524

OTHERS
A novel computed tomography-based three-column MLP
classification of intertrochanteric fracture
Qi-Long Jiang1, Yan Li2, Xin-Wen Bai1, Yu Deng1, Hao Hong1, Jun Li1, Yong Cao3, and Xiao-Yu Peng31
Department of Orthopaedic Surgery, Chongqing Orthopedic Hospital Of Traditional Chinese Medicine, Chongqing, China, 2Central Sterile
Supply Department, Chonggang General Hospital, Chongqing, China, 3Department of emergency, Chongqing Orthopedic Hospital Of Traditional Chinese Medicine, Chongqing, China

Abstract : Objectives : The aim of the present study was to introduce a novel three-dimensional computed tomography (3DCT)-based three-column classification (named “MLP classification system”) of intertrochanteric fractures and evaluate its reproducibility and reliability. Methods : From September 2020 to September 2022, a totalof 258 consecutive patients (60 male, 198 female ; mean age 81.3 years) with intertrochanteric fractures were included in this study. The fracture in each case was assessed using a novel three-dimensional computed tomography-based three-column classification. Two examiners tested the intra and inter-observer reliability of this newclassification system using kappa variance. Results : The intertrochanteric region was divided into the medialcolumn, lateral column, and posterior column. Intertrochanteric fractures were documented as M0/1/2L0/1/2/3P0/1/2/3.
All fractures were classifiable into the new classification system. The intra-observer kappa values were 0.91 and
0.89, while the inter-observer kappa value was 0.82, both indicating almost perfect reliability. Conclusion : This
novel 3DCT-based MLP classification system for intertrochanteric fractures is comprehensive, and reproduciblewith good agreement. It is based on proximal femur biomechanic characteristics and traumatic mechanism,
contributing to formulating more reasonable treatment protocols involving various late-model internal fixation
devices. J. Med. Invest. 70 : 524-529, August, 2023
Keywords : Intertrochanteric fracture, Computed tomography, Classification system

INTRODUCTIONClassification of femoral intertrochanteric fractures is usually based on plain X-ray findings using the Evans, Jensen,
or AO / OTA classification system (1-3). However, conventional
two-dimensional classification systems are inefficient in getting
detailed information to formulate optimal treatment protocols.
According to literature published recently, although scholars
have proposed several classification systems based on three-dimensional computed tomography, these systems are mainly built
based on morphological patterns of fracture fragments, without
the involvement of proximal femoral biomechanical characteristics and traumatic mechanism (4-6). Moreover, the consistency
and reliability are relatively vulnerable to using these classification methods (3, 7).
In the management of intertrochanteric fractures, cephalomedullary nails have been deemed to be the mainstay of internal
fixation options with the advantages of small incisions, minimal
invasion, and less blood loss (8). However, inadequate fracture
reduction and fixation are associated with high incidences of
postoperative complications such as nonunion and cut out of thelag screw or blade (9-11). Based on the biomechanical characteristics and fracture patterns of the proximal femur, various
late-model internal fixation devices have been designed forstability augmentation (12-16). It remains confusing to use theseclassification systems to formulate optimal therapeutic options
and sequential rehabilitation schedules (17). Therefore, the present
Received for publication January 12, 2023 ; accepted April 18, 2023.
Address correspondence and reprint requests to QiLong Jiang, Department of Orthopaedic Surgery, Chongqing Orthopedic Hospital Of
Traditional Medicine, ChongQing, China, No. 9, Jiefang West Road,
ChongQing, 400010, China and E-mail : jys19870607@qq.com

study was conducted to propose a novel three-dimensional computed tomography-based three-column classification of intertrochanteric fracture and to assess the inter and intra-observer
reliability, meanwhile, to optimize device choice of fixations.

MATERIAL AND METHODS
The study was approved by our institutional review board.
Written informed consent was obtained from all subjects.

