Question: In patients with extracapsular proximal femoral fractures,
how do cephalocondylic intramedullary nails compare with extramedullary
fixation implants?
Data sources: Studies were identified by searching the Cochrane
Musculoskeletal Injuries Group trials register (up to May 2003), MEDLINE,
EM-BASE/Excerpta Medica, and CINAHL; hand-searching 9 orthopaedic journals;
scanning the reference lists of studies and reviews; and contacting
manufacturers of the Gamma nail and the intramedullary hip screw (IMHS).
Study selection and assessment: Studies in any language were
selected if they were randomized or quasi-randomized controlled trials that
compared a type of cephalocondylic intramedullary nail with an extramedullary
implant in patients with an extracapsular proximal femoral fracture. The
scheme within the Cochrane Reviewers' Handbook Study was used to assess study
methodological quality (maximum score, 13).
Main outcome measures: (1) Operative details (length of surgery,
operative blood loss, and radiographic screening time); (2) fracture fixation
complications: a composite end point of all technical complications of
fixation (operative fracture of the femur, later fracture of the femur, cutout
of the implant from the femoral head, non-union of the fracture, detachment of
the implant from the femur, and breakage of the implant) and reoperation,
wound infection, and wound hematoma; (3) postoperative general complications
(pressure sores, pneumonia, thromboembolic complications, any medical
complications, and length of hospital stay); (4) anatomical restoration; and
(5) final outcomes (mortality, persistent pain, mobility, and failure to
return to prefracture residential status).
Main results: 28 trials were included: 18 trials (n = 2575) compared
the short Gamma nail with a sliding hip screw (SHS), 5 trials (n = 623)
compared the short intramedullary hip screw (IMHS) with the SHS, 1 trial (n =
206) compared the short proximal femoral nail (PFN) with the SHS, 1 trial (n =
60) compared an experimental mini-invasive static intramedullary nail with the
SHS, 1 trial (n = 230) compared the Kuntscher-Y nail with the SHS, 1 trial (n
= 26) compared the Gamma nail with the 90° angled blade-plate, and 1 trial
(n = 39) compared the PFN with the dynamic condylar screw.
Pooling the trials of the 3 types of short femoral nails (Gamma, IMHS, and
PFN) compared with the SHS showed better results for the SHS for the key
outcomes of intraoperative and later fracture of the femur and the composite
end point of all technical complications
(Table). All technical
complications were increased with the Gamma nail but did not differ for the
IMHS and PFN compared with the SHS
(Table). The Gamma nail and the
PFN did not differ from the SHS for operative, postoperative, or other
outcomes. Operative details and technical complications favored the Gamma nail
and the PFN compared with the blade-plate and condylar screw.
Short femoral nails were superior to the bladeplate or condylar screw with
regard to length of surgery and length of hospital stay.
Conclusions: In patients with extracapsular proximal femoral
fractures, the sliding hip screw performs better than the short Gamma nail. No
advantage is seen with the intramedullary hip screw or the proximal femoral
nail compared with the sliding hip screw. Limited evidence supports the use of
the short intramedullary nails compared with the blade-plate or condylar
screws.
This systematic review by Parker and Handoll confirms the commonly held
opinion that short interlocking cephalomedullary nails do not provide an
appreciable clinical advantage over the more conventional sliding hip screw
devices in the treatment of intertrochanteric fractures. The search of studies
for this systematic literature review was relevant and
exhaustive1. The
important conclusions are related to the comparison between short nails
(Gamma, IMHS, or PFN) and standard sliding hip screws for intertrochanteric
fractures.
This review shows that no difference exists between sliding hip screws and
short interlocking cephalomedullary nails in terms of the technical aspects
(operating-room time, screening time, and blood loss), hospital stay,
malunion, nonunion, failure of fixation, general postoperative complications,
or final outcome measures for the treatment of intertrochanteric fractures.
The short intramedullary nails, however, are associated with a higher risk of
intraoperative and postoperative femoral fracture, which leads to a higher
rate of reoperation. Although design changes to all of the different types of
short intramedullary nails have been made in an attempt to reduce the risk of
femoral fracture2,
adequately powered randomized trials will be needed before the efficacy of
these design changes can be fully assessed.
The review contains only a small amount of information about the more
uncommon extracapsular proximal femoral fracture patterns (reverse obliquity
and subtrochanteric). Intramedullary devices may be superior to extramedullary
devices for the treatment of reverse obliquity trochanteric
fractures3, but more
research with adequately powered trials is necessary. Trials are also
necessary to determine the optimal management of subtrochanteric
fractures.
On the basis of this review, the sliding hip screw is the
"gold" standard for fixation of intertrochanteric hip
fractures.
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Devereaux PJ, Swiontkowski MF. User's guide to the orthopaedic literature:
how to use a systematic literature review. J Bone Joint Surg
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Lorich DG, Geller DS, Nielson JH.
Osteoporotic pertrochanteric hip fractures: management and current
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441-54.53441
2004
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Sadowski C, Lubbeke A, Saudan M,
Riand N, Stern R, Hoffmeyer P. Treatment of reverse oblique and transverse
intertrochanteric fractures with use of an intramedullary nail or a 95 degrees
screw-plate: a prospective, randomized study. J Bone Joint Surg
Am.2002;84:
372-81.84372
2002