Cephalomedullary Device - Stable Intertrochanteric Fractures
In patients with stable intertrochanteric fractures, use of either a sliding hip screw or a cephalomedullary device is recommended.

Rationale

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.