Open Journal of Orthopedics, 2013, 3, 283-289
http://dx.doi.org/10.4236/ojo.2013.36052 Published Online October 2013 (http://www.scirp.org/journal/ojo)
283
Reattachment of the Osteotomized Greater Trochanter in
Hip Surgery Using an Ultrahigh Molecular Weight
Polyethylene Fiber Cable: A Multi-Institutional Study
Seiya Jingushi1*, Tsutomu Kawano1, Hirokazu Iida2, Kenichi Oe2, Kenji Ohzono3,
Yoshihide Nakamura4, Makoto Osaki5, Hidetsugu Ohara6, Seung Bak Lee7, Toshihiko Hara8,
Naohide Tomita9
1Department of Orthopaedic Surgery, Kyushu Rosai Hospital, Kitakyushu, Japan; 2Department of Orthopaedic Surgery, Kansai
Medical University, Hirakata, Japan; 3Department of Orthopaedic Surgery, Kansai Rosai Hospital, Amagasaki, Japan; 4Department
of Orthopaedic Surgery, Hirosaki University Hospital, Hirosaki, Japan; 5Department of Orthopaedic Surgery, Nagasaki University
Graduate School of Medical Science, Nagasaki, Japan; 6Department of Orthopaedic Surgery, Osaka Medical College, Takatsuki,
Japan; 7Department of Rehabilitation, Toyonaka Municipal Hospital, Toyonaka, Japan; 8Department of Orthopaedic Surgery, Kyushu
Kosei Nenkin Hospital, Kitakyushu, Japan; 9Bioengineering Laboratory, Graduate School of Engineering, Kyoto University, Kyoto,
Japan.
Received September 3rd, 2013; revised October 5th, 2013; accepted October 15th, 2013
Copyright © 2013 Seiya Jingushi et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
The purpose of this multicenter study was to evaluate the clinical performance of an ultrahigh molecular weight poly-
ethylene (UHMWPE) fiber cable for re-attachment of the osteotomized greater trochanter in hip surgery. Included in the
study were 85 hips that had undergone surgery with greater trochanter osteotomy, including 50 hip arthroplasty proce-
dures and 35 hip osteotomies. The osteotomized greater trochanter was reattached using one or more UHMWPE fiber
cables. The bone union and displacement of the greater trochanter were assessed in radiographs for up to 12 months
after surgery. Non-union of the osteotomy site occurred in 4.7% of the cases. In approximately 90% of the cases, dis-
placement was less than 2 mm at up to 12 months after surgery. The UHMWPE fiber cable was a good biomaterial for
reattaching the osteotomized greater trochanter and may also be an option for osteosynthesis procedures.
Keywords: Ultrahigh Molecular Weight Polyethylene Fiber Cable; Biomaterials; Osteosynthesis; Greater Trochanter
Osteotomy; Hip Operations; Arthroplasty
1. Introduction
In hip operations, techniques for how to fix a fractured or
osteotomized greater trochanter may produce challenges.
An encircling metal fixation device, such as a steel wire
or titanium cable, has long been used in the internal fixa-
tion of fractures and the re-attachment of the osteoto-
mized greater trochanter in total hip arthroplasty (THA),
revision THA, or osteotomy. However, these implants
have associated problems, including breakage of fixation
materials, trochanteric nonunion, and bursitis. The break-
age rate following these procedures has been reported to
be 0.4% - 28% for steel wire [1-5] and 3.1% - 43% for
wire cable [6-9]. Wire failure due to low-cycle fatigue re-
mains the most common problem. Cable fraying and
fragmentation have been reported to develop in 50% of
patients, and the use of cables has limited effectiveness
in reducing the incidence of trochanteric nonunion [6,7].
