Cephalomedullary Device - Subtrochanteric/Reverse Obliquity Fractures
In patients with subtrochanteric or reverse obliquity fractures a cephalomedullary device is recommended.

Rationale

There were 3 high (Miedel 2005, Schipper 2004, Zehir 2015), and 6 moderate quality (Arktelis 2014, Fernandez 2017, Griffin 2016, Hardy 1998, Reindle 2015, Tao 2013) studies evaluating the use of cephalomedullary devices in the treatment of unstable intertrochanteric and subtrochanteric fractures. Although many comparative studies have been done, the variability of fracture classification systems and implants used makes interpretation of the literature challenging. Evaluation of these studies shows an apparent treatment benefit with cephalomedullary devices for unstable peritrochanteric fractures compared to extramedullary devices.

One high strength comparative study (Schipper 2004) showed similar results and outcomes between different cephalomedullary devices in unstable fractures.

Another high strength study (Miedel 2005) demonstrated a lower complication rate with use of a cephalomedullary versus an extramedullary device in treatment of unstable intertrochanteric and subtrochanteric fractures.  Another moderate strength study (Hardy 1998) showed improved mobility and decreased limb shortening in unstable intertrochanteric fractures treated with a cephalomedullary device versus a sliding hip screw. 

Benefits/Harms of Implementation

There are no known harms associated with implementing this recommendation. 

Future Research

Continued comparative studies between modern cephalomedullary and extramedullary devices in unstable subtrochanteric and reverse obliquity fractures (OTA 31.A3) which control for fracture reduction and implant position (specifically tip-to-apex distance) may further clarify the utility of cephalomedullary devices for this fracture cohort.