International Orthopaedics - 2026-08-11 - Journal Article; Review
From classification to anteromedial cortical contact: an integrative review of the Japanese and international literature on trochanteric fracture reduction and fixation.
Inui T
Topics
Key Takeaway
Anterior malreduction lacking anteromedial cortical contact carries an adjusted odds of cut-out comparable to a tip-apex distance ≥20 mm, establishing it as an equally important modifiable intraoperative target.
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Summary
This integrative review of MEDLINE and Ichushi-Web literature examined classification systems, reduction strategies, and fixation techniques for trochanteric femoral fractures through the lens of anteromedial cortical contact. Loss of posteromedial support and lateral wall fractures are the primary structural instability drivers, and anterior malreduction was independently associated with cut-out at an adjusted odds estimate equivalent to TAD ≥20 mm. A randomized trial cited within the review demonstrated that adding an anterior support screw reduced loss of reduction and early sliding.
Key Limitation
The review lacks a formal systematic methodology with PRISMA reporting and quality assessment, meaning the strength of individual study conclusions—particularly the quantitative odds estimate for anterior malreduction—cannot be independently verified or weighted.
Original Abstract
PURPOSE
Internal fixation of trochanteric femoral fractures achieves a high union rate, yet mechanical failure - cut-out, excessive sliding, loss of reduction and reoperation - remains a problem. Among the factors a surgeon can control, reconstructing anteromedial cortical contact has recently drawn attention. This review examines developments in classification, reduction, and fixation through this contact and its intraoperative assessment.
METHODS
MEDLINE (via PubMed) and Ichushi-Web (a Japanese medical literature database) were used in June 2026, with no limit on publication date.
RESULTS
The main structural drivers of instability are loss of posteromedial support and a lateral wall fracture. Fractures without posteromedial support are easily misread as stable on plain radiographs. When posteromedial support is lost, anteromedial cortical contact becomes a support that can be rebuilt. Anterior malreduction, which lacks this contact, was independently associated with cut-out, with an adjusted odds estimate similar to that for a tip-apex distance of at least 20 mm. The anteromedial cortex cannot be assessed reliably on the standard anteroposterior and true lateral views; an oblique (tangential) view is needed to profile it. Some patterns are not reduced by traction and need active, direction-specific reduction. In a randomised trial, adding an anterior support screw reduced loss of reduction and early sliding. The optimal amount of sagittal reduction remains uncertain.
CONCLUSION
This development can be organised around reconstructing anteromedial cortical contact and visualising it during surgery. The remaining task is to visualise the anteromedial cortex reliably, define the optimal amount of contact, and test prospectively whether reconstruction improves radiographic and functional outcomes.