Abstract
Purpose
The management of irreducible, sagittally unstable peritrochanteric fractures presents a significant challenge due to the inability to achieve closed reduction using conventional techniques. This study introduces a novel minimally invasive technique leveraging the mechanical advantage principle with long, angled hemostatic clamps.
Methods
A retrospective review was performed on 16 patients who sustained sagittally unstable peritrochanteric fractures and underwent a percutaneous hemostatic clamp leverage reduction procedure. Inclusion criteria: (1) Preoperative confirmation of fracture type as peritrochanteric fracture; (2) Intraoperative imaging confirms the presence of sagittal plane displacement at the fracture site; (3) Age > 18 years. Exclusion criteria: (1) Open fractures, pathological fractures, and diabetes; (2) Long-term use of corticosteroids; (3) Patients with local skin or systemic conditions not suitable for surgery. Regular follow-ups at intervals of 6 – 8 weeks continued until evidence of bone consolidation was apparent in radiographic assessments. Evaluation of the alignment quality considered factors such as the re-establishment of the neck-shaft angle, the integrity of all cortical bone edges, and the rectification of any translational displacement, while the assessment of hip functionality was performed using the Harris scoring system. Statistical analysis of the relevant data was performed using SPSS 25.0 software.
Results
The average age of these 16 patients was 56.8 years (ranging from 25 to 81 years), consisting of 8 males and 8 females. According to the AO/OTA fracture classification, the cohort included 13 cases of type 31A, 2 cases of type 32A, and 1 case of type 32C. The time from hospital admission to the day of surgery ranged from 3 to 11 days, with an average of 5.1 days. Closed reduction was successfully implemented in all 10 instances, negating the necessity for transition to open reduction procedures. The mean operative duration was 105.8 min (range 80 – 180 min). Satisfactory results of the quality of reduction were determined by comparison with the normal side. The average Harris hip score was 94.1 (range 87 – 99), and the fracture healing time was 4.2 months (3 – 6 months). Implant failure and malunion were not observed.
Conclusions
This study provides an alternative, minimally invasive technique for reducing sagittally unstable, irreducible peritrochanteric fractures. This technique holds the potential to manage complex fractures with the same efficacy as is typically reserved for simple and easily reducible fractures.
Keywords: Trochanteric fractures, Sagittal, Unstable, Closed fracture reduction
1. Introduction
There have been significant advancements in the management of both trochanteric and subtrochanteric fractures over the past several decades.1 While acceptable closed reduction of most intertrochanteric and subtrochanteric fractures can typically be achieved through longitudinal traction and internal rotation of the fractured limb, there are instances where these fractures prove challenging to realign satisfactorily by closed means, thus classifying them as irreducible peritrochanteric fractures.2, 3, 4, 5 The incidence of irreducible intertrochanteric fractures classified as 31A1 and A2 according the AO/OTA classification system has been reported to vary from 3% to 17%, and that of fractures classified as 31A3 is 67%,5 while open reduction is very common in the treatment of subtrochanteric fractures.6 Poor reduction quality is the main risk factor for fixation failure and nonunion in patients with peritrochanteric fractures.6, 7, 8
Therefore, the achievement of minimally invasive reduction of irreducible peritrochanteric fractures is a challenge for orthopedists.
Apprehending the deformative forces at play in diverse fracture configurations and employing appropriate surgical methodologies are critical for achieving favorable treatment results. Sharma et al.4 considered that irreducible AO/OTA 31A1 and A2 fractures could be grouped into 4 patterns, one of which is a proximal anterior and medial long oblique fracture extending to the lesser trochanter with flexion of the proximal fragment, classified as 31A1. Chun et al.9 described this fracture pattern featuring anterior angulation of the head-neck fragment and posterior sagging of the shaft segment, characterizing it as a fracture with sagittal instability. Similar sagittal displacement has been widely described in AO/OTA 31A3,5 and subtrochanteric fractures.6 The common feature of these sagittally unstable peritrochanteric fractures is that closed reduction cannot be achieved by longitudinal traction, which could even increase the deformity. Therefore, many scholars have even suggested open reduction.2,3,6,10
A new, straightforward approach to managing these fractures has been devised. Building on the foundation of prior longitudinal traction techniques, this method applies the lever principle by using the soft tissue envelope as the fulcrum and 2 sets of long, curved hemostatic forceps as the lever arms. Such a setup allows percutaneous reduction and stabilization of sagittally displaced peritrochanteric fractures. This paper presents this uncomplicated technique along with preliminary outcomes.
