Liu et al.

BMC Musculoskeletal Disorders (2020) 21:573

https://doi.org/10.1186/s12891-020-03593-8

REVIEW Open Access

Revision surgery due to failed internal

fixation of intertrochanteric femoral
fracture: current state-of-the-art
Pei Liu, Dongxu Jin, Changqing Zhang* and Youshui Gao*

Abstract
Failed treatment of intertrochanteric (IT) femoral fractures leads to remarkable disability and pain, and revision
surgery is frequently accompanied by higher complication and reoperation rates than primary internal fixation or
primary hip arthroplasty. There is an urgent need to establish a profound strategy for the effective surgical
management of these fragile patients. Salvage options are determined according to patient physiological age,
functional level, life expectancy, nonunion anatomical site, fracture pattern, remaining bone quality, bone stock, and
hip joint competency. In physiologically young patients, care should be taken to preserve the vitality of the femoral
head with salvage internal fixation; however, for the elderly population, conversion arthroplasty can result in early
weight bearing and ambulation and eliminates the risks of delayed fracture healing. Technical challenges include a
difficult surgical exposure, removal of broken implants, deformity correction, critical bone defects, poor bone
quality, high perioperative fracture risk, and prolonged immobilization. Overall, the salvage of failed internal fixations
of IT fractures with properly selected implants and profound techniques can lead to the formulation of valuable
surgical strategies and provide patients with satisfactory clinical outcomes.
Keywords: Intertrochanteric femoral fracture, Hip fracture, Revision surgery, Failed fracture fixation, Salvage internal
fixation

Background affect the vital prognosis of these fragile patients, thereby

Intertrochanteric (IT) fractures are common, accounting necessitating effective surgical intervention [10]. Surgery
for almost half of all hip fractures and resulting in a indications include implant failure, nonunion, malunion,
great burden on orthopedic services [1–3]. Although fracture, dislocation, femoral head necrosis, posttrau-
most IT fractures can be treated successfully with con- matic arthritis and infection [4, 11, 12]. Salvage osteo-
temporary surgical techniques and internal fixations synthesis and conversion hip arthroplasty remain the
such as intramedullary nails and sliding hip screws, clin- mainstays of treatment for the failed internal fixation of
ical failures still occasionally occur, with reported data IT fractures rather than conservative, nonoperative ther-
indicating a range from 0.5 to 56% depending on the apy, which is limited to incredibly infirm patients [13].
fracture type, patient status, and quality of the reduction Several technical hurdles emerge in this situation, in-
and fixation [4–9]. Failed treatment of IT fractures leads cluding residual bone deformity, distorted soft tissue
to remarkable disability and pain, which may cause com- anatomy, broken implants, poor bone stock, and femoral
plications associated with prolonged recumbency and deficiency. Accordingly, management of these cases has
been reported with increased risks of perioperative mor-
* Correspondence: zhangcq@sjtu.edu.cn; gaoyoushui@sjtu.edu.cn bidity, prolonged operative times, escalated blood loss,
Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated frequent intraoperative fracture, and a high rate of early
Sixth People’s Hospital, 600 Yishan Road, Xuhui, Shanghai 200233, China

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Liu et al. BMC Musculoskeletal Disorders (2020) 21:573 Page 2 of 8