Furthermore, Oh et al. [10] noted that a 1% notch has
been reported to be enough to reduce the fatigue resis-
tance of the wire by 63%. Trochanteric non-union rates
of 0.4% - 21% for steel wire [1-5] and 1.5% - 38% for
wire cable have been reported [6-9]. Trochanteric non-
union may lead to pain, limp, and postoperative disloca-
tion. Additionally, these metal implants could cause loca-
lized bursitis. The need for materials with greater strength
that can resist both fatigue and static tensile forces, as
well as reduce abrasiveness, has prompted the develop-
ment of new biomaterials for use as orthopedic recon-
structive appliances.
Ultrahigh molecular weight polyethylene (UHMWPE)
*Corresponding author.

Reattachment of the Osteotomized Greater Trochanter in Hip Surgery Using an Ultrahigh Molecular
Weight Polyethylene Fiber Cable: A Multi-Institutional Study
284
fiber cable is a soft, flexible material created in the form
of a tape. It is used to bind a metal rod to the bone in
spinal surgeries due to its strong fixation ability. Dick-
man et al. reported that UHMWPE fiber cables are supe-
rior in static ultimate tensile strength, fatigue strength,
conformance, and abrasion as compared with titanium
cable, steel cable, or steel wire in spinal fusion surgeries
[11]. Murakami et al. reported that UHMWPE fiber ca-
bles perform better than steel wire or titanium cable in
laminar cut-through and biomechanical stiffness tests
[12]. Our preliminary experiment showed that the prac-
tical strength of the UHMWPE fiber cable was compara-
ble to that of wire cable, but that the fatigue strength of
the UHMWPE cable was significantly higher [13]. Our
animal model experiment showed that the UHMWPE fi-
ber cable was as easily removed as the soft wire cable,
and that it caused minimal biological reactivity with the
surrounding tissue [13]. Due to the UHMWPE fiber ca-
ble design (soft, wide, flat tape), it is useful for binding
and causes less local stress with little possibility of cut-
ting into bone, unlike the soft wire or titanium cable.
This design may ameliorate the “cheese wire effect” that
can occur during fixation of fragile bones in elderly os-
teoporotic patients. We hypothesized that a UHMWPE
fiber cable would be an excellent material for use in os-
teosynthesis for the osteotomized greater trochanter, as
well as for binding a metal rod to bone in spinal surgical
procedures. The purpose of this multicenter study was to
evaluate the clinical performance of a UHMWPE fiber
cable in re-attachment of the osteotomized greater tro-
chanter in hip operations.
2. Patients and Methods
Patients who had hip operations with a greater trochanter
osteotomy at one of the eight hospitals (Kyushu Rosai
Hospital, Kitakyushu, Japan; Kansai Medical University,
Hirakata, Japan; Kansai Rosai Hospital, Osaka, Japan;
Hirosaki University Hospital, Hirosaki, Japan; Nagasaki
University Hospital, Nagasaki, Japan; Osaka Medical Col-
lege Hospital, Takatsuki, Japan; Toyonaka Municipal
Hospital, Toyonaka, Japan; and the Kyushu Kosei Nen-
kin Hospital, Kitakyuushu, Japan) were included in the
study. In the institutions, the UHMWPE fiber cable was
used in hip operations with a greater trochanter osteot-
omy. Following institutional review board approval at
each hospital, data were collected from the patient re-
cords.
Eighty-five hips (of 14 male and 71 female patients)
were included in the evaluation of the UHMWPE fiber
cable. Fifty hip arthroplasties and 35 hip osteotomies
were performed. Patient characteristics are shown in the
Table 1. Patients undergoing osteotomy were younger
and taller than those undergoing arthroplasty procedures.
Forty-eight of the hips that needed arthroplasty had pri-
mary total hip arthroplasty and two had revision proce-
dures. Of the hips undergoing osteotomy, 27 had pelvic
osteotomy with coverage of the articular cartilage [14],
four had Chiari pelivic osteotomy [15], and four had trans-
trochanteric rotational osteotomy [16] procedures per-
formed.
