sdü tıp fak derg

Medical Journal of Süleyman Demirel University

2602-2109

Süleyman Demirel Üniversitesi

10.17343/sdutfd.1673603

Orthopaedics

Ortopedi

Comparative Study of Proximal Femoral Nailing in Trochanteric and Subtrochanteric Fractures with or Without Cerclage Cable Augmentation

https://orcid.org/0000-0002-6878-2243

Karapınar

Sefa Erdem

SULEYMAN DEMIREL UNIVERSITY, SCHOOL OF MEDICINE

https://orcid.org/0000-0001-9088-3940

Dinçer

Recep

SULEYMAN DEMIREL UNIVERSITY, SCHOOL OF MEDICINE

https://orcid.org/0000-0002-7437-4465

Ceylan

Devran

Aksehir State Hospital

12 01 2025

32 4 283 290 04 12 2025 09 10 2025

1994

Süleyman Demirel Üniversitesi Tıp Fakültesi Dergisi

Objective: This study aimed to examine the effect of the use of proximal femoral nail (PFN) and cable cerclage on the radiological and functional results and correlation with complications such as non-union and malunion, in cases of trochanteric and subtrochanteric femur fractures.Material and Method: The study included patients treated with PFN and/or cable cerclage because of closed, isolated spiral/oblique subtrochanteric and trochanteric fractures with a minimum follow-up period of 1 year. Patients were excluded if they had a pathological fracture, open fracture, any additional fracture, or if the epiphyseal line was open. The fractures were classified according to the AO/OTA classification. Bone union was evaluated on anteroposterior and lateral/oblique radiographs taken at postoperative 2, 4, 6, and 12 months. Functional evaluation was made according to the lower extremity functional scale and visual analog scale. Results: The time to union was a mean of 20 weeks (range, 16-28 weeks) for patients treated with PFN + cable and a mean of 17 weeks (range, 17-32 weeks) for the group treated with PFN alone. In the lower extremity functional evaluation scale, the mean score was 74 (range, 74-80) and the percentage was calculated as 93% (88-100%) in the study group, and the mean score was 55 (range, 20-74) and 56% (35-93%) in the control group. According to the Baumgartner et al criteria for radiological reduction quality evaluation, 33 patients were reported as good, 17 patients as acceptable, and 8 patients as poor. Radiological and clinical union was obtained within 6 months in 45 patients. Delayed union was determined in 1 patient in the study group and in 3 patients in the control group. Although the PFN-only group showed slightly faster union, this may reflect differences in age distribution or fracture complexity rather than treatment superiority. (Figure 1 shows a representative postoperative X-ray of a PFN with cerclage).Conclusion: The results of this study demonstrated that the use of PFN and cable cerclage is a reliable method in the treatment of trochanteric and subtrochanteric fractures, which increases fixation stability, allows early mobilisation and weight-bearing, and may provide improved functional outcomes. Surgical success and patient functionality will be increased with the additional use of cable cerclage in patients with a free unstable fracture where an acceptable closed reduction cannot be made.

cable cerclage pfn trochanteric fracture subtraochanteric fracture

1. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am. 2001;83(5):643-50.

2. Robinson CM, Houshian S, Khan LA. Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma. J Bone Joint Surg Am. 2005;87(10):2217-26.

3. Tomás J, Teixidor J, Batalla L, et al. Subtrochanteric fractures: Treatment with cerclage wire and long intramedullary nail. J Orthop Trauma. 2013 Jul;27(7):e157-60.

4. Kennedy MT, Mitra A, Hierlihy TG, et al. Subtrochanteric hip fractures treated with cerclage cables and long cephalomedullary nails: A review of 17 consecutive cases over 2 years. Injury. 2011 Nov;42(11):1317-21.

5. Lundy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg. 2007 Nov;15(11):663-71.

6. Browner D, Jüpiter J, Levine A, et al. Skeletal Trauma, V: 2. WB Saunders Company; 1996.

7. Lewinnek GE, Kelsey J, White AA, et al. The significance and a comparative analysis of the epidemiology of hip fractures. Clin Orthop Relat Res. 1980;(152):35-43.

