Enhancing Reduction Quality and Union Time in Reverse Oblique Intertrochanteric Femur Fractures: A Comparative Analysis of Cephalomedullary nail with Side Plate Augmentation

Enhancing Reduction Quality and Union Time in Reverse Oblique Intertrochanteric Femur Fractures: A Comparative Analysis of Cephalomedullary nail with Side Plate Augmentation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Enhancing Reduction Quality and Union Time in Reverse Oblique Intertrochanteric Femur Fractures: A Comparative Analysis of Cephalomedullary nail with Side Plate Augmentation Chiu-Yu Shih, Chih-Hui Chen, Sung-Yeh Yang, Yu-Cheng Lo, Yu-Jun Chang, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5074439/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: This study aimed to evaluate and compare the efficacy of the cephalomedullary nail (CMN) with side plate, CMN with cerclage wire, and CMN alone in the treatment of reverse oblique intertrochanteric femur fractures with respect to reduction quality, loss of reduction, union time, and complications. Methods: This retrospective study evaluated patients aged 18 years or older with reverse oblique intertrochanteric fractures (OTA/AO 31A3.1 and 31A3.3) treated with CMN. Exclusion criteria included pathological fractures, open fractures, previous hip surgery, segmental fractures, and follow-up less than 2 years. Outcome measures included reduction quality (modified Baumgaertner criteria), union time, loss of reduction (varus collapse), and complications. These results were compared among the three treatment groups. Results: 54 patients were included. 12 in the side plate group, 15 in the cerclage wire group, and 27 in the CMN group. No significant differences in demographic parameters were observed between the groups. The plate group demonstrated superior reduction quality and shorter union time compared to the cerclage and CMN groups (p < 0.01). A higher incidence of reduction loss was observed in the CMN group compared to the cerclage and plate groups. Reduction quality was significantly associated with a reduced incidence of reduction loss and a shorter union time (p < 0.05). Conclusions: In the treatment of reverse oblique intertrochanteric femur fractures, the incorporation of a side plate alongside CMN appears to offer superior reduction quality, reduced incidence of varus collapse, and shorter union time compared to cerclage wire or CMN alone. This approach may represent a valuable alternative for treating surgeons facing these challenging fracture patterns. Reverse oblique fractures Cephalomedullary Nail Augmentation plate Reduction quality Union time Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Background The reverse oblique fracture, comprising approximately 2–23% of all intertrochanteric fractures, is characterized by a major fracture line that extends from the distal lateral to proximal medial regions ( 1 – 4 ). This type of fracture is particularly notable due to the elevated stress concentration in the anatomical area. The deforming forces originate from the abductors of the hip and short external rotators, which are inserted into the greater trochanter. Additionally, tension from the iliacus and psoas muscles affects the lesser trochanter. Biomechanically, these result in abduction, flexion, and external rotation of the proximal fragment, while the adductor muscles acting on the distal fragment contribute to shortening. The overall presentation of the fracture site reveals varus and apex anterior deformities( 5 ). Therefore, a high rate of malreduction and subsequent varus collapse or shaft medialization have been observed in the treatment of reverse oblique fractures( 6 )(Fig. 1 ). Traditionally, the sliding hip screw (SHS) has been widely used as the primary implant for the treatment of intertrochanteric fractures. However, several investigations have raised concerns about its suitability for 31A3 fractures when considering biomechanical factors ( 7 – 9 ). Studies have shown a higher failure rate associated with the use of SHS in the treatment of reverse oblique fractures compared to intramedullary nail (IMN) ( 10 , 11 ). Two comprehensive studies, drawing data from the Norway Hip Fracture Register, revealed a higher reoperation rate in cases treated with SHS as opposed to IMN ( 3 , 12 ). With decreased lever arm leading to better stability and effectively preventing lateral sliding of the proximal fragment as well as shaft medialization ( 11 , 13 , 14 ), modern cephalomedullary nail (CMN) treatment has shown a favorable result compared to SHS and is considered more suitable in managing 31A3 fractures ( 5 , 15 , 16 ). Despite these advantages, it should be noted that even with CMN, a significant cut-out rate persists in the context of reverse oblique fractures, resulting in substantial pain and arthritis( 17 ). Studies have shown that poor reduction quality is significantly related with fixation failure ( 18 – 20 ). Therefore, avoiding malreduction becomes a paramount consideration in the management of this challenging fracture pattern. To address this, various adjunctive techniques have been proposed, including open clamp-assisted reduction, cerclage wires and minifragment plate ( 21 , 22 ). In this retrospective study, patients with reverse oblique fractures who underwent treatment with either CMN alone, CMN with side plate, or CMN with cerclage wire were examined. The objective was to assess and compare reduction quality, the incidence of reduction loss, time to union and complications between these three treatment groups. We hypothesize that the treatment of reverse oblique fractures with CMN with side plate will result in improved reduction quality, reduced incidence of reduction loss, and faster time to union compared to CMN alone or CMN with cerclage wire. Methods The retrospective comparative study included 54 patients presented to our institution from January 2015 to December 2020 with a reverse oblique intertrochanteric fracture. Inclusion criteria were patients older than 18 years with a radiologically diagnosed reverse oblique fracture classified as 31A3.1 and 31A3.3 according to OTA/AO Fracture and Dislocation Classification Compendium-2018, with the major fracture line running from distal-lateral to proximal medial. The patients were treated with a cephalomedullary nail (CMN). Exclusion criteria were pathological fractures, open fractures, previous ipsilateral hip surgery, segmental fracture and patients’ follow-up less than 2 years. Patients with a simple transverse fracture line classified as 31A3.2 were also excluded. Three different groups were defined. The first group was treated with CMN using a closed, percutaneous or mini open reduction maneuver. The second group was treated with CMN and a side plate. The third group was treated with CMN and cerclage wire. The patients were classified into each group according to the postoperative radiograph, determined by the treating surgeons. Demographic data including age, sex, BMI, side of the fracture, and smoking status were recorded. Fractures were classified according to the Orthopedic Trauma Association classification. Union was determined by evaluating the standard orthogonal radiograph during clinical follow-up. Union was defined as the presence of bridging bone callus over at least three cortices in two orthogonal views. Nonunion was defined by the fracture line that does not show radiological union 9 months after a fracture, lack of signs of progressive healing for three consecutive months or implant breakage ( 23 , 24 ). The quality of the fracture reduction was classified as good, acceptable and poor based on the modified Baumgaertner criteria. Angulation criteria were defined as normal or slight valgus alignment on AP radiograph, < 20° of angulation on the lateral radiograph. The displacement criterion was defined as < 4mm of displacement of any major fragments, excluding the lesser trochanter. Good reduction quality meets both the angulation and displacement standards. While acceptable meets only one standard, poor meets none of the standards( 25 , 26 ). Varus collapse was measured as an indicator of a loss of reduction. It was measured by calculating the change in neck shaft angle (NSA) from intraoperative AP fluoroscopy to final follow-up AP radiograph. The neck shaft angle is calculated with the correction formula to counter different rotation. (NSA = Nail angle (130°) ×Measures NSA/Measured nail angle). Varus collapse is determined by changing > 5° of the NSA( 27 ). Tip Apex Distance (TAD) and Parker’s Ratio were also recorded according to the measures described in the literature. TAD represents the sum of the distances from the tip of the lag screw to the apex of the femoral head on both anteroposterior (AP) and lateral radiographs( 28 ) and The Parker’s ratio quantifies the position of the lag screw within the femoral head by calculating the ratio of the distance from the center of the femoral head to the screw on AP and lateral views relative to the total diameter of the femoral head.( 29 ) Orthopedic complications including fixation failure, reoperation, and wound infection were recorded. Reoperation was done due to fixation failure with lag screw cut out or nonunion. Wound infection is defined as a superficial or deep wound infection that required surgical debridement. The radiographs were reviewed by a certified orthopedic surgeon, further validated by another professional. In cases of disparity, a third qualified orthopedic surgeon performed a review, and the result was determined by the majority consensus among experts. This study was exempted from a full ethical review and was approved by the Changhua Christian Hospital Institutional Review Board, approval number 230325. The Changhua Christian Hospital Institution Review Board waived the requirement of informed consent based on Taiwan’s Human Subjects Research Act. Operative technique The patients were placed in a supine position on the fracture table. The uninjured leg was placed on the leg holder in hemi lithotomy position. The fractured extremity was fixed to the traction boot. A close reduction was achieved by axial traction to distract the fragments and restore length. Rotation was done until the patella was facing forward in the AP view of the knee. Fluoroscopy was used to check the reduction in both the AP and the lateral view and to fine-tune the reduction by manipulating the fractured extremity. If the reduction is considered adequate, a standard cephalomedullary nailing sequence is performed. A 5-cm incision was made proximal to the tip of the greater trochanter, in line with the femoral shaft axis. The entry point was slightly medial to the greater trochanter. A guide wire was inserted, followed by sequential reaming of the medullary canal. The nail was then inserted and secured with a lag screw, and the locking mechanism was tightened. Two distal screws were inserted using the freehand technique. Gamma3 Nail system (Stryker) or Natural Nail system (Zimmer) long nails were routinely used in 31A3 patients. No suction drains were used after surgery. When closed reduction was inadequate, percutaneous or mini-open reduction was performed at the discretion of the surgeon. Reduction aids such as a ball-spike pusher, Hoffmann retractor, or bone clamps were applied depending on fracture morphology, in line with previously described clamp-assisted reduction techniques. ( 21 ) Side plate If persistent abduction and varus angulation of the proximal head-neck segment were observed after closed reduction, an approximately 8-cm longitudinal incision was made, centered at the level of the lesser trochanter. Careful dissection was performed through the soft tissue, splitting the fascia lata and vastus lateralis to expose the fracture site. The bone surface was prepared using a periosteal elevator. Manual reduction was achieved with a bone hook or ball-spike pusher, and the fracture table was used to adjust length and rotation to obtain near-anatomical alignment. A 3.5-mm small reconstruction plate (Synthes) was routinely used for augmentation. Prior to application, the plate was pre-bent to conform to the lateral curvature of the femur, spanning from the vastus tubercle proximally to the subtrochanteric region distally, and crossing the fracture site. The plate typically contained 6 to 7 holes, although the exact number varied depending on patient anatomy and fracture configuration. The plate was positioned slightly anteriorly to avoid impingement at the entry point of the lag screw. Fixation was achieved by inserting two screws proximally and two screws distally to the fracture site, providing semi-rigid, temporary stabilization and anti-rotational support prior to cephalomedullary nail insertion. The total number of screws was not standardized and was determined intraoperatively based on individual patient anatomy and fracture characteristics. After plate fixation, cephalomedullary nailing was performed as previously described (see Fig. 2 ). Cerclage wire An incision of about 5 cm was made proximal to the apex of the fracture. Cerclage wire was passed by using an AO wire passer. Tensioning of the cerclage wire was applied with adjustment of rotation and length through the fracture table. After the cerclage wire was applied, the CMN was inserted in the manner mentioned above. (Fig. 3 ) Postoperative Rehabilitation and Follow-up Protocol Postoperative care followed a standardized protocol. Patients were mobilized under the supervision of a physiotherapist. The weight bearing status was determined on the basis of the patient's age and activity level. For the elderly patients, weight bearing as tolerated with walking aids was initiated the day after surgery. For younger, more active patients, initial restricted weight-bearing was required, with reassessment after 6 weeks. Patients were encouraged to perform active range-of-motion exercises for the hip and knee starting on the first postoperative day. However, slight modifications