Pertrochanteric Hip Fractures Research Articles

A prospective, comparative study between the use of the proximal femoral nail and trochanteric support plate for management of pertrochanteric hip fracture

Introduction: The proximal femoral nail (PFN) and dynamic hip screw with trochanteric support plate are two implants used in the management of pertrochanteric hip fracture. In this study, we try to find out if one implant is better than the other. Materials and Methods: A total of 40 patients were included with 20 each in both the groups between August 2016 and February 2018 in this prospective observational study. All patients were recorded and analyzed for the length of incision (LoI), period of hospitalization (PoH), blood loss, time of union (ToU), duration of surgery (DoS), Parker and Palmer mobility score (PPMS), and Harris hip score (HHS). Results: PFN was found to have a statistical advantage over TFN in terms of LoI (6.4 vs. 14.7 cm.), DoS (70.65 vs. 105.25 min), blood loss (97.25 vs. 294.0 ml), ToU (14.9 vs. 17 days), and PoH (18.1 vs. 21.6 days). While PPMS (7.05 vs. 6.5) was comparable in both groups, HHS (90.25 vs. 81.6) was better in the PFN group. Conclusions: PFN was found to be a better minimally invasive implant for pertrochanteric fractures when closed reduction is possible in terms of LoI, PoH, ToU, DoS, blood loss, and HHS but not for PPMS.

The Effect of Hospital and Surgeon Volumes on Complication Rates After Fixation of Peritrochanteric Hip Fractures.

This study evaluates the relationship between hospital and surgeon volumes of peritrochanteric hip fracture fixation and complication rates. Adults (60 years of age or older) who underwent surgical fixation for closed peritrochanteric fractures from 2009 to 2015 were identified using International Classification of Diseases 9 and 10 Clinical Modification and Procedural codes in the New York Statewide Planning and Research Cooperative System database. Readmission, reoperations, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes. Statistical significance was set at P < 0.05. A total of 29,656 patients were included in the study. Low-volume (LV) facilities had higher rates of readmission [hazard ratio (HR) 1.07, 95% confidence interval (CI), 1.05-1.17], pneumonia (HR 1.36, 95% CI, 1.22-1.51), wound complications (HR 1.24, 95% CI, 1.03-1.49), and mortality (HR 1.15, 95% CI, 1.04-1.27) but lower rates of acute renal failure (HR 0.90, 95% CI, 0.83-0.98), deep vein thrombosis (HR 0.66, 95% CI, 0.55-0.78), and acute respiratory failure (HR 0.77, 95% CI, 0.62-0.95) than high-volume (HV) facilities. Patients treated by LV surgeons had lower rates of readmission (HR 0.92, 95% CI, 0.87-0.97) and deep vein thrombosis (HR 0.78, 95% CI, 0.66-0.94) but higher rates of acute renal failure (HR 1.13, 95% CI, 1.04-1.22) than those treated by HV surgeons. There are increased rates of mortality, readmission, and certain complications when peritrochanteric femur fractures are surgically managed at LV hospitals compared with those managed at HV hospitals. Thus, the benefit of a high-volume surgical facility is apparent in mortality and readmissions but not all complications. There was no significant decrease in complications if fixation was performed by HV surgeons relative to LV surgeons. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Additional Reduction Screw Fixation Technique for Pertrochanteric Hip Fractures: A Novel Method to Prevent Excessive Sliding in Cephalomedullary Nail Surgery

Extramedullary (EM) reduction, defined as the medial cortex of the head-neck fragment located outside the medullary canal of the distal shaft fragment, has been introduced to prevent excessive postoperative sliding or failure of the lag screw in pertrochanteric fracture surgeries. Favorable EM reduction results have recently been reported in several clinical and biomechanical studies. Despite these efforts, maintaining the head-neck fragment in an EM position is periodically a difficult and challenging problem. Herein, the technique for reduction and maintenance of the head-neck fragment was introduced in an EM position using a Kirschner wire and partially threaded cannulated screw fixation via screw fixation from EM to the head-neck fragment, which was positioned inferior to the lag screw on the femoral calcar, also called the reduction screw. The authors utilized this reduction screw in 34 pertrochanteric fracture surgeries using a cephalomedullary nail and fracture union was acheive in all cases by a minimum one-year follow-up period without surgical complications.

Breakage of sliding hip screw after fixation of pertrochanteric hip fracture: A rare complication.