8. Aksu N, Işıklar Z. Kalça kırıkları. TOTBİD (Türk Ortopedi ve Travmatoloji Birliği Derneği) Dergisi 2008;7(1-2):8-19.

9. Shukla S, Johnston P, Ahmad MA, et al. Outcome of traumatic subtrochanteric femoral fractures fixed using cephalo-medullary nails. Injury. 2007;38(11):1286-93.

10. Müller T, Topp T, Kühne CA, et al. The benefit of wire cerclage stabilisation of the medial hinge in intramedullary nailing for the treatment of subtrochanteric femoral fractures: A biomechanical study. Int Orthop. 2011;35(8):1237-43.

11. Perren SM, Fernandez Dell'Oca A, Lenz M,et al. Cerclage, evolution, and potential of a Cinderella technology. An overview with reference to periprosthetic fractures. Acta Chir Orthop Traumatol Cech. 2011;78(3):190-9.

12. Karayiannis P, James A. The impact of cerclage cabling on unstable intertrochanteric and subtrochanteric femoral fractures: A retrospective review of 465 patients. Eur J Trauma Emerg Surg. 2020;46(5):969-975.

13. Pazzaglia UE, Congiu T, Raspanti M, et al. Anatomy of the intracortical canal system: Scanning electron microscopy study in rabbit femur. Clin Orthop Relat Res. 2009;467(9):2446-56.

14. Aleto T, Ritter MA, Berend ME. Case report: Superficial femoral artery injury resulting from cerclage wiring during revision THA. Clin Orthop Relat Res. 2008;466(3):749-53.

15. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S1-133.

16. Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures. Clin Orthop Relat Res. 1998;(348):87-94.

17. Baumgaertner MR, Curtin SL, Lindskog DM, et al. 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(7):1058-64.

18. B Binkley JM, Stratford PW, Lott SA, et al. The Lower Extremity Functional Scale (LEFS): Scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys Ther. 1999;79(4):371-83.

19. McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: A critical review. Psychol Med. 1988 Nov;18(4):1007-19.

20. Gong J, Yang Y, Liu P, et al. PFNA with reduction assisted by a pointed clamp and cable cerclage for select subtrochanteric fractures of the femur. Int J Clin Exp Med. 2016;9(2):2961-2968.

21. Kim JW, Park KC, Oh JK, 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(9):1227-35.

22. Boopalan PR, Oh JK, Kim TY, et al. Incidence and radiologic outcome of intraoperative lateral wall fractures in OTA 31A1 and A2 fractures treated with cephalomedullary nailing. J Orthop Trauma. 2012;26(11):638-42.

23. Gupta RK, Sangwan K, Kamboj P, et al. Unstable trochanteric fractures: The role of lateral wall reconstruction. Int Orthop. 2010;34(1):125-9.

24. Afsari A, Liporace F, Lindvall E, Infante A Jr, Sagi HC, Haidukewych GJ. Clamp-assisted reduction of high subtrochanteric fractures of the femur. J Bone Joint Surg Am. 2009;91(8):1913-8.

25. Hoskins W, Bingham R, Joseph S, et al. Subtrochanteric fracture: The effect of cerclage wire on fracture reduction and outcome. Injury. 2015;46(10):1992-5.

26. Ban I, Birkelund L, Palm H, et al. Circumferential wires as a supplement to intramedullary nailing in unstable trochanteric hip fractures: 4 reoperations in 60 patients followed for 1 year. Acta Orthop. 2012;83(3):240-3.

27. Apivatthakakul T, Phaliphot J, Leuvitoonvechkit S. Percutaneous cerclage wiring, does it disrupt femoral blood supply? A cadaveric injection study. Injury. 2013;44(2):168-74.

28. Codesido P, Mejía A, Riego J, et al. Subtrochanteric fractures in elderly people treated with intramedullary fixation: Quality of life and complications following open reduction and cerclage wiring versus closed reduction. Arch Orthop Trauma Surg. 2017;137(8):1077-1085.

29. Wilson RJ volume JSB. The Blood Supply of Bone. An Approach to Bone Biology. 1972;54(1):208.

30. Steinberg EL, Shavit R. Braided cerclage wires: A biomechanical study. Injury. 2011;42(4):347-51.