to the standard protocol may be made based on the patient’s condition, treating surgeon, and physiotherapist. Follow-up visits were scheduled at regular intervals to monitor clinical and radiographic progress. The first follow-up was carried out at 2 weeks postoperatively, followed by visits every 6 weeks until fracture union was achieved. After union, follow-up continued at three-month intervals during the first year and then at six-month intervals until the two-year mark. At the 2-year follow-up, patients were routinely asked to return for clinical and radiographic evaluation. If no specific events or complications were identified at the two-year mark, follow-up was concluded. Statistical analysis Due to the small sample size in this study, continuous variables are presented as medians and interquartile ranges, while categorical variables are presented as numbers and percentages. The Kruskal Wallis test was used to compare the medians of continuous variables between groups, while the chi-square test or Fisher's exact test was used for categorical variables. Post-hoc pairwise comparisons were performed using Bonferroni correction to adjust for multiple comparisons. In addition, bivariable and multivariable Firth logistic regression analyzes were conducted to identify factors significantly associated with union time ≤ 3 months. All data were analyzed using the IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY). P-values < 0.05 were considered statistically significant. Sample size estimation Sample size estimation was performed a priori based on the assumption that the expected proportions of patients achieving union time ≤ 3 months would be 3%, 10%, and 90% in the CMN alone, CMN with cerclage, and CMN with plate groups, respectively, with an allocation ratio of 2:1:1. Using a 2×3 Pearson chi-square test with a significance level of α = 0.05 and power of 0.80, the minimum required sample size was calculated to be 14 participants (7, 4, and 3 in each group). To account for potential random error and the need for covariate adjustment in regression analyses, additional participants were recruited, resulting in a final study population of 54 patients (27, 15, and 12 in each group, respectively). All calculations were performed in R version 4.4.1 using the pwr package. Results After applying the inclusion criteria, 68 patients were initially identified. Five patients were excluded based on the following exclusion criteria: pathological fracture (n = 1), open fracture (n = 1), previous ipsilateral hip surgery (n = 2), and segmental fracture (n = 1). Additionally, 8 patients were lost to follow-up. Among the eight patients lost to follow-up, two were confirmed deceased due to unrelated medical conditions, six reported no sequelae and chose not to return. Leaving a study population of 55 patients. However, one patient in the cerclage wire group underwent revision surgery and was converted to total hip arthroplasty one month after surgery due to lag screw cut out. Although the patient had acceptable reduction quality, a TAD of 32 mm and a Parker’s AP ratio of 62.1 likely contributed to the fixation failure, as supported by previous literature( 29 – 31 ). Given these interfering factors, the patient was excluded from the cohort analysis. This exclusion ensures that the analysis of union time and its correlation with other factors is not confounded by this early fixation failure, which is considered a separate mechanical complication rather than a case of nonunion. Therefore, the final study population consisted of 54 patients, with a mean age of 68.6 years. The Recruitment Algorithm is shown in Fig. 4 . There were no significant differences in demographic parameters with respect to age, height, sex, BMI, side of the fracture, and smoking status between each group. There were no significant differences with respect to the type of fracture according to the AO classification and TAD. Parker’s ratio exhibited a higher median value in the CMN group (median = 48.6) compared to both the cerclage group (median = 45.9) and the plate group (median = 38.1), reaching statistical significance (p = 0.028). The plate group demonstrated superior results in terms of reduction quality (p < 0.001) and significantly reduced union time, compared to the other groups. There were no significant differences in the postoperative NSA, the last follow NSA and NSA change. A trend emerged, although statistically not significant (p = 0.088), indicating a higher incidence of loss of reduction (△NSA > 5°) in the CMN group (N = 7, 25.9%) compared to the cerclage group (N = 1, 6.7%) and the plate group (N = 0, 0%). Detailed results are presented in Table 1 and Table 2 . Table 1 The demographics and clinical characteristics Group Total (n = 54) CMN (n = 27) Cerclage (n = 15) Plate (n = 12) P-value Post Hoc Test N % N % N % N % Gender Female 33 61.1 19 70.4 8 53.3 6 50.0 0.372 Male 21 38.9 8 29.6 7 46.7 6 50.0 Smoking status No 50 92.6 26 96.3 12 80.0 12 100.0 0.113 Yes 4 7.4 1 3.7 3 20.0 0 0.0 AO classification 31A3.1 21 38.9 11 40.7 4 26.7 6 50.0 0.448 31A3.3 33 61.1 16 59.3 11 73.3 6 50.0 Side of the fracture Left 29 53.7 16 59.3 8 53.3 5 41.7 0.596 Right 25 46.3 11 40.7 7 46.7 7 58.3 Reduction quality Poor 7 13.0 6 22.2 1 6.7 0 0.0 Plate Good 15 27.8 2 7.4 3 20.0 10 83.3 CMN, Cerclage < Plate Loss of reduction No 46 85.2 20 74.1 14 93.3 12 100.0 0.088 Yes 8 14.8 7 25.9 1 6.7 0 0.0 Union time 1–3 months 15 27.8 1 3.7 2 13.3 12 100.0 < 0.001 CMN, Cerclage Plate > 6 months 13 24.1 12 44.4 1 6.7 0 0.0 CMN, Cerclage > Plate Not healed 4 7.4 2 7.4 2 13.3 0 0.0 P-value by chi-square test or Fisher's exact test when appropriate, along with Bonferroni correction for multiple paired comparisons. Table 2 Comparison of measurement results between groups CMN (n = 27) Cerclage (n = 15) Plate (n = 12) P-value Post Hoc Median IQR Median IQR Median IQR Tests Age 78.0 66.0–88.0 64.0 42.0–86.0 72.0 56.0–83.5 0.448 Height(cm) 160.0 152.0–164.0 158.0 153.0–170.0 164.0 151.0–170.0 0.816 Body weight(kg) 55.0 48.9–67.0 63.0 51.0–73.0 63.5 55.0–69.5 0.662 BMI 23.3 18.7–28.3 23.8 18.8–28.5 23.6 22.2–27.3 0.928 Post-op NSA 133.8 130.4–135.9 132.3 126.4–141.3 133.0 128.9–137.6 0.917 Last follow-up NSA 132.0 128.2–133.9 129.8 123.6–136.8 132.5 128.0–136.6 0.747 NSA change -1.3 -5.8 - -0.1 -3.8 -4.5 - -1.4 -2.4 -3.9–0.6 0.496 TAD 22.0 18.8–25.1 22.4 19.1–29.0 23.9 19.5–26.6 0.752 Parker’s ratio 48.6 41.0–56.0 45.9 39.9–51.1 38.1 36.5–46.5 0.028 CMN > Plate IQR: interquartile range; P-value by Kruskal Wallis Test; Bonferroni correction for multiple paired comparisons. Reduction quality, Union time and Loss of reduction Among the patients, 3 out of 7 with poor reduction quality and 5 out of 32 with acceptable reduction quality experienced loss of reduction. None of the 15 patients with good reduction quality encountered loss of reduction, demonstrating a statistically significant association between better reduction quality and reduced incidences of loss of reduction (p = 0.02). Regarding the time of union, among the 8 patients experiencing loss of reduction, 3 were classified into the > 6 months, while 3 resulted in nonunion. On the contrary, among patients without loss of reduction, the majority achieved healing in 6 months, with 15 of 46 patients in 1–3 months and 20 of 46 patients in 4–6 months. This indicated a statistically significant association between loss of reduction and prolonged union time (p = 0.003). A significant association (p < 0.001) was observed between reduction quality and union time. In particular, 80% of the cases with good reduction quality achieved union within 1 to 3 months. On the contrary, cases with poor reduction quality predominantly experienced union times exceeding 6 months or end up with nonunion (85.7%). The detailed results are presented in Table 3 . Table 3 Reduction quality, union time, and loss of reduction Reduction quality Union time Poor Acceptable Good 1–3 months 4–6 months > 6 months Non-union Total N % N % N % P-value N % N % N % N % P-value Loss of reduction No 46 4 8.7 27 58.7 15 32.6 0.020 15 32.6 20 43.5 10 21.7 1 2.2 0.003 Yes 8 3 37.5 5 62.5 0 0.0 0 0.0 2 25.0 3 37.5 3 37.5 Reduction quality Poor 7 0 0.0 1 14.3 3 42.9 3 42.9 < 0.001 Acceptable 32 3 9.4 18 56.3 10 31.3 1 3.1 Good 15 12 80.0 3 20.0 0 0.0 0 0.0 Union time 1–3 months 15 0 0.0 3 20.0 12 80.0 6 months 13 3 23.1 10 76.9 0 0.0 Non-union 4 3 75.0 1 25.0 0 0.0 P-value by Fisher’s exact test. In the bivariate analysis, age, TAD, NSA change, and AO classification did not show significant associations with the likelihood that union time would be < 3 months. In particular, a significant negative association (p = 0.011) was observed with the Parker's ratio. Furthermore, compared to the CMN reference category, the Plate group showed a significant association (p < 0.001) with higher odds of achieving union time < 3 months, while the Cerclage group did not exhibit significance. Upon conducting a multivariate analysis while adjusting for other factors, the impact of Parkers Ratio lost its significance (p = 0.734). This suggests possible confounding effects from other variables influencing this relationship. Despite this, the Plate group maintained a highly significant association (p = 0.001) with higher odds of achieving union time ≤ 3 months, emphasizing its substantial influence even after considering other factors. The detailed results are presented in Table 4 . Table 4 Firth logistic regression analysis of union time not exceeding 3 months Bivariable analysis (crude) Multivariable analysis (adjusted) Odds ratio 95% CI P-value Odds ratio 95% CI P-value Age 1.001 0.974–1.030 0.931 1.003 0.959–1.048 0.907 TAD 1.009 0.909–1.120 0.868 0.986 0.842–1.156 0.866 Parkers ratio 0.882 0.802–0.971 0.011 0.981 0.875–1.098 0.734 NSA change 1.162 0.963–1.403 0.117 1.062 0.836–1.348 0.621 AO classification 31A3.1 1.000 1.000 31A3.3 0.640 0.191–2.140 0.469 0.961 0.161–5.749 0.965 Group CMN 1.000 1.000 Cerclage 3.272 0.37–28.917 0.286 1.576 0.259–9.602 0.622 Plate 441.674 14.954–999.999 < 0.001 77.958 5.886–999.999 0.001 TAD = Tip Apex Distance, NSA = Neck Shaft Angle, CMN = cephalomedullary nail Complications One patient in the cerclage wire group experienced fixation failure due to poor TAD and Parker’s AP ratio and was excluded from the study cohort, as discussed earlier. Four patients had radiographic nonunion, but refused reoperation due to good clinical tolerance and the restricted requirement for ambulation. There were no wound infections that required surgical intervention in our cohort. The complications are presented in Table 5 . Table 5 Orthopedic complications Complications Fixation failure Re-operation Wound infection (superficial or deep) Number of patients (n) 1 1 0 Discussion The primary finding of our study suggested that incorporating a side plate along the standard cephalomedullary nail (CMN) yields superior reduction quality and shorter union time compared to cerclage wire with CMN or CMN alone in the management of reverse oblique intertrochanteric fractures. The management of reverse oblique fracture remains a challenge and a topic of significant clinical interest among treating physician ( 21 , 32 , 33 ). The prevalence of malalignment has been observed to be high when closely treated, leading to complications such as nonunion, malunion, and fixation failure. Therefore, an open reduction becomes necessary( 34 ). Reviewing the literature, clamp-assisted open reduction and cerclage wire are fundamental and effective strategies to aid and maintain reduction in reverse oblique fracture to improve outcome ( 35 – 37 ). The advantage of clamp-assisted open reduction lies in its ability to restore anatomical alignment and facilitate reduction ( 37 , 38 ). However, the nature of the fracture presents certain challenges. In particular, the lag screw frequently traverses or aligns parallel to the fracture site, resulting in a compromised fixation strength and a less robust connection between the proximal and distal fragments. This inherent characteristic may contribute to postoperative fracture displacement (Fig. 5 ). Furthermore, a significant concern is the possible interference between the insertion of head-neck screws and the clamping process ( 37 ). Cerclage wire has been extensively discussed in the literature, highlighting its role in providing additional stability to the lateral and posterior medial wall when used in conjunction with a CMN ( 35 , 36 ). Cerclage wire is associated with shorter union time and reduced prevalence of varus reduction and overall complications compared with CMN alone ( 39 ). However, it is crucial to recognize that not all fracture patterns are suitable for cerclage wiring. Long oblique, spiral, and spiral wedge configurations are identified as more suitable fracture patterns for the application of cerclage wiring, as highlighted in previous studies ( 40 ). From our clinical experience, patients with characteristics such as obesity and a large caliber femur, a high fracture apex, and posteromedial comminution pose challenges in achieving optimal fixation with the use of cerclage wire. Consequently, in such cases, plate augmentation emerges as a valuable alternative in the armamentarium available to treating surgeons. Several studies have found that the augmentation plate leads to a higher union rate and shorter union time compared to the exchange of nails for aseptic nonunion of the femoral shaft aseptic nonunion ( 41 , 42 ). This suggests that an augmentation plate could also be a valuable adjunct in the treatment of challenging reverse oblique fractures. However, unlike the extensive discussions of cerclage wire, there is a paucity of literature on the use of plates as an adjunct to CMN in the treatment of reverse oblique fractures. In our study, all 12 fractures in the plate augmentation group achieved union in 3 months, including six cases (50%) classified as 31A3.3 fractures. This finding is notable, as 31A3.3 fractures are typically associated with