REVIEW ARTICLE
Subtrochanteric Femur Fractures Treated With Femoral
Nail: The Effect of Cerclage Wire Augmentation on
Complications, Fracture Union, and Reduction: A
Systematic Review and Meta-Analysis of Comparative
Studies
Wayne Hoskins, FRACS, PhD,a b Laura McDonald, MBBS, Dip Anat,c Tim Spelman, MBBS, PhD,d
,
and Roger Bingham, FRACSb
Objective: To perform a systematic review and meta-analysis of
subtrochanteric femur fractures treated with an intramedullary nail,
augmented with or without cerclage wiring, comparing the risk of
reoperation, nonunion, loss of fixation, and implant failure; fracture
reduction and time to union.
Data Source: A systematic review according to Preferred
Reporting Items for Systematic Reviews and Meta-Analyses guide-
lines was performed through MEDLINE, EMBASE, PubMed, Web
of Science, and Scopus databases using a combination of controlled
vocabulary and keywords on September 30, 2020.
Study Selection: All comparative (prospective and retrospective)
studies of subtrochanteric fractures managed with intramedullary
nail, that compared the addition of cerclage wire to without in
patients 16 years of age or older were included. Pathological,
atypical bisphosphonate, and segmental fractures were excluded, as
were non-English literature.
Data Extraction: Data from each study were independently
recorded by 2 investigators.
Data Synthesis: Agreement was obtained on 18 studies (all
retrospective) for final inclusion, with 378 patients receiving
Accepted for publication September 2, 2021.
From the aFaculty of Medicine, Dentistry and Health Sciences, The University
of Melbourne, Parkville, VIC, Australia; bTraumaplasty.Melbourne, East
Melbourne, VIC, Australia; cDepartment of Orthopaedics, The Alfred
Hospital, Melborune, VIC, Australia; and dDepartment of Surgery, The
University of Melbourne, St. Vincent’s Hospital, Melbourne, VIC,
Australia.
W. Hoskins has given paid educational presentations for Smith & Nephew. R.
Bingham has given paid educational presentations for Smith & Nephew
and DePuy-Synthes. The remaining authors report no conflict of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.jorthotrauma.
com).
Reprints: Wayne Hoskins, FRACS, PhD, Faculty of Medicine, Dentistry and
Health Sciences, The University of Melbourne, Building 181, Grattan St,
Melbourne, VIC 3010, Australia (e-mail: wayne.hoskins@outlook.com).
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DOI: 10.1097/BOT.0000000000002266
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cerclage wire and 911 without. A random-effects meta-analysis
was used to analyze the pooled aggregate data.
Conclusions: There is no statistically significant advantage in
using cerclage wire with femoral intramedullary nail when treating
subtrochanteric femur fractures regarding risk of reoperation, non-
union, loss of fixation, and implant failure or time to union. An
advantage favoring cerclage wire was seen for accuracy of fracture
reduction. Cerclage wiring was used more often in cases associated
with high-energy trauma. Given the relatively small number of
events available to be modelled, a clinical benefit for cerclage wiring
may still exist for certain fracture types.
Key Words: femur, hip fractures, femoral neck fractures, femoral
nail, cerclage wire
Level of Evidence: Therapeutic Level III. See Instructions for
Authors for a complete description of levels of evidence.
(J Orthop Trauma 2022;36:e142–e151)
INTRODUCTION
Subtrochanteric femur fractures have a predisposition
for varus deformity1,2 and are a challenge to treat because of
anatomical and biomechanical reasons.3 Cephalomedullary
femoral nails have become the preferred modern implant
choice.4,5 Despite contemporary surgical techniques, subtro-
chanteric fractures have high rates of malreduction,4–6 with
associated complications including delayed union, nonunion,
loss of fixation, and implant failure.7,8 Reoperation rates for
implant or fracture related complications in large series have
ranged between 9% and 10%.9,10
With certain fracture patterns, in particular spiral or
oblique fractures, clamp assisted reduction 6 cerclage wiring
are valid treatment options before femoral intramedullary
nailing when closed reduction has failed.4,10–12 The advan-
tages of open reduction techniques are improved reduction
while reaming and inserting the intramedullary nail. If cerc-
lage wire is used, reduction may be maintained and there may
be improvements in the overall stability of the construct.