The definition of three columns
According to the biomechanical characteristics of the proximal femur, three columns were defined as the medial column,
lateral column, and posterior column (Figure 1). The definitions
and demarcation between columns are described as follows : 1)
The medial and lateral columns were classified on the basis ofpressure trabecular bone and tension trabecula of the proximal
femur (18). This is mainly due to the difference in stress distribution on the proximal femur in the process of walking. Thus,
the anterior demarcation line between the medial and lateralcolumns was drawn in an arc from the middle femoral neck to
the middle shaft. 2) Regarding the medial column versus theposterior column, the demarcation line was drawn vertically
across the anterior edge of the lesser trochanter (LT) base. 3)
The demarcation line of the lateral and posterior columns originated from the anterior edge of the gluteus medius attachment,
and ran obliquely to the edge of the vastus lateralis ridge. In
other words, the greater trochanter (GT) was divided into twoparts. The anterior part was classified into the lateral column,
while the posterior part was classified into the posterior column.
This is because the gluteus medius and gluteus minimus arecomprised of compartments and inserted into the posterior lateral ridge and anterolateral ridge of the greater trochanter (GT)The Journal of Medical Investigation Vol. 70 2023

The Journal of Medical Investigation Vol. 70 August 2023
separately, GT fractures frequently arise as a consequence ofexcessive tension of gluteus medius (19).
The medial and lateral columns work as a lever and bear
compressive stress and tensile stress respectively. In this classification, the medial column was subdivided into M0 (intact), M1(simple fracture), and M2 (wedge or multifragmentary fracture).
The lateral column was subdivided into L 0 (intact), L1 (anterior
part of greater trochanter), L2 (extension between superior and525

inferior femoral neck), and L3 (below femoral neck fundus). The
posterior column is composed of the posterior part of GT, LT, andbase. This column mainly serves as the attachment site of hip
muscles including the gluteus medius and rotator muscles. It
was subdivided into P0 (intact), P1 (posterior part of GT), P2 (LT),and P3 (involvement of both GT and LT). As a consequence, anintertrochanteric fracture can be documented as M0/1/2L0/1/2/3P0/1/2/3(Figure 2 and Table 1).

Figure 1. Appearance of Three-column MLP classification of proximal femur.
M, medial column (Green area) ; L, lateral column (Red area) ; P, posterior column (Blue area). a-f present circumferential views with rotation.

Figure 2. Actual images of three-dimensional computed tomography (3D-CT) in each subtype. A intertrochanteric fracture is characterized

as M0 / 1 / 2 L0 / 1 / 2 / 3 P0 / 1 / 2 / 3.
M, medial column (Green area) ; M0, intact wall ; M1, simple fracture ; M2, multifragmentary fracture. L, lateral column (Red area) ; L0, intact
wall ; L1, proximal portion fracture ; L2, intermediate portion fracture ; L3, distal portion fracture. P, posterior column (Blue area) ; P0, intact
wall ; P1, GT fracture ; P2, LT fracture ; P3, GT + LT fracture.

Q.L. Jiang, et al. Intertrochanteric fracture classification

526
Data collection and analysis

RESULTSThis study included 258 consecutive patients who were admitted to our hospital with an intertrochanteric fracture over 2
years from September 2020 to September 2022. Patients withpathologic fractures were excluded. Both plain X-rays and 3DCTbased reconstruction were performed for all study participants.
Two orthopedic surgeons (a senior orthopedic surgery resident
and an experienced consultant orthopedic surgeon) classified
these fracture imaging independently. The first assessment was
performed immediately following the CT examination while thesecond assessment was eight weeks later. The kappa coefficient
was used to determine the inter-observer reliability (initial responses of all the evaluators) and intra-observer reliability (thesame evaluator’s responses between two evaluations with an interval of eight weeks). Statistical analysis was performed using
SPSS version 25.0 (SPSS Inc., Chicago, IL, USA). All results
are expressed with 95% confidence intervals, generated by 1000
bootstrapping replications (α = 0.05).

We studied 258 patients (198 female and 60 male), with a
median age of 81.3 years (ranging from 36 to 99 years old). All
the fractures were classifiable into the new classification system.
The frequency distribution of fracture subtypes is listed in Table
2. By using the three-dimensional classification system in ourstudy, the intra-observer kappa values were 0.91 (JL) and 0.89
(HH), indicating almost perfect reliability, and the inter-observer kappa value was 0.82, indicating almost perfect reliability.
The reproducibility and reliability of this novel classification system appeared to be superior to several reported systems(3-7, 20,
21). A comparison between intra and inter-observer reliability inseveral classification systems is listed in Table 3.
The classification of lateral and posterior columns presented
perfect consistency between intra- and inter-observers. For the
medial column, there were 19 cases (7.4%) in which the classification was not consistent between the two examiners. The mostcommon reason for disagreement was the fracture line running
across the posterior and medial columns, leading to confusion inclassifying M1 or M2.

