Moderate evidence supports using a cephalomedullary device for the treatment of patients with unstable intertrochanteric fractures.

Management of Hip Fractures in the Elderly
Endorsed by: OTA, AGS, AAPM&R, ASBMR, USBJI, The Hip Society, AACE, ORA
Moderate Evidence MODERATE EVIDENCE
Rationale
Five moderate (Adams et al 102, Knobe et al 103, Papasimos 2005 104,Utrilla et al 95, Leung et al 105) and one high strength (Verettas et al 106)  studies evaluated the use of cephalomedullary devices in unstable intertrochanteric fractures with a separate lesser trochanteric fragment but no subtrochanteric involvement (OTA 31.A2).   Although many studies have been done, the variability of fracture classification systems and implants used makes interpretation of the literature challenging.    Evaluation of these studies shows moderate strength evidence supporting the treatment benefit of cephalomedullary devices for unstable intertrochanteric fractures.  
 
Two moderate strength studies (Utrilla et al 95; Leung et al 105) recommended a cephalomedullary device over sliding hip screw. Utrilla et al 95 found improved postoperative walking ability and fewer blood transfusions in the cephalomedullary group. Leung et al. 105 showed no difference in mortality or ultimate hip function but did show a shorter convalescence in the cephalomedullary cohort.  A high strength study (Verettas et al 106) found no difference in pain and the systemic physiologic responses (O2 requirement, mental status, hematocrit) between treatment with a either sliding hip screw or a cephalomedullary device for this fracture pattern.  Similarly, a moderate strength study (Knobe et al 103) found similar mortality and functional results between an extramedullary and a cephalomedullary device. Papasimos et al 104 conducted a moderate strength study evaluating treatment with a sliding hip screw and two different cephalomedullary devices showing no difference between devices with respect to ultimate fracture consolidation and a return to pre-fracture level of function.  Adams et al 102 conducted a moderate strength comparative study evaluating a cephalomedullary device to an extramedullary plate and screw including 31.A1, 31.A2 and 31.A3 fractures and found the use of an intramedullary device in the treatment of intertrochanteric femoral fractures is associated with a higher but nonsignificant risk of postoperative complications.  By controlling for TAD, there was found to be no statistical difference in the performance of the implants when looking at fracture stability.
 
Risks and Harms of Implementing this Recommendation
There are no known harms associated with implementing this recommendation
 
Future Research
The current trend for increasing use of cephalomedullary devices in the treatment of intertrochanteric fractures (Yli-Kyyny, Injury 2012; 2008, Jeffery Anglen, JBJS) in the absence of strong supporting evidence as well as the recent concerns regarding increased complication rates with conversion of failed cephalomedullary implants to total hip arthroplasty (Pui et al JOA 2013) warrants caution and further investigation.  High level trials comparing modern cephalomedullary devices with sliding hip screws in a large cohort of patients with intertrochanteric fractures classified as OTA 31.A2 should specifically assess functional outcomes, radiographic outcomes, complications, and cost. These studies should control for patient demographics, quality of fracture reduction, hardware placement (specifically tip-to-apex distance) and the changing experience of practicing surgeons. 
  1. (102) Adams CI, Robinson CM, Court-Brown CM, McQueen MM. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma 2001;15(6):394-400.
  2. (103) Knobe M, Drescher W, Heussen N, Sellei RM, Pape HC. Is helical blade nailing superior to locked minimally invasive plating in unstable pertrochanteric fractures? Clin Orthop Relat Res 2012;470(8):2302-2312.
  3. (104) Papasimos S, Koutsojannis CM, Panagopoulos A, Megas P, Lambiris E. A randomised comparison of AMBI, TGN and PFN for treatment of unstable trochanteric fractures. Arch Orthop Trauma Surg 2005;125(7):462-468.
  4. (105) Leung KS, So WS, Shen WY, Hui PW. Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised prospective study in elderly patients. J Bone Joint Surg Br 1992;74(3):345-351.
  5. (95) Utrilla AL, Reig JS, Munoz FM, Tufanisco CB. Trochanteric gamma nail and compression hip screw for trochanteric fractures: a randomized, prospective, comparative study in 210 elderly patients with a new design of the gamma nail. J Orthop Trauma 2005;19(4):229-233.