dislocation [14, 15]. In this review, we discuss novel with this procedure, especially in active patients younger
strategies regarding salvage options and surgical tech- than 50 years of age [2, 21].
niques to improve the outcome of patients with failed Implants used for revision internal fixation are typic-
internal fixations of IT fractures. ally selected according to the quality and location of the
remaining bone stock of the proximal femur. The bone
Salvage options stock of the inferior femoral head has usually not been
In properly selected patients, a high rate of successful re- violated by the prior device. Fixed angle devices, such as
vision surgery can be achieved [1, 5, 16]. The decision to angled blade plates and dynamic condylar screws
perform either revision osteosynthesis or prosthetic re- (DCSs), are preferred and often accompanied by au-
placement is based on multiple factors: patient physio- togenous bone grafting [17]. Multiple cervicodiaphyseal
logical age, functional level, life expectancy, nonunion angles are available for fixation of the proximal bone
anatomical site, fracture pattern, remaining bone quality, fragment according to the preoperative plan. Alterna-
bone stock, and hip joint competency (Fig. 1) [17, 18]. tively, it is possible to reinsert sliding hip screws, such as
Briefly, salvage osteosynthesis is preferable for physiolo- dynamic hip screws (DHSs), if there is adequate bone
gically young patients with long life expectancies and ad- stock in the femoral head to hold another screw [22]. In
equate bone quality for fixation; hip arthroplasty, in one study, 26 patients with failed DHS fixations of IT
contrast, is preferred for the geriatric population with fractures were included [22]. Eighteen patients were
poor bone quality, inadequate bone stock, and severely treated with revision internal fixations, and 8 patients
damaged hip articular surfaces. Conversion hip arthroplasty were treated with prosthetic replacements. Among the
is beneficial for early weight bearing and mobilization, elim- revision internal fixation group, DHS reinsertion was
inating the risks of delayed fracture healing and accelerating used in 8 patients, valgus osteotomy and revision DHS
functional recovery, which are pivotal for prognosis in fixation in 6 patients, and valgus osteotomy and inser-
elderly, debilitated patients [1, 2, 10]. tion of a single-angled 130° plate in 4 patients. All pa-
tients in the revision internal fixation group achieved
Femoral head salvage procedures fracture union without bone grafting at a mean time of
Failure of fixation of IT fractures in young patients is 17 weeks. Four of 18 patients had occasional hip pain
exceedingly rare [19, 20]. However, open reduction and that did not interfere with their daily activities, and the
revision internal fixation with or without osteotomy or rest were pain-free after a femoral head salvage proced-
bone grafting have been reported to achieve high union ure at the last follow-up. All 18 patients could walk
rates and few complications [5]. Unlike hip arthroplasty, without support at the final follow-up. In another series
which is characterized by limited longevity, revision in- of 20 patients with failed IT fractures, repeat open re-
ternal fixation preserves the femoral head; thus, further ductions and internal fixations (angled blade plates in 11
revision surgery due to prosthesis abrasion is unneces- patients, DHSs in 5, DCSs in 3 and a Zickel nail in 1)
sary. In this regard, orthopedic surgeons should spare no with bone grafting were evaluated [5]. Nineteen of 20
effort to preserve native bone and achieve fracture union nonunions healed, and 16 of 19 patients who achieved

Fig. 1 The strategy to treat failed osteosynthesis of intertrochanteric fractures is weighed between salvage osteosynthesis and conversion
arthroplasty. The decision is multifactorial and should be individualized
Liu et al. BMC Musculoskeletal Disorders (2020) 21:573 Page 3 of 8

fracture union reported no pain, while the other 3 had replacement in 6 [24]. According to the radiographic
mild pain (related to the retained implant). All were am- follow-up, fracture union in the repeated nailing group
bulatory. In a recent retrospective study, 11 salvages for was observed at a mean period of 118.6 days, while the
nail breakage were identified [23]. Salvage procedures in- plate revision group required a longer time of 427.6 days.
cluded conservative treatment in 2 cases, an intramedul- Barthel scores decreased from the third month to the
lary long nail in 4, 95° DCSs in 3 and conversion total twelfth month postoperatively; however, the result was
hip arthroplasty in 2. All revision internal fixation de- not statistically significant. Importantly, the mortality rates
vices were combined with decortication and bone graft- of the nail group (25%) were lower than those of the plate
ing. The main Barthel score improved from 63.2 group (33%) and arthroplasty group (33%) 12 months after
preoperatively to 72.8 postoperatively. Regarding the SF- revision surgery. This study illustrates that intramedullary
12 score collected at the final follow-up, the physical nails may have a slight advantage in terms of lower mor-
summation was 36.43, and the mental summation was tality and could therefore be a beneficial option when
35.83. A better result in the Bodily Pain (0.708, p = treating failed nail fixation in these frail patients.
0.049) and Role-Emotional (0.815, p = 0.01) subscores in Locking plate systems are useful alternatives for revi-
the SF-12 score was observed among the population sion internal fixation of IT fractures. Although the bio-
with an elevated Barthel score. All of the above literature mechanical superiority of the intramedullary nail is
demonstrates that fracture union and a good outcome substantial, locking plates provide sufficient stability to
can be achieved with revision internal fixation for maintain the alignment of the proximal femur, with a
physiologically young patients and even some older pa- low demand for the entrance point and medullary canal
tients with good remaining bone stock. (Fig. 2). In our own experience, the time to full weight
Intramedullary nails have a role in revision surgery. bearing should be postponed when radiographic callus
They are characterized by a short lever arm, with as formation is distinguishable. However, active functional
much as a 30% reduction in bending stresses with re- exercises can be initiated immediately after the oper-
spect to that of extramedullary devices. Additionally, ation. All beneficial maneuvers to promote fracture heal-
they act as an intramedullary buttress to avoid excessive ing can be attempted postoperatively.
shaft medialization. Some advocates claim they have Some authors have proposed additional cement aug-
clinical benefits such as minimal surgical exposure, pre- mentation around the blade tip to enhance anchorage in
vention of fracture hematoma, less blood loss, lower pain the remaining bone of the femoral head in specified
scores, improved functional ability and early mobilization cases, including lateral blade migration or peri-implant
[24, 25]. Most recently, 20 failed intramedullary nail fixa- fracture [26, 27]. Rotational stability and pull-out
tions were examined through 4 different revision proce- strength increased after augmentation of the previously
dures, including proximal femoral locking plates in 6 extracted proximal femur nail antirotation (PFNA) blade
patients, intramedullary nails in 8 (40%) and prosthesis based on biomechanical investigations [26]. In a study

