Two high quality (Cai 2016, Varela 2009) and 6 moderate strength (Caruli 2017, Li 2018, Sanders 2017, Utrilla 2005, Wang 2019, Xu 2018) studies compared the use of an extramedullary sliding hip screw device with a cephalomedullary device for stable intertrochanteric fractures. Fixation with either an extramedullary or intramedullary implant show similar clinical outcomes. One moderate strength study (Utrilla 2005) found no difference in walking ability with either a sliding hip screw or cephalomedullary nail for the stable intertrochanteric fractures. While one study (Sanders 2017) did show improved walking ability in the cephalomedullary group, another high strength study (Varela 2009) found no difference in functional outcome, hospital stay, fracture collapse, or mortality between a cephalomedullary nail and an extramedullary sliding hip screw and plate device that offers two points of fixation into the femoral head. This recommendation includes stable peritrochantaric fractures, 31.A1 and 31.A2, that are stable after anatomical reduction.
Benefits/Harms of Implementation
There are no known harms associated with implementing this recommendation.
Cost Effectiveness/Resource Utilization
The cost of cephalomedullary devices is generally more than sliding hip screw fixation in most institutions. Cephalomedullary nail fixation had reduced length of hospital stay and fewer complications (Xu 2018) which can lead to overall decreased costs with cephalomedullary devices.
Future Research
Randomized, prospective trials comparing modern cephalomedullary nails with extramedullary devices in a large cohort of patients with only stable intertrochanteric fractures (OTA 31.A1) should specifically assess pain, functional outcomes, radiographic parameters, complications, and cost. These studies should control for patient demographics as well as quality of fracture reduction and placement of fixation (tip-to-apex distance). The potential difficulty with conversion to total hip arthroplasty for failed fracture treatment also should be considered when comparing fixation methods.
- Cai, L., Wang, T., Di, L., Hu, W., Wang, J. Comparison of intramedullary and extramedullary fixation of stable intertrochanteric fractures in the elderly: a prospective randomised controlled trial exploring hidden perioperative blood loss. BMC Musculoskeletal Disorders 2016; 1: 475
- Carulli, C., Piacentini, F., Paoli, T., Civinini, R., Innocenti, M. A comparison of two fixation methods for femoral trochanteric fractures: A new generation intramedullary system vs sliding hip screw. Clinical cases in mineral and bone metabolism 2017; 1: 40-47
- Li, H., Wang, Q., Dai, G. G., Peng, H. PFNA vs. DHS helical blade for elderly patients with osteoporotic femoral intertrochanteric fractures. European Review for Medical & Pharmacological Sciences 2018; 1: 1-7
- Sanders, D., Bryant, D., Tieszer, C., Lawendy, A. R., MacLeod, M., Papp, S., Liew, A., Viskontas, D., Coles, C., Gurr, K., Carey, T., Gofton, W., Bailey, C., Bartley, D., Trenholm, A., Stone, T., Leighton, R., Foxall, J., Zomar, M., Trask, K. A Multicenter Randomized Control Trial Comparing a Novel Intramedullary Device (InterTAN) Versus Conventional Treatment (Sliding Hip Screw) of Geriatric Hip Fractures. Journal of Orthopaedic Trauma 2017; 1: 1-8
- Utrilla, A. L., Reig, J. S., Muñoz, F. M., Tufanisco, C. B. 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. Journal of Orthopaedic Trauma 2005; 4: 229-33
- Varela-Egocheaga, J. R., Iglesias-Colao, R., Suárez-Suárez, M. A., Fernández-Villán, M., González-Sastre, V., Murcia-Mazón, A. Minimally invasive osteosynthesis in stable trochanteric fractures: a comparative study between Gotfried percutaneous compression plate and Gamma 3 intramedullary nail. Archives of Orthopaedic & Trauma Surgery 2009; 10: 1401-7
- Wang, B., Liu, Q., Liu, Y., Jiang, R. Comparison of Proximal Femoral Nail Antirotation and Dynamic Hip Screw Internal Fixation on Serum Markers in Elderly Patients with Intertrochanteric Fractures. Jcpsp, Journal of the College of Physicians & Surgeons - Pakistan 2019; 7: 644-648
- Xu, R., Ru, J., Ji, F., Liu, J., Ji, Y., Wu, Z., Shi, D. Comparison of efficacy, complications and TGF-beta2 expression between DHS and PFNA in elderly patients with osteoporotic femoral intertrochanteric fracture. Experimental & Therapeutic Medicine 2018; 1: 394-399