’ functional B β 95% CI of B p-value to confounding factors independent of hip function in elderly
outcome patients following proximal femoral fracture [35]. To address
Harris hip score this, we also assessed functional outcome using the Barthel
6 month FU 1.514 0.018 0.911; 1.098 0.832 index, a comprehensive measure of activities of daily living that
12 month FU -8.923 -0.113 -22.800; 4.953 0.205 focuses on global mobility.
Barthel index The nature of our study also meant that we were unable to
6 month FU -2.624 -0.020 -19.004; 13.756 0.752 ascertain the exact pre-traumatic femoral offset of the injured hip.
12 month FU -2.107 -0.015 -22.325; 18.110 0.836
The issue of patient-specific hip dimensions was addressed by

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 S92 Benjamin Buecking et al. / Injury, Int. J. Care Injured 46S4 (2015) S88–S92
the assessment of the relative offset, the ratio between the rota-
tion-corrected femoral offset and femoral head circumference. A
number of other investigators have used contralateral hip anat-
omy to estimate the femoral offset of the fractured side; however,
substantial inaccuracies may occur when using this method due
to the relatively high distance between the central ray and the
center of the contralateral hip, exacerbating hip rotation-depen-
dent projection errors [5]. Furthermore, it is not unusual for the
presence of inequality between left and right femoral offsets [37].
The strengths of our study are the relatively large number
of prospectively enrolled patients and the high proportion fol-
lowed up considering the age and comorbidity of the cohort. All
patients were treated according to a highly standardized pro-
tocol developed for the special needs of the elderly population,
and functional outcome was assessed using validated and highly
standardized scoring systems, making our findings reproducible
and highly generalizable. With a total of 188 patients who under-
went very similar treatment, our study was sufficiently powered
to identify the clinically relevant effects of femoral offset.
Conclusion
Our results underline the importance of reconstructing fem-
oral offset in patients with trochanteric femoral fractures treated
by intramedullary nailing. In contrast to THA, there was a trend
towards superior hip function in patients with a lower post-trau-
matic femoral offset, while the overcorrection of femoral offset was
associated with poorer functional hip-specific and global outcome
scores. We encourage further studies to identify additional means of
optimizing strategies when treating fractures of the proximal femur.
Ethics approval
The study protocol followed the principles of the Declaration
of Helsinki and was approved by the local ethics committee (ref-
erence AZ 175/08). All subjects gave informed consent to partic-
ipate in the study.
Source of funding
There was no external source of funding.
Conflict of Interest Statement
The authors have no conflict of interest.
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