Journal of Musculoskeletal Trauma

Original Articles

Percutaneous anterior leverage technique for anteromedial cortical support in intertrochanteric femur fractures: a computed tomography-based validation study: Whee Sung Son, Bum Jin Shim, Oog-jin Shon; Received September 24, 2025 Accepted December 10, 2025 Published online March 27, 2026; DOI: https://doi.org/10.12671/jmt.2025.00311 [Epub ahead of print]

Abstract PDF: Background
Anteromedial cortical support (AMCS) enhances stability in intertrochanteric femur fractures. However, reproducible, validated methods of achieving AMCS have not previously been reported. This study introduces a percutaneous anterior leverage technique and validates its AMCS effects using computed tomography (CT).
Methods
We retrospectively reviewed patients treated by a single surgeon between March 2022 and December 2024. The inclusion criteria were an AO/OTA classification of A1–A3, application of the percutaneous anterior leverage technique, available pre- and postoperative CT, and ≥6 months follow-up. Outcomes included CT-based AMCS (anterior on axial and medial on coronal images, classified as positive, neutral, or negative), time to union, union rate, changes in neck-shaft angle, and treatment failure (varus collapse, blade cut-through, or nonunion without the former two). The risk factors for failure were analyzed.
Results
Of 273 patients reviewed, 53 met the inclusion criteria. Follow-up was at least 6 months in all cases. Positive anterior support was achieved in 37 patients (69.8%) and positive medial support in 42 (79.25%). No patient demonstrated negative anterior support; one (1.9%) had negative medial support. Cortical support improved significantly after surgery. CT images demonstrated significant postoperative improvements (anterior P=0.026; medial P<0.001). Bone union was achieved in 50 patients (94.34%) at a mean of 3.93±1.48 months. The mean change in the neck-shaft angle at last follow-up was 1.75°±2.34° varus. Three patients (5.66%) experienced treatment failure. Anteromedial cortical breakage during follow-up differed between failure and non-failure groups (P=0.002), but regression identified no independent predictors. No technique-related complications were observed.
Conclusions
Our percutaneous anterior leverage technique produced favorable CT-confirmed AMCS and high union with low failure, supporting its safety and effectiveness in intertrochanteric femur fractures. Level of evidence: IV.

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Sex-specific bottlenecks and risk zones in the retrograde superior pubic ramus screw corridor: a 3D CT-based morphometric cadaver study: Ji Won Jeong, Jung Tae Ahn, Gu Hee Jung, Kun Tae Kim; Received January 22, 2026 Accepted February 7, 2026 Published online March 26, 2026; DOI: https://doi.org/10.12671/jmt.2026.00066 [Epub ahead of print]

Abstract PDF Supplementary Material: Background
Superior ramus screw fixation is commonly used to stabilize anterior pelvic ring injuries but is constrained by a narrow, irregular, and curved intraosseous corridor. Trajectory-based morphometric analysis may assist in screw diameter selection and enable identification of reproducible anatomic constriction zones.
Methods
We conducted a cross-sectional computed tomography (CT)-based morphometric study of 82 cadaveric pelvises (42 males, 40 females). Bottleneck diameter was defined as the diameter of the largest fully contained virtual cylinder along the planned trajectory, and cylinder length was recorded. Orthogonal cross-sections at 9.5-mm intervals (up to 12 segments) were generated to measure segment-wise effective diameter (defined as twice the minimum centerline-to-cortex distance) and cortical clearance, which was used as a diameter-based safety margin. Segments were realigned to the acetabular start segment to define relative segment positions (Δ seg). Feasibility was assessed for prespecified screw diameters ranging from 3.5 to 7.3 mm.
Results
Mean bottleneck diameter was larger in males than in females (7.34±1.10 vs. 5.93±0.98 mm), whereas trajectory length was similar between sexes (127.85±8.54 vs. 128.85±8.20 mm). Δ seg realignment localized corridor constriction to two discrete zones: a preacetabular zone (Δ seg −6 to −4) and a periacetabular zone (Δ seg 1 to 2), where effective diameter and cortical clearance were most limited. Feasibility rates were 100% at 3.5–4.5 mm, 95.2% vs. 82.5% at 5.0 mm, 81.0% vs. 27.5% at 6.5 mm, and 59.5% vs. 10.0% at 7.3 mm in males and females, respectively.
Conclusions
Female models demonstrated smaller trajectory-wide bottleneck diameters and segment-wise effective diameters than male models. Acetabular-referenced Δ seg realignment identified two reproducible anatomic risk zones: a preacetabular zone adjacent to the obturator neurovascular bundle and a periacetabular zone near the external iliac vessels. At diameters ≥6.5 mm, cortical proximity increased more prominently in females than in males. Level of evidence: III.

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Three-dimensional computed tomography-based differentiation of engaged versus displaced intertrochanteric fractures using the anterior fracture line: a cross-sectional study from Korea: Jae-Suk Chang, Jin Yeob Park, Sang-Ok Chun, Chul-Ho Kim; J Musculoskelet Trauma 2026;39(1):30-37. Published online January 25, 2026; DOI: https://doi.org/10.12671/jmt.2025.00318