Table 1. The definition of subtypes in each column. A intertrochanteric fracture is characterized as M0/1/2L0/1/2/3P0/1/2/3.
ColumnThe definition of subgroups

Lateral column

Posterior column

M1

M0

Medial column

intact wall

M2

simple fracture

multifragmentary fracture

L0

L1

L2

L3

intact wall

proximalportion fractureintermediate
portion fracture

distal portion fracture

P0

P1

P2

P3

intact wall

GT fracture

LT fracture

GT + LT fracture

GT, greater trochanter ; LT, lesser trochanter.

Table 2. Frequency distribution of fracture subtypes in this study and corresponding treatment recommendation.
Fracture typen (%)

Proposed Treatment modality

M 0 L 0 P1 / 2

11 (4.2%)

Conservative treatment

M 0 L 1 P0 / 1 / 2

6 (2.3%)

Conservative treatment / fixation of LT

M 1 L 0 / 1 P0 / 1

92 (35.7%)

Short cephalomedullary nails

M 1 L 0 / 1 P2 / 3

103 (39.9%)

Short cephalomedullary nails, with / without fixation of LT

M 1 L 2 P0 / 1

2 (0.7%)

Long cephalomedullary nails, with / without lateral column reconstruction

M 1 L 2 P2 / 3

21 (8.1%)

Long cephalomedullary nails + lateral column reconstruction + fixation ofposterior column

M 1 L 3 P0 / 1 / 2 / 3

14 (5.4%)

Long cephalomedullary nails + lateral column reconstruction, with / without
fixation of posterior column

M 2 L 0 / 1 / 2 / 3P0 / 1 / 2 / 3

9 (3.5%)Medial column support + cephalomedullary nails, with / without lateral andposterior column reconstruction

The Journal of Medical Investigation Vol. 70 August 2023

527

Table 3. Comparison between intra and inter-observer reliability in several classification systems.
Classification system (study)

Intra-observer kappa value

Inter-observer kappa value

AO / OTA-main group (Yıldırım et al.)

0.74

0.70

AO / OTA-subgroup (Yıldırım et al.)

0.49

0.44

Evans- Jensen system (Yıldırım et al.)

0.48

0.50

Tronzo system (Yıldırım et al.)

0.53

0.55

Boyd-Griffin system (Yıldırım et al.)

0.66

0.57

Wada system (Wada et al.)

0.88

0.70

Tang system (BoYin et al.)

0.63

0.64

MLP system (Current study)