Osteotomy of the greater trochanter was classified into
two types depending on the continuity between abductor
and vastus lateralis muscle (Table 2). More than half of
the total number of cases (52.9%, 45/85 patients) showed
maintained continuity after the osteotomy. In most of the
hips undergoing arthroplasty (86%, 43/50 patients), con-
tinuity was maintained according to Dall’s approach [17].
In contrast, continuity was maintained in only 6% (2/35
patients) of the hips undergoing osteotomy.
In all the cases, the osteotomized greater trochanter
was reattached using one or more UHMWPE fiber cable
(NESPLON Cable System, Alfresa Pharma Corporation,
Osaka, Japan). Cables of 3 mm or 5 mm width were used.
Fixation status (Table 2) varied by institution. The cables
Table 1. Patient characteristics.
Variable Osteotomy
(n = 35)
Arthroplasty
(n = 50) p value
Sex (n), Male/Female 7/28 7/43 0.556a
Age (years), mean ± SD36.5 ± 12.4 64.6 ± 10.0 <0.001b
Height (cm), mean ± SD158.9 ± 7.5 152.2 ± 9.0 <0.001b
Weight (kg), mean ± SD57.1 ± 12.8 55.3 ± 10.1 0.449b
Body mass index
(kg/m2), mean ± SD 22.6 ± 4.5 23.7 ± 3.2 0.162b
Hip disease 0.026a
Osteoarthritis of the hip31 48
Osteonecrosis of the
femoral head 4 0
Revisions 0 2
aFischer’s exact test, bTwo-sample t-test.
Table 2. Fixation conditions of the osteotomized greater tro-
chanter.
Variable Osteotomy
(N = 35)
Arthroplasty
(N = 50) p value*
Maintenance of continuity
between abductor and
vastus lateralis (n/N)
5.7% (2/35) 86.0% (43/50)<0.001
Around the bone (n/N) 8.6% (3/35) 96.0% (48/50)<0.001
Through the bone (n/N)91.4% (32/35) 4.0% (2/50)<0.001
Combined fixation
materials (n), Y/N 22.9% (8/35) 66.0% (33/50)<0.001
*Fisher’s exact test; N = total number of patient hips, n = number of patient
hips fitting this variable.

Reattachment of the Osteotomized Greater Trochanter in Hip Surgery Using an Ultrahigh Molecular
Weight Polyethylene Fiber Cable: A Multi-Institutional Study
285
were tightened circumferentially around the bone or
through the bones after drilling holes (diameter of holes:
2 - 3 mm). In most of the hips undergoing arthroplasty
(96%), the cable was tightened around the bone (Figure
1(b)). In contrast, in most of the undergoing osteotomy
(91%), the cable was passing through the bone of the
greater trochanter and the proximal femur for the fixation
(Figure 1(a)). Two cables were used for 24 of the hips
undergoing osteotomy, while one cable was used along
with additional fixation materials (one cortical screw or
one soft wire) for eight hips. In contrast, one (64%, 32/50)
or two cable (32%, 16/50) was used in most of the hips
undergoing arthroplasty. None of the hips had additional
fixation materials. The average tension strength of the
osteotomy and arthroplasty hips was 21 ± 3.5 kg and 30
± 2.0 kg, respectively. The cable tightening tension for
the arthroplasty hips was significantly greater than that
for the osteotomy hips.
The representative fixation status of the osteotomized
greater trochanter in the osteotomy or arthroplasty hips is
shown in Figure 1. In the osteotomy hips, the whole
greater trochanter was osteotomized without continuity
between the abductor and vastus lateralis muscles. Two
cables were passing through the greater trochanter frag-
ment and the proximal part of the femur, and were tight-
ened to tension strength of approximately 20 kg. In the
arthroplasty hip, the anterior part of the greater trochanter
was osteotomized with continuity between the abductor
and vastus lateralis muscles. One cable was tightening
(a) (b)
Figure 1. The representative fixation status of the osteoto-
mized greater trochanter in the osteotomy (a) or arthro-
plasty hips (b). In the osteotomy hip, the total greater tro-
chanter was osteotomized without continuity between the
abductor muscle and the vastus lateralis, and it was reat-
tached using two cables running through the bone tissue. In
the arthroplasty hip, the anterior part of the greater tro-
chanter was osteotomized with continuity between the ab-
ductor muscle and the vastus lateralis, and it was reat-
tached using one or more cables around the bone and the
stem neck.
over the greater trochanter fragment and the femoral im-
plant neck to tension strength of approximately 30 kg.
