We read your article title “The effect on outcomes of the application of circumferential cerclage cable following Intramedullary nailing in reverse intertrochanteric femoral fractures” with great interest. The article gives insight regarding the advantages of using a cerclage cable in adjunct to intramedullary fixation for reverse intertrochanteric fractures. However, as readers, we feel that elaboration of the following points shall lead to better understanding and application of this technique.

The authors have determined the lateral femoral wall (LFW) displacement as well as the telescoping using a plain AP and lateral radiograph. We feel that the same may give different readings as the position of rotation of limb might change with each radiograph. A computed tomography (CT) scan could be a better modality to calculate these measurements as even a slight variation in extremity positioning would introduce a bias in these measurements.

LFW displacement was evaluated on the radiograph as the perpendicular distance from the apex of the lateral femoral fragment to the lateral edge of the nail in this study. However, we believe that callus formation or re-modelling during bone healing can lead to an erroneous measurement, thus creating a bias.

All the patients in the “cerclage cable” group underwent an open reduction. However, only 21.2% patients in the “no-cable” group were managed with open reduction. We would like to know from the authors whether they feel that this would cause a bias in average healing times between groups.

In the study, 16.6% patients with 31A 3.2 fractures were managed with an additional encirclage. 31A 3.2 are “simple transverse fractures”, and application of cerclage cable in transverse fractures is not only technically difficult but also may not lead to any additional biomechanical advantage. We would like to know the authors view on this aspect.

The results in the study state that “The LFW displacement was determined as 2 ± 2.74 mm in the group without cerclage cable and 8 ± 6.35 mm (t test, p = 0.001) in the group where cerclage cable was used”. In context of the paper, we are unable to understand whether it is a typing error or the “without cerclage cable” group has lower rates of LFW displacement.

We would like to thank the authors for this innovative study. We feel that the identification of the above factors will allow better use of this approach in treating these complex fractures.