2. Methods
The stainless-steel hemostatic forceps (J31346, JZ, Shanghai, China) we applied were 26 cm in length with a curved, blunt tip.
From August 2017 to September 2021, 13 intertrochanteric fractures and 3 subtrochanteric fractures that failed to achieve closed reduction after longitudinal traction under regional or general anesthesia were included in the present study and were treated surgically with this technique. The inclusion criteria were as follows: (1) confirmation of the presence of sagittal displacement of the fracture site on intraoperative imaging and (2) age > 18 years. (This criterion ensures that the study covers adult patients, excluding children and adolescents who might be affected by physiological and anatomical differences that could impact surgical outcomes.) Exclusion criteria encompassed instances of open fracture, diabetes, extended use of steroids, and fractures of a pathological nature. The operations were uniformly conducted by the same surgical team. Ethical approval for the study was granted by the local hospital's ethics committee, and all patients provided informed consent.
2.1. Surgical technique
The patient was positioned supine, with the affected extremity extended using either a fracture table or a “double reverse traction repositioning device”.11 The traction force was gradually increased until the length of the limb was almost restored. C-arm visualization was used to confirm the sagittal displacement of the fracture site. A 0.5 cm incision was created, located at the level of the distal fragment and positioned 1 – 2 cm anterior to the femoral shaft's longitudinal axis. The initial insertion of a set of elongated, curved hemostatic clamps was achieved by penetrating through the medial and posterior muscle tissues to reach the distal fragment, and then gently sliding the instrument along the surface of the bone towards the posterior aspect. Elevation of the distal fragment was achieved by angling down the forceps' handles. Subsequently, a further 0.5 cm cut was executed at the level corresponding to the proximal fragment, positioned 1 – 2 cm posterior to the femoral shaft's longitudinal axis. The second set of elongated, curved hemostatic clamps was introduced medially and anteriorly through the muscle tissue until contact was made with the proximal fragment. The instruments were then guided along the bone's surface towards the anterior aspect. By raising the handles of the hemostatic forceps, the proximal fragment was subsequently depressed (Fig. 1, Fig. 2, Fig. 3, Fig. 4). These 2 pairs of hemostatic forceps could be interlocked to maintain the reduction by clamping them with Kocher forceps, thereby preventing sliding and avoiding holding by hand (Fig. 2D and E). Any associated coronal displacement could be reduced using a ball spiker percutaneously (Fig. 3G). Upon achieving satisfactory reduction, the intramedullary (IM) nail fixation procedure could then be performed by the standard method. If the hemostatic forceps impeded IM nail insertion, Kirschner wires could be used to temporarily maintain the reduction.
Fig. 1.
Schematic diagram of reduction by the lever principle. (A) Lever structure. (B) & (C) Cross-section of the proximal fragment before and after reduction. Fi: in-force; Fo: out-force; Fr: resistance; Li: in-lever arm; Lo: out-lever arm.
Fig. 2.
Reduction procedure with 2 pairs of hemostatic forceps. (A) & (B) Position of the incision at the proximal and distal fragment level. (C) Elevation of the proximal hemostatic forceps and lowering of the distal forceps to complete reduction. (D) The 2 pairs of hemostatic forceps can be interlocked to maintain the reduction.
Fig. 3.