IntroductionThe authors report a rare case of lag screw breakage in a patient treated using locking DHS with home-made trochanteric stabilizing plate (TSP) for pertrochanteric hip fracture.Case presentationA 67 year-old female was operated for pertrochanteric hip fracture with incompetent lateral wall using locking DHS with home-made TSP. At seven months postoperative, there was radiographic nonunion with breakage of the sliding lag screw. Patient was consequently scheduled for total hip replacement.DiscussionBreakage of DHS lag screw has been attributed to multiple-cycle, low-stress fatigue failure associated with nonunion. Predisposing factors are: situation of the medial edge of the barrel at the level of the fracture site prohibiting fracture compression, and mechanical obstacle to the lag screw back sliding into the barrel. In our case, the use of handmade TSP interdicted lag screw back sliding and prevented fracture impaction which was already impaired by the location of the medial edge of the barrel at the fracture level. Additionally our fixation construct was very rigid because of the use of locking screws in the DHS side plate.ConclusionWhen DHS fixation is planned for unstable or potentially unstable trochanteric hip fracture the surgeon should be prepared by making available a TSP from the manufacturer in the operative room rather than improvising intra-operatively with handmade TSP; this augmentation device shouldn't interfere with lag screw back sliding. Furthermore the DHS barrel should ideally not impinge with the fracture site, and the use of locking screws in the DHS plate should be cautious.

Minimizing Nonessential Follow-up for Hip Fracture Patients.

Introduction:Hip fractures pose a significant burden to patients and care providers. The optimal protocol for postoperative care across all surgically treated hip fracture patients is unknown. The purpose of this study was to investigate the effect that routine follow-up had on changing the clinical course.Methods:This was a retrospective review of all low-energy hip fractures (ie, femoral neck fractures, pertrochanteric hip fractures, and subtrochanteric fractures) treated surgically from January 2018 through December 2019. Charts were reviewed for demographic information; the procedure performed; the number of postoperative follow-up visits each patient had with the orthopaedic surgery team; the number of sets of postoperative radiographic images obtained; and postoperative complications.Results:Eight hundred eleven patients with 835 hip fractures were included in the study. The overall number of patient visits was 1,788, and the number of radiograph sets was 1,537. The median number of follow-up visits was two visits/fracture (interquartile range: 1 to 3 visits, maximum = 9 visits), with the median follow-up length of 54 days (interquartile range: 33 to 97 days) with the treating orthopaedic surgeons. Sixty-two (7.6%) patients had 81 (4.5%) postoperative visits and 26 (1.7%) sets of images that led to treatment changes. Among them, 48 (77.4%) patients had concerns that were initiated by the patients and/or care provider. Fourteen standard patient visits led to treatment changes that were not initiated as concerns by the patient and/or care provider.Discussion:Most clinic visits and radiographs did not lead to a change in the care plan. We recommend that emphasis be placed on comprehensive orthogeriatric care of these patients, and we believe that these data provide the impetus to work toward improving the care pathways for elderly patients with hip fractures.

A Simple Procedure for a Common Problem: Screw/Blade Exchange for Symptomatic Lateral Hardware Associated With Fracture Compression Following Dynamic Cephalomedullary Fixation of Pertrochanteric Hip Fractures

A Simple Procedure for a Common Problem: Screw/Blade Exchange for Symptomatic Lateral Hardware Associated With Fracture Compression Following Dynamic Cephalomedullary Fixation of Pertrochanteric Hip Fractures

Intramedullary nailing confers an increased risk of medial migration compared to dynamic hip screw fixation in unstable intertrochanteric hip fractures