delayed healing due to their inherent instability and the high degree of comminution( 4 ). Previous studies have reported mean union times for 31A3 fractures treated with intramedullary nailing ranging from 4 to 6.5 months, and some cases requiring even longer durations( 4 , 16 , 43 ). The shorter union time observed in our plate augmentation group may be attributed to the enhanced stability and fracture reduction provided by the side plate, which likely improved alignment and reduced micromotion at the fracture site. Wang et al. introduced a five-point stability theory aimed at restoring lateral wall integrity for unstable intertrochanteric fractures by combining the intramedullary nail (IMN) with a reconstruction plate ( 44 ) This innovative concept is based on the established three-point stability theory ( 45 ). The addition of two additional fixation points improves the connection between the proximal bone mass and the distal femoral shaft, resulting in a more stable structure (Fig. 6 ). This modification has shown advantages, including shorter healing times and a reduced fixation failure rate compared to IMN alone. Unlike the approach of Wang et al., our surgical technique adopts the initial application of the plate prior to the application of CMN. We ensure anatomical reduction of the fractured lateral wall with the assistance of fluoroscopy and palpation of the fracture ends. Frequently, when the proximal fragment exhibits abduction despite traction and rotational adjustments on the fracture table, a ball spike pusher or bone hook is used to facilitate reduction. This reduction is then maintained or achieved by the application of a prebent reconstruction plate, contoured to match the curvature of the vastus tubercle to the femoral shaft distal to the fracture apex through compression. These plates serve a dual purpose. First, they facilitate the anatomical reduction of the fractured lateral wall by acting as a reduction tool. This is achieved by contouring the plate to match the curvature of the vastus tubercle and the femoral shaft distal to the fracture apex, allowing for compression and alignment of the fracture ends. Second, the plate temporarily maintains the reduction by acting as a lateral wall buttress when placing over the apex of the lateral wall spike. This ensures stability during the subsequent application of the CMN, which serves as the definitive fixation construct. It is imperative to position the plate slightly anterior to the lateral aspect of the femur to prevent interference with the path of the lag screw (Fig. 7 ). Lo et al. published a retrospective series of 21 cases of subtrochanteric fracture nonunion treated with IMN with side plate augmentation fixation, all patients united with well without major complication. They emphasize the rigid fixation construct both rotationally and axially to provide an optimal mechanical environment for nonunion to heal( 46 ). For simple transverse fractures (OTA/AO 31A3.2), the unique property of the distal-lateral to proximal-medial fracture plane, which characterizes reverse oblique fractures, is absent. This fracture pattern does not provide the ideal geometry for assessing reduction or for utilizing plate buttressing as an adjunct. Therefore, OTA/AO 31A3.2 fractures were excluded from our cohort. For these fracture patterns, when optimal reduction cannot be achieved, the authors prefer the use of a blocking screw or pin to facilitate reduction. The main result of our study reveals that the plate group exhibited superior reduction quality and shorter union time compared to the cerclage and CMN groups (p < 0.01). Although the difference did not achieve clinical significance (p = 0.08), a higher incidence of reduction loss was observed in the CMN group (N = 7, 25.9%) compared to the cerclage (N = 1, 6.7%) and plate (N = 0, 0%) groups. The Parker’s ratio exhibited statistical variance among the three groups, with CMN (48.5) > cerclage (45.4) > plate (40.6), which could serve as a confounding factor in our primary findings given the preference for an inferior placement of the lag screw to mitigate the risk of cut-out( 29 , 30 ). However, the multivariate analysis still demonstrated the advantageous outcomes associated with the plate in terms of reduction quality and union time. We consider that the enhanced reduction quality achieved by the plate facilitates the placement of the lag screw in a lower position near the calcar femoris, which contributes to the reduction of the Parker’s ratio. Our data showed significant interrelationships between reduction quality, union time, and the appearance of loss of reduction within the studied cohort. Specifically, superior reduction quality correlates with a lower probability of loss of reduction (p = 0.02). Furthermore, the occurrence of loss of reduction is notably associated with a prolonged union time, whereas better reduction quality demonstrates an association with decreased union time. These findings underscored the critical importance of effective and timely reduction strategies in promoting favorable clinical outcomes, particularly as early weight-bearing protocols are pursued to reduce complications( 47 ) No significant differences were observed between the groups regarding fixation failure and reoperation rates, which can be attributed to the limitations inherent in our study, including a small cohort size and the refusal of the patients to undergo reoperation. However, multiple studies have shown that poor reduction quality is related to fixation failure ( 20 , 48 , 49 ) . In our perspective, ensuring adequate fracture reduction and stable fixation represents the cornerstone of a successful operation rather than the specific implant used in conjunction with CMN. A study addressing the role of cerclage wiring in reverse oblique fractures observed that cerclage wire effectively improves the stiffness of the construction when anatomical reduction is achieved, while its efficacy diminishes when anatomical reduction is not achieved( 50 ). In contrast to the benefits associated with improved reduction quality and reduced union time achieved by plate reinforcement, there is an unavoidable increase in cost, operation time and blood loss, as evidenced by previous studies ( 44 , 51 ). While our study did not directly investigate this comparison, it is worth noting that plate reinforcement may require a larger incision and more soft tissue dissection, even when applied meticulously. Theoretically, this increased invasiveness may increase the risk of infection. However, no infections were observed in our cohort. The present study is not without limitations. First, due to the relative rarity of reverse oblique fractures and the fact that plate fixation remains a preliminary fixation method, most surgeons continue to use traditional techniques. This contributed to the relatively small sample size, particularly in the plate group, which may restrict the generalizability of the results. Second, the retrospective nature of the study design introduces inherent biases and limitations. Third, while radiological evaluation provided valuable insights into fracture reduction and union, the lack of biomechanical assessments and functional outcome measures constitutes a notable limitation. Conclusions In conclusion, incorporating a side plate into the standard cephalomedullary nail appears to offer better reduction quality, reduced incidence of varus collapse, and reduced union time compared to cerclage wire or a cephalomedullary nail alone in the treatment of reverse oblique fracture patterns. In cases where fracture reduction proves challenging or technically unattainable via closed reduction techniques, mini-open clamp assistance, or cerclage wire, the use of a side plate presents a viable alternative for treating surgeons managing such complex fracture patterns. These findings may serve as a foundation for future research, encouraging larger prospective studies to further evaluate the efficacy of this approach. Abbreviations SHS Sliding Hip Screw IMN Intramedullary Nail CMN Cephalomedullary Nail TAD Tip Apex Distance NSA Neck Shaft Angle BMI Body Mass Index OTA/AO Orthopedic Trauma Association/Association for Osteosynthesis AP Anteroposterior (X-ray view) Declarations Ethics approval and consent to participate This study was exempted from a full ethical review and was approved by the Changhua Christian Hospital Institutional Review Board, approval number 230325. The Changhua Christian Hospital Institution Review Board waived the requirement of informed consent based on Taiwan’s Human Subjects Research Act. Consent for publications Not applicable Funding No fund was received for this study Author Contribution Chiu-Yu Shih: Study design, Data collection, Writing – Original Draft, major revision Chih-Hui Chen: Study design, Validation, Writing – Review & EditingSung Yeh Yang: Data collection, Data visualizationYu-Cheng Lo: Writing – Review & Editing, Study supervisionYu-Jun Chang: Methodology, Software development, Statistical analyses, Data curationChiung-Chiung Chang: Data collectionHui-Chen Huang: Data collectionI-Ching Kuo: Data collectionShu-O Huang: Data collectionPao-Kuei Lee: Data collectionYun-Yi Huang: Data collection Acknowledgement We extend our gratitude to Professor Huang Chun-Hsiung for valuable instructions. 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Does augmentation of intramedullary nails by a buttress plate effectively restore lateral wall integrity in intertrochanteric fractures. Int Orthop. 2022;46(10):2365–71. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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07:43:30","extension":"png","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":87542,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5074439/v1/8ca4122a7f1e1ddec2f05566.png"},{"id":95223253,"identity":"213b040d-21aa-41eb-98f0-d92156544c9a","added_by":"auto","created_at":"2025-11-05 16:21:55","extension":"png","order_by":23,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":158589,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5074439/v1/99f869699a13aaaa8bed88ae.png"},{"id":95087846,"identity":"5d2f03b3-edf9-4446-9b97-811aed3eafaf","added_by":"auto","created_at":"2025-11-04 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16:21:34","extension":"png","order_by":28,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":29716,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefigure4.png","url":"https://assets-eu.researchsquare.com/files/rs-5074439/v1/6b8c2489fca7e787adc5baf9.png"},{"id":95087839,"identity":"248ba7c7-def2-44c4-9854-e7549e6378b4","added_by":"auto","created_at":"2025-11-04 07:43:30","extension":"xml","order_by":29,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":173225,"visible":true,"origin":"","legend":"","description":"","filename":"bb27c3f279414fb2b4cc474f18884e9d1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-5074439/v1/0bc195515355a13dd895e4a5.xml"},{"id":95087847,"identity":"de572dbb-32c1-483d-b405-15279ef17d67","added_by":"auto","created_at":"2025-11-04 07:43:30","extension":"html","order_by":30,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":185658,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-5074439/v1/fbe7b5688534ff3c13d5be86.html"},{"id":95087820,"identity":"018fa05f-f485-4ef9-9a98-9f46999a7ca4","added_by":"auto","created_at":"2025-11-04 07:43:29","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":366604,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Abduction and external rotation of the proximal fragment.\u003c/p\u003e\n\u003cp\u003e(b) Malreduction with varus alignment after cephalomedullary nail insertion.\u003c/p\u003e","description":"","filename":"Figure1.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5074439/v1/41d30c2ce15ec4e198d0b9cb.jpg"},{"id":95224522,"identity":"325c355f-90d0-441c-8148-fc38ddcef562","added_by":"auto","created_at":"2025-11-05 16:23:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":596567,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Preoperative radiograph of a 58-year-old male with reverse oblique fracture after traffic accident\u003c/p\u003e\n\u003cp\u003e(b) AP view of intraoperative fluoroscopy with cephalomedullary nail and side plate\u003c/p\u003e\n\u003cp\u003e(c) Lateral view of intraoperative fluoroscopy with cephalomedullary nail and side plate\u003c/p\u003e\n\u003cp\u003e(d) Postoperative radiograph with cephalomedullary nail and side plate\u003c/p\u003e","description":"","filename":"Figure2.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5074439/v1/303edf5fe5810efff5336b8f.jpg"},{"id":95224944,"identity":"573687ee-ba5f-4a33-9fd0-0d46566b4978","added_by":"auto","created_at":"2025-11-05 16:24:28","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":654687,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Preoperative radiograph of a 47-year-old male with reverse oblique fracture after traffic accident\u003c/p\u003e\n\u003cp\u003e(b) Postoperative radiograph with cephalomedullary nail and cerclage wire\u003c/p\u003e\n\u003cp\u003ePostoperative radiograph with cephalomedullary nail and cerclage wire\u003c/p\u003e","description":"","filename":"Figure3.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5074439/v1/fbb8b43bb8a16d444b2fe62e.jpg"},{"id":95224461,"identity":"5dfb5854-a0bc-4e04-a4d4-7d1efbac6de4","added_by":"auto","created_at":"2025-11-05 16:23:47","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":439833,"visible":true,"origin":"","legend":"\u003cp\u003eThe Recruitment Algorithm\u003c/p\u003e","description":"","filename":"figure4.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5074439/v1/1e70aa6c53ae0cc89c7d86d9.jpg"},{"id":95087822,"identity":"fdcacb47-de38-47e6-b923-bdbf2b752b25","added_by":"auto","created_at":"2025-11-04 07:43:29","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":364039,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Preoperative radiograph of a 94-year-old female with reverse oblique fracture after a fall\u003c/p\u003e\n\u003cp\u003e(b) Intraoperative fluoroscopy with mini-open clamp-assisted reduction and cephalomedullary nail\u003c/p\u003e\n\u003cp\u003e(c) The postoperative radiograph showed a subsequent loss of reduction with displacement.