Fig. 2 Failed nailing of an intertrochanteric fracture in an active 78-year-old man. a The intertrochanteric fracture had been stabilized by an
antegrade long γ nail and circumferential cerclage 4 years ago. The patient first experienced significant hip pain and restricted hip motion 1
month ago without trauma history. Radiography showed nonunion of the intertrochanteric fracture and breakage of the γ nail. b Transverse and
c coronal sections of CT scans showed osteolysis of the great trochanter as well as coxa vara with obvious fracture gaps. d Prior implants were
removed. The malalignment was corrected, causing a larger gap in the calcar. Sufficient bone grafting was used to fill the gap, and the fracture
was stabilized by a reverse LISS for the distal femur
Liu et al. BMC Musculoskeletal Disorders (2020) 21:573 Page 4 of 8

enrolling 10 patients with failed proximal femoral frac-

tures, revision surgeries were conducted via augmented
PFNA [27]. Fracture healing was documented in all cases
except for 2 patients who died from heart failure before
full consolidation during a limited follow-up period of
5.4 months. No negative biological side effects were ob-
served from the cement. In certain cases, proceeding re-
vision surgery with either blade exchange or cement
augmentation should be prudent. Salvage options in-
cluding blade exchange, cement-augmented PFNA,
PFNA renailing and arthroplasty were investigated in 57
cases with blade ‘cut-out’ and ‘cut-through’ after fixation
of IT fractures with PFNA or trochanter fixation nails
(TFNs) [28]. In the ‘cut-through’ group, 8 of 16 patients
(50%) who were revised with blade exchange and 2 of 6
(33%) revised with blade exchange and augmentation re- Fig. 3 Failed plate osteosynthesis of an intertrochanteric fracture in
quired further revision operations. Total hip arthroplasty a 77-year-old lady. a Obvious sclerosis, coxa vara, limb shortening,
and screw pull-out was observed, indicating nonunion of the
(THA) was the definitive treatment in all cases. In the
intertrochanteric fracture. Significant osteoporosis should be noted,
‘cut-out’ group, 2 of 3 patients (66%) revised with blade as reflected by the thin femoral cortices. The patient’s painful
exchange and 2 of 3 (66%) who underwent renailing re- limping was evident. b A cemented modular long-stem prosthesis
quired additional procedures. Resistance to axial migra- was used to restore the limb length and facilitate enhanced
tion of the blade is minimal when the blade has already recovery after the surgery
perforated through the femoral head cortex (cut-
through). The residual bone stock may not have suffi- preexisting degenerative arthritis and erosion caused by
cient strength to hold another blade; thus, high reopera- metalwork penetration, THA was the better choice. As
tion rates are inevitable after blade exchange. mentioned above, THA was recommended as the ideal
Collectively, the data on revision intramedullary nails are salvage procedure for ‘cut-out’ and ‘cut-through’ of hel-
either scarce or include too few cases for broad inter- ical blades after fixation of IT fractures with PFNA and
pretability of the results. Further multicentric studies TFN over revision nail fixation, which often has an
with prospective designs may offer improved treatment unacceptable reoperation rate [28]. Recently, a meta-
for patients with failed IT fractures. analysis was performed to compare the outcome be-
tween THA and HA for failed internal fixations of IT
Conversion hip arthroplasty fractures [14]. Six studies with 188 patients (100 THA
Clinical failure of internal fixation of IT fractures is and 88 HA) were analyzed. No significant difference was
relatively common in osteopenic elderly patients. As found between THA and HA based on postoperative
the success of revision osteosynthesis is limited by the dislocations, reoperations, infections, intraoperative or
host’s healing capacity, salvage arthroplasty becomes a postoperative fractures, and stem subsidence. Harris Hip
reasonable treatment alternative in this affected popula- Scores were slightly higher in THA than in HA at a
tion [14, 29, 30]. minimum 14-month follow-up. This study elucidated
The decision to perform a hemiarthroplasty (HA) or a that both THA and HA are effective salvage procedures
THA should be made based on the functional demand for these specific populations.
of the patient and the status of the acetabular articular Successful femoral component fixation can be
cartilage (Fig. 3). With well-preserved cartilage, HA may achieved with either cemented or cementless implants
be considered, providing minimal invasiveness and desir- [21, 30, 32]. In a series of 33 conversion arthroplasties,
able stability in patients with several comorbidities and cementless prostheses were used due to a concern for
low activity demand [17]. A previous study reported that cement-related cardiopulmonary complications [6]. At
16 patients with failed hip screw fixation of IT fractures the time of the last follow-up, all acetabular cups and
were treated by HA [31]. HA was selected since the fem- femoral stems demonstrated radiographic bone ingrown
oral head was evacuated by the loosened lag screw. stability. No detectable wear or periprosthetic osteolysis
However, the acetabular cartilage was found to be intact was observed, and none of the patients underwent com-
during the surgery. All patients experienced functional ponent dislocations. Cement fixation is more suitable for
improvement based on the SF-36 questionnaire score, relatively elderly patients (generally more than 70 years
which increased from 41.9 to 82.7. In cases of badly of age), especially when bone quality is poor and the
damaged articular cartilage of the hip, such as canal is capacious [11, 17].
Liu et al. BMC Musculoskeletal Disorders (2020) 21:573 Page 5 of 8