Although minimally invasive techniques have been devel-
oped to insert cerclage wire, a biological insult with the open
approach and application occurs.13,14 Theoretically, this has
J Orthop Trauma  Volume 36, Number 4, April 2022
J Orthop Trauma  Volume 36, Number 4, April 2022
consequences to fracture zone vascularity and fracture heal-
ing. The surgical procedure is also longer and blood loss
greater.15–18
The aim of this systematic review and meta-analysis is
to ask: in patients receiving femoral intramedullary nailing for
the management of a subtrochanteric femur fracture, does the
rate of reoperation differ if the fracture fixation is augmented
with cerclage wire compared with that without, and what is
the effect on the rate of nonunion, loss of fixation and implant
failure; accuracy of fracture reduction, and time to union?
METHODS
Search Strategy
This systematic review was performed according to the
guidelines of Preferred Reporting Items for Systematic
Reviews and Meta-Analyses. A literature search was per-
formed in EMBASE, PubMed, Web of Science, and Scopus
databases using a combination of controlled vocabulary and
keywords. The search strategy in MEDLINE (Ovid) illus-
trates the approach:
1. Hip Fractures/su
2. Femoral Neck Fractures/su
3. ((hip or femur or femoral) and (fracture* or break*)).tw.
4. 1 or 2 or 3
5. (subtrochanteric or trochanteric or intertrochanteric).tw.
6. cerclage*.tw.
7. (wire* or wiring or cable* or cabling).tw.
8. 6 or 7
9. 4 and 5 and 8
10. limit 9 to (yr = “1986–2020” and English).
The search included studies published between January 1,
1986 and September 30, 2020 and limited to full-text articles in
English and was conducted by 2 independent investigators
(W.H. and R.B.). Where there was disagreement over the
inclusion of a study, the investigators reviewed the study
together until consensus was reached, with a further investigator
if required (L.M.). The search was supplemented with hand
searching conference proceedings and publication reference lists,
and experts in the field were contacted to ask whether they knew
of additional studies to ensure complete capture of the literature.
Inclusion and Exclusion Criteria
We included all comparative (prospective and retro-
spective) studies that compared subtrochanteric femur frac-
tures managed with intramedullary femoral nail with cerclage
wire to without cerclage wire in patients 16 years of age or
older. Studies including patients under 16 years of age,
pathological fractures, atypical bisphosphonate associated
fractures, and segmental fractures were excluded. Articles in
languages other than English were also excluded.
Data Extraction
Data were extracted from eligible studies by the 2
investigators (W.H. and L.M.) into a bespoke piloted Excel
(2003; Microsoft, Redmond, WA) spread sheet. We recorded
details of study methods, participants, interventions, and
outcomes. The primary outcome measure was the risk of
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Subtrochanteric Femur Fractures
return to theatre for reoperation at any time point, whereas the
secondary outcome measures were the risk of nonunion, loss
of fixation, and implant failure; accuracy of fracture reduc-
tion, and time to union, set a priori. Accuracy of fracture
reduction was determined modified from Baumgaertner
et al19 as being good (both maximal cortical displacement
,4 mm and angulation #10 degrees), acceptable (either max-
imal cortical displacement ,4 mm or angulation #10
degrees), or poor (maximal cortical displacement $4 mm
and angulation .10 degrees). The data collected were ana-
lyzed using R version 3.6.3 (R Foundation for Statistical
Computing, Vienna, Austria) by a single investigator (T.S.).
Assessment of Risk of Bias
Two review investigators (W.H. and L.M.) independently
assessed the risk of bias of the included studies using the
Newcastle-Ottawa Scale for observational studies.20 The “other
sources of bias” that we assessed were major imbalances in
important baseline confounders (eg, age, sex, energy of injury).
No attempt was made to mask the trial reports. Where disagree-
ment existed concerning the assessment, we reached consensus
through discussion among all investigators.
Unit of Analysis Issues
The studies and data included in the final analysis were
assessed for potential unit of analysis issues relating to the
clustering of patients to the cerclage wire intervention or
comparator group based on surgeon, clinic, or hospital and/or