Abstract PDF: Background
With the advent of an aging society, osteoporotic fractures—particularly hip fractures—are increasing, with a 1-year mortality rate of 17%. Achieving stable fixation that enables early ambulation is essential but remains challenging because complex intertrochanteric (IT) fracture patterns are often underestimated on plain radiographs. Using three-dimensional computed tomography (3D-CT), this study analyzed whether the anterior fracture line lies medial or lateral to the IT line and examined its relationship with displacement or distal medullary canal engagement, highlighting the potential influence of the joint capsule and capsular ligaments on fracture morphology and fixation stability.
Methods
A retrospective review was conducted on 96 osteoporotic IT fractures in patients aged ≥60 years treated between April 2013 and December 2022 at National Police Hospital and Asan Medical Center, Seoul, Korea. Fractures were classified as engaged, completely displaced, and partially displaced based on 3D-CT findings. The anterior fracture-line position (medial or lateral to the IT line) and the status of the lesser trochanter (LT) were evaluated. The chi-square or Fisher exact test was used for statistical comparisons.
Results
In total, 96 patients were analyzed. Of these, 49 cases (51.0%) were classified as engaged type, 27 cases (28.1%) as completely displaced type, and 20 cases (20.8%) as partially displaced type. When comparing fracture pattern with anterior fracture-line position, the completely displaced type showed a significantly higher proportion of lateral anterior fracture lines than the other two types (P<0.001). However, no significant association was identified between fracture pattern and LT displacement. When the anterior fracture-line position and LT displacement were evaluated together, only the engaged type demonstrated a possible association between a lateral anterior fracture line and LT displacement, though the statistical significance was weak (P=0.047).
Conclusions
Fracture lines lateral to the IT line were strongly associated with displacement in IT fractures; however, their relationship with LT involvement, reflecting iliopsoas tendon traction, was not clearly demonstrated. Although the factors contributing to the engaged-type fracture remain uncertain, the statistical association between fracture pattern and anterior fracture-line position suggests that capsular structures may play a stabilizing role in select fracture configurations. Further studies are needed to clarify these anatomical interactions. Level of evidence:

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Computed tomography plane reformatting to reduce projection error in measuring Pauwels angle of femoral neck fractures: a cross-sectional study: Gyu Min Kong, Jae-Young Lim, Se-Lin Jeong, Gu-Hee Jung; J Musculoskelet Trauma 2026;39(1):38-47. Published online January 25, 2026; DOI: https://doi.org/10.12671/jmt.2025.00038

Abstract PDF: Objectives
This study aimed to assess fracture verticality in both coronal and axial planes after eliminating projection error in femoral neck fractures among non-older adults, and to demonstrate its clinical utility using computed tomography (CT)-based modeling at actual size.
Methods
This retrospective observational study enrolled 57 patients (30 males and 27 females), aged 20–65 years, with displaced femoral neck fractures. Based on CT images, an actual-size fracture model was constructed. The CT scanning plane was reformatted with the neck-shaft fragment realigned vertically to the ground and parallel to the femoral neck axis. Three consecutive images were used to generate coronal reformats at the centerline and posterior border to measure central and posterior coronal plane verticality as Pauwels’ angle (PA). The central image of the reformatted axial plane was used to assess axial plane verticality. Differences in verticality were analyzed using analysis of variance.
Results
Three coronal morphology types were identified: linear (n=30), concave (n=25), and convex (n=2). Two axial morphology types were observed: cephalad (n=35) and trochanteric (n=22). The mean central PA, posterior PA, and axial verticality were 55.43°±13.79°, 51.44°±11.13°, and 85.74°±18.41°, respectively. Only the central PA showed a significant difference (P<0.001). The PA was significantly higher in the linear coronal type between images (P<0.05) and in the trochanteric axial type (P<0.05).
Conclusions
After reformatting the scanning plane, the central PA showed significant variation between images. Femoral neck fractures of the linear type in the coronal plane and the trochanteric type in the axial plane demonstrated greater verticality than other morphological types. Level of evidence:

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Relationship of lateral malleolar fracture patterns to posterior malleolar fracture morphology in supination-external rotation ankle fractures in Korea: a retrospective cohort stduy: Jong-Eun Kim, Chan-Jin Park, Jun-Young Lee, Keun-Bae Lee, Gun-Woo Lee; J Musculoskelet Trauma 2025;38(4):212-220. Published online October 24, 2025; DOI: https://doi.org/10.12671/jmt.2025.00234

Abstract PDF: Background
Posterior malleolar fractures frequently accompany rotational ankle fractures. However, the morphological relationship between lateral and posterior malleolar fractures in supination-external rotation (SER) ankle fractures remains unclear. This study aimed to classify lateral malleolar fracture patterns in SER type 3 and 4 ankle fractures and investigated their associations with posterior malleolar fracture morphology.
Methods
We retrospectively reviewed 132 patients with SER type 3 or 4 ankle fractures and concurrent posterior malleolar fractures between January 2016 and December 2021. Lateral malleolar fractures were categorized as fibular fractures extending <4.5 cm proximal to the ankle joint (102 ankles) or fibular fractures extending ≥4.5 cm proximal to the ankle joint (30 ankles) based on posterior cortex height measured using three-dimensional computed tomography (3D-CT). Posterior malleolar fracture morphology was assessed using the Haraguchi and Bartonicek classifications. Quantitative parameters—including fracture height, angle, and articular involvement—were analyzed using 3D-CT imaging.
Results
Fibular fractures extending ≥4.5 cm proximal to the ankle joint were associated with a significantly higher frequency of Haraguchi type II and Bartonicek types 3 and 4 posterior malleolar fractures. This group also exhibited greater articular involvement (19.2% vs. 12.0%) and posterior cortical height (55.4 mm vs. 24.8 mm) compared to the <4.5 cm group (all P<0.001).
Conclusions
In SER type 3 and 4 ankle fractures, a fibular fracture extending ≥4.5 cm proximal to the ankle joint may be associated with posterior malleolar fractures exhibiting greater articular involvement and medial extension. Preoperative evaluation of the lateral malleolar fracture pattern may provide useful insights into posterior malleolar morphology and assist in surgical planning. However, these findings should be interpreted with caution due to inherent study limitations. Level of evidence: IV

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