IntroductionMedial migration of the femoral neck element (FNE) superomedially against gravity with respect to the intramedullary component of the cephalomedullary nail is a complication increasingly recognized to cause femoral head cut-out in intramedullary nailing of pertrochanteric hip fractures. Although cut-outs are common to both intra- and extramedullary fixation, especially in unstable pertrochanteric hip fractures, FNE medial migration in sliding hip screws continues to remain sparse despite increased awareness of the phenomenon. This study aims to investigate whether intramedullary nailing is biomechanically predisposed to FNE medial migration compared to extramedullary fixation with sliding hip screws to account for the discrepancy in reported FNE medial migration rates. Materials and methodsTwelve fourth-generation synthetic femurs (Sawbones) with unstable intertrochanteric fractures were divided into 2 groups (n=6 per group). Fracture fixation was performed using the Proximal Femoral Nail Antirotation (PFNA, Synthes) (n=6) in the first group, and the Dynamic Hip Screw (DHS, Synthes) (n=6) in the second group. Both groups were subjected to bidirectional cyclic loading (600N compression loading, 120N tensile loading) at 2 Hz for 5000 cycles. The medial migration distance (MMD) was recorded at the end of the testing cycles. ResultsThe mean MMD in the PFNA group was 4.56mm (SD 0.69mm) with consistent reproduction of medial migration across all constructs tested. This was significantly more compared to the MMD of 1.17mm (SD 0.69mm) in the DHS group (p<0.001). ConclusionIntramedullary nailing of unstable intertrochanteric hip fractures is inherently predisposed to FNE medial migration making it more susceptible to consequent cut-out compared to fixation with the DHS.

The Pre-Loaded Set-Screw in InterTAN Nail: Should It Be Tightened or Not Tightened in Pertrochanteric Hip Fractures.

Background:InterTAN is a specific type of cephalomedullary nail with a twin interlocking de-rotation and compression screw, which has inherent ability of anti-rotation. Whether to tighten or not to tighten the preloaded setscrew to allow or not allow secondary sliding in InterTan nail is controversial in clinical practice.Methods:We retrospectively collected 4 nonunion cases of unstable pertrochanteric femur fractures (AO/OTA-31A2), all were treated with InterTan nail and the preloaded setscrew was tightened in order to prevent further secondary sliding and femoral neck shortening.Results:After 6 months to 2 years follow-up, the fractures showed nonunion in radiography and the patients complained slight to middle degrees of pain, and had to use walking stick assistant in activities of daily life. Tightening the pre-loaded setscrew to prevent postoperative secondary sliding as static constructs might keep the femoral neck length, but lose the opportunity of telescoping for fracture impaction, and take the risk of healing complications, such as fracture nonunion, femoral head cutout or nail breakage.Conclusions:As the harm outweighs benefit, we advocate the preloaded setscrew in InterTan nail should not be tightened in standard-obliquity pertrochanteric hip fractures (AO/OTA-31A1 and A2).

The effect of nail diameter on proximal femoral shortening after internal fixation of pertrochanteric hip fractures with short cephalomedullary nails

ObjectiveInvestigate the effect of distal nail diameter on proximal femoral shortening (PFS) after cephalomedullary nailing of hip fractures. MethodsA retrospective cohort study of 80 patients aged 50 years and older with pertrochanteric hip fractures treated with a 10 or 11 mm short cephalomedullary nail (CMN) was performed. We measured abductor lever arm shortening, femoral height shortening, and PFS. ResultsThere was no difference in abductor lever arm shortening (p = 0.09), femoral height shortening (p = 0.86), and PFS (p = 0.34) between the 10 and 11 mm groups. ConclusionsOur results suggest that distal nail diameter does not affect PFS. Level of evidenceIII.

Distal interlocking for short trochanteric nails: static, dynamic or no locking? Review of the literature and decision algorithm.

Pertrochanteric hip fractures are among the most common and the use of short cephalomedullary nails as the treatment of choice is increasing.A systematic review regarding distal locking options for short cephalomedullary nails was undertaken using Medline/PubMed®, Embase® and Cochrane Library® in order to evaluate current indications, associated complications and to provide treatment recommendations.The results seem to support the use of distal static locking for unstable fractures, dynamic locking for length stable/rotational unstable fractures and no locking for stable fractures.Complications associated with distal locking include iatrogenic fractures, thigh pain, delayed union and nonunion, implant failure, screw loosening and breaking, drill bit breaking, soft tissue irritation, femoral artery branch injury, intramuscular haematoma and compartment syndrome. It is also associated with longer operative time and radiation exposure.In unlocked constructs, dorsomedial comminution and nail/medullary canal mismatch contribute to peri-implant fractures. Anterior cortical impingement is associated with cut-out and nonunion.Most studies comparing distally locked and unlocked nails report a short follow-up.Distal locking mode should be based on the fracture’s stability.Cite this article: EFORT Open Rev 2020;5:421-429. DOI: 10.1302/2058-5241.5.190045

Management of Lateral Thigh Pain following Cephalomedullary Nail: A Technical Note

