Bone substitutes and augmentation in intertrochanteric femoral fractures: a narrative review

Intertrochanteric fractures of the proximal femur are a major source of morbidity in ageing populations.Despite advances in cephalomedullary nail (CMN) constructs and perioperative care, mechanical failure persists in osteoporotic bone-particularly in unstable AO/OTA A2-A3 patterns marked by loss of the medial buttress or compromise of the lateral femoral wall.Tissue-engineering research defines desirable attributes of bone substitutes, but translation to peritrochanteric fixation requires a surgical lens.This narrative review integrates material science with decision-making and appraises two complementary strategies: polymethyl-methacrylate (PMMA) augmentation of the head element to secure immediate purchase, and selective calcium-phosphate (CaP)-based void filling to restore the medial buttress without impeding controlled sliding; lateral-wall reconstruction is addressed where structural deficiency dictates.Across randomized trials, meta-analyses, multicentre cohorts, and biomechanical studies, PMMA augmentation in osteoporotic, unstable patterns is associated with stronger initial fixation and lower cut-out signals when meticulous leak surveillance is applied.CaP materials contribute to reduction maintenance when used to buttress discrete metaphyseal defects but are not load-bearing substitutes.Augmentation is best conceived as an amplifier of good surgery rather than a replacement.A pattern-specific, indication-driven approach-anchored in uncompromising reduction quality and ideal head-element placement-offers a coherent path to earlier mobilisation and fewer reoperations in the highest-risk patients.