treated with multiple interventions that were analyzed on a per
surgical fixation basis. No studies in this review included
analysis of patients treated with bilateral surgical fixation as
part of that study.
Data Synthesis and Analysis
Outcome variables that were reported in a comparable
manner among studies (criteria set a priori) were included in
the meta-analysis. A random effects logistic meta-analysis
model was used to compare binary outcomes between the
cerclage wiring and noncerclage groups. Continuous out-
comes were compared using a random-effects mean differ-
ence meta-analysis regression. A random-effects model was
preferred over a fixed effects approach to control for
differences in the treatment effect between studies attributable
to differences in study patient populations, settings and
observation periods. We expected heterogeneity in follow-
up times and planned for pooled analysis of reoperation
(primary outcome measure). Therefore, our pooled analysis of
reoperation was performed on data at the final follow-up of
each study. Continuous variables will be reported as mean 6
SD, with the mean weighted for sample size. Categorical
variables will be reported as frequencies with percentages.
For all comparisons, P , 0.05 was considered significant.
Assessment of Heterogeneity
Heterogeneity (variation in the outcomes between studies)
was assessed via inspection of forest plots and via derivation of
the I2-statistic.21 A P-value of ,0.1 for x2 was set to indicate
significant heterogeneity. I2 was interpreted as 0%–40% might
not be important; 30%–60% may represent moderate
www.jorthotrauma.com | e143
Hoskins et al
heterogeneity; 50%–90% may represent substantial heterogene-
ity; and 75%–100% indicated considerable heterogeneity.22
RESULTS
The search yielded 906 studies with no additional
studies identified, and after 453 duplicates were removed,
453 titles and abstracts remained for screening. Three
hundred Fifty-Six studies were deemed irrelevant, leaving
97 studies assessed for eligibility. Agreement was obtained on
18 studies for final inclusion after full text review with 378
patients receiving cerclage wire and 911 without (Fig. 1). All
studies were retrospective comparative studies (Table 1). The
Newcastle–Ottawa assessment showed risks of bias in patient
selection (heterogeneity of the groups) and attrition, with lack
of follow-up.
Patient characteristics for the studies included are
shown in Supplemental Digital Content 1 (See Table,
http://links.lww.com/JOT/B548). The mean reported age of
the patients in years was 63.8 for cerclage wire and 64.1
for without cerclage. Women comprised 44.4% of cerclage
wire and 48.3% without. High-energy trauma caused fracture
in 72.3% of cases where cerclage wire was used and 40.3%
where it was not.
The raw data for the primary outcome measure and the
secondary outcome measures is presented in Table 2.
FIGURE 1. Study flow chart per PRISMA
standards. Overall records identified 906
studies which were included in the final
inclusions of 18 studies for quantitative
analysis. PRISMA, Preferred Reporting
Items for Systematic Reviews and Meta-
Analyses.
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J Orthop Trauma  Volume 36, Number 4, April 2022
Risk of Reoperation
Seventeen studies compared the risk of reoperation for
861 patients in the control group and 373 patients in the
cerclage wire group. There was no statistical difference
between cerclage wiring and noncerclage wiring for reopera-
tion (Odds Ratio [OR] = 0.72 favoring cerclage wiring (95%
Confidence Interval [CI] 0.31–1.65), P = 0.630) (Fig. 2).
Risk of Nonunion
Seventeen studies compared the risk of nonunion for
889 patients in the control group and 367 patients in the
cerclage wire group. There was no statistical difference
between cerclage wiring and noncerclage wiring for risk of
nonunion [OR = 0.84 favoring cerclage wiring (95% CI 0.32–
2.16), P = 0.731] (Fig. 3).
Risk of Loss of Fixation
Fourteen studies compared the risk of loss of fixation
for 559 patients in the control group and 267 patients in the
cerclage wire group. There was no statistical difference
between cerclage wiring and noncerclage wiring for risk of
loss of fixation [OR = 0.30 favoring cerclage wiring (95%
CI 0.01–15.71), P = 0.793] (see Figure, Supplemental
Digital Content 2, http://links.lww.com/JOT/B549).
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J Orthop Trauma  Volume 36, Number 4, April 2022 Subtrochanteric Femur Fractures

