G Model

JINJ 6987 No. of Pages 8

Injury, Int. J. Care Injured xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Wiring technique for lesser trochanter fixation in proximal IM nailing

of unstable intertrochanteric fractures: A modified candy-package
wiring technique$
Gyeong Min Kima , Kwang Woo Nama , Kyu-Bum Seoa , Chaemoon Lima , Jiyun Kimb ,
Yong-Geun Parka,*
a
Department of Orthopedic Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, South Korea
b
Jeju National University School of Medicine, Jeju, South Korea

A R T I C L E I N F O A B S T R A C T

Introduction: The purpose of this study was to introduce a new surgical technique, that involves modified
Keywords: Candy-package wiring followed by IM nailing fixation and to determine the clinical and radiological
Hip fracture
results obtained in patients with unstable intertrochanteric fractures with a lesser trochanter fragment.
Unstable intertrochanteric fracture
Materials and methods: This study included 22 patients who were undergone proximal IM nailing with
Lesser trochanter wire fixation
Intramedullary nail fixation lesser trochanter wiring between January 2014 to June 2015. All patients were treated with minimally
invasive technique of candy-package wiring for lesser trochanter fragments. The mean age was 75.8 years
(range, 53–88) and average follow-up period was 15.1 months (range, 12–24). Each patient was followed
up for a minimum of 12 months and their clinical and radiological results were analyzed.
Results: The mean period required for fracture union was 16.6 weeks. (range, 8–25) and union was
successfully completed in all cases. The WOMAC scores at the last F/U visit (average; 45.4, range; 21–75)
were not significantly different to pre-trauma status (average; 36.5, range; 19–59) (p = 0.087). In
comparison of ambulatory capacity prior to trauma, ambulatory aggravation was noted in four cases
(18.2%), and eighteen cases (81.8%) was sustained walking ability of prior of trauma. Wiring breakage was
found in two cases and heterotrophic ossification in one case. There were no functional deficeit related to
the radiologic finding in these patients. With regard to postoperative complications, were no cut-outs,
breakage, or pullout of screws.
Conclusion: When surgically repairing unstable intertrochanteric fractures with lesser trochanter
comminution using proximal IM nailing method, the modified Candy-packaging wiring technique
increases the fixation force at the fracture site. Thus, through this technique, both firm fixation of the
lesser trochanter and more stable bony union were obtained.
ã 2016 Elsevier Ltd. All rights reserved.

Introduction
Proximal intermedullary (IM) nails have overtaken the use of
sliding hip screws as treatment for intertorchanteric fractures due
to their advantages such as shorter opertation times and lack of
$
This study was approved by institutional review board of Jeju National
University Hospital (IRB file No.2016-08-004).
* Corresponding author at: Department of Orthopaedic Surgery, Jeju National
University Hospital, Jeju National University School of Medicine, Aran 13gil 15, Jeju-
si, Jeju Self-Governing Province, 63241, South Korea.
E-mail addresses: cellulosae@naver.com, pyk184@hanmail.net (Y.-G. Park).
soft tissue injuries surrounding the fracture site during the past
decade [1–4]. In unstable intertrochanteric fractures with commi-
nuted spicule of the lesser trochanter, using the IM nailing
technique may be difficult to obtain precise reduction due to its
inconvenience in fixating the lesser trochanter. There have been
reports that IM nail is not superior in such unstable intertrochan-
teric fractures [5,6], and the use of extrameduallary implants such
as a sliding hip srew are sometimes recommended in preference to
an IM nail in patients with trochanteric fractures above and
including the lesser trochanter [6].
Lee et al. [7,8] has reported on ‘Candy-package wiring
technique’ that provides posteromedial stability including the

http://dx.doi.org/10.1016/j.injury.2016.11.016
0020-1383/ã 2016 Elsevier Ltd. All rights reserved.