View of a 67-year-old female with a 31A3.3 fracture. (A) & (B) Preoperative CT image of the fracture. (C) & (D) Intraoperative anteroposterior and lateral X-rays after longitudinal traction. (E)–(I) Reduction and fixation procedure. (J) Minimally invasive incision.
Fig. 4.
View of an 81-year-old female with a 31A1.2 fracture. (A) & (B) CT image of the fracture. (C) & (D) Intraoperative anteriorposterior and lateral X-rays after longitudinal traction. (E)–(H) Reduction and fixation procedure.
2.2. Postoperative management
Postoperatively on day 2, patients commenced functional exercises of the implicated limb with the aid of a continuous passive motion apparatus and were permitted to engage in partial weight-bearing as soon as the pain levels became manageable. Regular follow-up appointments were arranged at intervals of 6 – 8 weeks until radiographic evidence confirmed bone healing. Should initial radiographic evaluations indicate stable screw placement and sustained reduction, patients were then encouraged to gradually escalate their weight-bearing activities to a tolerable level. During the first month of post-surgery follow-up, the main focus will be on wound healing, early signs of infection, pain control, and preliminary recovery of limb function. Each monthly follow-up will further evaluate the patient's functional recovery, including walking ability and activities of daily living. Additionally, another X-ray examination will be conducted to monitor the progress of fracture healing.
3. Results
The 10 patients had an average age of 56.8 years (range 25 – 81 years) years and comprised 6 males and 4 females. Based on the AO/OTA fracture classification, the cohort included 8 cases of type 31A, alongside 1 case each of type 32A and 32C (Table 1). The duration from hospital admission to the day of surgery ranged from 3 to 11 days, averaging out at 5.1 days.
Table 1.
Patient information.
| No. | Age | Sex | FT | AF | OD (min) | Nail | TDa (mm) | NSA | FUNC (p) |
|---|---|---|---|---|---|---|---|---|---|
| 1 | 67 | F | 31A3.3 | O | 126 | PFNA | 15 | Neutral | 87 |
| 2 | 81 | F | 31A1.2 | X | 80 | PFNA | 10 | Neutral | 93 |
| 3 | 45 | M | 31A1.2 | X | 98 | PFNA | 10 | Neutral | 98 |
| 4 | 60 | M | 31A1.2 & 32A1 | X | 147 | ZNN | 7 | Neutral | 94 |
| 5 | 25 | M | 32C2 | O | 180 | A2FN | 12 | Neutral | 99 |
| 6 | 52 | M | 31A3.3 | X | 100 | PFNA | 3 | Neutral | 94 |
| 7 | 35 | M | 31A1.2 | X | 86 | ZNN | 1 | Neutral | 99 |
| 8 | 56 | M | 32A1 | O | 132 | A2FN | 3 | 2° varus | 93 |
| 9 | 79 | F | 31A1.2 | X | 92 | PFNA | 7 | Neutral | 92 |
| 10 | 68 | F | 31A1.2 | X | 100 | PFNA | 9 | Neutral | 92 |
| 11 | 72 | F | 31A1.2 | X | 95 | PFNA | 7 | Neutral | 94 |
| 12 | 46 | F | 31A1.2 | X | 90 | PFNA | 10 | Neutral | 94 |
| 13 | 69 | F | 31A1.2 | X | 80 | PFNA | 8 | Neutral | 92 |
| 14 | 70 | M | 31A1.2 | X | 92 | PFNA | 5 | Neutral | 93 |
| 15 | 59 | M | 32A1 | X | 105 | A2FN | 9 | Neutral | 92 |
| 16 | 70 | F | 31A1.2 | X | 89 | PFNA | 6 | Neutral | 92 |
F: female; M: male; FT: fracture type according to the AO/OTA classification system, and subtrochanteric fractures are classified as 32A, B, and C; AF: associated fracture; OD: operative duration; PFNA: proximal femoral nail antirotation; A2FN: expert intramedullary nail; ZNN: Zimmer natural nail system; TD: translation decrease; NSA: neck-shaft angle; FUNC: function assessed by Harris hip score.