TABLE 1. Summary of Studies Included in Systematic Review

Study Newcastle–Ottawa Scale Number without Number with
Study Author Year Design Score Cerclage Cerclage Classification
Afsari et al4 2009 Retrospective 5 35 9 AO classification
Alho et al24 1996 Retrospective 5 7 3 Not specified
Annappa et al1 2020 Retrospective 5 41 14 Not specified
Boldin et al28 2003 Retrospective 5 50 5 AO classification
Choi et al23 2014 Retrospective 6 21 10 AO classification and fielding
classification
Codesido et al13 2017 Retrospective 6 60 30 OTA/AO and Seinsheimer
Fauconnier et al16 2020 Retrospective 5 92 23 Not specified
Gong et al25 2016 Retrospective 6 8 5 AO classification
Hoskins et al9 2015 Retrospective 5 115 20 Russell Taylor
Jiang et al29 2007 Retrospective 5 32 17 Seinsheimer
Karayiannis and 2019 Retrospective 5 16 69 AO classification
James32
Mehta et al30 2019 Retrospective 5 89 52 Not specified
Ramakrishnan 2004 Retrospective 6 16 8 Seinsheimer
et al17
Rehme et al18 2020 Retrospective 5 188 72 OTA/AO classification
Seyhan et al26 2012 Retrospective 5 22 11 Seinsheimer
Trikha et al2 2018 Retrospective 6 27 21 OTA/AO classification
Wang et al31 2010 Retrospective 6 21 4 Seinsheimer
Zhou et al27 2015 Retrospective 5 71 5 Seinsheimer

Open Reduction
Study Author IMN Implant Nail Length Cerclage Type No. of Cerclage Used without Cerclage
Afsari et al4 91% cephalomedullary, Not specified Not specified 1 100% opened
9% recon
Alho et al24 Gross–Kempf Not specified Not specified Not specified Not specified
(Howmedica)
Annappa et al1 Long PFN (Synthes), Not specified Not specified Not specified 39% opened
PFNA (Synthes)
Boldin et al28 PFN (Synthes) 240 or 320–420 mm Not specified Not specified 0% opened
Choi et al23 PFN, PFNA, A2FN Not specified Not specified Not specified 38% opened
(Synthes)
Codesido et al13 Gamma (Stryker), Not specified Dall Miles (Stryker) 1-2 cables—28 · 1, 2 · 0% opened
Charfix (ChM) 2
Fauconnier Not specified 74% long nail Not specified Not specified Not specified
et al16
Gong et al25 PFNA (Synthes) 280–380 mm Not specified 1 100% opened
Hoskins et al9 86% cephalomedullary, 82% long no cerclage, Not specified Not specified 27% opened
14% recon 95% with cerclage
Jiang et al29 Long PFN (Synthes), 340 mm Not specified Not specified 0% opened
Long Gamma (Stryker)
Karayiannis and Gamma 3 (Stryker) Not specified Cable or wire 1, 2 or 3 Not specified
James32
Mehta et al30 PFNA (Synthes) Not specified Not specified Not specified 0% opened
Ramakrishnan Long proximal femoral 340/380/420 mm Dall Miles Cables Not specified 0% opened
et al17 nail (Stratec Medical) (Stryker–Howmedica)
Rehme et al18 Gamma3 (Stryker), Between 180 mm and Cerclage cables (Stryker) 1-3 cables—10 · 1, 31 0% opened
InterTAN (Smith and 420 mm · 2, 11 · 3
Nephew)
Seyhan et al26 PFN (Synthes), Standard Not specified Cerclage cables (Smith Not specified 100% opened
PFNA (Synthes), Long & Nephew)
PFNA (Synthes), Smith
& Nephew piriformis
entry long nails
Trikha et al2 Not specified Not specified Cerclage wire (DePuy– 1 or 2 Not specified
Synthes)
Wang et al31 Long PFNA (Synthes) 300, 340, 380 mm Not specified Not specified 5% opened
Zhou et al27 Not specified Not specified Not specified Not specified 93% opened

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Hoskins et al J Orthop Trauma  Volume 36, Number 4, April 2022