\u003c/p\u003e\n\u003cp\u003e(d) The postoperative radiograph showed a subsequent loss of reduction with displacement.\u003c/p\u003e","description":"","filename":"Figure5.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5074439/v1/6bfab9118f2e239e9b45f9f9.jpg"},{"id":95087825,"identity":"4c89cde3-b8f9-4cb2-babf-9b1a22a10746","added_by":"auto","created_at":"2025-11-04 07:43:29","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":371047,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Preoperative radiograph of a 79-year-old female with reverse oblique fracture after a fall\u003c/p\u003e\n\u003cp\u003e(b) Postoperative radiograph with cephalomedullary nail and side plate. Point A (the head of the lag screw), point B (the nail at the entrance of greater trochanter) and point C (lag screw at the entrance of the lateral wall) are the established three-point theory.\u003c/p\u003e\n\u003cp\u003e(c) Postoperative radiograph with cephalomedullary nail and side plate. Point E (proximal fixation point of the side plate) and point F (distal fixation point of the side plate) along with point A, B and C form the five-point stability theory\u003c/p\u003e","description":"","filename":"Figure6.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5074439/v1/c3a8ac69f8fb3f6eba7c0f44.jpg"},{"id":95087844,"identity":"69b284a3-d351-4615-829d-4862bfd44290","added_by":"auto","created_at":"2025-11-04 07:43:30","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":407205,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Preoperative radiograph of a 25-year-old male with reverse oblique fracture after traffic accident\u003c/p\u003e\n\u003cp\u003e(b) Postoperative radiograph with cephalomedullary nail and side plate\u003c/p\u003e\n\u003cp\u003e(c) Lateral view of intraoperative fluoroscopy with cephalomedullary nail and side plate, the plate was placed slightly anterior to the lateral aspect of the femur to prevent interference with the insertion of the lag screw.\u003c/p\u003e","description":"","filename":"Figure7.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5074439/v1/0923bf10da2419b4d63e6dc3.jpg"},{"id":107522446,"identity":"5bde5c0e-1bd1-4823-833d-1ac94ce77b5b","added_by":"auto","created_at":"2026-04-22 09:13:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3865696,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5074439/v1/c84a0f1f-20fe-4f1b-854f-33d50a8248d1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Enhancing Reduction Quality and Union Time in Reverse Oblique Intertrochanteric Femur Fractures: A Comparative Analysis of Cephalomedullary nail with Side Plate Augmentation","fulltext":[{"header":"Background","content":"\u003cp\u003eThe reverse oblique fracture, comprising approximately 2–23% of all intertrochanteric fractures, is characterized by a major fracture line that extends from the distal lateral to proximal medial regions (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This type of fracture is particularly notable due to the elevated stress concentration in the anatomical area. The deforming forces originate from the abductors of the hip and short external rotators, which are inserted into the greater trochanter. Additionally, tension from the iliacus and psoas muscles affects the lesser trochanter. Biomechanically, these result in abduction, flexion, and external rotation of the proximal fragment, while the adductor muscles acting on the distal fragment contribute to shortening. The overall presentation of the fracture site reveals varus and apex anterior deformities(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Therefore, a high rate of malreduction and subsequent varus collapse or shaft medialization have been observed in the treatment of reverse oblique fractures(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eTraditionally, the sliding hip screw (SHS) has been widely used as the primary implant for the treatment of intertrochanteric fractures. However, several investigations have raised concerns about its suitability for 31A3 fractures when considering biomechanical factors (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e–\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Studies have shown a higher failure rate associated with the use of SHS in the treatment of reverse oblique fractures compared to intramedullary nail (IMN) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Two comprehensive studies, drawing data from the Norway Hip Fracture Register, revealed a higher reoperation rate in cases treated with SHS as opposed to IMN (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWith decreased lever arm leading to better stability and effectively preventing lateral sliding of the proximal fragment as well as shaft medialization (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), modern cephalomedullary nail (CMN) treatment has shown a favorable result compared to SHS and is considered more suitable in managing 31A3 fractures (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Despite these advantages, it should be noted that even with CMN, a significant cut-out rate persists in the context of reverse oblique fractures, resulting in substantial pain and arthritis(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Studies have shown that poor reduction quality is significantly related with fixation failure (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e–\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Therefore, avoiding malreduction becomes a paramount consideration in the management of this challenging fracture pattern. To address this, various adjunctive techniques have been proposed, including open clamp-assisted reduction, cerclage wires and minifragment plate (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn this retrospective study, patients with reverse oblique fractures who underwent treatment with either CMN alone, CMN with side plate, or CMN with cerclage wire were examined. The objective was to assess and compare reduction quality, the incidence of reduction loss, time to union and complications between these three treatment groups. We hypothesize that the treatment of reverse oblique fractures with CMN with side plate will result in improved reduction quality, reduced incidence of reduction loss, and faster time to union compared to CMN alone or CMN with cerclage wire.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe retrospective comparative study included 54 patients presented to our institution from January 2015 to December 2020 with a reverse oblique intertrochanteric fracture. Inclusion criteria were patients older than 18 years with a radiologically diagnosed reverse oblique fracture classified as 31A3.1 and 31A3.3 according to OTA/AO Fracture and Dislocation Classification Compendium-2018, with the major fracture line running from distal-lateral to proximal medial. The patients were treated with a cephalomedullary nail (CMN). Exclusion criteria were pathological fractures, open fractures, previous ipsilateral hip surgery, segmental fracture and patients’ follow-up less than 2 years. Patients with a simple transverse fracture line classified as 31A3.2 were also excluded.\u003c/p\u003e\u003cp\u003eThree different groups were defined. The first group was treated with CMN using a closed, percutaneous or mini open reduction maneuver. The second group was treated with CMN and a side plate. The third group was treated with CMN and cerclage wire. The patients were classified into each group according to the postoperative radiograph, determined by the treating surgeons.\u003c/p\u003e\u003cp\u003eDemographic data including age, sex, BMI, side of the fracture, and smoking status were recorded. Fractures were classified according to the Orthopedic Trauma Association classification. Union was determined by evaluating the standard orthogonal radiograph during clinical follow-up. Union was defined as the presence of bridging bone callus over at least three cortices in two orthogonal views. Nonunion was defined by the fracture line that does not show radiological union 9 months after a fracture, lack of signs of progressive healing for three consecutive months or implant breakage (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The quality of the fracture reduction was classified as good, acceptable and poor based on the modified Baumgaertner criteria. Angulation criteria were defined as normal or slight valgus alignment on AP radiograph, \u0026lt; 20° of angulation on the lateral radiograph. The displacement criterion was defined as \u0026lt; 4mm of displacement of any major fragments, excluding the lesser trochanter. Good reduction quality meets both the angulation and displacement standards. While acceptable meets only one standard, poor meets none of the standards(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eVarus collapse was measured as an indicator of a loss of reduction. It was measured by calculating the change in neck shaft angle (NSA) from intraoperative AP fluoroscopy to final follow-up AP radiograph. The neck shaft angle is calculated with the correction formula to counter different rotation. (NSA = Nail angle (130°) ×Measures NSA/Measured nail angle). Varus collapse is determined by changing \u0026gt; 5° of the NSA(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Tip Apex Distance (TAD) and Parker’s Ratio were also recorded according to the measures described in the literature. TAD represents the sum of the distances from the tip of the lag screw to the apex of the femoral head on both anteroposterior (AP) and lateral radiographs(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) and The Parker’s ratio quantifies the position of the lag screw within the femoral head by calculating the ratio of the distance from the center of the femoral head to the screw on AP and lateral views relative to the total diameter of the femoral head.(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eOrthopedic complications including fixation failure, reoperation, and wound infection were recorded. Reoperation was done due to fixation failure with lag screw cut out or nonunion. Wound infection is defined as a superficial or deep wound infection that required surgical debridement. The radiographs were reviewed by a certified orthopedic surgeon, further validated by another professional. In cases of disparity, a third qualified orthopedic surgeon performed a review, and the result was determined by the majority consensus among experts.\u003c/p\u003e\u003cp\u003e This study was exempted from a full ethical review and was approved by the Changhua Christian Hospital Institutional Review Board, approval number 230325. The Changhua Christian Hospital Institution Review Board waived the requirement of informed consent based on Taiwan’s Human Subjects Research Act.\u003c/p\u003e\u003cp\u003eOperative technique\u003c/p\u003e\u003cp\u003eThe patients were placed in a supine position on the fracture table. The uninjured leg was placed on the leg holder in hemi lithotomy position. The fractured extremity was fixed to the traction boot. A close reduction was achieved by axial traction to distract the fragments and restore length. Rotation was done until the patella was facing forward in the AP view of the knee. Fluoroscopy was used to check the reduction in both the AP and the lateral view and to fine-tune the reduction by manipulating the fractured extremity. If the reduction is considered adequate, a standard cephalomedullary nailing sequence is performed. A 5-cm incision was made proximal to the tip of the greater trochanter, in line with the femoral shaft axis. The entry point was slightly medial to the greater trochanter. A guide wire was inserted, followed by sequential reaming of the medullary canal. The nail was then inserted and secured with a lag screw, and the locking mechanism was tightened. Two distal screws were inserted using the freehand technique. Gamma3 Nail system (Stryker) or Natural Nail system (Zimmer) long nails were routinely used in 31A3 patients. No suction drains were used after surgery.\u003c/p\u003e\u003cp\u003eWhen closed reduction was inadequate, percutaneous or mini-open reduction was performed at the discretion of the surgeon. Reduction aids such as a ball-spike pusher, Hoffmann retractor, or bone clamps were applied depending on fracture morphology, in line with previously described clamp-assisted reduction techniques. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eSide plate\u003c/p\u003e\u003cp\u003eIf persistent abduction and varus angulation of the proximal head-neck segment were observed after closed reduction, an approximately 8-cm longitudinal incision was made, centered at the level of the lesser trochanter. Careful dissection was performed through the soft tissue, splitting the fascia lata and vastus lateralis to expose the fracture site. The bone surface was prepared using a periosteal elevator. Manual reduction was achieved with a bone hook or ball-spike pusher, and the fracture table was used to adjust length and rotation to obtain near-anatomical alignment.