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Nail or Plate Fixation of Intertrochanteric Hip Fractures: Changing Pattern of PracticeA Review of the American Board of Orthopaedic Surgery Database
Jeffrey O. Anglen, MD1; James N. Weinstein, DO2
1 Department of Orthopaedic Surgery, Indiana University, 541 Clinical Drive, Suite 600, Indianapolis, IN 46202. E-mail address: janglen@iupui.edu
2 Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Rubin 596, Lebanon, NH 03756. E-mail address: james.weinstein@dartmouth.edu
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Apr 01;90(4):700-707. doi: 10.2106/JBJS.G.00517
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Background: A new method of fixation for intertrochanteric hip fractures that involves the use of an intramedullary nail that interlocks proximally into the femoral head was introduced in the early 1990s. Anecdotal observation of practice patterns during the Part II (oral) American Board of Orthopaedic Surgery examination suggested that the use of this method had increased substantially in recent years in comparison with the more traditional sliding compression screw technique. A study of the Part II database was undertaken to detect changing patterns of care for intertrochanteric fractures.

Methods: During the process of Board certification, candidates for the Part II (oral) examination submit a six-month surgical case list and patient data into a secure database. The database was searched for all intertrochanteric fractures (International Classification of Diseases, Ninth Revision, code 820.20 or 820.21) over a seven-year period (1999 through 2006). The cases were categorized by intramedullary nail or plate fixation on the basis of surgeon-reported Current Procedural Terminology codes. Relative utilization of the two devices was analyzed according to year and region, and the devices were compared in terms of complications and outcomes.

Results: A dramatic change in practice was demonstrated, with the intramedullary nail fixation rate increasing from 3% in 1999 to 67% in 2006. Regional variation was substantial. The highest rate of utilization of intramedullary nail fixation was recorded by candidates from the South, Southeast, and Southwest, who converted to the new technology faster than those in the Northeast, Northwest, and Midwest. Overall, patients managed with plate fixation had slightly less pain and deformity in comparison with those managed with intramedullary nailing, with no significant differences being identified in terms of function or satisfaction. Patients managed with intramedullary nailing had more procedure-related complications, particularly bone fracture.

Conclusions: From 1999 to 2006, a dramatic change in surgeon preference for the fixation device used for the treatment of intertrochanteric fractures has occurred among young orthopaedic surgeons. This change has occurred despite a lack of evidence in the literature supporting the change and in the face of the potential for more complications.

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    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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