TABLE 2. Reoperation Because of All Cause, Nonunion, Loss of Fixation, Implant Failure, Fracture Reduction, and Time to Union
(Reported in Raw Numbers)
Number Without Number With Rtt Without Rtt with Nonunion Without Nonunion With
Study Author Year Cerclage Cerclage Cerclage Cerclage Cerclage Cerclage
Afsari et al4 2009 35 9 1 0 1 0
Alho et al24 1996 7 3 2 0 0 0
Annappa et al1 2020 41 14 8 5 5 3
Boldin et al28 2003 50 5 Not specified Not specified 0 0
Choi et al23 2014 21 10 3 0 3 0
Codesido et al13 2017 60 30 4 1 5 0
Fauconnier et al16 2020 92 23 4 1 14 3
Gong et al25 2016 8 5 0 0 0 0
Hoskins et al9 2015 115 20 13 0 7 0
Jiang et al29 2007 32 17 0 0 0 1
Karayiannis and 2019 16 69 1 5 1 4
James32
Mehta et al30 2019 89 52 14 2 3 0
Ramakrishnan 2004 16 8 0 0 0 0
et al17*
Rehme et al18 2020 188 72 0 3 8 4
Seyhan et al26 2012 22 11 6 3 Not specified Not specified
Trikha et al2 2018 27 21 2 1 0 0
Wang et al31 2010 21 4 0 0 0 0

Loss of Loss of Implant Implant Fracture Fracture Mean Time Mean Time
Fixation/Cut- Fixation/Cut- Failure Failure Reduction Reduction to Union to Union
Out Without Out With Without With Without With Without With
Study Author Cerclage Cerclage Cerclage Cerclage Cerclage Cerclage Cerclage Cerclage
Afsari et al4 0 0 0 0 100% good 100% good Not specified Not specified
Alho et al24 0 0 2 0 Not specified Not specified Not specified Not specified
Annappa et al1 0 0 3 2 33% good 64% good Not specified Not specified
Boldin et al28 Not specified Not specified Not specified Not Not specified Not specified Not specified Not specified
specified
Choi et al23 0 0 0 0 Not specified Not specified Not specified Not specified
Codesido 3 1 0 0 38% good 97% good 6.9 mo 4.4 mo
et al13
Fauconnier Not specified Not specified Not specified Not Not specified Not specified 8.6 6.9
et al16 specified mo 6 4.2 mo 6 2.8
Gong et al25 0 0 0 0 Not specified Not specified 4.8 mo 5.4 mo
Hoskins et al9 5 0 2 0 17% good 60% good Not specified Not specified
Jiang et al29 0 0 0 0 Not specified Not specified Not specified Not specified
Karayiannis 0 0 0 0 Not specified Not specified Not specified Not specified
and James32
Mehta et al30 8 0 6 4 26% good 83% good Not specified Not specified
Ramakrishnan 0 0 0 0 Not specified Not specified Not specified Not specified
et al17*
Rehme et al18 Not specified Not specified Not specified Not Not specified Not specified 96% at 1 y 94% at 1 y
specified
Seyhan et al26 Not specified Not specified Not specified Not Not specified Not specified 21 wk 6 9 19 wk 6 8
specified
Trikha et al2 0 0 2 0 74% good 95% good 18.15 wk 17.14 wk
(SD 2.13) (SD 3.29)
Wang et al31 0 0 0 0 Not specified Not specified Not specified Not specified
*Ramakrishnan et al17 recorded 19.4 weeks (16–30) time to union for fracture with and without cerclage wire combined.

Risk of Implant Failure between cerclage wiring and noncerclage wiring for risk of
Fourteen studies compared the risk of implant failure implant failure [OR = 0.99 favoring cerclage wiring (95% CI
for 889 patients in the control group and 367 patients in the 0.24–4.09), P = 0.986] (see Figure, Supplemental Digital
cerclage wire group. There was no statistical difference Content 3, http://links.lww.com/JOT/B550).

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J Orthop Trauma  Volume 36, Number 4, April 2022 Subtrochanteric Femur Fractures

FIGURE 2. Reoperation.

Accuracy of Fracture Reduction wiring for good fracture reduction compared with noncerclage
Six studies compared the accuracy of fracture reduction wiring [b-coefficient = 42.52 favoring cerclage wiring (95% CI
for 367 patients in the control group and 146 patients in the 23.49–61.56), P , 0.001] (see Figure, Supplemental Digital
cerclage wire group. There was a benefit favoring cerclage Content 4, http://links.lww.com/JOT/B551).