Please cite this article in press as: G.M. Kim, et al., Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable
intertrochanteric fractures: A modified candy-package wiring technique, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.11.016
G Model
JINJ 6987 No. of Pages 8

2 G.M. Kim et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx

Fig. 1. Candy-package wiring technique. Reduction of the fragment achieved using ring placed between the lesser trochanter fragment and the psoas muscle.

lesser trochanter in unstable intertrochanteric fractures (Fig. 1).
The technique showed to have secured a more stable poster-
omedial stability compared to existing techiques such a screw
fixation or circumferencial wiring. However, this technique is
applied during open reduction using compression hip screw plate
or arthroplasty, and may be difficult to apply during IM nailing
beause the goal of treatment mechanism does not coincide
(minimizes soft tissue damage) and is technically challanging.
The purpose of this study was to introduce a new surgical
technique, that involves modified Candy-package wiring followed
by IM nailing fixation and to determine the clinical and radiological
results obtained in patients with unstable intertrochanteric
fractures with a lesser trochanter fragment.
Materials and methods
A retrospective analysis was performed to identify the unstable
intertrochanter fracture treated operatively from January 2014 to
June 2015. Of these, the inclusion criteria for this study were the
followings: patients (1) who had unstable intertrochanter fracture
with lesser trochanter fracture, (2) who were treated with
proximal intramedullary nail and wiring technique, and (3) of
these, lesser trochanteric fractures were complete fractures with
more than 5 mm of displacement and large enough to apply wiring
technique. Exclusion criteria included patients who had previous
ipsilateral hip or femoral surgery, non-osteoporotic pathologic
fractures, and whose fracture reduced anatomically with closed
reduction, and also patients with comorbiding diseases with

Fig. 2. The Jensen modification of Evans classification. (A) type 1 – two part, Undisplaced, (B) type 2 – two part, displaced, (C) type 3 – three part, loss of posterolateral support,
(D) type 4 – three part, loss of medial support and (E) type 5 – four part.

Please cite this article in press as: G.M. Kim, et al., Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable
intertrochanteric fractures: A modified candy-package wiring technique, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.11.016
G Model
JINJ 6987 No. of Pages 8
G.M. Kim et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Fig. 3. Minimally invasive application of cerclage wires (Cerclage Passer, Synthes,
Oberdorf, Switzerland). (A) Dividable forcep – clamped (B) Diviable forcep –
opened.
severe perioperative risks including patients who had difficulty
with self-ambulation.
Throughout the study, a total of 109 patients underwent
operation for intertrochanteric fractures at our institution. Of these
patients, 57 were unstable intertrochateric fractures involving the
lesser trochanter. Among those patients, 35 patients showed good
reduction with proximal intramedullary nailing technique without
Fig. 4. Minimally invasive reduction technique using a Homann retractor. (A) Displaced intertrochanteric fracture. (B) Reduced fragment using a Homann retractor on
translateral image of C-arm intensifier.
Please cite this article in press as: G.M. Kim, et al., Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable
intertrochanteric fractures: A modified candy-package wiring technique, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.11.016
3
additional wiring around lesser trochanter. Ultimately 22 patients
were within the inclusion criteria. All patients were treated with
modified candy package wiring technique in regards to the lesser
trochanter fragment along with IM nailing fixation.
The patients included nine men and thirteen women with a
mean age of 75.8 years (range, 53–88). A right hip injury was
involved in 10 cases (46%) and a left hip in 12 cases (54%). Trauma
was associated with slip down in 14 cases (63.6%), traffic accidents
in 5 cases (22.7%) and falls in 3 cases (13.6%). Fifteen cases (68.2%)
had 31-A2 fractures and seven cases (31.8%) had 31-A3 fractures
according to the AO/OTA classification [9]. Eighteen cases (81.8%)
had type 4 fractures and five cases (18.2%) had type 5 fractures
according to the Jensen modification of Evans classification; type 1
(two part, Undisplaced), type 2 (two part, displaced), type 3 (three
part, loss of posterolateral support), type 4 (three part, loss of
medial support) and type 5 (four part) [10] (Fig. 2). All patients
were treated with proximal IM nail and wiring technique for lesser
trochanter fragment. The Zimmer Natural Nail (ZNN, Zimmer,
Winterthur, Switzerland) was used in thirteen patients and
proximal femoral nail anti-rotation (PFNA, Synthes, Oberdorf,
Switzerland) in nine patients. Of these, 6 patients were used long
length option of nail (long PFNA) due to the extended fracture at
subtrochanteric area. Mean surgical time was 96.2 min (range, 70–
120). The average follow-up (F/U) period was 15.1 months (range,
12–24).
Postoperative outcomes were assessed using radiological and
clinical evaluations. Radiological evaluations that included both
hip anteroposterior (AP), translateral and teleradiogram views
were performed in 4 weeks interval postoperatively until union
was observed, and 3 months, 6 months postoperatively thereafter.
Radiological assessment included three measurements: the
distance of the tip of the lag screw to the femoral head apex
(tip-apex distance, TAD) [11], the extent of screw sliding, femoral
neck-shaft angle, assessing fracture healing, and recording
complications such as intra-articular or lateral migration of
screws, cut-outs, fixation failures, implant-related fractures and
non-unions. In order to adjust for error due to the external rotation
of lower extremities between immediate post-operative and last F/
U radiologic findings, we measured the sliding distance of lag
screw and the varus change in the femoral neck shaft angle using
the method used by Doppelt [12]. Screw sliding was measured by
comparing the postoperative radiographs with the most recent
radiograph and was based on the changes in the relative length of
the unengaged part of the screw [13]. Radiographic union was
G Model
JINJ 6987 No. of Pages 8