The translation decrease data indicate the difference between the translation of all 4 cortices after longitudinal traction and that after fixation.
Closed reduction was accomplished in all 16 instances without the need to resort to open reduction. The average length of the procedures was 105.8 min, ranging from 80 to 180 min. Anatomical realignment was attained in every case, restoring length, angle, and rotational alignment. The reduction quality was appraised by comparing the restoration of the neck-shaft angle on the anteroposterior image, the re-establishment of all 4 cortical bone edges, and the correction of any translational shifts on both anteroposterior and lateral images. Satisfactory outcomes were ascertained by juxtaposing with the unaffected side (Table 1). Cephalomedullary nails (PFNA, Synthes®, Oberdorf, Switzerland or ZNN, Zimmer®, Warsaw, Indiana, USA) or reconstruction nails (A2FN, Synthes®, Oberdorf, Switzerland) were implanted in the studied patients. The average follow-up time was 14.3 months (range 12 – 18 months). The average Harris hip score was 93.6 (range 87 – 99). In every instance, successful bone union was attained, with the average time to consolidation being 4.2 months (3 – 6 months). Implant failure (loosening, breakage, screw cutout) and malunion were not observed.
4. Discussion
Peritrochanteric fractures that are unstable in the sagittal plane present challenges for satisfactory closed reduction via longitudinal traction. This instability is due in part to the anterior displacement of the head-neck fragment, influenced by the iliopsoas muscle, while the femoral shaft tends to sag posteriorly under the force of gravity. Furthermore, increasing the traction force could even cause more aggressive displacement. As one type of irreducible peritrochanteric fracture, this fracture pattern occurs in intertrochanteric fractures classified as AO/OTA 31A1, A3, and subtrochanteric fractures.4, 5, 6,9,12 The location of the lesser trochanter plays a significant role in determining the outcome of closed reduction, whether successful or otherwise.12 In type 31A1 sagittally unstable intertrochanteric fractures, the fragment comprising the head and neck is situated anteriorly relative to the fragment of the femoral shaft, the characteristic feature is the proximal anterior and medial long oblique fracture, the medial portion of the proximal fragment extends into a pronounced beak, encompassing a segment of the lesser trochanter (Fig. 4),9 or in scenarios where the lesser trochanter is split, the tendon of the iliopsoas remains connected to the proximal section.2 Consequently, applying longitudinal traction exacerbates the posterior sag of the shaft fragment while increasing the anterior angle of the proximal fragment. Elevating the thigh with external aid can rectify the sagging; however, it fails to correct the anterior angulation of the proximal fragment.9 In type 31A3 fractures, sagittal instability is characterized by a transverse or short oblique primary fracture line, with the lesser trochanter affixed to the head-neck fragment. This flexion arises from the iliopsoas muscle's tension. Concurrently, the fragment of the femoral shaft posteriorly sags under the influence of gravity and frequently exhibits coronal displacement, which is attributed to the traction exerted by the abductors, external rotators, and adductors.5 Likewise, subtrochanteric fractures intrinsically display deformities in the proximal fragment that manifest as flexion, abduction, and external rotation.6,13,14 Although the position of the iliopsoas and lesser trochanter plays an important role in the mechanism of sagittally unstable peritrochanteric fractures, in the present study, we find anterior displacement of the head-neck fragment in cases with avulsion of the lesser trochanter (Fig. 3). The iliopsoas could not play a role in this situation, and the flexion of the proximal fragment may result from the pectineus, which requires further investigation.
