{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T06:34:37Z","timestamp":1793169277479,"version":"4.5.0"},"reference-count":27,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"37","license":[{"start":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T00:00:00Z","timestamp":1789084800000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"A Study on the Immediate Stability of Treating Three-Part Intertrochanteric Fractures with PFNA Combined with Modified Candy Bag Steel Wire Compression Method","award":["2021-4-214"],"award-info":[{"award-number":["2021-4-214"]}]}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2026,9,11]]},"abstract":"<jats:sec>\n                    <jats:title\/>\n                    <jats:p>\n                      Proximal femoral nail antirotation (PFNA) may not provide sufficient control of unstable fracture fragments in complex intertrochanteric fractures. The modified candy-package wiring technique may supplement PFNA by improving resistance to rotational and shear displacement. This biomechanical model study compared PFNA combined with modified candy-package wiring with PFNA alone in an Evans type III intertrochanteric fracture model. Ten standardized femoral fracture models were randomly allocated to a PFNA group (n\u2005=\u20055) or a PFNA plus modified candy-package wiring group (PFNA\u2005+\u2005MCW group; n\u2005=\u20055). Torsional and axial compression tests were performed. Three repeated loading cycles were conducted for each specimen as conditioning cycles; the prespecified third cycle was used for analysis. Torsional stiffness was calculated as the change in torque divided by the corresponding change in angular displacement (Kt\u2005=\u2005\u0394\n                      <jats:italic toggle=\"yes\">T<\/jats:italic>\n                      \/\u0394\n                      <jats:italic toggle=\"yes\">\u03b8<\/jats:italic>\n                      ). The mean torsional angle was significantly lower in the PFNA\u2005+\u2005MCW group than in the PFNA group (2.09\u2005\u00b1\u20050.24\u00b0 vs 2.90\u2005\u00b1\u20050.18\u00b0;\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      \u2005=\u2005.0007). Torsional stiffness was also significantly lower in the PFNA\u2005+\u2005MCW group than in the PFNA group (0.48\u2005\u00b1\u20050.0529 vs 0.59\u2005\u00b1\u20050.0850 N\u00b7m\/\u00b0;\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      \u2005=\u2005.045). The maximum failure load was numerically higher in the PFNA\u2005+\u2005MCW group than in the PFNA group (571.26\u2005\u00b1\u200592.75\u2009N vs 510.34\u2005\u00b1\u200576.59\u2009N), although the difference was not statistically significant (\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      \u2005=\u2005.291). In this small biomechanical model study, PFNA combined with modified candy-package wiring reduced torsional displacement and showed favorable trends in axial load-bearing performance compared with PFNA alone. Because several outcomes were not statistically significant and only 5 models were included per group, these findings should be interpreted as preliminary biomechanical evidence rather than proof of superiority. Larger biomechanical studies and clinical validation are required.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1097\/md.0000000000050596","type":"journal-article","created":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T16:08:30Z","timestamp":1789142910000},"page":"e50596","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Biomechanical comparison of PFNA combined with the modified candy-package wiring technique versus PFNA alone in complex unstable intertrochanteric femoral fractures"],"prefix":"10.1097","volume":"105","author":[{"given":"Qiong","family":"Chen","sequence":"first","affiliation":[{"name":"Jinhua City Traditional Chinese Medicine Hospital, Jinhua City, Zhejiang Province, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiaan","family":"Chen","sequence":"additional","affiliation":[{"name":"Jinhua City Traditional Chinese Medicine Hospital, Jinhua City, Zhejiang Province, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Suqi","family":"Wu","sequence":"additional","affiliation":[{"name":"Jinhua City Traditional Chinese Medicine Hospital, Jinhua City, Zhejiang Province, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hansong","family":"Wu","sequence":"additional","affiliation":[{"name":"Jinhua City Traditional Chinese Medicine Hospital, Jinhua City, Zhejiang Province, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rongrong","family":"Chi","sequence":"additional","affiliation":[{"name":"Jinhua City Traditional Chinese Medicine Hospital, Jinhua City, Zhejiang Province, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiangu","family":"Li","sequence":"additional","affiliation":[{"name":"Canwell Medical Co., Ltd., Jinhua City, Zhejiang Province, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-0941-4429","authenticated-orcid":false,"given":"Jiaqi","family":"Wang","sequence":"additional","affiliation":[{"name":"School of Clinical Medicine, Hangzhou Medical College, Hangzhou City, Zhejiang Province, China."