Various prostheses with different special designs have femoral preparation, can provide excellent exposure of
been reported, and most of them can yield ideal out- the hip joint. In a study involving 71 failed IT fracture
comes with few complications. Surgeons may determine treatments, trochanteric sliding osteotomy was per-
the most suitable prosthesis according to its advantages formed in 22% of patients during salvage surgery, aiming
and disadvantages when facing unique clinical cases. to facilitate exposure of the hip. None of the patients ex-
Modular implants enable separate preparation of the perienced greater trochanteric fractures or neurovascular
proximal and distal bone in the femur to maximize pros- injuries after surgery [39].
thesis filling. Additionally, modular stems may be indi- When performing IT salvage procedures, the removal
vidually adjusted for leg length discrepancies (LLDs), of failed fixation devices involves a more extensive dis-
offsets, anteversions, and proximal femoral bone loss section and frequently requires the removal of broken
[33, 34]. Cementless modular stems designed for meta- screws. It is helpful to prepare instruments such as tre-
physodiaphyseal anchorage were investigated in the sal- phines, grasping tools, standard broken screw removal
vage of 29 patients after failed internal fixations of IT sets, and metal-cutting high-speed burrs ahead of time
fractures [35]. During a mean follow-up of 20 months, [37, 40]. Several studies recommended dislocating the
all the patients reported notable pain relief and func- femoral head before extracting the implant, which may
tional improvement, indicating that the modular stem reduce the possibility of intraoperative fracture if con-
was a reliable implant. Furthermore, another study in- version arthroplasty is planned [6]. A technical report
volving 11 patients confirmed modular arthroplasty as provided more details on lag screw removal for failed
an effective salvage procedure [1]. DHS revisions [41]. Briefly, after removing the DHS
Nonmodular revision prostheses are also a rational op- plate and carefully dissecting the soft tissue with subse-
tion. Since they are simple to assemble during surgery, quent hip dislocation, saw cuts are made around the lag
there is no concern for fracture of the modular stem at screw in 4 different directions (superior, anterior, infer-
the mid-stem junction. In a retrospective study of 31 ior and posterior) of the femoral neck. Next, the femoral
failed IT fixations, all patients were salvaged using non- head is simply removed by straight traction with the
modular cementless long-stem distal fixation [36]. After screw in situ. This avoids large torques when a trad-
a mean follow-up of 47.5 months, all patients reported itional backing screw out is applied.
significant pain relief and a return to ambulation. The If the decision is made to proceed with revision in-
Harris Hip score increased from 28.4 to 85.6 postopera- ternal fixation, it is important to obtain stable fixation of
tively. Radiological records showed that all presented the fracture fragments and avoid varus malreduction
with bony union. [19]. Eliminating the fracture gap by means of a com-
pression technique and sufficient bone grafting and tak-
Technical challenges and considerations ing care to preserve the vascularity of fracture sites
Revision surgery for failed internal fixation of IT fractures could jointly improve the environment for fracture heal-
is a challenging and highly demanding procedure. Ortho- ing [2, 42].
pedic surgeons often face technical hurdles, including the For conversion arthroplasty, there are several pitfalls
removal of broken fixation devices, a difficult surgical ex- to consider when preparing the femoral canal. Fracture
posure, altered anatomy, compromised bone quality due callus, nonunited fracture translation, and malunion
to pre-existing osteopenia, bone defects after the extrac- often result in bone deformity of the proximal femur,
tion of failed implants, new device placement, a high peri- which increases the risk of intraoperative fracture during
operative fracture risk, and prolonged immobilization. canal preparation or implant placement [39, 43]. Thus,
Attention to technical details can minimize potential com- trochanteric fragments and distorted anatomies must be
plications [17]. mobilized before opening the femoral canal. Careful dis-
The initial exposure is complicated by the presence of section aiming to avoid damaging adjacent neurovascu-
prior fixed metalwork and anatomical deformities [37]. lar structures and muscles is required during this
The status of the greater trochanter is important: it can process [39]. It might be difficult to estimate the correct
be malunited and block the intramedullary canal or relationship between comminuted fracture patterns for
completely ununited. If trochanter malunion prevents reconstructing the proximal femoral anatomy; however,
adequate preparation of the proximal femur, a trochan- restoring the relationship of the tip of the greater tro-
teric sliding osteotomy can be useful [19, 38]. This tech- chanter and the center of rotation of the femoral head
nique preserves the continuity of the abductors, the can indicate a reasonable reference point. Elaborate in-
trochanter and the vastus lateralis, which are important traoperative trials and imaging are encouraged to pro-
in maintaining hip stability. As a result, the possibility of duce a successful surgery [19]. Endosteal sclerotic bone
postoperative hip dislocation is reduced. Retraction of along the track of the previous intramedullary nails and
the overhanging trochanter, as an obstacle during lag screws may lead to fracture of the femur and/or
Liu et al. BMC Musculoskeletal Disorders (2020) 21:573 Page 6 of 8