Given that the prognostic outcome of fractures is largely contingent on the precision of reduction, numerous experts have advocated for open reduction.2,3,6,10 Meanwhile, some minimally invasive methods have been developed to reduce sagittal displacement. Chun et al.9 used 1 or 2 Steinmann pins as joysticks to reduce the proximal fragment percutaneously, and a mallet was used to elevate the thigh. However, the femoral shaft could not be precisely controlled. This disadvantage was also present in a study that adopted a crutch.13,15 Hao et al.5 utilized a Schanz screw in the capacity of a joystick, which was suspended from the G-arm with a T-handle. Nonetheless, the placement of the Schanz screw posed an obstruction to the insertion of the IM nail. Other tools have been used in the reduction of subtrochanteric fractures, such as finger reduction tools, ball spikes, and bone clamps,6,16 which have inherent advantages and disadvantages.
In our current research, we applied the principle of leverage. Once limb length had been reinstated through the application of longitudinal force, we constructed an efficient lever system utilizing extended, curved hemostatic clamps as the lever arm and leveraging soft tissues as the pivot point. Only a small effort exerted by the surgeons was necessary to counteract the resistance from the retracting force of the hip muscles, allowing percutaneous reduction of the sagittally unstable peritrochanteric fracture to be completed easily. The very important first step is longitudinal traction, by which the limb length could be restored; additionally, the tension induced by traction adequately stiffens the soft tissue casing, enabling it to function effectively as the fulcrum for the lever, a state unattainable in the presence of relaxed musculature. We opted for hemostatic clamps measuring 26 cm in curvature as their substantial thickness and rigidity render them optimal as lever arms. Meanwhile, the length was convenient because the lever arm would not be long enough to achieve the requirement of a labor-saving lever structure if the forceps were too short, and the surgeons’ ability to feel and control the fragment would be reduced if the forceps were too long. Furthermore, the curved, blunt tip of the forceps restricted the skidding of the fragment during the reduction process. With counteractive forces from the proximal and distal fragments, the final reduction is achieved by simultaneously lowering the proximal fragment while raising the distal one. Once aligned, the 2 pairs of hemostatic clamps engage each other, counteracting the forces and stabilizing the reduction, resulting in a self-sustaining structure that preserves alignment without manual intervention (Fig. 2, Fig. 3E). This permits the operating surgeon to maintain a safe distance during the radiographic evaluation of the fracture. While percutaneous pins are utilized in certain protocols to sustain alignment, their application may be limited in managing transverse and short oblique fractures.17,18
In addition to sagittal displacement, coronal displacement is often associated with AO/OTA type 31A3 and subtrochanteric fractures, especially after longitudinal traction; thus, additional tools, such as ball spikers, are needed to achieve reduction. Furthermore, the external rotation deformity of the proximal fragment in subtrochanteric fractures could be restored with hemostatic forceps utilizing the technique introduced by Park et al.19 Due to the biomechanical advantages and minimal invasiveness of IM nail fixation,20,21 this method was applied in our study (Table 1).
Although minimally invasive surgery reduces the risk of infection associated with open surgery, there is still a possibility of infection with any invasive procedure. Management strategies include the use of antibiotics before and after surgery, and maintaining cleanliness and sterile conditions in the surgical area. At the same time, the use of minimally invasive techniques in the reduction and internal fixation of fractures carries the risk of damaging surrounding nerves or blood vessels. This can be minimized through careful anatomical assessment and the use of auxiliary devices such as nerve stimulators.
The minimally invasive technique utilizing the principle of leverage has shown the potential to improve the success rate in the reduction of complex fractures and may reduce the need for open surgery. To further validate the effectiveness and safety of this technique, future studies need to conduct clinical trials in a broader range of patient populations. At the same time, improving the design of surgical instruments to enhance their operability and stability will help increase the precision and reliability of the surgery. This not only ensures the smooth progress of the surgical procedure but also provides patients with safer and more effective treatment plans.