\u003c/p\u003e\u003cp\u003eA 3.5-mm small reconstruction plate (Synthes) was routinely used for augmentation. Prior to application, the plate was pre-bent to conform to the lateral curvature of the femur, spanning from the vastus tubercle proximally to the subtrochanteric region distally, and crossing the fracture site. The plate typically contained 6 to 7 holes, although the exact number varied depending on patient anatomy and fracture configuration. The plate was positioned slightly anteriorly to avoid impingement at the entry point of the lag screw. Fixation was achieved by inserting two screws proximally and two screws distally to the fracture site, providing semi-rigid, temporary stabilization and anti-rotational support prior to cephalomedullary nail insertion. The total number of screws was not standardized and was determined intraoperatively based on individual patient anatomy and fracture characteristics. After plate fixation, cephalomedullary nailing was performed as previously described (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCerclage wire\u003c/p\u003e\u003cp\u003eAn incision of about 5 cm was made proximal to the apex of the fracture. Cerclage wire was passed by using an AO wire passer. Tensioning of the cerclage wire was applied with adjustment of rotation and length through the fracture table. After the cerclage wire was applied, the CMN was inserted in the manner mentioned above. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003cp\u003ePostoperative Rehabilitation and Follow-up Protocol\u003c/p\u003e\u003cp\u003ePostoperative care followed a standardized protocol. Patients were mobilized under the supervision of a physiotherapist. The weight bearing status was determined on the basis of the patient's age and activity level. For the elderly patients, weight bearing as tolerated with walking aids was initiated the day after surgery. For younger, more active patients, initial restricted weight-bearing was required, with reassessment after 6 weeks. Patients were encouraged to perform active range-of-motion exercises for the hip and knee starting on the first postoperative day. However, slight modifications to the standard protocol may be made based on the patient’s condition, treating surgeon, and physiotherapist.\u003c/p\u003e\u003cp\u003eFollow-up visits were scheduled at regular intervals to monitor clinical and radiographic progress. The first follow-up was carried out at 2 weeks postoperatively, followed by visits every 6 weeks until fracture union was achieved. After union, follow-up continued at three-month intervals during the first year and then at six-month intervals until the two-year mark. At the 2-year follow-up, patients were routinely asked to return for clinical and radiographic evaluation. If no specific events or complications were identified at the two-year mark, follow-up was concluded.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eDue to the small sample size in this study, continuous variables are presented as medians and interquartile ranges, while categorical variables are presented as numbers and percentages. The Kruskal Wallis test was used to compare the medians of continuous variables between groups, while the chi-square test or Fisher's exact test was used for categorical variables. Post-hoc pairwise comparisons were performed using Bonferroni correction to adjust for multiple comparisons. In addition, bivariable and multivariable Firth logistic regression analyzes were conducted to identify factors significantly associated with union time ≤ 3 months. All data were analyzed using the IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY). P-values \u0026lt; 0.05 were considered statistically significant.\u003c/p\u003e\u003cp\u003eSample size estimation\u003c/p\u003e\u003cp\u003eSample size estimation was performed a priori based on the assumption that the expected proportions of patients achieving union time ≤ 3 months would be 3%, 10%, and 90% in the CMN alone, CMN with cerclage, and CMN with plate groups, respectively, with an allocation ratio of 2:1:1. Using a 2×3 Pearson chi-square test with a significance level of α = 0.05 and power of 0.80, the minimum required sample size was calculated to be 14 participants (7, 4, and 3 in each group). To account for potential random error and the need for covariate adjustment in regression analyses, additional participants were recruited, resulting in a final study population of 54 patients (27, 15, and 12 in each group, respectively). All calculations were performed in R version 4.4.1 using the pwr package.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAfter applying the inclusion criteria, 68 patients were initially identified. Five patients were excluded based on the following exclusion criteria: pathological fracture (n\u0026thinsp;=\u0026thinsp;1), open fracture (n\u0026thinsp;=\u0026thinsp;1), previous ipsilateral hip surgery (n\u0026thinsp;=\u0026thinsp;2), and segmental fracture (n\u0026thinsp;=\u0026thinsp;1). Additionally, 8 patients were lost to follow-up. Among the eight patients lost to follow-up, two were confirmed deceased due to unrelated medical conditions, six reported no sequelae and chose not to return. Leaving a study population of 55 patients. However, one patient in the cerclage wire group underwent revision surgery and was converted to total hip arthroplasty one month after surgery due to lag screw cut out. Although the patient had acceptable reduction quality, a TAD of 32 mm and a Parker\u0026rsquo;s AP ratio of 62.1 likely contributed to the fixation failure, as supported by previous literature(\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Given these interfering factors, the patient was excluded from the cohort analysis. This exclusion ensures that the analysis of union time and its correlation with other factors is not confounded by this early fixation failure, which is considered a separate mechanical complication rather than a case of nonunion. Therefore, the final study population consisted of 54 patients, with a mean age of 68.6 years. The Recruitment Algorithm is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThere were no significant differences in demographic parameters with respect to age, height, sex, BMI, side of the fracture, and smoking status between each group. There were no significant differences with respect to the type of fracture according to the AO classification and TAD. Parker\u0026rsquo;s ratio exhibited a higher median value in the CMN group (median\u0026thinsp;=\u0026thinsp;48.6) compared to both the cerclage group (median\u0026thinsp;=\u0026thinsp;45.9) and the plate group (median\u0026thinsp;=\u0026thinsp;38.1), reaching statistical significance (p\u0026thinsp;=\u0026thinsp;0.028). The plate group demonstrated superior results in terms of reduction quality (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and significantly reduced union time, compared to the other groups. There were no significant differences in the postoperative NSA, the last follow NSA and NSA change. A trend emerged, although statistically not significant (p\u0026thinsp;=\u0026thinsp;0.088), indicating a higher incidence of loss of reduction (△NSA\u0026thinsp;\u0026gt;\u0026thinsp;5\u0026deg;) in the CMN group (N\u0026thinsp;=\u0026thinsp;7, 25.9%) compared to the cerclage group (N\u0026thinsp;=\u0026thinsp;1, 6.7%) and the plate group (N\u0026thinsp;=\u0026thinsp;0, 0%). Detailed results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe demographics and clinical characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"12\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c10\" namest=\"c5\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eCMN\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003eCerclage\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003ePlate\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003ePost Hoc Test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e70.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e53.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e50.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.372\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e29.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e46.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e50.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e92.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e96.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e80.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.113\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e20.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAO classification\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31A3.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e40.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e26.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e50.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.448\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31A3.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e59.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e73.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e50.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSide of the fracture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e59.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e53.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e41.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.596\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e40.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e46.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e58.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReduction quality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAcceptable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e59.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e70.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e73.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eCMN, Cerclage\u0026thinsp;\u0026gt;\u0026thinsp;Plate\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e20.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e83.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eCMN, Cerclage\u0026thinsp;\u0026lt;\u0026thinsp;Plate\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLoss of reduction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e74.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e93.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.088\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnion time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u0026ndash;3 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e13.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eCMN, Cerclage\u0026thinsp;\u0026lt;\u0026thinsp;Plate\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u0026ndash;6 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e44.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e66.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eCMN, Cerclage\u0026thinsp;\u0026gt;\u0026thinsp;Plate\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;6 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e44.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eCMN, Cerclage\u0026thinsp;\u0026gt;\u0026thinsp;Plate\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot healed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e13.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"12\" nameend=\"c12\" namest=\"c1\"\u003e\u003cp\u003eP-value by chi-square test or Fisher's exact test when appropriate, along with Bonferroni correction for multiple paired comparisons.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of measurement results between groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eCMN (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eCerclage (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003ePlate (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003ePost Hoc\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIQR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIQR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eIQR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eTests\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.0\u0026ndash;88.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e64.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e42.0\u0026ndash;86.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e72.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e56.0\u0026ndash;83.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.448\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight(cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e160.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e152.0\u0026ndash;164.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e158.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e153.0\u0026ndash;170.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e164.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e151.0\u0026ndash;170.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.816\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody weight(kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.9\u0026ndash;67.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e63.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e51.0\u0026ndash;73.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e63.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e55.0\u0026ndash;69.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.662\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.7\u0026ndash;28.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.8\u0026ndash;28.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e23.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e22.2\u0026ndash;27.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.928\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-op NSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e133.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e130.4\u0026ndash;135.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e132.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e126.4\u0026ndash;141.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e133.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e128.9\u0026ndash;137.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.917\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLast follow-up NSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e132.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e128.2\u0026ndash;133.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e129.