4 G.M. Kim et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx

Fig. 5. Make a anterior knot of candy-package ring. (A) Place two wires using a cerclage passer. (B) Twist two wires anteriorly. Then pull the wires inferiorly.

defined as no pain at the fracture site with evidence of callus
formation on standard plain X-rays.
Clinical evaluations were assessed at the last F/U visit and
compared with pre-trauma status using the Western Ontario
McMaster Universities Index of Osteoarthritis (WOMAC) score [14]
to measure pain and function and ambulation capacity according
to the Clawson classification [15]. The Clawson classification was
categorized as class I (wheelchair ambulation), II (Cruch or two
cane), III (one cane or simple brace) or IV (self ambulation). The
statistical analysis was performed with the SPSS for Windows 18.0
software package (SPSS Inc, Chicago, IL). The Mann-Whitney test
was used to analyze the clinical score (WOMAC score) to compare
the difference between pre-trauma state and at the last F/U.
Surgical technique
A minimally invasive surgical technique of Candy-packaging
wiring using a cerclage passer (Fig. 3).
After positioning the patient in supine position on the fracture
operation table, reduce the fracture site through traction and
rotation. The state of reduction is checked under fluoroscopy on
the AP and translateral views. After closed reduction of fracture, 5–
6 cm incision is performed on the lateral side of the thigh (at the lag
screw insertion site below the greater trochanter). If the
characteristic deformities are present, reduction of the fracture
through a minimally invasive approach is performed prior to
wiring. The fascia lata is incised, and blunt dissection of the vastus
lateralis is performed until the fracture site is palpated. Then a
Homann retracter is used to reduce the fracture under fluoroscopy
control (Fig. 4). Place two wires, one each at the proximal and distal
portion of the lesser trochanter using a cerclage passer. Twist the
two wires anterior to the femur, then pull the two wires inferiorly,
fastening the anterior lasso portion on the lesser trochanter
(Fig. 5). Then, twist the two wires posterior to the femur, making a
candy-package like ring. The ring should be placed between the
lesser trochanter fragement and the psoas muscle so that when the
wires are pulled together, the placement of the fragment could be
adjusted. Reduce the fracture site as much as possible under C-arm
intensified imaging (Fig. 6). The two wires should be adjusted by
pulling inferolaterally in order to obtain an anatomical reduction
because the lesser trochanter fragements tends to be displaced
superomedially and antereiorly due to the effect of the psoas
muscle. Once the fracture site has been reduced as much as
possible, fixation is carried out using proximal IM nail. Firmly
fastening of wires winding the lesser trochanter to the proximal
femur is followed (Fig. 7).
Results
Bony union was achieved in all cases with average time of 16.6
weeks. (range, 8–25). Femoral neck angle was assessed with
postoperative radiographs. Average femoral neck was measured to
be 129.2 (range; 124–137) and which were maintained through-
out the F/U period. The average TAD was measured in AP as well as
translateral radiographs, with 9.9 mm (range, 5.0–15.1) and
12.7 mm (range, 7.3–17.6) respectively. Average distraction of
femoral lag screw was 3.6 mm (range, 1–11). Two patients showed

Please cite this article in press as: G.M. Kim, et al., Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable
intertrochanteric fractures: A modified candy-package wiring technique, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.11.016
G Model
JINJ 6987 No. of Pages 8

G.M. Kim et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx 5

Fig. 6. Make a posterior knot of candy-package ring. Thereafter, reduction of lesser trochanter fragment using candy-package ring. (A) AP and (B) translateral image of C-arm
intensifier.