Considering the retrospective and non-randomized nature of this study, its findings cannot be considered definitive due to inherent research limitations and a small sample size. Additionally, the study's limitations include a limited number of patients involved and the absence of a control group. Moreover, the relatively short follow-up period means that we lack an in-depth analysis of the patient's long-term outcomes. Long-term follow-up studies are crucial for assessing the lasting effects of new technologies and the comprehensive recovery of patients. At the same time, because there are various patterns of sagittally unstable peritrochanteric fractures, it is difficult to establish a statistically significant control group. The main objective of this study was to introduce a new minimally invasive reduction method rather than to compare 2 methods. Our surgical approach, as a novel minimally invasive technique, may require a certain period of learning and practice for other physicians to master. The novelty of the technique may affect its dissemination and application in different medical settings.
Sagittally displaced, irreducible peritrochanteric fractures could be reduced with 2 pairs of long, curved hemostatic forceps percutaneously utilizing the lever principle. Peritrochanteric fractures, when sagittally displaced and irreducible, can be aligned percutaneously with 2 sets of long, curved hemostatic forceps employing the concept of leverage. This study provides an alternative minimally invasive reduction technique for the highly selected cases with the same difficult fracture geometry, which may be possible to treat a difficult fracture in the same way as simple and reducible fractures.
CRediT authorship contribution statement
Ke Li: Data curation, Writing – original draft, Writing – review & editing. Xing Du: Data curation, Investigation. Zhongyao Chen: Data curation, Investigation. Wei Shui: Data curation, Methodology.
Ethical statement
Ethical clearance for this investigation was granted by the Institutional Review Board of The First Affiliated Hospital of Chongqing Medical University (Authorization Code 20161069). Before the dissemination of this data, documented consents were secured from all subjects involved.
Funding
Chongqing Medical Scientific Research Project (Joint project of Chongqing Health Commission and Science and Technology Bureau) 2022MSXM096.
Declaration of competing interest
The authors declare that they have no competing interests.
Footnotes
Peer review under responsibility of Chinese Medical Association.
References
- 1.Biber R., Berger J., Bail H.J. The art of trochanteric fracture reduction. Injury. 2016;47:S3–S6. doi: 10.1016/S0020-1383(16)30845-2. [DOI] [PubMed] [Google Scholar]
- 2.Moehring H.D., Nowinski G.P., Chapman M.W., et al. Irreducible intertrochanteric fractures of the femur. Clin Orthop Relat Res. 1997:197–199. doi: 10.1097/00003086-199706000-00027. [DOI] [PubMed] [Google Scholar]
- 3.Said G.Z., Farouk O., Said H.G. An irreducible variant of intertrochanteric fractures: a technique for open reduction. Injury. 2005;36:871–874. doi: 10.1016/j.injury.2005.01.011. [DOI] [PubMed] [Google Scholar]
- 4.Sharma G., Kumar G.N.K., Yadav S., et al. Pertrochanteric fractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: causes of irreducibility. Injury. 2014;45:1950–1957. doi: 10.1016/j.injury.2014.10.007. [DOI] [PubMed] [Google Scholar]
- 5.Hao Y.L., Zhang Z.S., Zhou F., et al. Predictors and reduction techniques for irreducible reverse intertrochanteric fractures. Chin Med J (Engl). 2019;132:2534–2542. doi: 10.1097/CM9.0000000000000493. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Kasha S., Yalamanchili R.K. Management of subtrochanteric fractures by nail osteosynthesis: a review of tips and tricks. Int Orthop. 2020;44:645–653. doi: 10.1007/s00264-019-04404-z. [DOI] [PubMed] [Google Scholar]
