Positive cortical support reduction in treatment of trochanteric femur fractures: history in theory establishment and its inspiration for clinical innovations_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

 CHANG Shimin

Department of Orthopedic Surgery, Yangpu Hospital, Tongji University, Shanghai, 200090, P. R. China;

Corresponding?author：

CHANG Shimin, Email: shiminchang11@aliyun.com

Keywords：

Trochanteric fracture; cortical support; positive support; internal fixation; analogical reasoning; scientific opportunity

DOI：

10.7507/1002-1892.202511026

Video：

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Reduction is the first step in fracture treatment, and is the predominant factor for treatment outcomes. The positive anteromedial cortical support (AMCS) reduction theory was established by Prof Shi-Min Chang in 2014 for the fixation treatment of trochanteric femur fractures. It was referenced to the nonanatomic reduction theory proposed by Gotfried in 2013 for subcapital femoral neck fractures. Both are nonanatomic cortical support reductions to share medial compressive load, but were just the opposite with each other in the bearing and direction of the proximal head-neck fragment. For femoral neck fractures, positive cortical support means the proximal femoral head-neck fragment is intentionally positioned slightly lateral-superior to the distal neck (less than 1 cortical thickness) and is intramedullarily buttressed by the distal inferior cortex. For trochanteric fractures, positive cortical support means the proximal head-neck fragment is deliberately positioned slightly medial-superior to the distal shaft (less than 1 cortical thickness) and is extramedullarily buttressed by the anteromedial cortex of the femoral shaft. Currently positive reduction theory and its derivative Chang reduction quality criterion (CRQC) is widely accepted and practiced worldwide, and are appraised as one of the three keystone theories in the treatment of trochanteric fracture, which are tip-apex distance, lateral wall, and cortical support reduction. From the point of scientific methodology, this new theory establishment is related to several important factors, such as identify unusual events in clinical practice, seize the opportunity, abundant knowledge reserves, keep up with the latest progress, conduct analogical reasoning, and promptly summarize the results and publish academic papers.

