Aims Inaccurate femoral neck osteotomy is a recognized technical challenge in direct anterior approach total hip arthroplasty (DAA-THA), largely due to limited femoral exposure and the absence of a standardized intraoperative landmark. This study aimed to investigate whether the ITL is an alternative bony landmark for femoral neck osteotomy during the DAA. Patients and methods Three anatomical references, the Intertrochanteric line (ITL) height (ITL-H), ITL angle (ITL-A), and femoral saddle height (SH), were measured from 3D-CT models of 60 normal hip patients (30 males and 30 females) to simulate a cutting height of 10 mm above the LT. Twenty cadaveric hip specimens were then used to evaluate the accuracy of the proposed anatomical references. Results The mean ITL-H, ITL-A, and SH were 23 ± 4 mm, 17.4° ± 3.5°, and 26 ± 4 mm, respectively. While ITL-H showed no sex difference (23 ± 3.4 mm vs 23.1 ± 4.1 mm, P = 0.96), significant differences existed for ITL-A (15.8° ± 3.4° vs 19.9° ± 1.4°, P = 0.001) and SH (27.2 ± 3.9 mm vs 23.9 ± 3 mm, P = 0.002). ITL-H was not correlated with age (P = 0.063), femoral length (P = 0.31), or femoral neck shaft angle (P = 0.41). Femoral neck osteotomy performed 23 mm above the ITL-H could yield 80% and 100% success rates for cutting heights of 10–15 mm and > 5 mm above the LT, respectively. Conclusions ITL-H serves as a reproducible anatomical landmark for femoral neck osteotomy during DAA-THA. An osteotomy level of approximately 23 mm above the ITL-H represents a safe lower margin to avoid excessive calcar bone resection. Nevertheless, individualized preliminary osteotomy based on preoperative templating remains necessary, with intraoperative adjustment according to patient-specific ITL-H. <MediaObject ID="MOESM1"> <VideoObject FileRef="MediaObjects/42836_2025_365_MOESM1_ESM.mp4" VideoID="CZo8SBnS4Xczfh3tLYj-vh"> <Caption Language="En" xml:lang="en"> <CaptionContent> Video Abstract </CaptionContent> </Caption> </VideoObject> </MediaObject>

Anatomical relationship between the intertrochanteric line and femoral neck osteotomy level in direct anterior approach total hip arthroplasty: a 3D morphometric and cadaveric validation study

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2026年3月3日

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Sakkadech Limmahakhun,
Suchate Runraksar,
Nitchanant Kitcharanant,
Warakorn Jingjit

摘要

Aims

Inaccurate femoral neck osteotomy is a recognized technical challenge in direct anterior approach total hip arthroplasty (DAA-THA), largely due to limited femoral exposure and the absence of a standardized intraoperative landmark. This study aimed to investigate whether the ITL is an alternative bony landmark for femoral neck osteotomy during the DAA.

Patients and methods

Three anatomical references, the Intertrochanteric line (ITL) height (ITL-H), ITL angle (ITL-A), and femoral saddle height (SH), were measured from 3D-CT models of 60 normal hip patients (30 males and 30 females) to simulate a cutting height of 10 mm above the LT. Twenty cadaveric hip specimens were then used to evaluate the accuracy of the proposed anatomical references.

Results

The mean ITL-H, ITL-A, and SH were 23 ± 4 mm, 17.4° ± 3.5°, and 26 ± 4 mm, respectively. While ITL-H showed no sex difference (23 ± 3.4 mm vs 23.1 ± 4.1 mm, P = 0.96), significant differences existed for ITL-A (15.8° ± 3.4° vs 19.9° ± 1.4°, P = 0.001) and SH (27.2 ± 3.9 mm vs 23.9 ± 3 mm, P = 0.002). ITL-H was not correlated with age (P = 0.063), femoral length (P = 0.31), or femoral neck shaft angle (P = 0.41). Femoral neck osteotomy performed 23 mm above the ITL-H could yield 80% and 100% success rates for cutting heights of 10–15 mm and > 5 mm above the LT, respectively.

Conclusions

ITL-H serves as a reproducible anatomical landmark for femoral neck osteotomy during DAA-THA. An osteotomy level of approximately 23 mm above the ITL-H represents a safe lower margin to avoid excessive calcar bone resection. Nevertheless, individualized preliminary osteotomy based on preoperative templating remains necessary, with intraoperative adjustment according to patient-specific ITL-H.

Video Abstract