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e123.6\u0026ndash;136.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e132.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e128.0\u0026ndash;136.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.747\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNSA change\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-1.3\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-5.8 - -0.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-3.8\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-4.5 - -1.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-2.4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-3.9\u0026ndash;0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.496\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTAD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.8\u0026ndash;25.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19.1\u0026ndash;29.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e23.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e19.5\u0026ndash;26.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.752\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParker\u0026rsquo;s ratio\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.0\u0026ndash;56.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e39.9\u0026ndash;51.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e38.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e36.5\u0026ndash;46.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.028\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eCMN\u0026thinsp;\u0026gt;\u0026thinsp;Plate\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003eIQR: interquartile range; P-value by Kruskal Wallis Test; Bonferroni correction for multiple paired comparisons.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eReduction quality, Union time and Loss of reduction\u003c/p\u003e\u003cp\u003eAmong the patients, 3 out of 7 with poor reduction quality and 5 out of 32 with acceptable reduction quality experienced loss of reduction. None of the 15 patients with good reduction quality encountered loss of reduction, demonstrating a statistically significant association between better reduction quality and reduced incidences of loss of reduction (p\u0026thinsp;=\u0026thinsp;0.02).\u003c/p\u003e\u003cp\u003eRegarding the time of union, among the 8 patients experiencing loss of reduction, 3 were classified into the \u0026gt;\u0026thinsp;6 months, while 3 resulted in nonunion. On the contrary, among patients without loss of reduction, the majority achieved healing in 6 months, with 15 of 46 patients in 1\u0026ndash;3 months and 20 of 46 patients in 4\u0026ndash;6 months. This indicated a statistically significant association between loss of reduction and prolonged union time (p\u0026thinsp;=\u0026thinsp;0.003).\u003c/p\u003e\u003cp\u003eA significant association (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) was observed between reduction quality and union time. In particular, 80% of the cases with good reduction quality achieved union within 1 to 3 months. On the contrary, cases with poor reduction quality predominantly experienced union times exceeding 6 months or end up with nonunion (85.7%).\u003c/p\u003e\u003cp\u003eThe detailed results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eReduction quality, union time, and loss of reduction\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"19\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c18\" colnum=\"18\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c19\" colnum=\"19\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c9\" namest=\"c4\"\u003e\u003cp\u003eReduction quality\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"8\" nameend=\"c18\" namest=\"c11\"\u003e\u003cp\u003eUnion time\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eAcceptable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u003cp\u003e1\u0026ndash;3 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e4\u0026ndash;6\u003c/p\u003e\u003cp\u003emonths\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;6\u003c/p\u003e \u003cp\u003emonths\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\u003cp\u003eNon-union\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLoss of reduction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e58.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e32.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e32.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e43.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e21.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e62.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e25.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e37.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e37.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReduction quality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAcceptable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e9.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e56.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e31.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e3.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e80.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e20.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnion time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u0026ndash;3 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e20.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e80.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u0026ndash;6 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e81.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e13.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;6 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e76.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-union\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e25.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"19\" nameend=\"c19\" namest=\"c1\"\u003e\u003cp\u003eP-value by Fisher\u0026rsquo;s exact test.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn the bivariate analysis, age, TAD, NSA change, and AO classification did not show significant associations with the likelihood that union time would be \u0026lt;\u0026thinsp;3 months. In particular, a significant negative association (p\u0026thinsp;=\u0026thinsp;0.011) was observed with the Parker's ratio. Furthermore, compared to the CMN reference category, the Plate group showed a significant association (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) with higher odds of achieving union time\u0026thinsp;\u0026lt;\u0026thinsp;3 months, while the Cerclage group did not exhibit significance.\u003c/p\u003e\u003cp\u003eUpon conducting a multivariate analysis while adjusting for other factors, the impact of Parkers Ratio lost its significance (p\u0026thinsp;=\u0026thinsp;0.734). This suggests possible confounding effects from other variables influencing this relationship. Despite this, the Plate group maintained a highly significant association (p\u0026thinsp;=\u0026thinsp;0.001) with higher odds of achieving union time\u0026thinsp;\u0026le;\u0026thinsp;3 months, emphasizing its substantial influence even after considering other factors.\u003c/p\u003e\u003cp\u003eThe detailed results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFirth logistic regression analysis of union time not exceeding 3 months\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003eBivariable analysis (crude)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eMultivariable analysis (adjusted)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOdds ratio\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOdds ratio\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.974\u0026ndash;1.030\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.931\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.959\u0026ndash;1.048\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.907\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTAD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.909\u0026ndash;1.120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.868\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.986\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.842\u0026ndash;1.156\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.866\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParkers ratio\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.882\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.802\u0026ndash;0.971\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.011\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.981\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.875\u0026ndash;1.098\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.734\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNSA change\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.162\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.963\u0026ndash;1.403\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.117\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.062\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.836\u0026ndash;1.348\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.621\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAO classification\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31A3.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31A3.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.640\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.191\u0026ndash;2.140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.469\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.961\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.161\u0026ndash;5.749\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.965\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCMN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCerclage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.272\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.37\u0026ndash;28.917\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.286\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.576\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.259\u0026ndash;9.602\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.622\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePlate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e441.674\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.954\u0026ndash;999.999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e77.958\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5.886\u0026ndash;999.999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eTAD\u0026thinsp;=\u0026thinsp;Tip Apex Distance, NSA\u0026thinsp;=\u0026thinsp;Neck Shaft Angle, CMN\u0026thinsp;=\u0026thinsp;cephalomedullary nail\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eComplications\u003c/p\u003e\u003cp\u003eOne patient in the cerclage wire group experienced fixation failure due to poor TAD and Parker\u0026rsquo;s AP ratio and was excluded from the study cohort, as discussed earlier. Four patients had radiographic nonunion, but refused reoperation due to good clinical tolerance and the restricted requirement for ambulation. There were no wound infections that required surgical intervention in our cohort.\u003c/p\u003e\u003cp\u003eThe complications are presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOrthopedic complications\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplications\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFixation failure\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRe-operation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWound infection\u003c/p\u003e\u003cp\u003e(superficial or deep)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of patients\u003c/p\u003e\u003cp\u003e(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe primary finding of our study suggested that incorporating a side plate along the standard cephalomedullary nail (CMN) yields superior reduction quality and shorter union time compared to cerclage wire with CMN or CMN alone in the management of reverse oblique intertrochanteric fractures.\u003c/p\u003e\u003cp\u003eThe management of reverse oblique fracture remains a challenge and a topic of significant clinical interest among treating physician (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). The prevalence of malalignment has been observed to be high when closely treated, leading to complications such as nonunion, malunion, and fixation failure. Therefore, an open reduction becomes necessary(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Reviewing the literature, clamp-assisted open reduction and cerclage wire are fundamental and effective strategies to aid and maintain reduction in reverse oblique fracture to improve outcome (\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe advantage of clamp-assisted open reduction lies in its ability to restore anatomical alignment and facilitate reduction (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). However, the nature of the fracture presents certain challenges. In particular, the lag screw frequently traverses or aligns parallel to the fracture site, resulting in a compromised fixation strength and a less robust connection between the proximal and distal fragments. This inherent characteristic may contribute to postoperative fracture displacement (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Furthermore, a significant concern is the possible interference between the insertion of head-neck screws and the clamping process (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eCerclage wire has been extensively discussed in the literature, highlighting its role in providing additional stability to the lateral and posterior medial wall when used in conjunction with a CMN (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Cerclage wire is associated with shorter union time and reduced prevalence of varus reduction and overall complications compared with CMN alone (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). However, it is crucial to recognize that not all fracture patterns are suitable for cerclage wiring. Long oblique, spiral, and spiral wedge configurations are identified as more suitable fracture patterns for the application of cerclage wiring, as highlighted in previous studies (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). From our clinical experience, patients with characteristics such as obesity and a large caliber femur, a high fracture apex, and posteromedial comminution pose challenges in achieving optimal fixation with the use of cerclage wire. Consequently, in such cases, plate augmentation emerges as a valuable alternative in the armamentarium available to treating surgeons.