OBJECTIVE: This review summarized the first 10-year progresses and controversies in the concept of anteromedial cortical support reduction, to provide references for further study and clinical applications. METHODS: Relevant domestic and foreign literature on cortical support reduction was extensively reviewed to summarize the definition of positive, neutral, and negative support, anteromedial cortices at the inferior corner, intraoperative technical tips for fracture reduction, radiographic assessment at different periods, comparison between positive versus neutral and medial versus anterior support, and the clinical efficacy of Chang reduction quality criteria (CRQC) and postoperative stability score. RESULTS: Anteromedial cortical support reduction was only focused on the cortex of anteromedial inferior corner, with no concern the status of lateral wall or lesser trochanter. Anteromedial cortex was seldom involved by fracture comminution, it was thicker, denser, and stronger, and was the key for mechanical buttress of the head-neck fragment to share compression load. Positive, neutral, and negative support were also called "extramedullary, anatomic, and intramedullary reduction", respectively. There was hardly seen parallel cortical apposition, but characterized by some kinds of head-neck rotation, for example 10°-15° flexed rotation for positive cortical contact and support. Due to intraoperative compression and postoperative impaction, the status of cortical support may be changed at different time of radiographic examination. The positive medial cortex support was more reliable with less reduction loss than its neutral counterpart, and the anterior cortex contact was more predictive than the medial cortex for final results. As incorporation the bearing of cortex apposition and using a 4-point score, CRQC demonstrated more efficacy and was gradually accepted and applied in the evaluation of trochanteric fracture reduction quality. Postoperative stability score (8 points) provided a assessment tool for early weight-bearing in safety to prevent mechanical failure. CONCLUSION Anteromedial cortical support reduction is a key point for stability reconstruction in the treatment of trochanteric femur fractures. Evidence has definitely shown that non-negative (positive and neutral) is superior to negative (loss of cortical support). There is a tendency that positive cortex support is superior to neutral, but high quality study with large sample size is needed for a clear conclusion.
Humans ; Femur/diagnostic imaging* ; Fracture Fixation, Internal/methods* ; Hip Fractures/diagnostic imaging* ; Treatment Outcome ; Fracture Fixation, Intramedullary/methods*

OBJECTIVE: To review the advancement made in the understanding of valgus impacted proximal humeral fracture (PHF). METHODS: The domestic and foreign literature about the valgus impacted PHF was extensively reviewed and the definition, classification, pathological features, and treatment of valgus impacted PHFs were summarized. RESULTS: PHF with a neck shaft angle ≥160° is recognized as a valgus impacted PHF characterized by the preservation of the medial epiphyseal region of the humeral head, which contributes to maintenance of the medial periosteum's integrity after fracture and reduces the occurrence of avascular necrosis. Therefore, the valgus impacted PHF has a better prognosis when compared to other complex PHFs. The Neer classification designates it as a three- or four-part fracture, while the AO/Association for the Study of Internal Fixation (AO/ASIF) categorizes it as type C (C1.1). In the management of the valgus impacted PHF, the selection between conservative and surgical approaches is contingent upon the patient's age and the extent of fracture displacement. While conservative treatment offers the advantage of being non-invasive, it is accompanied by limitations such as the inability to achieve anatomical reduction and the potential for multiple complications. Surgical treatment includes open reduction combined with steel wire or locking plate and/or non-absorbable suture, transosseous suture technology, and shoulder replacement. Surgeons must adopt personalized treatment strategies for each patient with a valgus impacted PHF. Minimally invasive surgery helps to preserve blood supply to the humeral head, mitigate the likelihood of avascular necrosis, and reduce postoperative complications of bone and soft tissue. For elderly patients with severe comminuted and displaced fractures, osteoporosis, and unsuitable internal fixation, shoulder joint replacement is the best treatment option. CONCLUSION Currently, there has been some advancement in the classification, vascular supply, and management of valgus impacted PHF. Nevertheless, further research is imperative to assess the clinical safety, biomechanical stability, and indication of minimally invasive technology.
Aged ; Humans ; Bone Plates ; Bone Wires ; Fracture Fixation, Internal/adverse effects* ; Fractures, Comminuted/surgery* ; Humeral Fractures ; Osteonecrosis ; Retrospective Studies ; Shoulder Fractures/surgery* ; Treatment Outcome

With accelerated aging process of the population, femoral intertrochanteric fractures have gradually become another major social health problem in China. Internal fixation is still the gold standard treatment for the fractures. Fracture reduction is the first step of the treatment and also the first element that affects the treatment efficacy. It is still controversial in clinical practice how to evaluate the quality of fracture reduction during internal fixation of the fractures. This article systematically expounds and analyzes the 7 systems of judging criteria for the reduction of intertrochanteric fractures from the aspects of fracture alignment, fracture apposition, difference in judgment criteria, and difference in imaging methods, in order to provide a reference for reaching consensus and improving curative effects.