Peritrochanteric hip fractures are most commonly treated with proximal femoral fixation devices, such as a cephalomedullary nail or sliding hip screw. As usage rates increase for these fixation devices, complications from their insertion are becoming more prevalent. Lateral hip pain from proximal locking device insertion and prominence continues to be one of the most frequent complaints regarding hardware irritation following this surgical procedure. Conservative treatment options for this complaint include local corticosteroid injection and physical therapy, although once these treatments have been exhausted, surgical intervention may be recommended. This has generally been managed previously with implant removal, although studies have shown associated femoral neck fractures after removal even with the prescribed protected postoperative weight bearing. Additionally, in certain situations (e.g., when the nail is placed for prophylactic treatment), its removal is contraindicated. The purpose of this manuscript is to describe an alternative treatment option that would limit morbidity, and the need for proximal locking device or implant removal by excising the portion of the iliotibial band causing hip irritation at the level of the proximal locking device, while leaving the retained implant in place. This surgical option would allow most patients to return to their pre-operative weight-bearing status immediately following surgery without the need for additional postoperative precautions.

Pertrochanteric Fractures in the Elderly: Is the Severity of Fracture Pattern associated with age and an increased rate of mortality?

Purpose: This study was aimed at assessing whether there is a correlation between age and pertrochanteric femur fracture severity and if this may be tied to mortality at a 1-year interval. Background: Pertrochanteric hip fractures are a common low energy fractures and represent a major cause of morbidity and mortality in the elderly population. To date, association of a worse fracture pattern to loss of Bone Mineral Density has not been proven. We set out to assess whether fracture severity may be tied to age in this specific patient population. Methods: From May 2010 to January 2013, we retrospectively collected the data of all patients (&gt;60 years old) sustaining a low energy pertrochanteric fracture which were admitted at the Kaplan Medical Center. The following parameters were collected and evaluated: (1) demographics, (2) fracture pattern, (3) time from admission to surgery, (4) time from surgery to mortality. Results: We included 578 fractures in the study. These were divided into 4 groups according to age. We analyzed the data using a Spearman's rho correlation and Pearson Chi-Square Test but found no significant difference in fracture stability with increase in age. For the 544 fractures that were operated on at Kaplan Medical Center we found that 1-year mortality was significantly higher with increasing age (p=0.000) and male sex (p=0.001). With every additional patient year, the mortality risk rose by 8.3%. Moreover, the relative mortality risk in the male patients of our cohort was 1.93 as compared to the female ones. Fracture severity and time from admission to surgery were not found to have a significant effect on mortality. Conclusions: Statistically the pertrocanteric fracture severity classified after the AO does not correlate with the age or one-year mortality of the patient. The one-year mortality rate was significant higher with increased age and male sex.

Timing of proximal femoral shortening in the early postoperative period after cephalomedullary nailing of hip fractures

ObjectivesExamine the timing of proximal femoral shortening (PFS) after cephalomedullary nailing of hip fractures. MethodsA retrospective cohort study of 21 patients ≥50 years old with pertrochanteric hip fractures treated with a short cephalomedullary nail (CMN) was performed. Abductor lever arm shortening, femoral height shortening, and PFS were measured. ResultsMean PFS at 10–21 days postoperatively was 5.54 mm, compared to 11.31 mm at final follow-up. The percentage of total PFS that occurred within 10–21 days postoperatively was 53.9%. ConclusionApproximately half of total PFS occurs within 1.5–3 weeks and is notable on radiographs by the first postoperative visit.

Fast-track care for pertrochanteric hip fracture: What impact on function and autonomy after discharge?

IntroductionFast-track treatment of pertrochanteric fracture is being developed in traumatology. The present study hypothesis was that fast-track treatment of pertrochanteric fracture does not jeopardize patient autonomy. Material and methodA single-center prospective comparative observational study, conducted from 2014 to 2016 in the University Hospital of Angers, France, included patients presenting with isolated A1 or A2 pertrochanteric fracture on the AO classification, managed by intramedullary nailing and requiring transfer to Post-acute Recovery (PAR). The fast-track exposure group were transferred directly on postoperative day 1, while the non-exposure group received postoperative care in the surgery department before transfer to PAR. The main endpoint was difference in Parker score between admission and discharge. Secondary endpoints comprised type of walking aid at discharge and destination of discharge from PAR. Results109 patients were initially included, with 54 patients (27 pairs) after matching. There was a significant difference in reduction in Parker score in favor of fast-track: −1.27 (95% CI: −2.27; −0.32) (p=0.012). There were no differences in amount or type of aid at discharge or discharge destination, although there was a trend toward greater discharge to the initial place of residence with fast-track. DiscussionOrthopedics is heading to the fast-track. Previous studies reported shorter hospital stay, comparable survival and complications rates, and significant cost-saving. The present study addressed progression: fast-track patients showed significantly less loss of walking autonomy. ConclusionFast-track management of pertrochanteric fracture significantly reduced loss of walking autonomy, without significant impact on discharge destination or walking aids. Level of evidenceIIB, exposure/non-exposure cohort.

