From classification to anteromedial cortical contact: an integrative review of the Japanese and international literature on trochanteric fracture reduction and fixation.

PURPOSE: Internal fixation of trochanteric femoral fractures achieves a high union rate, yet mechanical failure - cut-out, excessive sliding, loss of reduction and reoperation - remains a problem. Among the factors a surgeon can control, reconstructing anteromedial cortical contact has recently drawn attention. This review examines developments in classification, reduction, and fixation through this contact and its intraoperative assessment. METHODS: MEDLINE (via PubMed) and Ichushi-Web (a Japanese medical literature database) were used in June 2026, with no limit on publication date. RESULTS: The main structural drivers of instability are loss of posteromedial support and a lateral wall fracture. Fractures without posteromedial support are easily misread as stable on plain radiographs. When posteromedial support is lost, anteromedial cortical contact becomes a support that can be rebuilt. Anterior malreduction, which lacks this contact, was independently associated with cut-out, with an adjusted odds estimate similar to that for a tip-apex distance of at least 20 mm. The anteromedial cortex cannot be assessed reliably on the standard anteroposterior and true lateral views; an oblique (tangential) view is needed to profile it. Some patterns are not reduced by traction and need active, direction-specific reduction. In a randomised trial, adding an anterior support screw reduced loss of reduction and early sliding. The optimal amount of sagittal reduction remains uncertain. CONCLUSION: This development can be organised around reconstructing anteromedial cortical contact and visualising it during surgery. The remaining task is to visualise the anteromedial cortex reliably, define the optimal amount of contact, and test prospectively whether reconstruction improves radiographic and functional outcomes.