International Orthopaedics (SICOT)
DOI 10.1007/s00264-017-3623-y
ORIGINAL PAPER
Anteromedial cortical support reduction in unstable
pertrochanteric fractures: a comparison of intra-operative
fluoroscopy and post-operative three dimensional
computerised tomography reconstruction
Shi-Min Chang 1 & Ying-Qi Zhang 2 & Shou-Chao Du 1 & Zhuo Ma 1 & Sun-Jun Hu 1 &
Xi-Zhou Yao 1 & Wen-Feng Xiong 1
Received: 2 May 2017 / Accepted: 15 August 2017
# SICOT aisbl 2017
Abstract
Purpose Anteromedial cortical support reduction is
favourable for secondary stability after limited sliding in un-
stable pertrochanteric fractures. The aim of this study was to
compare the accuracy and agreement between intra-operative
fluoroscopy and post-operative 3D reconstruction.
Materials and methods A retrospective analysis of 28 patients
(mean 81.6 years) treated with short cephalomedullary nails
was performed. All patients had full sets of intra-operative
fluoroscopy and post-operative 3D CT images. Observation
was focused on the position of the anteromedial cortices of the
inferior corner between the head-neck fragment and femoral
shaft, and their relationship was categorised into three types:
positive, neutral and negative. The percentage of subsequent
changes in cortical reduction quality between fluoroscopy and
3D CT was calculated and compared.
Results There were 24 positive (85.7%), four neutral and no
negative positions in the anteroposterior (AP) view and one
positive, 20 neutral (71.4%) and seven negative positions in
the lateral view from fluoroscopy. On post-operative 3D CT
images with a full range of rotation, definitive anteromedial
cortical contact (positive and neutral support) was observed in
18 cases (64.3%). Ten cases lost the anteromedial cortical
buttress. With the posteromedial region of the lesser trochanter
* Shi-Min Chang
shiminchang11@aliyun.com
1
The Department of Orthopaedic Surgery, Yangpu Hospital, Tongji
University School of Medicine, 450 Tengyue Road,
Shanghai 200090, People’s Republic of China
2
Department of Orthopaedic Surgery, Tongji Hospital, Tongji
University School of Medicine, Shanghai 200065, People’s Republic
of China
detached, a positive AP cortical position combined with a
positive/neutral lateral position on fluoroscopy (17 cases)
was highly predictive of reliable, definitive cortical support
(15 cases, 88.2%) on 3D CT. A negative lateral position on
fluoroscopy (seven cases), regardless of the combination in
the AP view, was likely to predict the final loss of cortical
support (six cases, 85.7%) on 3D CT; a positive/neutral lateral
position (21 cases) was only associated with loss of support in
four cases (19.1%) (p < 0.05).
Conclusions A lateral negative position of the anterior cortex
on fluoroscopy for unstable pertrochanteric fractures may be
highly predictive of post-operative final loss of the anteromedial
cortical buttress, which should be avoided during operation.
Keywords Pertrochanteric fracture . Fracture reduction .
Cortical support reduction . Medial cortex . Anterior cortex .
Secondary stability . Cephalomedullary nail . Telescoping .
Sliding
Introduction
Geriatric hip fractures continue to increase in frequency as the
population ages, and per/intertrochanteric femur fractures are
a significant proportion of these injuries, which continues to
be a challenge for orthopaedic trauma surgeons in daily
practice [1]. Surgical treatment is recommended for pain relief
and getting patients off of bed rest as early as possible, and
more and more surgeons prefer to use intramedullary nails for
the fixation of unstable fractures [2]. For the stability of
reconstructions after fracture fixation, five influencing factors
have been summarised, i.e. bone quality, fragment geometry,
fracture reduction quality, implant selection and implant
placement(TAD/CalTAD) [3]. However, adequate fracture
 International Orthopaedics (SICOT)

