Stable Intertrochanteric Fractures

One high quality (Ahrengart et al⁹⁴) and two moderate strength (Utrilla et al ⁹⁵, Varela et al⁹⁶) studies compared the use of an extramedullary sliding hip screw device with a cephalomedullary device for stable intertrochanteric fractures.  The high strength study compared a cephalomedullary device and sliding hip screw in both stable and unstable intertrochanteric fractures (Ahrengart et al ⁹⁴).  Subgroup evaluation of the stable fractures favored the use of a sliding hip screw with respect to operative time and blood loss. One moderate strength study (Utrilla et al ⁹⁵) found no difference in walking ability with either a sliding hip screw or cephalomedullary nail for the stable intertrochanteric fractures. The other moderate strength study (Varela et al⁹⁶) 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. 
 
Risks and Harms of Implementing this Recommendation
There are no known harms associated with implementing this recommendation.
 
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 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.