Cephalomedullary blade cut-ins: a poorly understood phenomenon.

Proximal femoral nail antirotation (PFNA) cut-in is a unique phenomenon seen in pertrochanteric hip fractures treated with the PFNA. Cut-in refers to the superomedial migration of the proximal femoral blade into the femoral head and hip joint. We recognize that cut-in is a completely separate entity from the well-described cut-out failure. This study assesses relevant radiological and patient risks factors for cut-in. Retrospective multicenter study looking at patients with pertrochanteric hip fractures managed with the Synthes PFNA SETTING: Four tertiary hospitals over 7years. Patients with cut-ins were identified. The radiological appearance of this mode of failure was assessed and compared to cut-outs. Patient demographics, fracture configuration, time to implant failure (cut-in), bone mineral density, tip-apex distance, neck-shaft angle and position of the tip of the helical blade in the femoral head were collected. There was a total of 1027 patients across 4 institutions with 23 patients with cut-in. Average neck-shaft angle was 133 degrees. 16 out of 19 patients had severe osteoporosis with BMD < - 2.5. 14 of 23 patients had poor placement of the blade. 13 of 23 had a tip-apex distance of more than 20mm. We propose a standardized nomenclature of "cut-in" for the phenomenon of superomedial migration of the proximal femoral blade. An anatomical neck-shaft reduction, accurate blade placement and increased surveillance for patients with severe osteoporosis are required to reduce the incidence and morbidity of cut-in.

Scanning Electron Microscopy Study of Retrieved Implants Suggests a Ratcheting Mechanism Behind Medial Migration in Cephalomedullary Nailing of Hip Fractures.

Introduction:Medial migration is the paradoxical migration of the femoral neck element (FNE) superomedially against gravity with respect to the intramedullary component of the cephalomedullary device, increasingly seen in the management of pertrochanteric hip fractures with the intramedullary nail. We postulate that the peculiar anti-gravity movement of the FNE in the medial migration phenomenon stems from a ratcheting mechanism at the intramedullary nail-FNE interface, which should inadvertently produce unique wear patterns on the FNE that can be seen with high-powered microscopy. By examining the wear patterns on retrieved implants from patients with medial migration, our study aims to draw clinical correlations to the ratcheting mechanism hypothesis.Material and Methods:Four FNEs were retrieved from revision surgeries of four patients with prior intramedullary nail fixation of their pertrochanteric hip fractures complicated by femoral head perforation. The FNEs were divided into two groups based on whether or not there was radiographic evidence of medial migration prior to the revisions. Wear patterns on the FNEs were then assessed using both scanning electron microscopy and light microscopy.Results:Repetitive, linearly-arranged, regularly-spaced, unique transverse scratch marks were found only in the group with medial migration, corresponding to the specific segment of the FNE that passed through the intramedullary component of the PFNA during medial migration. These scratch marks were absent in the group without medial migration.Conclusion:Our findings are in support of a ratcheting mechanism behind the medial migration phenomenon with repetitive toggling at the intramedullary nail-FNE interface and progressive propagation of the FNE against gravity.

Does Implant Choice Affect the Episode Cost of Pertrochanteric Hip Fracture for US Veterans?