reduction is always of greater importance than the other

factors.
Anteromedial cortex-to-cortex support reduction was
first introduced in 2015 by Chang et al. for unstable
pertrochanteric fractures [4]. It involves a pattern of functional
buttress reduction and is specific for the proximal femur as it
relates to the neck-shaft angle in the alignment, and various
implant devices with sliding mechanisms are used for fixation.
Controlled fracture impaction via limited telescoping provides
secondary axial and torsional stability between the head-neck
fragment and the shaft of the femur [5]. Cortex-to-cortex
support reduction is a key element for the stable reconstruction
of unstable fractures as it allows limited sliding along the
lag screw/helical blade axis to provide a good mechanical
environment for fracture healing and better clinical outcomes
[4].
Anteromedial cortical support reduction is classified into
three types according to the interrelation between the
components, i.e. positive, neutral and negative. Reduction is
assessed intra-operatively via fluoroscopy and immediately
post-operatively via radiography and 3D CT reconstruction.
The aim of this study was to compare the accuracy and agree-
ment between intra-operative fluoroscopy and post-operative
3D reconstruction, and it attempted to determine which
patterns did and did not predict final cortical contact.

Fig. 1 Schematic drawing to show the positive, neutral and negative

pattern in AP view for medial cortical reduction (a), and in lateral view
The concept of cortical support reduction patterns for anterior cortical reduction (b)

A full description of anteromedial cortical support reduction,

or cortex-to-cortex contact, involves assessment in both the
anteroposterior (AP) view (for the medial cortex) and the
lateral view (for the anterior cortex), with an emphasis on
the inferior anteromedial corner. The relationship between
the femoral head-neck fragment and the shaft, which describes
the position of their cortical layers or the trend in their change
in position after sliding along the implant axis (usually 130
degrees), was evaluated and classified into three categories
(positive, neutral and negative) for both medial and anterior
displacement (Fig. 1, a & b).
In the AP view, the relationship between the two medial
cortices of the head-neck and shaft fragments was evaluated
after oblique, lateral sliding. If the medial cortex of the head-
neck fragment was located slightly (one cortical thickness,
or 4-5 mm) superomedial to the upper medial edge of the
femoral shaft, it was classified as a positive position of medial
cortical support. If the medial cortex of the head-neck
fragment smoothly contacted the medial cortex of the femoral
shaft, it was classified as a neutral position. If the medial
cortex of the head-neck fragment was displaced laterally to
the upper medial edge of the shaft fragment, it was classified
as a negative position, which meant that there was a
malreduction, and the medial cortical buttress from the femo-
ral shaft had been lost.
In the lateral view, the relationship between the two anterior
cortices of the head-neck and shaft fragments was assessed
after parallel sliding. If the anterior cortices made a smooth
contact or if the step-off (neck was shifted anterior or posteri-
or) was less than half of the cortical thickness, or 2 mm, it was
classified as a neutral position for anterior cortical support. If
the head-neck cortex was anteriorly displaced more than half
of the cortical thickness, or 2 mm, it was classified as positive,
and if it was posteriorly displaced by more than half of the
cortical thickness, or 2 mm, it was classified as negative.
Cortex-to-cortex support reduction is a functional nonana-
tomic buttress reduction. It differs from the exact anatomic
reduction of the anteromedial cortex. A positive cortical
support reduction pattern is easy to obtain in practice for
unstable fracture patterns and is used to achieve secondary
stability, while anatomic reduction is difficult to obtain and
is used to achieve primary fracture stability.
In a medial positive cortical support pattern, the cortical
contact between the two main fragments is achieved;
meanwhile, the medial cortex of the femoral shaft can prevent
International Orthopaedics (SICOT)

further lateral sliding of the femoral head-neck fragment.

Anterior cortical contact after head-neck sliding can also pro-
vide a rigid buttress for secondary stability. However,
considering the nature of the lateral sliding of the head-neck
fragment, medial cortical support maybe more effective than
anterior cortical contact. In addition, obtaining both medial
and anterior cortical support (anteromedial reduction) is the
best option for fracture reduction.