The cable was looped by tying with a double loop-sliding
knot technique using a tensioning device (Alfresa Phar-
ma) (Figure 2).
The bone union and displacement of the osteotomized
greater trochanter were examined in two views of radio-
graphs taken 3, 6, and 12 months after surgery, compare-
ing the images with those obtained just after surgery. The
bone union score was assessed as one of four grades: 0 =
no change; 1 = bridging callus; 2 = trabecular or cortical
bone continuity; or 3 = trabecular or cortical bone con-
tinuity in both views. Displacement of the osteotomized
greater trochanter was assessed as one of four grades: 0 =
≥ 10 mm; 1 = ≥ 5 mm to < 10 mm; 2 = ≥ 2 mm to < 5
mm; or 3 = < 2 mm.
Patient characteristics (except for sex) were analyzed
using a two-sample t-test. Sex and fixation condition were
analyzed using Fisher’s exact test. Bone union score and
displacement score were analyzed using a two sample
t-test. Proportions of the bone union score and displace-
ment score were analyzed using Fisher’s exact test. Val-
ues with a p-value of less than 0.05 were regarded as sta-
tistically significant. Results are presented as means ±
standard deviation.
3. Results
The average bone union score was less than 2 at 3
months after surgery in both the osteotomy and arthro-
plasty hips (Table 3), with no significant difference be-
tween the group values. At 6 months after surgery, bone
union scores were significantly lower in the osteotomy
hips than that in the arthroplasty hips. By 12 months after
surgery, the mean score was greater than 2.5 in both op-
erative groups. At 3 months after surgery, the proportion
of osteotomy and arthroplasty hips in which the bone
union score was 2 or 3 was 32% and 52%, respectively
(Figure 3). At 6 months after surgery, the proportion of
osteotomy hips at a score of 2 or 3 (62%) was signifi-
cantly lower than that of the arthroplasty hips (96%) (p <
0.001). Twelve months after the operation, most hips in
Table 3. Bone union score of the osteotomized greater tro-
chanter at each postoperative interval.
Postoperative interval
3 months 6 months 12 months
nmean ± SDn mean ± SD n mean ± SD
Total 841.4 ± 1.0 84 2.3 ± 0.9 78 2.7 ± 0.7
Osteotomy341.2 ± 1.1 34 2.0 ± 1.0* 31 2.5 ± 0.7
Arthroplasty501.5 ± 0.9 50 2.5 ± 0.7 47 2.8 ± 0.6
*
p < 0.01, two sample t-test vs. arthroplasty.

Reattachment of the Osteotomized Greater Trochanter in Hip Surgery Using an Ultrahigh Molecular
Weight Polyethylene Fiber Cable: A Multi-Institutional Study
286
(a) (b) (c) (d) (e)
(f) (g) (h) (i)
Figure 2. The representative method for reattaching the osteotomized greater trochanter in the osteotomy hip using the ca-
bles. a-c: Four holes were drilled in the greater trochanter fragment, with two holes in the proximal part of the femur paral-
leling the osteotomy plane. The cable was passed through the hole in the proximal femur and two holes of the fragment. d-g:
The cable was looped by tying with double loop-sliding knot technique using the tensioning device. h and i: The remnant ca-
ble was cut off using a scalpel.