1.	田楚偉, 謝添, 石柳, 等. 中國老年髖部骨折報告2025. [J/OL]. 重慶醫科大學學報 (2025-10-29) [2025-12-10]. https://doi.org/10.13406/j.cnki.cyxb.003975.
2.	Tian C, Shi L, Wang J, et al. Global, regional, and national burdens of hip fractures in elderly individuals from 1990 to 2021 and predictions up to 2050: A systematic analysis of the Global Burden of Disease Study 2021. Arch Gerontol Geriatr, 2025, 133: 105832. doi: 10.1016/j.archger.2025.105832.
3.	Baumgaertner MR, Curtin SL, Lindskog DM, et al. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg (Am), 1995, 77(7): 1058-1064.
4.	Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res, 2004(425): 82-86.
5.	張世民, 張英琪, 李清, 等. 內側皮質正性支撐復位對老年股骨粗隆間骨折內固定效果的影響. 中國矯形外科雜志, 2014, 22(14): 1256-1261.
6.	Chang SM, Zhang YQ, Ma Z, et al. Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg, 2015, 135(6): 811-818.
7.	Rogmark C, Viberg B, Wolf O, et al. An acta orthopaedica educational article: Femoral neck fractures in adults with emphasis on surgical treatment. Acta Orthop, 2025, 96: 632-639.
8.	Haidukewych GJ, Rothwell WS, Jacofsky DJ, et al. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg (Am), 2004, 86(8): 1711-1716.
9.	Gotfried Y, Kovalenko S, Fuchs D. Nonanatomical reduction of displaced subcapital femoral fractures (Gotfried reduction). J Orthop Trauma, 2013, 27(11): e254-e259.
10.	Zhang YQ, Chang SM. Mechanism of “Gotfried reduction” in femoral neck fracture. J Orthop Trauma, 2013, 27(12): e291. doi: 10.1097/BOT.0000000000000007.
11.	Xiong WF, Chang SM, Zhang YQ, et al. Inferior calcar buttress reduction pattern for displaced femoral neck fractures in young adults: a preliminary report and an effective alternative. J Orthop Surg Res. 2019, 14(1): 70. doi: 10.1186/s13018-019-1109-x.
12.	Chang SM, Zhang YQ, Du SC, et al. Anteromedial cortical support reduction in unstable pertrochanteric fractures: a comparison of intra-operative fluoroscopy and post-operative three dimensional computerised tomography reconstruction. Int Orthop, 2018, 42(1): 183-189.
13.	Chen SY, Chang SM, Tuladhar R, et al. A new fluoroscopic view for evaluation of anteromedial cortex reduction quality during cephalomedullary nailing for intertrochanteric femur fractures: the 30° oblique tangential projection. BMC Musculoskel Disord, 2020, 21(1): 719. doi: 10.1186/s12891-020-03668-6.
14.	Chang SM, Hou ZY, Hu SJ, et al. Intertrochanteric Femur Fracture Treatment in Asia: what we know and what the world can learn. Orthop Clin North Am, 2020, 51(2): 189-205.
15.	Mao W, Liu CD, Chang SM, et al. Anteromedial cortical support in reduction of trochanteric hip fractures: from definition to application. J Bone Joint Surg (Am), 2024, 106(11): 1008-1018.
16.	Xie W, Shi L, Zhang C, et al. Anteromedial cortical support reduction of intertrochanteric fractures-A review. Injury, 2024, 55(12): 111926. doi: 10.1016/j.injury.2024.111926.
17.	張世民, 胡孫君, 杜守超, 等. 股骨轉子間骨折的穩定性重建概念演化與研究進展. 中國修復重建外科雜志, 2019, 33(10): 1203-1209.
18.	衛禛, 陳時益, 張世民. 股骨轉子間骨折治療中前內側皮質正性支撐復位的研究進展. 中國修復重建外科雜志, 2019, 33(10): 1216-1222.
19.	李世杰, 杜守超, 張世民. 股骨轉子間骨折復位質量判斷標準的研究進展. 中華創傷骨科雜志, 2022, 24(9): 793-798.
20.	茆瑋, 張世民, 張英琪, 等. 股骨轉子間骨折前內側皮質支撐復位的研究進展. 中華老年骨科與康復電子雜志, 2023, 9(3): 182-187.
21.	Lim EJ, Sakong S, Son WS, et al. Comparison of sliding distance of lag screw and nonunion rate according to anteromedial cortical support in intertrochanteric fracture fixation: A systematic review and meta-analysis. Injury, 2021, 52(10): 2787-2794.
22.	Yamamoto N, Tsujimoto Y, Yokoo S, et al. Association between immediate postoperative radiographic findings and failed internal fixation for trochanteric fractures: systematic review and meta-analysis. J Clin Med, 2022, 11(16): 4879. doi: 10.3390/jcm11164879.
23.	Kuroda H, Yokoo S, Okada Y, et al. Anterior redisplacement after intramedullary nail fixation for trochanteric femoral fractures: incidence and risk factors in 598 older patients. J Clin Med, 2025, 14(15): 5557. doi: 10.3390/jcm14155557.
24.	Wittauer M, Henry J, Sánchez-Rosenberg G, et al. Evaluation of reduction quality and implant positioning in intertrochanteric fracture fixation: A review of key radiographic parameters. World J Orthop, 2025, 16(8): 106982. doi: 10.5312/wjo.v16.i8.106982.
25.	Nikolaides AP, Abesamis JB, Hamed A, et al. The RESCUE technique: A mnemonic acronym to enhance outcomes in nail fixation of extracapsular hip fractures. J Clin Med, 2025, 14(15): 5419. doi: 10.3390/jcm14155419.
26.	Han S, Zhang ZY, Zhou K, et al. Positive buttress reduction in femoral neck fractures: a literature review. J Orthop Surg Res, 2024, 19(1): 262. doi: 10.1186/s13018-024-04649-4.
27.	Ye Y, Chen K, Tian K, et al. Medial buttress plate augmentation of cannulated screw fixation in vertically unstable femoral neck fractures: Surgical technique and preliminary results. Injury, 2017, 48(10): 2189-2193.
28.	倪明, 孫萬駒, 葉曄. 內側支撐鋼板輔助固定治療青壯年股骨頸骨折的研究進展. 中國修復重建外科雜志, 2020, 34(11): 1454-1457.
29.	McGarry L, Rotaru J, Gunaratne R, et al. Medial buttress plate use in neck of femur fracture fixations: A systematic review. Injury, 2025, 56(2): 112160. doi: 10.1016/j.injury.2025.112160.
30.	Gao Z, Wang M, Shen B, et al. Treatment of Pauwels type Ⅲ femoral neck fracture with medial femoral neck support screw: a biomechanical and clinical study. Sci Rep, 2021, 11(1): 21418. doi: 10.1038/s41598-021-01010-1.
31.	Shi X, Han M, Dai B. Medial cortical positive support: A key factor for the postoperative stability of proximal humerus fractures. Medicine (Baltimore), 2021, 100(22): e26073. doi: 10.1097/MD.0000000000026073.
32.	王凱, 李寧, 郭家良, 等. 肱骨近端骨折術后皮質支撐方式對患者功能預后的影響. 河北醫科大學學報, 2021, 42(7): 803-806.
33.	Kasha S, Yalamanchili RK, Rohit GPRK, et al. Medialization of shaft of humerus to provide medial buttress and prevent varus collapse in 3- and 4-part proximal humerus fractures: review of the surgical technique. JSES Rev Rep Tech, 2024, 5(1): 22-29.
34.	李波, 熊文峰, 張世民. 鎖定鋼板治療肱骨近端骨折中螺釘穿透關節面的研究進展. 中國修復重建外科雜志, 2021, 35(4): 403-408.
35.	姚川江, 張宏偉, 張曉剛, 等. 老年肱骨近端骨折內側柱重建的研究進展. 中國骨傷, 2022, 35(3): 300-304.
36.	張世民. 老年髖部轉子間骨折. 2版. 北京: 科學出版社, 2023.
37.	胡孫君, 杜守超, 張世民, 等. 股骨轉子間骨折前內側皮質支撐復位十年研究進展. 中國修復重建外科雜志, 2025, 39(12): 1501-1509.