Patients and methods

Over a oneyear period from November 2015 to October 2016,

we operated on 92 patients using a short cephalomedullary nail
to treat unstable geriatric pertrochanteric hip fractures. The op-
erations were carried out on a fracture traction table. Intra-op-
eratively, fluoroscopy was used to assess fracture reduction and
implant position (Fig. 2, a & b). In our practice, as a rule, we do
not use full-length nails to treat unstable 31A2 pertrochanteric
fractures because long nails are much more expensive than
short ones. Full-length nails (inserted at the femoral condyle
level) are used only for subtrochanteric fractures.
Post-operatively, radiography was performed for all
patients before discharge. However, as post-operative lateral
radiography often did not meet the standard criteria, some
patients were further evaluated with CT scanning post-
operatively (<1 week). The images from 3D CT reconstruc-
tion were considered to be accurate and the gold standard for
these assessments because they can be rotated 360 degrees to
provide a full range of view of the relationship between the
head-neck and shaft fragments (Fig. 3, a & b).
After Institutional Review Board approval (No. 2017- Fig. 3 Three-dimensional CT reconstruction image can be rotated to
ZRKX-013) and a thorough retrospective review, 28 patients have the best view for evaluation whether the anteromedial cortices are
with both full intra-operative fluoroscopy and post-operative contact or not (a: yes, b: no)
CT images were enrolled in the study. There were seven males
and 21 females, with an average age of 81.6 years (60-101). cases of A2.3 fractures. All patients had their fractures fixed
AO/OTA classification revealed ten cases of A2.2 and 18 with a newly designed short, curved cephalomedullary nail

Fig. 2 Fluoroscopy shows (a)

positive medial cortical support
reduction pattern in AP view, and
(b) neutral anterior cortical
support reduction pattern in
lateral view