- 7.Hao Y., Zhang Z., Zhou F., et al. Risk factors for implant failure in reverse oblique and transverse intertrochanteric fractures treated with proximal femoral nail antirotation (PFNA) J Orthop Surg Res. 2019;14:350. doi: 10.1186/s13018-019-1414-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Yoo J., Chang J., Park C., et al. Risk factors associated with failure of cephalomedullary nail fixation in the treatment of trochanteric hip fractures. Clin Orthop Surg. 2020;12:29–36. doi: 10.4055/cios.2020.12.1.29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Chun Y.S., Oh H., Cho Y.J., et al. Technique and early results of percutaneous reduction of sagittally unstable intertrochateric fractures. Clin Orthop Surg. 2011;3:217–224. doi: 10.4055/cios.2011.3.3.217. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Carr J.B. The anterior and medial reduction of intertrochanteric fractures: a simple method to obtain a stable reduction. J Orthop Trauma. 2007;21:485–489. doi: 10.1097/BOT.0b013e31804797cf. [DOI] [PubMed] [Google Scholar]
- 11.Chen W., Zhang T., Wang J., et al. Minimally invasive treatment of displaced femoral shaft fractures with a rapid reductor and intramedullary nail fixation. Int Orthop. 2016;40:167–172. doi: 10.1007/s00264-015-2829-0. [DOI] [PubMed] [Google Scholar]
- 12.Ikuta Y., Nagata Y., Iwasaki Y. Preoperative radiographic features of trochanteric fractures irreducible by closed reduction. Injury. 2019;50:2014–2021. doi: 10.1016/j.injury.2019.06.035. [DOI] [PubMed] [Google Scholar]
- 13.Kokkalis Z.T., Mavrogenis A.F., Ntourantonis D.I., et al. Reduction techniques for difficult subtrochanteric fractures. Eur J Orthop Surg Traumatol. 2019;29:197–204. doi: 10.1007/s00590-018-2239-2. [DOI] [PubMed] [Google Scholar]
- 14.Yoon R.S., Donegan D.J., Liporace F.A. Reducing subtrochanteric femur fractures: tips and tricks, do's and don'ts. J Orthop Trauma. 2015;29:S28–S33. doi: 10.1097/BOT.0000000000000287. [DOI] [PubMed] [Google Scholar]
- 15.Joseph T.N., Chen A.L., Kummer F.J., et al. The effect of posterior sag on the fixation stability of intertrochanteric hip fractures. J Trauma. 2002;52:544–547. doi: 10.1097/00005373-200203000-00021. [DOI] [PubMed] [Google Scholar]
- 16.Rhorer A.S. Percutaneous/minimally invasive techniques in treatment of femoral shaft fractures with an intramedullary nail. J Orthop Trauma. 2009;23:S2–S5. doi: 10.1097/BOT.0b013e31819f2569. [DOI] [PubMed] [Google Scholar]
- 17.Kim J.W., Park K.C., Oh J.K., et al. Percutaneous cerclage wiring followed by intramedullary nailing for subtrochanteric femoral fractures: a technical note with clinical results. Arch Orthop Trauma Surg. 2014;134:1227–1235. doi: 10.1007/s00402-014-2023-7. [DOI] [PubMed] [Google Scholar]
- 18.Gao Y.S., Guo Y.J., Yu X.G., et al. A novel cerclage wiring technique in intertrochanteric femoral fractures treated by intramedullary nails in young adults. BMC Musculoskelet Disord. 2018;19:359. doi: 10.1186/s12891-018-2284-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Park J., Yang K.H. Correction of malalignment in proximal femoral nailing--Reduction technique of displaced proximal fragment. Injury. 2010;41:634–638. doi: 10.1016/j.injury.2010.01.114. [DOI] [PubMed] [Google Scholar]
- 20.Paulsson J., Stig J.C., Olsson O. Comparison and analysis of reoperations in two different treatment protocols for trochanteric hip fractures - postoperative technical complications with dynamic hip screw, intramedullary nail and Medoff sliding plate. BMC Musculoskelet Disord. 2017;18:364. doi: 10.1186/s12891-017-1723-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Yu W., Zhang X., Zhu X., et al. Proximal femoral nails anti-rotation versus dynamic hip screws for treatment of stable intertrochanteric femur fractures: an outcome analyses with a minimum 4 years of follow-up. BMC Musculoskelet Disord. 2016;17:222. doi: 10.1186/s12891-016-1079-7. [DOI] [PMC free article] [PubMed] [Google Scholar]