Should We Reconstruct Coronal Plane Fractures in Multifragmentary Pertrochanteric Fractures? A Randomized Controlled Trial

Introduction: Coronal plane fractures are increasingly identified in multifragmentary pertrochanteric (AO Foundation/Orthopaedic Trauma Association [AO/OTA] 31-A2) fractures, yet their clinical significance is under-researched. The aim of this study was to evaluate whether wire augmentation during Proximal Femur Nail Antirotation Asia (PFNA-II) fixation improves functional outcomes-regain of abductor strength and modified Harris Hip Score (mHHS)-compared with PFNA-II alone at 18-month follow-up. The secondary outcomes such as time to union, pain scores (Visual Analog Scale [VAS]), and complications were also assessed. Methodology: In this single-center, randomized controlled trial, 142 patients of Asian race and Indian ethnicity aged older than 60 years with AO-OTA 31-A2 fractures were treated using PFNAII, with or without wire augmentation for coronal fragments. Preoperative computed tomography (CT) assessed coronal fragment size. Among them, 116 patients who completed 18-month follow-up were analyzed. Results: Modified intention-to-treat analysis was performed. At 18 months, augmentation produced greater abductor strength (Δ 8.21%, 95% confidence interval, 4.4-12.83; p < 0.001) with no significant difference in mHHS (Δ 3.31 points, -1.3-7.9; p = 0.16). In fragments >50%, wire augmentation led to a clinically relevant 10% strength gain, exceeding the minimal clinically important difference (MCID) of 8.2%. However, VAS was similar between groups. Controls showed more varus collapse, likely due to a persisting posteromedial void when the fragment is not stabilized. Conclusion: Wire augmentation improved abductor strength recovery, especially when fragment size exceeded 50%, supporting its use in such cases. However, mHHS were similar between the groups. Level of Evidence: Level I Therapeutic. See Instructions for Authors for a complete description of levels of evidence.