}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"R1-20261028","doi-asserted-by":"crossref","first-page":"727","DOI":"10.1186\/s13018-021-02874-9","article-title":"All-cause mortality risk in aged femoral intertrochanteric fracture patients.","volume":"16","author":"Li","year":"2021","journal-title":"J Orthop Surg Res"},{"key":"R2-20261028","doi-asserted-by":"crossref","first-page":"1167","DOI":"10.1080\/09638280500055966","article-title":"Endoprosthetic replacement of unstable, comminuted intertrochanteric fracture of the femur in the elderly, osteoporotic patient: a review.","volume":"27","author":"Haentjens","year":"2005","journal-title":"Disabil Rehabil"},{"key":"R3-20261028","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1007\/s00590-018-2285-9","article-title":"Analysis of risk factors for perioperative mortality in elderly patients with intertrochanteric fracture.","volume":"29","author":"Zhao","year":"2019","journal-title":"Eur J Orthop Surg Traumatol"},{"key":"R4-20261028","doi-asserted-by":"crossref","first-page":"263","DOI":"10.1111\/os.12456","article-title":"Differences in bone mineral density and hip geometry in trochanteric and cervical hip fractures in elderly Chinese patients.","volume":"11","author":"Li","year":"2019","journal-title":"Orthop Surg"},{"key":"R5-20261028","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1016\/0020-1383(90)90123-C","article-title":"Evans\u2019 classification of trochanteric fractures: an assessment of the interobserver and intraobserver reliability.","volume":"21","author":"Andersen","year":"1990","journal-title":"Injury"},{"key":"R6-20261028","doi-asserted-by":"crossref","first-page":"371","DOI":"10.1007\/s00590-012-0983-2","article-title":"Influence of fragment volume on stability of 3-part intertrochanteric fracture of the femur: a biomechanical study.","volume":"23","author":"Do","year":"2013","journal-title":"Eur J Orthop Surg Traumatol"},{"key":"R7-20261028","doi-asserted-by":"crossref","first-page":"500","DOI":"10.1186\/s12891-019-2793-8","article-title":"Proximal femoral nail anti-rotation versus cementless bipolar hemiarthroplasty for unstable femoral intertrochanteric fracture in the elderly: a retrospective study.","volume":"20","author":"Zhou","year":"2019","journal-title":"BMC Musculoskelet Disord"},{"key":"R8-20261028","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1186\/s13018-018-0911-1","article-title":"The relationship between the type of unstable intertrochanteric femur fracture and mobility in the elderly.","volume":"13","author":"Karakus","year":"2018","journal-title":"J Orthop Surg Res"},{"key":"R9-20261028","doi-asserted-by":"crossref","first-page":"926","DOI":"10.1186\/s13018-023-04415-y","article-title":"Finite element analysis of basicervical femoral neck fracture treated with proximal femoral bionic nail.","volume":"18","author":"Cheng","year":"2023","journal-title":"J Orthop Surg Res"},{"key":"R10-20261028","doi-asserted-by":"crossref","first-page":"346","DOI":"10.1016\/j.injury.2021.11.015","article-title":"The lateral femoral wall thickness on the risk of post-operative lateral wall fracture in intertrochanteric fracture after DHS fixation: a finite element analysis.","volume":"53","author":"Fan","year":"2022","journal-title":"Injury"},{"key":"R11-20261028","doi-asserted-by":"crossref","first-page":"512","DOI":"10.1080\/10255842.2021.1964488","article-title":"Risk of proximal femoral nail antirotation (PFNA) implant failure upon different lateral femoral wall thickness in intertrochanteric fracture: a finite element analysis.","volume":"25","author":"Zheng","year":"2022","journal-title":"Comput Methods Biomech Biomed Engin"},{"key":"R12-20261028","doi-asserted-by":"crossref","first-page":"201","DOI":"10.1016\/j.cjtee.2024.01.006","article-title":"Intramedullary administration of tranexamic acid reduces bleeding in proximal femoral nail antirotation surgery for intertrochanteric fractures in elderly individuals: a randomized controlled trial.","volume":"28","author":"Luo","year":"2025","journal-title":"Chin J Traumatol"},{"key":"R13-20261028","doi-asserted-by":"crossref","first-page":"e0304654","DOI":"10.1371\/journal.pone.0304654","article-title":"Proximal femoral nail antirotation versus InterTan nail for the treatment of intertrochanteric fractures: a systematic review and meta-analysis.","volume":"19","author":"Liao","year":"2024","journal-title":"PLoS One"},{"key":"R14-20261028","doi-asserted-by":"crossref","first-page":"1763","DOI":"10.1016\/j.injury.2020.06.008","article-title":"Modified candy-package technique vs cerclage technique for refixation of the lesser trochanteric fragment in pertrochanteric femoral fractures. A biomechanical comparison of 10 specimens.","volume":"51","author":"Schopper","year":"2020","journal-title":"Injury"},{"key":"R15-20261028","doi-asserted-by":"crossref","first-page":"e936923","DOI":"10.12659\/MSM.936923","article-title":"A retrospective