0.91 / 0.89

0.82

DISCUSSION
In the process of standing and walking, the human hip joint
bears 2.3–2.8 times the weight of gravity (22). The trabecularbone at the proximal femur is distributed regularly and orderly. Pressure trabecular bone and tension trabecula graduallyformed, which are similar to a lever system. The medial wall,
acting as a fulcrum, bears compressive stress (18). In the management of intertrochanteric fractures, effective medial buttresswill make a valuable contribution towards reducing the occurrence of postoperative complications (e.g. implant failure andcoxa vara) (16). According to the degree of stability, we divided
the medial column into intact wall (M0), simple fracture (M1),and multifragmentary fracture (M2). For M1 fractures, reduction
with positive or neutral medial cortical support and fixation withcephalomedullary nails is acceptable. Limited sliding between
the head-neck fragment and femur shaft can yield secondary
stability. This process is favorable to fracture healing (23). The
M2 fracture is conventionally regarded as an unstable pattern,which is approximately relative to the medial multifragmentary
fracture pattern (31A3.3) by AO classification-2018. Nevertheless, the occurrence of M2 fractures is much more infrequentcompared to M1 fractures. Furthermore, the M2 fractures always
appear to be fairly hard to get a rigid buttress with an adequate
reduction. Thus, delayed ambulation will be suggested postoperatively, which may be associated with a higher incidence of
postoperative complications. To augment the stability of the medial column, some new fixation systems, for instance, triangularsupport intramedullary nail (Double Medical Technology Inc,
China) and medial sustainable nail (Weigao Medical Technology
Inc, China) have been utilized (12, 16). In this new classification
system, the identification of medial column is the primary process of the whole assessment. Specific fracture information is
critical to optimizing fixation choices (Table 2).
On the contrary, the lateral wall of the proximal femur bears
tensile stress. Therefore, we defined the lateral column as theregion of tension bone trabecular. According to the relative position between the fracture line and femur neck fundus, we divided
the lateral column into L 0, L1, L2 , and L3, with increasing instability. With increasing attention to the integrity and thicknessof the lateral wall, various complementary methods have beendevised for the reconstruction and fixation of this region, whether using extramedullary or intramedullary implants (24, 25).
L1 fractures are considered stable fractures and need no extra
fixation. L 2 fractures are conventionally defined as transverse
fractures or oblique fractures. Concerning this fracture pattern,
the balance of the hip lever system has been broken, which maylead to overload on implants. Therefore, occurrences of implant
breakage have been reported frequently (24). Whereas, long
cephalomedullary nails are recommended, with or without additional augmentation (e.g. cerclage, screw, and plate). The L 3
fractures are defined as occurrences below the femoral neck fundus in our classification system. To prolong the working lengthof nails, long cephalomedullary nails combined with additional
lateral column reconstruction may be contributory to balancing
the strong moment from the hip (26). Based on the assessmentof the lateral column, the implant options and auxiliary fixation
can be properly determined.
In our observation, the fracture line involving the trochanterruns generally from the anterosuperior edge of the GT toward
the LT. On the other hand, GT and LT fragments are frequently
poor-reduced and fixed while using extramedullary or intramedullary implants (27). This situation is mainly due to theattachment of the gluteus medius, piriformis, and iliopsoas
muscle, which may produce specific fracture mechanisms (19).
Thus, we defined the region involving super-posterior GT and
LT as the posterior column. GT fracture (P1) and LT fracture(P2) may occur individually or simultaneously (P3). However,
the management of fractures involving the posterior column
remains ambiguous. In recent literature, it was reported thatpoor reduction and fixation of LT fragments may be significantly
associated with posterior sagging of the femoral neck (28). Fixation with nonabsorbable tape (Alfresa Pharma Co., Ltd., Japan),or twisted steel wires (Alfresa Pharma Co., Ltd., Japan) could
be an effective procedure to improve early ambulatory ability(13, 27, 29). The optimal management of fractures involving theposterior column still needs further research.
Based on the 3DCT reconstruction of intertrochanteric fractures, the medial, lateral, and posterior columns can be assessed
respectively. The detailed fracture information in each column
may attribute to making an optimal fixation strategy. Overall
evaluation can be documented as M0 / 1 / 2L 0 / 1 / 2 / 3P0 / 1 / 2 / 3. Therefore,
treatment protocol involving implant type, working length,
auxiliary device, and rehabilitation plan can be properly determined. In this study, 103 patients (39.9%) were classified as
M1L 0 / 1P2 / 3 , representing the majority of intertrochanteric fractures. For these patterns, short cephalomedullary nails may berecommended, with or without fixation of LT. Another fracture
type, M2L3P3 in our classification system, indicates severe comminution of intertrochanteric fractures and may need long cephalomedullary nails and three-column augmentation (8, 26, 30).
Our study has several limitations. First, the sample size wasrelatively small. Thus, only a few cases were classified into several less frequent fracture types (e.g. M0L1P0 / 1 / 2 , M1L2P0 / 1). This

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Q.L. Jiang, et al. Intertrochanteric fracture classification

may decrease clinical application and promotion value. Second,
the recommendations for fracture treatment were based on partial data from previous literature. Surgical recommendations
may require further study and systematic review. Third, according to fracture images from 258 consecutive patients, we foundthat young adults tend to have more transverse fractures oroblique fractures from high-energy mechanisms. Thus, the difference between young and elder patients regarding bony conditions, traumatic mechanisms, fracture patterns, and treatment
strategies should be taken into consideration. In conclusion, we
proposed this novel classification system for intertrochantericfractures based on 3DCT findings with good agreement. It iscomprehensive, reproducible, and easy to grasp compared toother classification systems. This method is proposed on bothproximal femur biomechanic characteristics and traumaticmechanisms. Based on the novel classification system, we canformulate more reasonable treatment protocols involving various
late-model internal fixation devices.

AUTHOR CONTRIBUTIONSJQL , YL, BXW and DY : main idea and research, contributed
equally to this work and should be considered as equal first authors. HH and LJ : two examiners. CY and PXY : data collection,
data analysis.

FUNDING
There is no funding for our article.

CONFLICT OF INTEREST
The authors declare that they have no Conflict of interest.

ACKNOWLEDGEMENTS
We would like to give our sincere appreciation to the reviewers
for their helpful comments on this article. Thanks to Xin-Yu
Jiang for her nice work in creating these exquisite illustrationsin this article.

ETHICAL APPROVALThis work was approved by the Ethics Committee of the
ChongQing Orthopedic Hospital Of Traditional Medicine (No.
CQ20220610). All procedures performed in this study were inaccordance with the ethical standards of the institutional and / ornational research committee.

INFORMED CONSENT
Written informed consent was obtained from all patients.

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