1. 田楚偉, 謝添, 石柳, 等. 中國老年髖部骨折報告2025. [J/OL]. 重慶醫科大學學報 (2025-10-29) [2025-12-10]. https://doi.org/10.13406/j.cnki.cyxb.003975.
2. Tian C, Shi L, Wang J, et al. Global, regional, and national burdens of hip fractures in elderly individuals from 1990 to 2021 and predictions up to 2050: A systematic analysis of the Global Burden of Disease Study 2021. Arch Gerontol Geriatr, 2025, 133: 105832. doi: 10.1016/j.archger.2025.105832.
3. Baumgaertner MR, Curtin SL, Lindskog DM, et al. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg (Am), 1995, 77(7): 1058-1064.
4. Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res, 2004(425): 82-86.
5. 張世民, 張英琪, 李清, 等. 內側皮質正性支撐復位對老年股骨粗隆間骨折內固定效果的影響. 中國矯形外科雜志, 2014, 22(14): 1256-1261.
6. Chang SM, Zhang YQ, Ma Z, et al. Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg, 2015, 135(6): 811-818.
7. Rogmark C, Viberg B, Wolf O, et al. An acta orthopaedica educational article: Femoral neck fractures in adults with emphasis on surgical treatment. Acta Orthop, 2025, 96: 632-639.
8. Haidukewych GJ, Rothwell WS, Jacofsky DJ, et al. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg (Am), 2004, 86(8): 1711-1716.
9. Gotfried Y, Kovalenko S, Fuchs D. Nonanatomical reduction of displaced subcapital femoral fractures (Gotfried reduction). J Orthop Trauma, 2013, 27(11): e254-e259.
10. Zhang YQ, Chang SM. Mechanism of “Gotfried reduction” in femoral neck fracture. J Orthop Trauma, 2013, 27(12): e291. doi: 10.1097/BOT.0000000000000007.
11. Xiong WF, Chang SM, Zhang YQ, et al. Inferior calcar buttress reduction pattern for displaced femoral neck fractures in young adults: a preliminary report and an effective alternative. J Orthop Surg Res. 2019, 14(1): 70. doi: 10.1186/s13018-019-1109-x.
12. Chang SM, Zhang YQ, Du SC, et al. Anteromedial cortical support reduction in unstable pertrochanteric fractures: a comparison of intra-operative fluoroscopy and post-operative three dimensional computerised tomography reconstruction. Int Orthop, 2018, 42(1): 183-189.
13. Chen SY, Chang SM, Tuladhar R, et al. A new fluoroscopic view for evaluation of anteromedial cortex reduction quality during cephalomedullary nailing for intertrochanteric femur fractures: the 30° oblique tangential projection. BMC Musculoskel Disord, 2020, 21(1): 719. doi: 10.1186/s12891-020-03668-6.
14. Chang SM, Hou ZY, Hu SJ, et al. Intertrochanteric Femur Fracture Treatment in Asia: what we know and what the world can learn. Orthop Clin North Am, 2020, 51(2): 189-205.
15. Mao W, Liu CD, Chang SM, et al. Anteromedial cortical support in reduction of trochanteric hip fractures: from definition to application. J Bone Joint Surg (Am), 2024, 106(11): 1008-1018.
16. Xie W, Shi L, Zhang C, et al. Anteromedial cortical support reduction of intertrochanteric fractures-A review. Injury, 2024, 55(12): 111926. doi: 10.1016/j.injury.2024.111926.
17. 張世民, 胡孫君, 杜守超, 等. 股骨轉子間骨折的穩定性重建概念演化與研究進展. 中國修復重建外科雜志, 2019, 33(10): 1203-1209.
18. 衛禛, 陳時益, 張世民. 股骨轉子間骨折治療中前內側皮質正性支撐復位的研究進展. 中國修復重建外科雜志, 2019, 33(10): 1216-1222.
19. 李世杰, 杜守超, 張世民. 股骨轉子間骨折復位質量判斷標準的研究進展. 中華創傷骨科雜志, 2022, 24(9): 793-798.
20. 茆瑋, 張世民, 張英琪, 等. 股骨轉子間骨折前內側皮質支撐復位的研究進展. 中華老年骨科與康復電子雜志, 2023, 9(3): 182-187.