limb length discrepancy of 1 cm, however, it was not significant as
to show any clinical symptoms such as limping.
As for the functional outcomes, WOMAC scores at the last F/U
visit (average; 45.4, range; 21–75) were not significantly different
to pre-trauma status (average; 36.5, range; 19–59) (p = 0.087). In
ambulation capacity values according to the Clawson classification,
thirteen cases showed class IV, six cases showed class III, and three
cases showed class II. In comparison of ambulatory capacity prior
to trauma, ambulatory aggravation was noted in four cases (18.2%),
and eighteen cases (81.8%) was sustained walking ability of prior of
trauma.
With regard to postoperative complications, were no cut-outs,
breakage, or pullout of screws. There were no reoperations in any
of the patients throughout the study. Wiring breakage was found in
two cases and heterotrophic ossification in one case. There were no
functional deficeit related to the radiologic finding in these
patients. Post-operative systemic complications were two cases of
pneumonia (13%) and one case of urinary tract infection (6%).
Discussion
Increase in life expectancy has led to an increase in the average
age for intertrochanteric fractures. Accordingly, many reduction
techniques and surgical methods have been developed to address
unstable and comminuted osteoporotic fractures. Evans [16]
reported unstable fractures involving the lesser trochanter with
a larger posterolateral fragment and comminuted greater
trochanter fragement consititue approximately 30% of all inter-
trochanteric fractures. When treating unstable intertrochanteric
femur fractures, even the use of compression screws can result in
fracture site collapse due to poor bone quality and posterolateral
cortical bone instability. This may lead to major complications such
as loss of reduction, penetration of femoral head, and varus
deformity of hip joint [5,17,18].
Techniques using trochanter stablilizing plates have been
reported in order to reduce these problems by preventing
excessive impaction, rotational and angular distortion [19,20].
Intramedullary nail usage has increased with more benefits of
intrameduallary fixation devices have been highlighted [3]. Also,
there has been progress in intra meduallary devices with the
development of antirotation lag screws used to prevent the
rotation of bone fragments [21]. However, failure to obtain an exact
reduction or lag screw placement, complications such as cut-out or
Z-effect may occur [22]. The more unstable the fracture, the
difficulty of reduction leading to reduction failure will ultimately
lead to a higher rate of complications, especially two- (AO/OTA 31-
A1) and three-part (AO/OTA 31-A2.1) fractures [23]. In order to
resolve the unstablity in unstable intertrochanteric femur fractures
due to the greater trochanteric fragment instablility and to secure a
more stable reduction, Jones [24] suggested a screw transfixtation
method of the lesser trochanteric fragment while Den Hartog et al.
[25] suggested re-establishing contact of the internal cortex of the
fracture site.

Please cite this article in press as: G.M. Kim, et al., Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable
intertrochanteric fractures: A modified candy-package wiring technique, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.11.016
G Model
JINJ 6987 No. of Pages 8

6 G.M. Kim et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx

Fig. 7. Complete a candy-package wiring after IM nail fixation of fracture site. (A) IM nail fixation and (B) fastening of candy packaging ring under C-arm intensifier.