displacement of the stem during its insertion [6]. A fixations and long-stem implants in 50% according to an
gauge osteotome and/or burr is useful to remove the investigation enrolling 61 cases [43]. Taken together,
endosteal bone. The horizontal axis of the knee joint can calcar-replacing implants and long-stem designs have been
be used as the reference rather than the deformed axis widely applied for revision arthroplasty in patients with
of the femoral neck when adjusting the anteversion of failed internal fixations of IT fractures. Moreover, tumor-
the stem [6]. The femoral canal can be opened using a specific endoprostheses are an alternative option for man-
high-speed burr and hand reamed with the reamer aging patients with inadequate proximal femoral bone
length selected according to the preoperative templating stock. They has been shown to be of significant benefit with
to obtain an optimal endosteal contact in the distal di- a mean Oxford Hip Score of 33 for patients with failed
aphyseal part of the femur. A C-arm image intensifier or osteosynthesis of proximal femoral fractures in a 5-year
fluoroscopic image intensifier is helpful in guiding this follow-up study [46].
process, as the index surgery can result in an abnormal Researchers have drawn attention to the fact that ce-
proximal femoral anatomy, medullary canal obstruction ment extrudes from empty screw holes when a cemen-
and stress-riser formation [10, 30]. ted stem is used. Leakage of cement through screw
Bone defects of the proximal femur after implant removal holes may lead to nonunion at the fracture site, postop-
are challenging events in revision surgeries of failed IT fixa- erative periprosthetic fracture or loss of cement
tions (Fig. 2). Either intramedullary bone defects or cortical pressurization [6]. Numerous techniques for preventing
screw holes should be taken into consideration to obtain a this extrusion have been advocated: for screw holes,
successful surgery. Bone loss distal to the standard neck re- direct finger pressure, gauze, and reinsertion of the
section level often requires revision-type implants, includ- screws can be used to plug the holes when cement is
ing calcar-replacing implants, to make up for any bone injected; for lag screw holes, the assistant’s thumb,
deficiency and restore limb length. Long-stem implants are firmly packed gauze, a surgical glove inflated with sa-
inserted to bypass the most distal screw hole by two cortical line, and a bone plug fashioned from the excised fem-
diameters, combined with or without a prophylactic cable oral head are valid [47, 48].
to avoid creation of a stress riser [17, 44]. In a series of 71 Acetabular bone quality in patients with IT nonunion
affected hips treated with conversion THA, 76% calcar- is also compromised because of disuse osteopenia. If a
replacing prostheses and 50% long-stem components were cementless cup is used, inadequate press-fit fixation or
reported [39]. Similarly, 14/21 long-stem implants were intraoperative fracture during implant fixation can
claimed in a study reported by D’Arrigo and colleagues occur. Reaming acetabular cartilage judiciously and aim-
[45]. Likewise, calcar replacement was used in almost 60% ing to preserve the subchondral bone are recommended.
of patients treated with salvage arthroplasty for failed IT Forceful acetabular component impaction is not allowed;
Table 1 Technical challenges and strategies
Challenge Strategy Reference
Surgical exposure Trochanteric sliding osteotomy [19, 38]
Removal of previous fixation devices Dislocating the hip joint before removing; excising the femoral head [6, 41]
with the lag screw in situ
Removal of broken screws Trephines, grasping tools, a standard broken screw removal set and a [37, 40]
metal-cutting high-speed burr
Revision internal fixation Avoiding a varus malreduction and obtaining stable fixation (compression [2, 19, 42]
technique and bone grafting)
Bone deformity of proximal femur Restoring the relationship between the tip of greater trochanter and [19]
the center of femoral head rotation
Femoral canal preparation for revision arthroplasty Endosteal sclerotic bone removal: gauge osteotome and/or a burr; [6, 10, 30]
refereing horizontal axis of the knee joint to adjust the anteversion of
the stem; using C-arm image intensifier or fluoroscopic image intensifier
to guide the placement of the stem
Bone defect of proximal femur Calcar-replacing and long-stem implant combined with or without a [17, 39, 44, 46]
prophylactic cable; tumor-type endoprosthesis
Leakage of cement through screw holes Finger pressure, packed gauze, re-inserted screws, surgical glove inflated [47, 48]
with saline, fashioned bone plug
Acetabula preparation in patients with poor Reaming acetabular cartilage judiciously; avoiding forceful component [17, 37]
bone quality impaction; considering screws augmentation
Greater trochanter reattachment Contoured plating, tension band wiring and trochanter claw plate [11, 30, 35, 36, 46]
with wiring
Liu et al. BMC Musculoskeletal Disorders (2020) 21:573 Page 7 of 8