21. Lim EJ, Sakong S, Son WS, et al. Comparison of sliding distance of lag screw and nonunion rate according to anteromedial cortical support in intertrochanteric fracture fixation: A systematic review and meta-analysis. Injury, 2021, 52(10): 2787-2794.
22. Yamamoto N, Tsujimoto Y, Yokoo S, et al. Association between immediate postoperative radiographic findings and failed internal fixation for trochanteric fractures: systematic review and meta-analysis. J Clin Med, 2022, 11(16): 4879. doi: 10.3390/jcm11164879.
23. Kuroda H, Yokoo S, Okada Y, et al. Anterior redisplacement after intramedullary nail fixation for trochanteric femoral fractures: incidence and risk factors in 598 older patients. J Clin Med, 2025, 14(15): 5557. doi: 10.3390/jcm14155557.
24. Wittauer M, Henry J, Sánchez-Rosenberg G, et al. Evaluation of reduction quality and implant positioning in intertrochanteric fracture fixation: A review of key radiographic parameters. World J Orthop, 2025, 16(8): 106982. doi: 10.5312/wjo.v16.i8.106982.
25. Nikolaides AP, Abesamis JB, Hamed A, et al. The RESCUE technique: A mnemonic acronym to enhance outcomes in nail fixation of extracapsular hip fractures. J Clin Med, 2025, 14(15): 5419. doi: 10.3390/jcm14155419.
26. Han S, Zhang ZY, Zhou K, et al. Positive buttress reduction in femoral neck fractures: a literature review. J Orthop Surg Res, 2024, 19(1): 262. doi: 10.1186/s13018-024-04649-4.
27. Ye Y, Chen K, Tian K, et al. Medial buttress plate augmentation of cannulated screw fixation in vertically unstable femoral neck fractures: Surgical technique and preliminary results. Injury, 2017, 48(10): 2189-2193.
28. 倪明, 孫萬駒, 葉曄. 內側支撐鋼板輔助固定治療青壯年股骨頸骨折的研究進展. 中國修復重建外科雜志, 2020, 34(11): 1454-1457.
29. McGarry L, Rotaru J, Gunaratne R, et al. Medial buttress plate use in neck of femur fracture fixations: A systematic review. Injury, 2025, 56(2): 112160. doi: 10.1016/j.injury.2025.112160.
30. Gao Z, Wang M, Shen B, et al. Treatment of Pauwels type Ⅲ femoral neck fracture with medial femoral neck support screw: a biomechanical and clinical study. Sci Rep, 2021, 11(1): 21418. doi: 10.1038/s41598-021-01010-1.
31. Shi X, Han M, Dai B. Medial cortical positive support: A key factor for the postoperative stability of proximal humerus fractures. Medicine (Baltimore), 2021, 100(22): e26073. doi: 10.1097/MD.0000000000026073.
32. 王凱, 李寧, 郭家良, 等. 肱骨近端骨折術后皮質支撐方式對患者功能預后的影響. 河北醫科大學學報, 2021, 42(7): 803-806.
33. Kasha S, Yalamanchili RK, Rohit GPRK, et al. Medialization of shaft of humerus to provide medial buttress and prevent varus collapse in 3- and 4-part proximal humerus fractures: review of the surgical technique. JSES Rev Rep Tech, 2024, 5(1): 22-29.
34. 李波, 熊文峰, 張世民. 鎖定鋼板治療肱骨近端骨折中螺釘穿透關節面的研究進展. 中國修復重建外科雜志, 2021, 35(4): 403-408.
35. 姚川江, 張宏偉, 張曉剛, 等. 老年肱骨近端骨折內側柱重建的研究進展. 中國骨傷, 2022, 35(3): 300-304.
36. 張世民. 老年髖部轉子間骨折. 2版. 北京: 科學出版社, 2023.
37. 胡孫君, 杜守超, 張世民, 等. 股骨轉子間骨折前內側皮質支撐復位十年研究進展. 中國修復重建外科雜志, 2025, 39(12): 1501-1509.

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Latest ArticlesPositive cortical support reduction in treatment of trochanteric femur fractures: history in theory establishment and its inspiration for clinical innovations

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