Lee et al. [8] introduced a ‘candy-packaging wiring techinque’
method for lesser trochanteric fixation including the posterolateral
fragment with good clinical results in treating unstable inter-
trochanteric fractures. The Candy-package wiring technique
involves surrounding the psoas muscle insertion site of the lesser
trochanter without compromising the cortex of the lesser
trochanter and the risk of wire displacement and iatrogenic
fractures. Hence, this method allows an easier anatomical
reduction with equivalent fixation strength compared to existing
techniques without the need to create a drill hole. However, this
technique involves open reduction that could prove to be difficult
to apply to surgical techinques that involve IM nailing. The authors
modified Lee et al.’s technique to a minimally invasive technique
that simultaneously involves the candy-package wiring method
whilst using IM nailing to address the intertrochanteric fracture.
This provided effective fixation of the posteromedial fragment so
that stability of the posterolateral cortex was achieved to allow
early ambulation by recovering normal anatomical structure while
reducing claudication and pain [7]. We suggest that the poster-
omedial stability provided the lost support in an unstable fracture
and ultimately resulted in bone union in all patients without
complication such as lag screw sliding and cut-out. Also, in our
experience, it seems that the preservation of the psoas muscle
fuction allowed for clinical function restoration in most cases,
although they were fractures of elderly population (Fig. 8).
Especially, all but one patient in this study showed less than
1 cm of lag screw sliding and in our opinion, this was due to the
stable fixation of firm posterolateral support preventing head-neck
fragment sliding.
Although a recent prospective randomised study failed to show
superiority in using a long IM nail over a sliding hip screw in
unstable intertrochanteric fractures [26], the technique we
introduced could provide promising results using a IM nailing
fixation in unstable intertrochanteric fractures. Wiring breakages
and heterotrophic ossification were found in some patients but
these were not major complications effecting clinical outcomes.
There were systemic complications such as infection (pneumonia,
urinary tract infection) but were successfully treated through early
ambulation and antibiotic treatment. In some patients, this
technique resulted in a less precise reduction compared to the
existing anatomical reduction techniques through open reduction.
However, the minimal invasive nature of this technique minimized
soft tissue damage so that a certain degree of reduction loss did not
affect bone union process and psoas muscle fuction preservation
(Fig. 9). This study revealed that the post-operative results are
slightly less than that of pre-trauma functional level. However,
considering the poor post-operative results of unstable intertro-
chanteric fracture patients, our patients showed good results.
Despite good results, our study also has some limitations. One
of limitation of our study is the small number of cases, due to the
low incidence of these unstable fractures with lesser trochanter
fragment. Another limitation is that the following study is
retrospective study without a control group, that is, our results
need further confirmation from large comparative series.

