Hip Pelvis.  2017 Dec;29(4):262-269. 10.5371/hp.2017.29.4.262.

Fixation of Trochanteric Fragments in Cementless Bipolar Hemiarthroplasty of Unstable Intertrochanteric Fracture: Cerclage Wiring

  • 1Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.
  • 2Department of Orthopedic Surgery, Yeungnam University Medical Center, Daegu, Korea. orthoparkch@gmail.com


Bipolar hemiarthroplasty (HA) is an option for the treatment of unstable intertrochanteric fracture in elderly patients. There is a raising concern regarding cable-grip related complications for the fixation of trochanteric fragments. Therefore, the aim of this study was to evaluate outcome of cementless HA with fixation for the trochanteric fragments using monofilament wires in unstable intertrochanteric fracture.
We reviewed 92 cementless bipolar HAs using a grit-blasted long stem design for unstable intertrochanteric fractures in 91 elderly patients with a mean age of 81.7 years. During the arthroplasty, trochanteric fracture fragments were fixed using 1 or 2 vertical wires and transverse wires. We evaluated the clinical outcomes such as abductor power, ambulatory ability and wire-related complications, and radiologic outcomes including the union of the trochanteric fragment and subsidence of stem.
Sixty-two patients were followed for a minimum of 2 years (mean, 59 months) postoperatively. The mean abductor power and Koval category was 4.1 (range, 3 to 5) and 4.6 (range, 1 to 6). The wire was broken in 3 hips (4.8%) and the nonunion of the greater trochanter occurred in 1 hips (1.6%). Two stems subsided by 3 mm and 8 mm, respectively, during postoperative 6 weeks, after which the subsidence was not progressive.
Cerclage wiring of the trochanter using monofilament wire leads to acceptable outcome in cementless HA for senile patients with unstable intertrochanteric fracture. Cerclage wiring using a monofilament wire is recommended for the fixation of trochanteric fragments.


Hip fracture; Cementless stem; Wiring technique; Hemiarthroplasty

MeSH Terms

Hip Fractures


  • Fig. 1 The Benfix stem is a tapered, rectangular extensive grit-blasted titanium stem with a distal slot.

  • Fig. 2 Diagram of cerclage wiring technique. Vertical wires were inserted through a hole below adductor tubercle and then passed through abductor insertion portion anteriorly and posteriorly. For lesser trochanter fragments, transverse wires were passed at the level of lesser trochanter.

  • Fig. 3 (A) An 81-year old woman, who had undergone a hemiarthroplasty for unstable intertrochanteric fracture with Benfix stem and cerclage wires. (B and C) Femoral crack extension occurred intraoperatively, which were treated by cerclage wires. (D) She sustained a periprosthetic fracture at 3 months after a fall from height. (E) On radiograph obtained 3 months after plate fixation.

  • Fig. 4 (A) An 84-year old woman who had undergone a hemiarthroplasty for unstable intertrochanteric fracture with Benfix stem and cerclage wires. (B) On anteroposterior radiographs obtained 6 weeks postoperatively, the stem was subsided about 8 mm.

  • Fig. 5 (A) An 89-year old women who had undergone a hemiarthroplasty for unstable intertrochanteric fracture with Benfix stem and cerclage wires. (B) An anteroposterior radiograph obtained 6 years postoperatively shows cortical stress shielding around the stem. However, there is no loosening sign around the femoral stem.


