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Increased Use of Intramedullary Nails for Intertrochanteric Proximal Femoral Fractures in Veterans Affairs HospitalsA Comparative Effectiveness Study
Tiffany A. Radcliff, PhD1; Elizabeth Regan, MD, PhD2; Diane C. Cowper Ripley, PhD3; Evelyn Hutt, MD4
1 Department of Health Policy and Management, Texas A&M School of Rural Public Health, TAMU MS 1266, College Station, TX 77843. E-mail address: Tiffany.Radcliff@ucdenver.edu
2 National Jewish Health, 1400 Jackson Street, K706, Denver, CO 80206
3 Research Service (151B), Rehabilitation Outcomes Research Center, 1611 Archer Road, Malcolm Randall VA Medical Center, Gainesville, FL 32608
4 Research Service (151), Colorado REAP to Improve Care Coordination, VA Eastern Colorado Healthcare System, 1055 Clermont Street, MS 151, Denver, CO 80220
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  • Disclosure statement for author(s): PDF

Investigation performed at the Colorado REAP to Improve Care Coordination, VA Eastern Colorado Healthcare System, Denver, Colorado

Disclaimer: The opinions expressed are those of the authors and not necessarily those of the Department of Veterans Affairs or the United States Government.



Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 May 02;94(9):833-840. doi: 10.2106/JBJS.I.01403
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Abstract

Background: 

Intramedullary nails for stabilizing intertrochanteric proximal femoral fractures have been available since the early 1990s. The nails are inserted percutaneously and have theoretical mechanical advantages over plates and screws, but they have not been demonstrated to improve patient outcomes. Still, use of intramedullary nails is becoming more common. The goal of this study was to examine trends in the use and associated outcomes of intramedullary nailing compared with sliding hip screws in Veterans Affairs (VA) hospitals.

Methods: 

Review of the VA Surgical Quality Improvement Program (VASQIP) data identified 5244 male patients in whom an intertrochanteric proximal femoral fracture had been treated in a VA hospital between 1998 and 2005. The overall sample was used to assess trends in device use, thirty-day mortality, thirty-day surgical complications, and one-year mortality. Next, propensity score matching methods were used to compare 1013 patients identified as having been treated with an intramedullary nail with 1013 patients who had a sliding-screw procedure. Multiple logistic regression models for the matched sample were used to calculate odds ratios for mortality and complications according to the choice of internal fracture fixation.

Results: 

Use of intramedullary nails in VA facilities increased from 1998 through 2005 and varied by geographic region. Unadjusted mortality and complication percentages were similar for the two procedures, with approximately 8% of patients dying within thirty days after surgery, 28% dying within one year, and 19% having at least one perioperative complication. While the choice of an intramedullary nail or sliding-screw procedure was related to the geographic region, year of surgery, surgeon characteristics, and several patient characteristics, it was not associated with thirty-day outcomes in either the descriptive or the multiple regression analysis.

Conclusions: 

Intramedullary nail use increased from 1998 through 2005 but did not decrease perioperative mortality or comorbidity compared with standard plate-and-screw devices for patients treated for intertrochanteric proximal femoral fractures in VA facilities.

Level of Evidence: 

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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