Please cite this article in press as: G.M. Kim, et al., Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable
intertrochanteric fractures: A modified candy-package wiring technique, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.11.016
G Model
JINJ 6987 No. of Pages 8
G.M. Kim et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Fig. 8. Patient #8 (A) Preoperative radiograph of both hip AP radiograph shows
unstable intertrochanteric fracture with lesser trochanter fragment (the AO/OTA
classification type 31–42 and Evans classification type 4). (B) Both hip AP
radiograph at the 12 months postoperatively. We applied proximal IM nail fixation
and modified candy-package wiring technique.
Conclusion
When surgically repairing unstable intertrochanteric fractures
with lesser trochanter comminution using proximal IM nailing
method, the modified Candy-package wiring technique increases
the fixation force at the fracture site. Thus, through this technique,
both firm fixation of the lesser trochanter and more stable bony
union were obtained. To recover a posteromedial stability of
intertrochanter area and to provide fixation to the fracture site, this
operative method is more than capable of being a therapeutic
option for an unstable intertrochanter fracture.
Conflict of interest statement
All four authors declare that they have no financial interest or
personal relationship with organizations or institutes other than
their mentioned affiliations.
Please cite this article in press as: G.M. Kim, et al., Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable
intertrochanteric fractures: A modified candy-package wiring technique, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.11.016
7
Fig. 9. Patient #3 (A) Immediate post-operative x-ray image with less precise
fragment reduction. (B) Postoperative radiograph after 12 months showed bone
union with intact psoas muscle function.
References
[1] Anglen JO, Weinstein JN. American board of orthopaedic surgery research C.
Nail or plate fixation of intertrochanteric hip fractures: changing pattern of
practice. A review of the American board of orthopaedic surgery database. J
Bone Joint Surg Am 2008;90:700–7.
[2] D’Arrigo C, Carcangiu A, Perugia D, Scapellato S, Alonzo R, Frontini S, et al.
Intertrochanteric fractures: comparison between two different locking nails.
Int Orthop 2012;36:2545–51.
[3] Forte ML, Virnig BA, Kane RL, Durham S, Bhandari M, Feldman R, et al.
Geographic variation in device use for intertrochanteric hip fractures. J Bone
Joint Surg Am 2008;90:691–9.
[4] Huang Y, Zhang C, Luo Y. A comparative biomechanical study of proximal
femoral nail (InterTAN) and proximal femoral nail antirotation for
intertrochanteric fractures. Int Orthop 2013;37:2465–73.
[5] Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary
nails versus extramedullary implants for extracapsular hip fractures in adults.
Cochrane Database Syst Rev 2008;CD000093.
[6] Ftouh S, Morga A, Swift C. Guideline development G. Management of hip
fracture in adults: summary of NICE guidance. BMJ 2011;342:d3304.
[7] Lee J, Kim K. Treatment of unstable trochanteric fracture using sliding hip
screw with wiring of lesser trochanter. J Korean Orthop Assoc 2000;35:861–6.
[8] Lee J, Lee J, Lee C, Kim H. New wiring method for lesser trochanter fixation in
unstable intertrochanteric fractures – technical note. J Korean Fract Soc
2005;18:209–12.
G Model
JINJ 6987 No. of Pages 8
8 G.M. Kim et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
[9] Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, et al. Fracture
and dislocation classification compendium – 2007: orthopaedic trauma
association classification, database and outcomes committee. J Orthop Trauma
2007;21:S1–133.
[10] Jensen JS, Michaelsen M. Trochanteric femoral fractures treated with
McLaughlin osteosynthesis. Acta Orthop Scand 1975;46:795–803.
[11] Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex
distance in predicting failure of fixation of peritrochanteric fractures of the hip.
J Bone Joint Surg Am 1995;77:1058–64.
[12] Doppelt SH. The sliding compression screw–today’s best answer for
stabilization of intertrochanteric hip fractures. Orthop Clin North Am
1980;11:507–23.
[13] Hardy DC, Descamps PY, Krallis P, Fabeck L, Smets P, Bertens CL, et al. Use of an
intramedullary hip-screw compared with a compression hip-screw with a
plate for intertrochanteric femoral fractures. A prospective, randomized study
of one hundred patients. J Bone Joint Surg Am 1998;80:618–30.
[14] Theiler R, Spielberger J, Bischoff HA, Bellamy N, Huber J, Kroesen S. Clinical
evaluation of the WOMAC 3.0 OA index in numeric rating scale format using a
computerized touch screen version. Osteoarthr Cartil 2002;10:479–81.
[15] Clawson DK. Intertrochanteric fracture of the hip. Am J Surg 1957;93:580–7.
[16] Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint
Surg Br 1949;31B:190–203.
[17] Jacobs RR, McClain O, Armstrong HJ. Internal fixation of intertrochanteric hip
fractures: a clinical and biomechanical study. Clin Orthop Relat Res 1980;62–
70.
[18] Rha J, Kim Y, Yoon S, Kang J, Park Y. Fixation failure in the treatment of
intertrochanteric fracture of the femur with compression hip screw. J Korean
Orthop Assoc 1991;26:1703–12.
Please cite this article in press as: G.M. Kim, et al., Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable
intertrochanteric fractures: A modified candy-package wiring technique, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.11.016
[19] Babst R, Renner N, Biedermann M, Rosso R, Heberer M, Harder F, et al. Clinical
results using the trochanter stabilizing plate (TSP): the modular extension of
the dynamic hip screw (DHS) for internal fixation of selected unstable
intertrochanteric fractures. J Orthop Trauma 1998;12:392–9.
[20] Madsen JE, Naess L, Aune AK, Alho A, Ekeland A, Stromsoe K. Dynamic hip
screw with trochanteric stabilizing plate in the treatment of unstable proximal
femoral fractures: a comparative study with the gamma nail and compression
hip screw. J Orthop Trauma 1998;12:241–8.
[21] Tyllianakis M, Panagopoulos A, Papadopoulos A, Papasimos S, Mousafiris K.
Treatment of extracapsular hip fractures with the proximal femoral nail (PFN):
long term results in 45 patients. Acta Orthop Belg 2004;70:444–54.
[22] Windolf J, Hollander DA, Hakimi M, Linhart W. Pitfalls and complications in the
use of the proximal femoral nail. Langenbecks Arch Surg 2005;390:59–65.
[23] Aktselis I, Kokoroghiannis C, Fragkomichalos E, Koundis G, Deligeorgis A,
Daskalakis E, et al. Prospective randomised controlled trial of an
intramedullary nail versus a sliding hip screw for intertrochanteric fractures of
the femur. Int Orthop 2014;38:155–61.
[24] Jones JB. Screw fixation of the lesser trochanteric fragment. Clin Orthop Relat
Res 1977;107.
[25] Den Hartog BD, Bartal E, Cooke F. Treatment of the unstable intertrochanteric
fracture. Effect of the placement of the screw, its angle of insertion, and
osteotomy. J Bone Joint Surg Am 1991;73:726–33.
[26] Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. A
comparison of the long gamma nail with the sliding hip screw for the
treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a
prospective randomized trial. J Bone Joint Surg Am 2010;92:792–8.