study of 98 elderly patients with high-risk lateral femoral wall intertrochanteric hip fractures to compare outcomes following surgery with proximal femoral nail antirotation (PFNA) versus dynamic hip screw (DHS).","volume":"28","author":"Tian","year":"2022","journal-title":"Med Sci Monit"},{"key":"R16-20261028","doi-asserted-by":"crossref","first-page":"406","DOI":"10.1016\/j.injury.2016.11.016","article-title":"Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable intertrochanteric fractures: a modified candy-package wiring technique.","volume":"48","author":"Kim","year":"2017","journal-title":"Injury"},{"key":"R17-20261028","first-page":"3","article-title":"Biomechanical analysis of PFNA and PCCP internal fixation for intertrochanteric femoral fractures in vitro.","volume":"29","author":"Yu","year":"2014","journal-title":"Chin J Bone Joint Injury"},{"key":"R18-20261028","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1097\/01.bot.0000151819.95075.ad","article-title":"Trochanteric gamma nail and compression hip screw for trochanteric fractures: a randomized, prospective, comparative study in 210 elderly patients with a new design of the gamma nail.","volume":"19","author":"Utrilla","year":"2005","journal-title":"J Orthop Trauma"},{"key":"R19-20261028","doi-asserted-by":"crossref","first-page":"184","DOI":"10.1016\/S0020-1383(03)00101-3","article-title":"Management of subtrochanteric femoral fractures and metastases using long proximal femoral nail.","volume":"35","author":"Ramakrishnan","year":"2004","journal-title":"Injury"},{"key":"R20-20261028","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1007\/s00113-002-0476-6","article-title":"Stabilisation of unstable trochanteric femoral fractures. Dynamic hip screw (DHS) with trochanteric stabilisation plate vs. proximal femur nail (PFN)].","volume":"106","author":"Nuber","year":"2003","journal-title":"Unfallchirurg"},{"key":"R21-20261028","doi-asserted-by":"crossref","first-page":"375","DOI":"10.1186\/s12891-022-05323-8","article-title":"Conversion of failed proximal femoral nail antirotation to uncemented or cemented femoral component fixation: a multicentre retrospective study with a median 10-year follow-up.","volume":"23","author":"Shi","year":"2022","journal-title":"BMC Musculoskelet Disord"},{"key":"R22-20261028","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1051\/sicotj\/2016052","article-title":"Augmentation of proximal femoral nail in unstable trochanteric fractures.","volume":"3","author":"Gadegone","year":"2017","journal-title":"SICOT J"},{"key":"R23-20261028","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1186\/1754-9493-5-17","article-title":"Failure of fixation of trochanteric femur fractures: clinical recommendations for avoiding Z-effect and reverse Z-effect type complications.","volume":"5","author":"Pires","year":"2011","journal-title":"Patient Saf Surg"},{"key":"R24-20261028","doi-asserted-by":"crossref","first-page":"313","DOI":"10.1302\/2046-3758.87.BJR-2018-0271.R1","article-title":"Medial migration in cephalomedullary nail fixation of pertrochanteric hip fractures: a biomechanical analysis using a novel bidirectional cyclic loading model.","volume":"8","author":"Law","year":"2019","journal-title":"Bone Joint Res"},{"key":"R25-20261028","doi-asserted-by":"crossref","first-page":"1368492","DOI":"10.3389\/fbioe.2024.1368492","article-title":"Biomechanical evaluation of ortho-bridge system and proximal femoral nail antirotation in intertrochanteric fractures with lateral wall fracture based on finite element analysis.","volume":"12","author":"Long","year":"2024","journal-title":"Front Bioeng Biotechnol"},{"key":"R26-20261028","doi-asserted-by":"crossref","first-page":"804","DOI":"10.2106\/JBJS.18.00997","article-title":"Implant fracture analysis of the TFNA proximal femoral nail.","volume":"101","author":"Lambers","year":"2019","journal-title":"J Bone Joint Surg Am"},{"key":"R27-20261028","doi-asserted-by":"crossref","first-page":"803","DOI":"10.1016\/j.injury.2017.02.022","article-title":"Unstable trochanteric fractures: issues and avoiding pitfalls.","volume":"48","author":"Babhulkar","year":"2017","journal-title":"Injury"}],"container-title":["Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.1097\/MD.0000000000050596","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T06:01:20Z","timestamp":1793167280000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.1097\/MD.0000000000050596"}},"subtitle":["A biomechanical model study"],"short-title":[],"issued":{"date-parts":[[2026,9,11]]},"references-count":27,"journal-issue":{"issue":"37","published-print":{"date-parts":[[2026]]}},"URL":"https:\/\/doi.org\/10.1097\/md.0000000000050596","relation":{},"ISSN":["0025-7974","1536-5964"],"issn-type":[{"value":"0025-7974","type":"print"},{"value":"1536-5964","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,11]]},"assertion":[{"value":"2026-01-08","name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-08-24","name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}}]}}