100
90
80
70
60
50
40
30
20
10
0
Score 3
Score 2
Score 1
Score 0
Osteo-
tom
y
Arthro-
plasty
Arthro-
plasty
Arthro-
plasty
Osteo-
tom
y
Osteo-
tom
y
3 months 6 months12 months
Figure 3. The proportion of the osteotomy and arthroplasty
hips, in which the bone union score was 0 to 3, where 0 = no
changes, 1 = bridging callus, 2 = trabecular or cortical bone
continuity, and 3 = trabecular or bone continuity in both of
two views.
both of the groups reached a score of 2 or 3, indicating
that there was bone continuity in at least one radiograph
view. The proportion of the osteotomy hips at a bone
union score of 3 (64.5%) was lower than seen in the ar-
throplasty hips (91.5%) (p = 0.006).
The average displacement score of all hips was ap-
proximately 3 at any time after the operation, and there
were no significant differences between the osteotomy
and the arthroplasty hip findings (Table 4). More than
90% of the osteotomy and arthroplasty hips had scores of
2 or 3 at any time after the operation (Figure 4). One
year after the surgery, the proportions of the osteotomy
and arthroplasty hips with displacement scores of 3 were
87.1% and 89.4%, respectively.
There were four non-union cases (4.7%), in which
bone union score was less than 2 at 12 months after the
operation. These low scores were reported for two os-
teotomy hips (5.7%) and two arthroplasty hips (4.0%). In
one of the osteotomy hips, re-operation to fix the greater
trochanter was necessary.
4. Discussion
Non-union of the osteotomy site occurred in 4.7% (4 hips)
of the cases studied. The previously reported rate of non-
union was 0.4% to 21% for procedures using a soft wire
[1-5] and 1.5% to 38% for wire cable fixation [6-9]. We
found that the new UHMEPE cable had relatively good
clinical performance in reattaching the osteotomized great-
er trochanter.
The bone union score of the osteotomy hips was
slightly less than that of the arthroplasty hips at 6 or 12
months after surgery, but this may be due to the differ-
ences in the osteotomy procedure of the greater trochan-
ter. Most hips undergoing arthroplasty had continuity be-

Reattachment of the Osteotomized Greater Trochanter in Hip Surgery Using an Ultrahigh Molecular
Weight Polyethylene Fiber Cable: A Multi-Institutional Study
287
Table 4. Displacement score of the osteotomized greater
trochanter at each postoperative interval.
Postoperative intervals
3 months 6 months 12 months
n mean ± SD nmean ± SD n mean ± SD
Total 84 2.8 ± 0.7 842.8 ± 0.7 78 2.8 ± 0.6
Osteotomy 34 2.7 ± 0.7 342.8 ± 0.7 31 2.8 ± 0.5
Arthroplasty 50 2.8 ± 0.7 502.8 ± 0.7 47 2.8 ± 0.7
100
90
80
70
60
50
40
30
20
10
0
Score 3
Score 2
Score 1
Score 0
Osteo-
tom
y
Arthro-
plasty
Arthro-
plasty
Arthro-
plasty
Osteo-
tom
y
Osteo-
tom
y
3 months 6 months12 months
Figure 4. The proportion of the osteotomy and arthroplasty
hips, in which the displacement score was 0 to 3, where 0 =
more than 10 mm, 1 = ≥ 5 mm to < 10 mm, 2 = ≥ 2 mm to <
5 mm, and 3 = < 2 mm.
tween the abductor and vastus lateralis muscle, while most
hips undergoing osteotomy did not. The greater trochanter
fragment in the arthroplasty hips was more stable than
noted in the osteotomy hips. Differences in the size of the
greater trochanter fragment might also have influenced
the bone union score.
One osteotomy hip had a re-operation due to the dis-
placement of the osteotomized greater trochanter; one ca-
ble with a screw was used to re-attach it. In the osteoto-
my hips, the bone union score of the hips using two ca-
bles was lower than that of the hips using one cable and
one other material like a screw (data not shown). These
inconsistent results may suggest that there was another
important factor for obtaining the union other than the
biomaterials used. Many doctors who participated in this
study pointed out a pitfall when tightening the UHMEPE
cable: One tightening action using the tensioning device
was not usually sufficient to fix the greater trochanter frag-
ment tightly. Since this cable was a soft, flexible material,
there was a time delay between the action of tightening
the cable using the tensioning device and the actual tight-
ness at the binding site. In order to obtain sufficient tight-
ness at the binding site, several tightening actions were
need. Since the tightening strength will be shown in a
display window of the tensioning device, the operator
should tighten the cable several times, until the strength
reaches and stays at approximately 20 to 30 kg.