(proximal diameter = 16.5 mm, distal diameter = 9/10 mm,
total length = 195 mm, distal segment radius = 120 cm; Wego
Orthopaedics Co. Ltd., China).
Together, four orthopaedic surgeons (attending and
fellows) reviewed the final intra-operative AP and lateral fluo-
roscopic images and post-operative CT images with 3D recon-
struction, focusing on the relationship of the anteromedial
cortices of the inferior corner between the head-neck fragment
and femoral shaft. If a disagreement was encountered, a final
agreement was achieved via discussion.
The percentage of change in cortical reduction quality be-
tween fluoroscopic images and 3D CT reconstructions was
calculated and compared. Fisher’s exact test was used for
comparisons. Statistical significance was defined as p < 0.05.
Results
In the intra-operative fluoroscopic images, there were 24
positive (85.7%), four neutral and no negative positions in
the AP view and one positive, 20 neutral (71.4%) and seven
negative positions in the lateral view. In post-operative 3D CT
reconstructions with a full range of image rotation, true
anteromedial cortical contact (positive and neutral support)
was observed in 18 cases (64.3%). Ten cases had no
anteromedial cortical buttress. Detailed results are shown in
Table 1.
There were five combination patterns of AP and lateral
cortical positions in our case series. If a positive AP cortical
position was combined with a positive/neutral lateral cortical
position seen on intra-operative fluoroscopy (17 cases), it was
highly predictive of a reliable, definitive cortical support, as
demonstrated by 3D CT reconstruction (15 cases, 88.2%). If a
negative lateral position was seen on intra-operative fluoros-
copy (seven cases), regardless of the AP view, it was generally
predictive of a final loss of cortical support, as demonstrated
by 3D CT (six cases, 85.7%). In contrast, a positive/neutral
lateral position (21 cases) was associated with the loss of
cortical contact in only four cases (19.1%). Fisher’s exact test
showed a significant difference (p < 0.05), and this was an
independent predictive factor.
Table 1 Changes in
anteromedial cortical contact Intra-op fluoroscopy
between intra-op fluoroscopy and
post-op 3D CT AP view Lat view No. of cases
positive positive 1 1, (100%)
positive neutral 16
positive negative 5 1, (25%)
neutral neutral 4 2, (50%)
neutral negative 2 0, (100%)
Total: 28
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Discussion
During the past decades, tremendous progress has been made
in the treatment of per/intertrochanteric fractures in geriatric
patients. Modern cephalomedullary nailing is minimally
invasive and provides a high degree of stability, allowing for
immediate weight bearing in most cases. Current proximal
femoral nails are designed to preserve the neck-shaft angle
and prevent implant perforation due to superior cut-out or
central cut-through [6]. They also allow for controlled
telescoping with fracture impaction to provide secondary
stability. Despite these achievements, complication rates are
still high in these common types of fractures, which may result
in devastating consequences for the patients [7–9].
Kaufer [3] noted that stability after fracture fixation is
determined by five principal factors, i.e. bone quality
(osteoporosis), fragment geometry (comminution), fracture
reduction quality, implant selection and implant placement
(TAD/Cal-TAD) [10, 11]. In operations on unstable
pertrochanteric fractures (AO/OTA type 31A2), the quality
of fracture reduction is of paramount importance. Good
reduction quality not only results in primary fracture stability
but also provides favourable conditions for the following
implant placement. Although reduction at the posteromedial
lesser trochanter is the key to a successful reduction, most
implants used today do not have the ability to attach to this
fragment [12, 13]. Therefore, Garden alignments and
anteromedial cortical contact between the femoral head-neck
and shaft fragments are extremely important [14].
In the elliptically fractured surface of pertrochanteric frac-
tures, the oblique diameter of the femoral neck is much small-
er than that of the trochanter. Furthermore, the posterior wall
(greater trochanter crest) and posteromedial wall (lesser tro-
chanter) are detached in A2 fracture patterns, leaving only the
anterior and the remnant partial medial wall for use in the
reduction to achieve cortical contact to support the head-
neck fragment [15, 16].
In these operations, the insertion of a cephalomedullary
nail between the head-neck and femoral shaft from the medial
edge of the greater trochanteric creates pressure on both sides,
i.e. the lateral trochanteric wall and the superomedial femoral
Post-op 3D CT
True cortical contact no. (%) Loss of cortical contact no. (%)
0, (0%)
14, (87.5%) 2, (12.5%)
4, (80%)
2, (50%)
2, (100%)
18, (64.3%) 10, (35.7%)
International Orthopaedics (SICOT)
neck cortex. This Bopen effect^ makes it easy to obtain a
positive medial cortical support reduction pattern observable
via intra-operative fluoroscopy [4]. However, obtaining ante-
rior cortical support is not so easy [17–19], possibly because
of the restriction of the strong iliofemoral ligament, which
prevents anterior displacement of the femoral neck [20].
After fracture reduction and fixation, the movement of the
head-neck fragment is mostly controlled to slide in an axial
direction along the implant (helical blade or lag screw) to the
lateral side. However, other directions of movements, such
as tilting (anterior/posterior and valgus/varus, often in the
posterior and varus direction) and rotation (clockwise/anti-
clockwise) are also possible, especially in patients with severe
osteoporosis with low degrees of implant-bone purchase.
Several factors may affect the final results of whether
cortical contact is obtained. The first is the ability of the
head-neck fragment to slide. In a biomechanical study, Loch
et al. [21] demonstrated that the resistance to initiating head-
neck sliding with intramedullary nails is approximately three
times higher than that with side-plate barrels. Devices with a
shorter oblique barrel (shorter bearing surface) required higher
loads to initiate sliding than did devices with a longer barrel.
The second factor is the direction of sliding of the head-neck
fragment. Most implants allow oblique telescoping along the