\u003c/p\u003e\u003cp\u003eSeveral studies have found that the augmentation plate leads to a higher union rate and shorter union time compared to the exchange of nails for aseptic nonunion of the femoral shaft aseptic nonunion (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). This suggests that an augmentation plate could also be a valuable adjunct in the treatment of challenging reverse oblique fractures. However, unlike the extensive discussions of cerclage wire, there is a paucity of literature on the use of plates as an adjunct to CMN in the treatment of reverse oblique fractures.\u003c/p\u003e\u003cp\u003eIn our study, all 12 fractures in the plate augmentation group achieved union in 3 months, including six cases (50%) classified as 31A3.3 fractures. This finding is notable, as 31A3.3 fractures are typically associated with delayed healing due to their inherent instability and the high degree of comminution(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Previous studies have reported mean union times for 31A3 fractures treated with intramedullary nailing ranging from 4 to 6.5 months, and some cases requiring even longer durations(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). The shorter union time observed in our plate augmentation group may be attributed to the enhanced stability and fracture reduction provided by the side plate, which likely improved alignment and reduced micromotion at the fracture site. Wang et al. introduced a five-point stability theory aimed at restoring lateral wall integrity for unstable intertrochanteric fractures by combining the intramedullary nail (IMN) with a reconstruction plate (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) This innovative concept is based on the established three-point stability theory (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). The addition of two additional fixation points improves the connection between the proximal bone mass and the distal femoral shaft, resulting in a more stable structure (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). This modification has shown advantages, including shorter healing times and a reduced fixation failure rate compared to IMN alone.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eUnlike the approach of Wang et al., our surgical technique adopts the initial application of the plate prior to the application of CMN. We ensure anatomical reduction of the fractured lateral wall with the assistance of fluoroscopy and palpation of the fracture ends. Frequently, when the proximal fragment exhibits abduction despite traction and rotational adjustments on the fracture table, a ball spike pusher or bone hook is used to facilitate reduction. This reduction is then maintained or achieved by the application of a prebent reconstruction plate, contoured to match the curvature of the vastus tubercle to the femoral shaft distal to the fracture apex through compression. These plates serve a dual purpose. First, they facilitate the anatomical reduction of the fractured lateral wall by acting as a reduction tool. This is achieved by contouring the plate to match the curvature of the vastus tubercle and the femoral shaft distal to the fracture apex, allowing for compression and alignment of the fracture ends. Second, the plate temporarily maintains the reduction by acting as a lateral wall buttress when placing over the apex of the lateral wall spike. This ensures stability during the subsequent application of the CMN, which serves as the definitive fixation construct. It is imperative to position the plate slightly anterior to the lateral aspect of the femur to prevent interference with the path of the lag screw (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). Lo et al. published a retrospective series of 21 cases of subtrochanteric fracture nonunion treated with IMN with side plate augmentation fixation, all patients united with well without major complication. They emphasize the rigid fixation construct both rotationally and axially to provide an optimal mechanical environment for nonunion to heal(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFor simple transverse fractures (OTA/AO 31A3.2), the unique property of the distal-lateral to proximal-medial fracture plane, which characterizes reverse oblique fractures, is absent. This fracture pattern does not provide the ideal geometry for assessing reduction or for utilizing plate buttressing as an adjunct. Therefore, OTA/AO 31A3.2 fractures were excluded from our cohort. For these fracture patterns, when optimal reduction cannot be achieved, the authors prefer the use of a blocking screw or pin to facilitate reduction.\u003c/p\u003e\u003cp\u003eThe main result of our study reveals that the plate group exhibited superior reduction quality and shorter union time compared to the cerclage and CMN groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Although the difference did not achieve clinical significance (p\u0026thinsp;=\u0026thinsp;0.08), a higher incidence of reduction loss was observed in the CMN group (N\u0026thinsp;=\u0026thinsp;7, 25.9%) compared to the cerclage (N\u0026thinsp;=\u0026thinsp;1, 6.7%) and plate (N\u0026thinsp;=\u0026thinsp;0, 0%) groups. The Parker\u0026rsquo;s ratio exhibited statistical variance among the three groups, with CMN (48.5)\u0026thinsp;\u0026gt;\u0026thinsp;cerclage (45.4)\u0026thinsp;\u0026gt;\u0026thinsp;plate (40.6), which could serve as a confounding factor in our primary findings given the preference for an inferior placement of the lag screw to mitigate the risk of cut-out(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). However, the multivariate analysis still demonstrated the advantageous outcomes associated with the plate in terms of reduction quality and union time. We consider that the enhanced reduction quality achieved by the plate facilitates the placement of the lag screw in a lower position near the calcar femoris, which contributes to the reduction of the Parker\u0026rsquo;s ratio.\u003c/p\u003e\u003cp\u003eOur data showed significant interrelationships between reduction quality, union time, and the appearance of loss of reduction within the studied cohort. Specifically, superior reduction quality correlates with a lower probability of loss of reduction (p\u0026thinsp;=\u0026thinsp;0.02). Furthermore, the occurrence of loss of reduction is notably associated with a prolonged union time, whereas better reduction quality demonstrates an association with decreased union time. These findings underscored the critical importance of effective and timely reduction strategies in promoting favorable clinical outcomes, particularly as early weight-bearing protocols are pursued to reduce complications(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eNo significant differences were observed between the groups regarding fixation failure and reoperation rates, which can be attributed to the limitations inherent in our study, including a small cohort size and the refusal of the patients to undergo reoperation. However, multiple studies have shown that poor reduction quality is related to fixation failure (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e.\u003c/p\u003e\u003cp\u003eIn our perspective, ensuring adequate fracture reduction and stable fixation represents the cornerstone of a successful operation rather than the specific implant used in conjunction with CMN. A study addressing the role of cerclage wiring in reverse oblique fractures observed that cerclage wire effectively improves the stiffness of the construction when anatomical reduction is achieved, while its efficacy diminishes when anatomical reduction is not achieved(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn contrast to the benefits associated with improved reduction quality and reduced union time achieved by plate reinforcement, there is an unavoidable increase in cost, operation time and blood loss, as evidenced by previous studies (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). While our study did not directly investigate this comparison, it is worth noting that plate reinforcement may require a larger incision and more soft tissue dissection, even when applied meticulously. Theoretically, this increased invasiveness may increase the risk of infection. However, no infections were observed in our cohort.\u003c/p\u003e\u003cp\u003eThe present study is not without limitations. First, due to the relative rarity of reverse oblique fractures and the fact that plate fixation remains a preliminary fixation method, most surgeons continue to use traditional techniques. This contributed to the relatively small sample size, particularly in the plate group, which may restrict the generalizability of the results. Second, the retrospective nature of the study design introduces inherent biases and limitations. Third, while radiological evaluation provided valuable insights into fracture reduction and union, the lack of biomechanical assessments and functional outcome measures constitutes a notable limitation.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, incorporating a side plate into the standard cephalomedullary nail appears to offer better reduction quality, reduced incidence of varus collapse, and reduced union time compared to cerclage wire or a cephalomedullary nail alone in the treatment of reverse oblique fracture patterns. In cases where fracture reduction proves challenging or technically unattainable via closed reduction techniques, mini-open clamp assistance, or cerclage wire, the use of a side plate presents a viable alternative for treating surgeons managing such complex fracture patterns. These findings may serve as a foundation for future research, encouraging larger prospective studies to further evaluate the efficacy of this approach.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSHS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSliding Hip Screw\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIMN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntramedullary Nail\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCMN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCephalomedullary Nail\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTAD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTip Apex Distance\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNSA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNeck Shaft Angle\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBody Mass Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOTA/AO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOrthopedic Trauma Association/Association for Osteosynthesis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnteroposterior (X-ray view)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eThis study was exempted from a full ethical review and was approved by the Changhua Christian Hospital Institutional Review Board, approval number 230325. The Changhua Christian Hospital Institution Review Board waived the requirement of informed consent based on Taiwan\u0026rsquo;s Human Subjects Research Act.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConsent for publications\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNo fund was received for this study\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eChiu-Yu Shih: Study design, Data collection, Writing \u0026ndash; Original Draft, major revision Chih-Hui Chen: Study design, Validation, Writing \u0026ndash; Review \u0026amp; EditingSung Yeh Yang: Data collection, Data visualizationYu-Cheng Lo: Writing \u0026ndash; Review \u0026amp; Editing, Study supervisionYu-Jun Chang: Methodology, Software development, Statistical analyses, Data curationChiung-Chiung Chang: Data collectionHui-Chen Huang: Data collectionI-Ching Kuo: Data collectionShu-O Huang: Data collectionPao-Kuei Lee: Data collectionYun-Yi Huang: Data collection\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe extend our gratitude to Professor Huang Chun-Hsiung for valuable instructions.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from\u003c/p\u003e\u003cp\u003ethe corresponding author on reasonable request.\u003c/p\u003e\u003cp\u003eCompeting interests\u003c/p\u003e\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHaidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am. 2001;83(5):643\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKannus P, Parkkari J, Siev\u0026auml;nen H, Heinonen A, Vuori I, J\u0026auml;rvinen M. Epidemiology of hip fractures. Bone. 1996;18(1 Suppl):s57\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMatre K, Havelin LI, Gjertsen JE, Vinje T, Espehaug B, Fevang JM. Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the Norwegian Hip Fracture Register. Injury. 2013;44(6):735\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePark SY, Yang KH, Yoo JH, Yoon HK, Park HW. The treatment of reverse obliquity intertrochanteric fractures with the intramedullary hip nail. J Trauma. 