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Hoskins et al J Orthop Trauma  Volume 36, Number 4, April 2022

FIGURE 3. Nonunion.

Time to Union cerclage wiring and noncerclage wiring for time to union
Five studies compared the time to union for 209 [b-coefficient = 21.21 favoring cerclage wiring (95% CI
patients in the control group and 90 patients in the cerclage 22.70 to 0.28), P = 0.260] (see Figure, Supplemental
wire group. There was no statistical difference between Digital Content 5, http://links.lww.com/JOT/B552).

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J Orthop Trauma  Volume 36, Number 4, April 2022
DISCUSSION
The clinical difference between augmenting subtro-
chanteric femur fractures treated with a femoral intramedul-
lary nail using a cerclage wire and without, is not known.
There are theoretical benefits of the addition of cerclage wire,
including improved reduction and construct stability. The
disadvantages include an open approach, increased surgical
time, and greater blood loss. There is limited literature
available with direct comparison of cases with cerclage wire
and without. This systematic review of the literature and
meta-analysis produced 18 comparative studies comparing
complications, fracture union, and accuracy of reduction
between subtrochanteric femur fractures managed with fem-
oral intramedullary nail, and augmented with cerclage wire or
without. We identified no statistical advantage in using
cerclage wire with intramedullary nail when treating sub-
trochanteric femur fractures regarding the risk of reoperation,
nonunion, loss of fixation, and implant failure or the time to
union. A benefit favoring cerclage wire was found for more
accurate fracture reduction. A higher percentage of fractures
as a result of high-energy trauma was seen in the cerclage
wire group. Although we found no statistical advantage in
using cerclage wire, the use of cerclage wire augmentation
was associated with a reduction in the odds of all of outcomes
and did so in a cohort that included a higher percentage of
high energy trauma. This study is likely to be underpowered,
given the relatively small number of events available to be
modelled. A clinical benefit for cerclage wiring may still exist
for certain fracture types. When surgeons decide to manage a
subtrochanteric femur fracture, consideration can still be
given to the use of cerclage wire if acceptable closed
reduction cannot be achieved and the fracture pattern allows
it. The routine use of cerclage wiring in simple facture
patterns that reduce closed seems difficult to justify.
As far as we are aware, this is the first systematic
review and meta-analysis performed about cerclage wire use
in the management of subtrochanteric femur fractures. A
limitation of the study is that the included studies were all
retrospective in nature, and mostly had a low number of
patients. Based on the Newcastle–Ottawa scoring system, the
study quality was average. The results may change if there
were more studies, increased patient numbers, longer follow-
up, higher quality studies, and prospective studies that better
controlled confounding variables. We did not exclude studies
from the meta-analysis based on the assessment of quality
because there was little variation in study quality. In the
included studies, groups were matched for age and sex,
although there was a greater percentage of high-energy
trauma in the cerclage wire group, which is a recognized
confounder. Time to union increases with fracture classifica-
tion severity and comminution.23 This may be a selection bias
for the cerclage wire cohort. There was a lack of uniform
definition of what fracture types based on fracture classifica-
tions were included in studies and what fracture patterns were
managed with or without cerclage wire. Because of this and a
lack of reporting, we were unable to subanalyze different
fracture types. Some studies solely included fractures when
deformity4 or comminution was present,24 only spiral or
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Subtrochanteric Femur Fractures
oblique fractures,1,25 or only low energy fractures.15 Some
studies excluded transverse or comminuted fractures25 or
fractures not amenable to cerclage wire.2 These limitations
with the inclusion criteria and the lack of reporting have likely
created heterogeneity in the pooled and compared fractures in
the study for these reasons.
For the control group we were unable to subanalyze on
the basis of whether the fracture was able to be reduced
through closed means, or if reduction occurred with open
techniques and the surgeon elected not to insert a cerclage
wire (Table 1). This would seem an important clinical differ-
entiation. Some studies control groups had 100% open reduc-
tion,4,25,26 or the majority reduced open (93%),27 but most all
had closed reduction1,15,17,18,28–30 or most fractures reduced
closed (5%–39% opened),9,23,31 with many studies not spec-
ifying.2,16,24,32 There were 5 included studies that docu-
mented quality of reduction and whether the control group’s