axis of the helical blade/lag screw, usually 130 degrees relative
to the femoral shaft. However, a short migration of the helical
blade/lag screw in the femoral head in the anterosuperior di-
rection and axial-central direction is possible in osteoporotic
patients, and complications such as cut-out or cut-through can
occur. The third factor is the space between the neck and shaft
after fracture reduction and fixation. The distance between the
two cortices should preferably be no greater than one cortical
thickness, or 4-5 mm, to avoid over-telescoping. The fourth
factor is head-neck rotation during subsequent sliding.
Torsional malalignment was reported in 25.7% subjects, with
a mean torsional malalignment angle of 20.7° (range, −31.2°
to 27.1°) [22]. For example, the flexed rotation of the head-
neck fragment may lead the anteromedial-inferior cortical
spike to move to an anterior position, which is favourable
for cortical contact, and an extended rotation of the head-
neck fragment may result in the cortical spike having a poste-
rior position. As the detached and displaced posteromedial
lesser trochanter is neither reduced nor fixed, head-neck pos-
terior rotation will likely lead to a loss of anteromedial cortical
contact. The fifth factor is head-neck tilting during sliding.
Varus tilting is usually accompanied with a loss of the medial
cortical buttress, and posterior shifting is accompanied with a
loss of anterior cortical contact.
Our results showed that a positive AP cortical position
combined with positive/neutral lateral cortical position
seen on intra-operative fluoroscopy is a reliable predictor
for final cortical support, as demonstrated by 3D CT
reconstruction. A negative cortical position in the lateral view
from intra-operative fluoroscopy, regardless of what is shown
in the AP view, is highly predictive of a loss of cortical contact
because the posteromedial lesser trochanter had been
detached. Posterior sag of the head-neck fragment is not
acceptable, as it indicates malreduction of the fracture.
Neutral positions in both the AP and lateral views on fluoros-
copy are acceptable, but they do not indicate anatomic reduc-
tion. In reality, exact anatomic reduction of the anteromedial
cortex is rare. Accurate differentiation of cortical reduction
depends on the surgeon’s experience, pixel resolution and
clarity of the image intensifier. The so-called Banatomic
reduction^ shown on intra-operative fluoroscopy may actually
include three sub-conditions: 1) an exact anatomic cortex-to-
cortex position, 2) a slightly positive position or 3) a slightly
negative position [4]. However, as intra-operative fluoroscop-
ic image resolution is limited, 2-mm cortical steps may not be
identifiable. Therefore, those three sub-conditions are
generally not able to be clearly distinguished. We therefore
used the term Bneutral^ instead of Banatomic^. After sliding,
a slight negative position might become a truly negative
pattern post-operation.
Our experience showed that a slightly open position with a
space of one cortical thickness, or 4-5 mm, is preferable as
positive medial cortical support can be maintained after sub-
sequent sliding, and secondary stability is achieved via medial
cortex-to-cortex contact between the femoral neck and shaft.
If a cortex-to-cortex buttress is not obtained, the head-neck
fragment will slide further until it contacts the intramedullary
nail, which gives it lateral support [23].
The forces caused by weight-bearing on the femoral head
are transmitted to the femoral shaft by three points through
direct bone contact and the bone-implant construct: (1) the
implant in the femoral head, (2) the superolateral corner be-
tween the neck and later trochanteric wall and (3) the
anteromedial corner between the neck and shaft cortices.
Post-operatively, if the anterior and/or medial cortex at the
inferior corner is in contact directly after secondary sliding,
it can share the load with the implant, and the whole construct
is in a highly stable pattern for immediate weight-bearing. If
the antero/medial cortex at the inferior corner is not in contact
after secondary sliding, bone-implant construct stability is
decreased, and the transmitted head-neck forces will be taken
fully by the bone-implant surface, which leads to a femoral
neck shortening and neck-shaft angle reduction and predicts a
lower functional outcome and a high complication rate [4, 9].
There are limitations of the current study. Firstly, the study
only compares the results between intra-operative fluoroscopy
and post-operative CT images, without clinical outcomes of
patient follow-up. Secondly, the sample is small. We limit
post-operative CT application only for those patients who do
not have standard radiographs, usually the lateral view.
Thirdly, the current classification of anteromedial cortices
(positive, neutral and negative) is descriptive, which highly

Fig. 4 Digital simulation of anteromedial cortex displacement and
subsequent sliding after cephalomedullary nailing in unstable
pertrochanteric fractures
relies on the subjective judgement of radiologists. Further stud-
ies such as using 3D CT digital simulation of anteromedial
cortex displacement and subsequent sliding may provide a
quantitative measurement based categorization (Fig. 4).
In conclusion, for unstable pertrochanteric hip fractures with
the lesser trochanter detached (31A2.2 and A2.3), anteromedial
cortical support reduction is a functional nonanatomic buttress
reduction, which is favourable for achieving secondary stabil-
ity after limited sliding. In intra-operative fluoroscopy exami-
nations, combinations of both positive/positive and positive/
neutral patterns are reliable for predicting final and definitive
cortical support, but a negative cortical position of anterior
cortex on a lateral view (head-neck posterior sag) is highly
predictive of post-operative loss of anteromedial cortical
contact, which should be avoided during operation.
Funding The study was supported by funding from Shanghai
Municipal Science Committee (No. 14411971900) and national Nature
Science Foundation of China (NSFC No.81772323).
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval The study was approved by Institutional Review
Board of Yangpu Hospital, Tongji University, No. 2016012.
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