Objective To compare the biomechanical stabilities among different combinations of anterior and medial cortical supports after intramedullary nailing for unstable intertrochanteric fractures.Methods Twenty-seven synthesized femur specimens were used to create models of unstable intertrochanteric fracture of type 31A2.1 according to AO/ASIF classification.They were divided into 9 groups (n =3) according to 9 combinations of anterior and medial cortical supports on the anteroposterior and lateral X-ray films:positive-positive,positive-neutral,positive-negative,neutral-positive,neutral-neutral,neutral-negative,negative-positive,negative-neutral,negative-negative groups.After all the fractures were fixated with the newly adapted femoral intertrochanteric nails (FITN),static loadings were applied for tests of fatigue and destruction to investigate the relative displacements and yield loads of the head-neck fragments.Results For the positive-positive,positive-neutral,positive-negative,neutral-positive,neutral-neutral,neutral-negative,negative-positive,negative-neutral,negative-negative groups,the vertical displacements of the head-neck fragments under fatigue loading were respectively 5.33 ±0.58 mm,7.83 ±0.29mm,7.73 ±0.15 mm,8.17 ± 0.29 mm,8.33±1.15 mm,8.83±0.29 mm,9.33±0.58 mm,9.67±1.15 mm and 12.0±1.0 mm,showing significant differences (P ＜ 0.05).The smallest displacement was observed in the positive-positive group,significantly smaller than that in any other groups (P ＜ 0.05).For the above 9 groups,the yield loads were respectively 4,967 ± 153 N,4,467 ± 58 N,3,717 ± 76 N,2,767 ± 58 N,2,533 ± 58 N,2,267 ± 58 N,1,833 ± 58 N,1,667 ± 58 N and 1,333 ± 58 N,showing significant differences between any 2 groups (P ＜ 0.05).In the destruction test,bone interface loosening in the femoral head happened in 2 cases,bone interface loosening in the intertrochanteric zone in 15 cases,split fracture at the zone of distal locking nail in 2 cases,and loosening and breakage of the internal fixator in the distal femur in 8 cases.Conclusions The medial cortical support plays a major role and the anterior cortical support plays a secondary role in the stability of unstable intertrochanteric fracture.In the surgical procedure,surgeons should avoid the medial cortical negative support as much as possible.

Objective: To measure the rotation angle of the head-neck fragment of intertrochanteric fracture after cephalomedullary nail fixation by three-dimensional CT imaging, and to explore its clinical significance. Methods: The clinical data of 68 patients with unstable intertrochanteric fracture of AO/Orthopaedic Trauma Association (AO-OTA) type 31-A2 treated with cephalomedullary nail fixation and with complete intraoperative fluoroscopy and postoperative three-dimensional CT imaging data between July 2016 and October 2018 were retrospectively analyzed. Among them, there were 21 males and 47 females, aged 68-93 years, with an average age of 81.8 years. There were 31 cases of AO/OTA type 31-A2.2 and 37 cases of 31-A2.3. Fracture reduction quality was evaluated according to Baumgaertner et al. and Chang et al. criteria. The anteromedial cortical contact or not of each patient was observed by three-dimensional CT imaging on T3DView software after operation. The rotation of head-neck fragments were divided into three types: non-rotation, flexion rotation, and hyperextension rotation. The rotation angles of each type were measured and the relationship between the rotation type of the head-neck fragments and the contact of the anteromedial cortex was analyzed. Results: The reduction and fixation of the small trochanter were not performed in 68 patients. According to Baumgaertner et al. criteria, the quality of fracture reduction was excellent in 15 cases (22.1%), acceptable in 50 cases (73.5%), and poor in 3 cases (4.4%). According to Chang et al. criteria, 31 cases were excellent (45.6%), 33 cases were acceptable (48.5%), and 4 cases were poor (5.9%). Thirty-nine cases (57.4%) received anteromedial cortical support and 29 cases (42.6%) did not receive cortical support. Three-dimensional CT imaging showed non-rotation in 12 cases (17.6%), flexion rotation in 39 cases (57.4%), and hyperextension rotation in 17 cases (25.0%). There were 7 cases (58.3%), 30 cases (76.9%), and 2 cases (11.8%) of cortical support in non-rotation group, flexion rotation group, and hyperextension rotation group, respectively. The rotation angles were (1.05±0.61), (13.96±6.17), (8.21±3.88)°, respectively. There were significant differences between groups ( P<0.05). Conclusion: In the unstable intertrochanteric fracture after cephalomedullary nail fixation, the rotation of head-neck fragment exists in most patients, and the types of flexion rotation and non-rotation can easily obtain cortical support reduction.