To investigate an association between a surgeon's choice of a cephalomedullary nail (CMN) or sliding hip screw (SHS) with the cost of treating a pertrochanteric hip fracture. Multicenter retrospective cohort study. US Veterans Health Administration Sierra Pacific Network. Two hundred ninety-four consecutive US veterans admitted for a principal diagnosis of an OTA/AO 31A-type pertrochanteric hip fracture of a native hip from 2000 to 2015. Internal fixation using a CMN or an SHS. Veterans Administration Health Economic Resource Center average national cost estimate of combined acute and postacute care episode cost, excluding implant cost, normalized to 2015 US dollars by the Consumer Price Index. Median episode cost was $8223 lower with a CMN than an SHS (95% confidence interval, $5700-$10,746, P < 0.001) after matching on a propensity score for treatment with a CMN based on age, sex, body mass index, Charlson Comorbidity Index, fracture characteristics, study site, and admission year. A subgroup propensity-matched analysis excluding reverse obliquity pertrochanteric fractures was not sufficiently powered to detect a difference in episode cost (β = 0.76, P = 0.311). Implant choice significantly affected the episode cost of care of hip fracture at Veterans Health Administration facilities. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Sagittal Plane Considerations During Long Cephalomedullary Nailing: Optimal Distal Positioning and the Role of Intraoperative Nail Bending.

To retrospectively review a large population of long cephalomedullary nails with special attention to distal implant position in the sagittal plane and assess the ability to avoid anterior cortical contact (ACC) by bending the distal tip of the nail intraoperatively. Retrospective review of single surgeon experience. Single Level 1 trauma center. Radiographic position of the cephalomedullary nail with respect to the anterior femoral cortex and the effects of intraoperative bending of the distal tip of the nail. A total of 215 patients who underwent long cephalomedullary nailing for peritrochanteric hip fractures between 2007 and 2017 were reviewed. In the period between 2007 and October 2013, ACC of the distal portion of the nail in the sagittal plane was a common finding. Its incidence significantly decreased after intraoperative bending of long cephalomedullary nails was incorporated into practice in cases where sagittal plane impingement was detected (P < 0.0001). ACC was more prevalent if the final nail position was proximal to the level of the patella. Careful attention should be paid to sagittal plane anatomy and distal ACC during insertion of a long cephalomedullary nail. One strategy to prevent anterior impingement or perforation may be intraoperative bending of the distal end of the nail. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

What’s New in Orthopaedic Trauma

What’s New in Orthopaedic Trauma

Medial migration in cephalomedullary nail fixation of pertrochanteric hip fractures: A biomechanical analysis using a novel bidirectional cyclic loading model.

ObjectivesThe paradoxical migration of the femoral neck element (FNE) superomedially against gravity, with respect to the intramedullary component of the cephalomedullary device, is a poorly understood phenomenon increasingly seen in the management of pertrochanteric hip fractures with the intramedullary nail. The aim of this study was to investigate the role of bidirectional loading on the medial migration phenomenon, based on unique wear patterns seen on scanning electron microscopy of retrieved implants suggestive of FNE toggling.MethodsA total of 18 synthetic femurs (Sawbones, Vashon Island, Washington) with comminuted pertrochanteric fractures were divided into three groups (n = 6 per group). Fracture fixation was performed using the Proximal Femoral Nail Antirotation (PFNA) implant (Synthes, Oberdorf, Switzerland; n = 6). Group 1 was subjected to unidirectional compression loading (600 N), with an elastomer (70A durometer) replacing loose fracture fragments to simulate surrounding soft-tissue tensioning. Group 2 was subjected to bidirectional loading (600 N compression loading, 120 N tensile loading), also with the elastomer replacing loose fracture fragments. Group 3 was subjected to bidirectional loading (600 N compression loading, 120 N tensile loading) without the elastomer. All constructs were tested at 2 Hz for 5000 cycles or until cut-out occurred. The medial migration distance (MMD) was recorded at the end of the testing cycles.ResultsThe MMDs for Groups 1, 2, and 3 were 1.02 mm, 6.27 mm, and 5.44 mm respectively, with reliable reproduction of medial migration seen in all groups. Bidirectional loading groups showed significantly higher MMDs compared with the unidirectional loading group (p < 0.01).ConclusionOur results demonstrate significant contributions of bidirectional cyclic loading to the medial migration phenomenon in cephalomedullary nail fixation of pertrochanteric hip fractures.Cite this article: G. W. Law, Y. R. Wong, A. K-S. Yew, A. C. T. Choh, J. S. B. Koh, T. S. Howe. Medial migration in cephalomedullary nail fixation of pertrochanteric hip fractures: A biomechanical analysis using a novel bidirectional cyclic loading model. Bone Joint Res 2019;8:313–322. DOI: 10.1302/2046-3758.87.BJR-2018-0271.R1.