It is interesting that the displacement score did not
change until the last assessment time at 12 months after
the operation in all hips. These findings indicate the ca-
pability of the cable to maintain the tightened condition.
There were no differences between the displacement scor-
es of the arthroplasty and osteotomy hips; the maintain-
ed tight fixation may overcome stability differences at
the osteotomy site between the arthroplasty and osteoto-
my hips. These advantages are likely based on the prac-
tical strength and fatigue strength of the cable. Our pre-
vious preliminary study showed that the practical strength
was approximately 1.5 or 2 times greater when compared
with that of a wire cable or soft wire, respectively. The
preliminary study also showed that the fatigue strength of
the UHMEPE cable was more than 500 or 5000 times
greater than seen with titanium cable or soft wire, respec-
tively [13].
The cables have been removed easily from several pa-
tients examined in this study (Figure 5). In our previous
animal experiments, the removability of the cable was
compared with a soft wire or a wire cable [13]. The
UHMWPE fiber cable was as easy to remove as a soft
wire and was easier than removing a titanium cable in
this surgical situation. Our histological study in the ani-
mal [13] showed that there was no bone formation in the
fibers of the cable and very little reaction with the adja-
cent soft tissue, supporting our claim that the UHMWPE
fiber cable is a user-friendly material.
This study had several limitations. First, all the cases
that were examined in this study were the first series for
each institution in the use this new biomaterial. During
this study, we found a pitfall in tightening this new mate-
rial of the UHMWPE fiber cable, as noted above. The
union rate of the greater trochanter might be improved
when the cable was tightened, while taking care to
tighten to adequate tension strength. Secondly, there was
a variety of ways to complete fixation of the osteoto-
mized greater trochanter and ways to reattach it. This
variation of techniques made it difficult for us to propose
the best method to reattach the trochanter using this cable,
although the clinical outcomes were relatively good us-
ing any of the methods we used. Additionally, assess-
ments were carried out at each institution, rather than by
a central assessor for all patient outcome evaluations;
there might be inter-observer differences in the scoring.
5. Conclusion
In conclusion, the UHMWPE fiber cable is a good bio-
material option for use in reattaching the osteotomized

Reattachment of the Osteotomized Greater Trochanter in Hip Surgery Using an Ultrahigh Molecular
Weight Polyethylene Fiber Cable: A Multi-Institutional Study
288
⇒
(a) (b) (c)
⇒
(d) (e)
Figure 5. A representative case of the osteotomy hip. a: Before the osteotomy. b: Just after the osteotomy. The arrowhead
points to the cable hole (the cable is not visible). c: Eighteen months after the osteotomy. The greater trochanter is united.
Two holes drilled for the cables are observed. d: The hole (the arrow) of the proximal femur after removal of the cable. e:
After the removal operation.
greater trochanter. We hypothesize that this cable might be
also a good biomaterial for osteosynthesis in many frac-
tured bones.
6. Acknowledgements
This study was supported by a grant from the Alfresa
Pharma Corporation. We would like to appreciate Drs.
Naofumi Okamoto (Department of Orthopaedic Surgery,
Kansai Medical University, Hirakata, Japan), Kengo Ya-
mamoto (Department of Orthopaedic Surgery, Kansai
Rosai Hospital, Amagasaki, Japan), Hisakata Goto (De-
partment of Orthopaedic Surgery, Nagasaki University
Graduate School of Medical Science, Nagasaki, Japan),
Tetsuro Nakamura (Department of Orthopaedic Surgery,
Kyushu Kosei Nenkin Hospital, Kitakyushu, Japan) for
their great help for this study.
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