instead, augmentation of the fixation with screws should Availability of data and materials
be considered [17, 37]. The data and materials supporting the conclusions of this article are
included within the article.
A separated greater trochanter, commonly seen in pa-
tients subjected to IT fixation failure, usually causes pain Ethics approval and consent to participate
and limping and even affects abductor function [31, 49]. Not applicable.
Additionally, evidence has revealed that a higher disloca-
tion rate of hip arthroplasty is correlated with displaced Consent for publication
Not applicable.
fracture of the greater trochanter [31]. Three methods
for fixation of the greater trochanter have been men-
Competing interests
tioned: contoured plating, tension band wiring, and tro- The authors declare that they have no competing interests.
chanter claw plating with wiring [11, 30, 31, 35, 36, 46]. In
a retrospective study of 16 failed IT fixations, all patients Received: 8 April 2020 Accepted: 17 August 2020

received surgery with HA and the cable-grip system. Fif-

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DCS: Dynamic condylar screw; DHS: Dynamic hip screw; dynamic hip screw augmented with trochanteric wiring for treatment of
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PL wrote the manuscript. DJ, CZ and YG conceived the idea, revised the
12. Morice A, Ducellier F, Bizot P, Orthopaedics, Traumatology Society of
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Funding 015.
The current study was supported by the Shanghai Municipal Health 13. Smith A, Denehy K, Ong KL, Lau E, Hagan D, Malkani A. Total hip
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