1. Zhang B, Chiu KY, Wang M. Hip arthroplasty for failed internal fixation of intertrochanteric fractures. J Arthroplasty. 2004; 19:329–333.
2. Hsu CJ, Chou WY, Chiou CP, Chang WN, Wong CY. Hemi-arthroplasty with supplemental fixation of greater trochanter to treat failed hip screws of femoral intertrochanteric fracture. Arch Orthop Trauma Surg. 2008; 128:841–845.
3. Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg Am. 2003; 85-A:899–904.
4. Celiktas M, Togrul E, Kose O. Calcar preservation arthroplasty for unstable intertrochanteric femoral fractures in elderly. Clin Orthop Surg. 2015; 7:436–442.
5. Kayali C, Agus H, Ozluk S, Sanli C. Treatment for unstable intertrochanteric fractures in elderly patients: internal fixation versus cone hemiarthroplasty. J Orthop Surg (Hong Kong). 2006; 14:240–244.
6. Parker MJ, Handoll HH. Replacement arthroplasty versus internal fixation for extracapsular hip fractures. Cochrane Database Syst Rev. 2000; (2):CD000086.
7. Abdelkhalek M, Ali AM, Abdelwahab M. Cemented bipolar hemiarthroplasty with a cerclage cable technique for unstable intertrochanteric hip fractures in elderly patients. Eur J Orthop Surg Traumatol. 2013; 23:443–448.
8. Kim Y, Moon JK, Hwang KT, Choi IY, Kim YH. Cementless bipolar hemiarthroplasty for unstable intertrochanteric fractures in octogenarians. Acta Orthop Traumatol Turc. 2014; 48:424–430.
9. Grimsrud C, Monzon RJ, Richman J, Ries MD. Cemented hip arthroplasty with a novel cerclage cable technique for unstable intertrochanteric hip fractures. J Arthroplasty. 2005; 20:337–343.
10. Charnley J. Total hip replacement by low-friction arthroplasty. Clin Orthop Relat Res. 1970; 72:7–21.
11. Silverton CD, Jacobs JJ, Rosenberg AG, Kull L, Conley A, Galante JO. Complications of a cable grip system. J Arthroplasty. 1996; 11:400–404.
12. Yasgur DJ, Stuchin SA, Adler EM, DiCesare PE. Subtrochanteric femoral shortening osteotomy in total hip arthroplasty for high-riding developmental dislocation of the hip. J Arthroplasty. 1997; 12:880–888.
13. Klinge SA, Vopat BG, Daniels AH, Bariteau JT, Rubin LE, Limbird R. Early catastrophic failure of trochanteric fixation with the Dall-Miles Cable Grip System. J Arthroplasty. 2014; 29:1289–1291.
14. Kim IS, Pansey N, Kansay RK, Yoo JH, Lee HY, Chang JD. Greater trochanteric reattachment using the third-generation cable plate system in revision total hip arthroplasty. J Arthroplasty. 2017; 32:1965–1969.
15. Cha YH, Ha YC, Yoo JI, Min YS, Lee YK, Koo KH. Effect of causes of surgical delay on early and late mortality in patients with proximal hip fracture. Arch Orthop Trauma Surg. 2017; 137:625–630.
16. Lee YK, Ha YC, Chang BK, Kim KC, Kim TY, Koo KH. Cementless bipolar hemiarthroplasty using a hydroxyapatitecoated long stem for osteoporotic unstable intertrochanteric fractures. J Arthroplasty. 2011; 26:626–632.
17. Harris WH. Revision surgery for failed, nonseptic total hip arthroplasty: the femoral side. Clin Orthop Relat Res. 1982; (170):8–20.
18. Koval KJ, Aharonoff GB, Rosenberg AD, Bernstein RL, Zuckerman JD. Functional outcome after hip fracture. Effect of general versus regional anesthesia. Clin Orthop Relat Res. 1998; (348):37–41.
19. Compston A. Aids to the investigation of peripheral nerve injuries. Medical Research Council: Nerve Injuries Research Committee. His Majesty's Stationery Office: 1942; pp. 48 (iii) and 74 figures and 7 diagrams; with aids to the examination of the peripheral nervous system. By Michael O'Brien for the Guarantors of Brain. Saunders Elsevier: 2010; pp. [8] 64 and 94 Figures. Brain. 2010; 133:2838–2844.
20. Meijerink HJ, Gardeniers JW, Buma P, Lemmens JA, Schreurs BW. Hydroxyapatite does not improve the outcome of a bipolar hemiarthroplasty. Clin Orthop Relat Res. 2004; (421):143–150.
21. Capello WN, D'Antonio JA, Geesink RG, Feinberg JR, Naughton M. Late remodeling around a proximally HAcoated tapered titanium femoral component. Clin Orthop Relat Res. 2009; 467:155–165.
22. Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am. 1973; 55:1629–1632.
23. Korea National Statistical Office. Abridged Life Tables[Internet]. Daejeon: Korean Statistical Information Service;2014. updated 2016 Dec 02. cited 2017 Mar 1. Available from: http://kosis.kr/statHtml/statHtml.do?orgId=101&tblId=DT_1B41&conn_path=I2/:2014.
24. Lee JM, Cho Y, Kim J, Kim DW. Wiring techniques for the fixation of trochanteric fragments during bipolar hemiarthroplasty for femoral intertrochanteric fracture: clinical study and technical note. Hip Pelvis. 2017; 29:44–53.
25. Yoo JI, Ha YC, Lim JY, Kang H, Yoon BH, Kim H. Early rehabilitation in elderly after arthroplasty versus internal fixation for unstable intertrochanteric fractures of femur: systematic review and meta-analysis. J Korean Med Sci. 2017; 32:858–867.
26. Grosso MJ, Danoff JR, Murtaugh TS, Trofa DP, Sawires AN, Macaulay WB. Hemiarthroplasty for displaced femoral neck fractures in the elderly has a low conversion rate. J Arthroplasty. 2017; 32:150–154.
27. Inngul C, Blomfeldt R, Ponzer S, Enocson A. Cemented versus uncemented arthroplasty in patients with a displaced fracture of the femoral neck: a randomised controlled trial. Bone Joint J. 2015; 97-B:1475–1480.
28. McCalden RW, McGeough JA, Barker MB, Court-Brown CM. Age-related changes in the tensile properties of cortical bone. The relative importance of changes in porosity, mineralization, and microstructure. J Bone Joint Surg Am. 1993; 75:1193–1205.
29. Noble PC, Box GG, Kamaric E, Fink MJ, Alexander JW, Tullos HS. The effect of aging on the shape of the proximal femur. Clin Orthop Relat Res. 1995; (316):31–44.
30. Jo WL, Lee YK, Ha YC, Park MS, Lyu SH, Koo KH. Frequency, developing time, intensity, duration, and functional score of thigh pain after cementless total hip arthroplasty. J Arthroplasty. 2016; 31:1279–1282.
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