fracture was opened. One study opened all fractures and
achieved good reduction in 100%.4 Two studies did not open
any and only achieved 26%–38% good reductions,1,15,30
although 2 studies selectively opened and achieved 33% good
reductions opening 39%,1 and 17% good reductions opening
27%.9 This may suggest that more should be done to obtain
and maintain reduction when a fracture is opened given the
low rates of good reduction when cerclage wire was not used.
Although we did not find that there was a statistical benefit for
time to union, other studies have demonstrated that there is a
linear relationship between postoperative fracture displace-
ment and bone union time.23 Only 2 included studies re-
corded the accuracy of reduction and time to union. The
first study achieved 38% good reduction with closed tech-
niques which united in 6.9 months, compared with 97% good
reduction in the cerclage wire group uniting in 4.4 months.15
The second achieved 74% good reduction in the noncerclage
group (reduction method not specified), which united in 18.2
weeks, compared with 95% good reduction in the cerclage
wire group which united in 17.1 weeks.2 This would suggest
that open reduction 6 cerclage wire should occur if reduction
cannot be achieved closed, with the benefits of better reduc-
tion and potentially time to union. Cerclage wire application
in this situation may produce a functional benefit to patients
as some studies have found,18,26 but not all.32 Improved
patient function could be due to fracture reduction, construct
stability and/or faster fracture healing. Other studies have
shown a relationship to poor fracture reduction with an
increased risk of implant failure.30 We found no statistical
benefit for cerclage wire for implant breakage rates or pre-
venting reoperation, but it is plausible to suggest that with
better fracture reduction this may occur. It remains unclear
whether the results of open reduction without cerclage wire
differ if a cerclage wire had have been applied. There may be
fracture patterns that are not amenable to cerclage wire and it
is unknown if other augments such as unicortical plates or
blocking screws may have a similar clinical utility in these
situations.26 Improved reporting of fracture types and surgical
decision-making is required in future studies.
Nail type, length, and diameter are all factors that may
affect outcomes. There was variability in the type of nail used
and its length (Table 1), with few studies overall reporting
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Hoskins et al
nail length. Most studies that specified an implant used a long
cephalomedullary nail, but reconstruction and short nails
were also used. We did not subanalyze on the basis of nail
type or nail length and there may be differences for these
reasons. Nail diameter was most frequently not recorded,
and we did not include this in our data collection. The type
or number of cerclage wires were not consistently reported
(Table 1). This also may have an impact on outcome. Future
studies should consider better reporting of all these implant
related variables. Finally, the exclusion of non-English stud-
ies secondary to logistic constraints may represent an addi-
tional limitation to the power and generalizability of the
current meta-analysis.
CONCLUSIONS
This systematic review and meta-analysis identified that
when subtrochanteric femur fractures treated with femoral
intramedullary nail are augmented with cerclage wire and
compared with that without, there is no statistical advantage
regarding the risk of reoperation, nonunion, loss of fixation,
and implant failure or the time to union. A statistical
advantage exists for the accuracy of fracture reduction.
Groups were not matched for the degree of energy of the
injury. Cerclage wiring was used more often in cases
involving high-energy trauma, which is an identified con-
founder. This study is likely to be underpowered given the
relatively small number of events available to be modelled. A
clinical benefit for cerclage wiring may still exist for certain
fracture types. Cerclage wire use was associated with a
nonstatistically significant reduction in the odds of major
complications, and there was no detriment identified.
We would recommend consideration of cerclage wiring
if acceptable closed reduction cannot be achieved, and the
fracture pattern allows it. The routine use of cerclage wiring
in simple fractures that reduce closed seems difficult to
justify. Surgeons should consider the biological impact of
opening fractures and use cerclage wire in a minimally
invasive manner. Well-designed prospective studies with
improved reporting are required, so that more accurate data
can be compared, and the subgroup analysis of fracture types
and reduction techniques can be compared.
ACKNOWLEDGMENTS
The authors would like to thank Jim Berryman from the
University of Melbourne for his assistance in developing the
search methodology and for conducting the search.
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