2008;65(4):852\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGarrison I, Domingue G, Honeycutt MW. Subtrochanteric femur fractures: current review of management. EFORT Open Rev. 2021;6(2):145\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKuzyk PR, Bhandari M, McKee MD, Russell TA, Schemitsch EH. Intramedullary versus extramedullary fixation for subtrochanteric femur fractures. J Orthop Trauma. 2009;23(6):465\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKregor PJ, Obremskey WT, Kreder HJ, Swiontkowski MF. Unstable pertrochanteric femoral fractures. J Orthop Trauma. 2005;19(1):63\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchipper IB, Marti RK, van der Werken C. Unstable trochanteric femoral fractures: extramedullary or intramedullary fixation. Rev literature Injury. 2004;35(2):142\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLundy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg. 2007;15(11):663\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRahme DM, Harris IA. Intramedullary nailing versus fixed angle blade plating for subtrochanteric femoral fractures: a prospective randomised controlled trial. J Orthop Surg (Hong Kong). 2007;15(3):278\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHonkonen SE, Vihtonen K, J\u0026auml;rvinen MJ. Second-generation cephalomedullary nails in the treatment of reverse obliquity intertrochanteric fractures of the proximal femur. Injury. 2004;35(2):179\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGr\u0026oslash;nhaug KML, Dybvik E, Matre K, \u0026Ouml;stman B, Gjertsen JE. 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Reverse Oblique and Transverse Intertrochanteric Femoral Fractures Treated With the Long Cephalomedullary Nail. J Orthop Trauma. 2015;29(9):e299\u0026ndash;304.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSadowski C, L\u0026uuml;bbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a prospective, randomized study. J Bone Joint Surg Am. 2002;84(3):372\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eİmerci A, Aydogan NH, Tosun K. A comparison of the InterTan nail and proximal femoral fail antirotation in the treatment of reverse intertrochanteric femoral fractures. Acta Orthop Belg. 2018;84(2):123\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHao Y, Zhang Z, Zhou F, Ji H, Tian Y, Guo Y, et al. Risk factors for implant failure in reverse oblique and transverse intertrochanteric fractures treated with proximal femoral nail antirotation (PFNA). J Orthop Surg Res. 2019;14(1):350.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDe Bruijn K, den Hartog D, Tuinebreijer W, Roukema G. Reliability of predictors for screw cutout in intertrochanteric hip fractures. J Bone Joint Surg Am. 2012;94(14):1266\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang W, Antony Xavier RP, Decruz J, Chen YD, Park DH. Risk factors for mechanical failure of intertrochanteric fractures after fixation with proximal femoral nail antirotation (PFNA II): a study in a Southeast Asian population. Arch Orthop Trauma Surg. 2021;141(4):569\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSekimura T, Son SJ, Lee C. Reverse Obliquity Intertrochanteric Femur Fractures: Technical Tips to Avoid Failure. J Orthop Trauma. 2023;37(10s):S19\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJoglekar SB, Lindvall EM, Martirosian A. Contemporary management of subtrochanteric fractures. Orthop Clin North Am. 2015;46(1):21\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBerk T, Halvachizadeh S, Martin DP, Hierholzer C, M\u0026uuml;ller D, Pfeifer R, et al. Trochanteric fracture pattern is associated with increased risk for nonunion independent of open or closed reduction technique. BMC Geriatr. 2022;22(1):990.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWillems A, van der Jagt OP, Meuffels DE. Extracorporeal Shock Wave Treatment for Delayed Union and Nonunion Fractures: A Systematic Review. J Orthop Trauma. 2019;33(2):97\u0026ndash;103.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMao W, Ni H, Li L, He Y, Chen X, Tang H, et al. Comparison of Baumgaertner and Chang reduction quality criteria for the assessment of trochanteric fractures. Bone Joint Res. 2019;8(10):502\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHao YL, Zhang ZS, Zhou F, Ji HQ, Tian Y, Guo Y, et al. Predictors and reduction techniques for irreducible reverse intertrochanteric fractures. Chin Med J (Engl). 2019;132(21):2534\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCiufo DJ, Ketz JP. Proximal Femoral Shortening and Varus Collapse After Fixation of Stable Pertrochanteric Femur Fractures. J Orthop Trauma. 2021;35(2):87\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGeller JA, Saifi C, Morrison TA, Macaulay W. Tip-apex distance of intramedullary devices as a predictor of cut-out failure in the treatment of peritrochanteric elderly hip fractures. Int Orthop. 2010;34(5):719\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMurena L, Moretti A, Meo F, Saggioro E, Barbati G, Ratti C, et al. Predictors of cut-out after cephalomedullary nail fixation of pertrochanteric fractures: a retrospective study of 813 patients. Arch Orthop Trauma Surg. 2018;138(3):351\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKashigar A, Vincent A, Gunton MJ, Backstein D, Safir O, Kuzyk PR. Predictors of failure for cephalomedullary nailing of proximal femoral fractures. Bone Joint J. 2014;96\u0026ndash;b(8):1029\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCaruso G, Bonomo M, Valpiani G, Salvatori G, Gildone A, Lorusso V, et al. A six-year retrospective analysis of cut-out risk predictors in cephalomedullary nailing for pertrochanteric fractures: Can the tip-apex distance (TAD) still be considered the best parameter? Bone Joint Res. 2017;6(8):481\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWarschawski Y, Ankori R, Rutenberg TF, Steinberg EL, Atzmon R, Drexler M. Expandable Proximal Femoral Nail versus Gamma Proximal Femoral Nail for the treatment of hip reverse oblique fractures. Arch Orthop Trauma Surg. 2022;142(5):777\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYamanaka T, Matsumura T, Ae R, Takeshita K. AO/OTA 31A3 fractures and postoperative complications in older patients. J Orthop Sci. 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShukla S, Johnston P, Ahmad MA, Wynn-Jones H, Patel AD, Walton NP. Outcome of traumatic subtrochanteric femoral fractures fixed using cephalo-medullary nails. Injury. 2007;38(11):1286\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTom\u0026aacute;s J, Teixidor J, Batalla L, Pacha D, Cortina J. Subtrochanteric fractures: treatment with cerclage wire and long intramedullary nail. J Orthop Trauma. 2013;27(7):e157\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoskins W, Bingham R, Joseph S, Liew D, Love D, Bucknill A, et al. Subtrochanteric fracture: the effect of cerclage wire on fracture reduction and outcome. Injury. 2015;46(10):1992\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMingo-Robinet J, Torres-Torres M, Moreno-Barrero M, Alonso JA, Garc\u0026iacute;a-Gonz\u0026aacute;lez S. Minimally invasive clamp-assisted reduction and cephalomedullary nailing without cerclage cables for subtrochanteric femur fractures in the elderly: Surgical technique and results. Injury. 2015;46(6):1036\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWu Z, Du B, Wang Q, Jiang T, Si Y, Zhang P, et al. Minimally invasive clamp-assisted reduction and long InterTAN nail fixation for Seinsheimer type V subtrochanteric fractures: a case series describing the technique and results. BMC Musculoskelet Disord. 2023;24(1):256.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHantouly AT, Salameh M, Toubasi AA, Salman LA, Alzobi O, Ahmed AF, et al. The role of cerclage wiring in the management of subtrochanteric and reverse oblique intertrochanteric fractures: a meta-analysis of comparative studies. Eur J Orthop Surg Traumatol. 2023;33(4):739\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTrikha V, Das S, Agrawal P, Kumar Dhaka MA. Role of percutaneous cerclage wire in the management of subtrochanteric fractures treated with intramedullary nails. Chin J Traumatol. 2018;21(1):42\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLai PJ, Hsu YH, Chou YC, Yeh WL, Ueng SWN, Yu YH. Augmentative antirotational plating provided a significantly higher union rate than exchanging reamed nailing in treatment for femoral shaft aseptic atrophic nonunion - retrospective cohort study. BMC Musculoskelet Disord. 2019;20(1):127.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJin YF, Xu HC, Shen ZH, Pan XK, Xie H. Comparing Augmentative Plating and Exchange Nailing for the Treatment of Nonunion of Femoral Shaft Fracture after Intramedullary Nailing: A Meta-analysis. Orthop Surg. 2020;12(1):50\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMin WK, Kim SY, Kim TK, Lee KB, Cho MR, Ha YC, et al. Proximal femoral nail for the treatment of reverse obliquity intertrochanteric fractures compared with gamma nail. J Trauma. 2007;63(5):1054\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang R, Zhang H, Wei Q, Ding C, Cao L, Yi M, et al. Intramedullary nails in combination with reconstruction plate in the treatment of unstable intertrochanteric femoral fractures with lateral wall damage. Int Orthop. 2021;45(11):2955\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbram SG, Pollard TC, Andrade AJ. Inadequate 'three-point' proximal fixation predicts failure of the Gamma nail. Bone Joint J. 2013;95\u0026ndash;b(6):825\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLo YC, Su YP, Hsieh CP, Huang CH. Augmentation Plate Fixation for Treating Subtrochanteric Fracture Nonunion. Indian J Orthop. 2019;53(2):246\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKubiak EN, Beebe MJ, North K, Hitchcock R, Potter MQ. Early weight bearing after lower extremity fractures in adults. J Am Acad Orthop Surg. 2013;21(12):727\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRaghuraman R, Kam JW, Chua DTC. Predictors of failure following fixation of intertrochanteric fractures with proximal femoral nail antirotation. Singap Med J. 2019;60(9):463\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFreigang V, Gschrei F, Bhayana H, Schmitz P, Weber J, Kerschbaum M, et al. Risk factor analysis for delayed union after subtrochanteric femur fracture: quality of reduction and valgization are the key to success. BMC Musculoskelet Disord. 2019;20(1):391.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoskins W, Moniz S, Day R, Hayes A, Bingham R, Kuster M. Fracture reduction has a dominant effect over cerclage wiring in increasing stiffness of intertrochanteric OTA/AO 31-A3.1 (reverse oblique) fractures managed with cephalomedullary osteosynthesis. OTA Int. 2021;4(4):e152.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJain S, Dawar H, Khare H, Kumar M, Ajmera A. Does augmentation of intramedullary nails by a buttress plate effectively restore lateral wall integrity in intertrochanteric fractures. Int Orthop. 2022;46(10):2365\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Reverse oblique fractures, Cephalomedullary Nail, Augmentation plate, Reduction quality, Union time","lastPublishedDoi":"10.21203/rs.3.rs-5074439/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5074439/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eThis study aimed to evaluate and compare the efficacy of the cephalomedullary nail (CMN) with side plate, CMN with cerclage wire, and CMN alone in the treatment of reverse oblique intertrochanteric femur fractures with respect to reduction quality, loss of reduction, union time, and complications.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eThis retrospective study evaluated patients aged 18 years or older with reverse oblique intertrochanteric fractures (OTA/AO 31A3.1 and 31A3.3) treated with CMN. Exclusion criteria included pathological fractures, open fractures, previous hip surgery, segmental fractures, and follow-up less than 2 years. Outcome measures included reduction quality (modified Baumgaertner criteria), union time, loss of reduction (varus collapse), and complications. These results were compared among the three treatment groups.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003e54 patients were included. 12 in the side plate group, 15 in the cerclage wire group, and 27 in the CMN group. No significant differences in demographic parameters were observed between the groups. The plate group demonstrated superior reduction quality and shorter union time compared to the cerclage and CMN groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). A higher incidence of reduction loss was observed in the CMN group compared to the cerclage and plate groups. Reduction quality was significantly associated with a reduced incidence of reduction loss and a shorter union time (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eIn the treatment of reverse oblique intertrochanteric femur fractures, the incorporation of a side plate alongside CMN appears to offer superior reduction quality, reduced incidence of varus collapse, and shorter union time compared to cerclage wire or CMN alone. This approach may represent a valuable alternative for treating surgeons facing these challenging fracture patterns.\u003c/p\u003e","manuscriptTitle":"Enhancing Reduction Quality and Union Time in Reverse Oblique Intertrochanteric Femur Fractures: A Comparative Analysis of Cephalomedullary nail with Side Plate Augmentation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-04 07:43:24","doi":"10.21203/rs.3.rs-5074439/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a72d171b-404b-4465-b363-fcd7ff158be8","owner":[],"postedDate":"November 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T09:13:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-04 07:43:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5074439","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5074439","identity":"rs-5074439","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}