Cephalomedullary Device - Unstable Intertrochanteric Fractures

Two high (Adams 2001, Zehir 2015) and 9 moderate quality studies, (Papasimos 2005, Utrilla 2005, Leung 1992, Aktselis 2014, Fernandez 2017, Griffin 2016, Reindl 2015, Tao 2013, Verettas 2010) 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 the fracture classification systems and the diverse designs of the implants used makes interpretation of the literature challenging. Evaluation of these studies shows strong evidence strength supporting the treatment benefit of using the cephalomedullary devices for unstable intertrochanteric fractures.  

Two moderate strength studies (Utrilla 2005, Leung 1992) recommended a cephalomedullary device over sliding hip screw. Utrilla (2205) found improved postoperative walking ability and fewer blood transfusions in the cephalomedullary group. Leung (1992) showed no difference in the mortality or in the ultimate hip function but did show a shorter convalescence period in the cephalomedullary cohort.  A moderate strength study (Verettas 2010) found no difference in pain and in the systemic physiologic responses (O2 requirement, mental status, hematocrit) between the treatment groups with using either a sliding hip screw or using a cephalomedullary device.  Papasimos (2005) conducted a moderate strength study evaluating treatment with using a sliding hip screw and using two different cephalomedullary devices. Their data showed no difference between the devices with respect to the ultimate fracture consolidation and the return to the pre-fracture level of function.  Adams (2001) conducted a comparative study evaluating using a cephalomedullary device to using an extramedullary plate and screw in the treatment of 31.A1, 31.A2 and 31.A3 fractures. They found the use of an intramedullary device in the treatment of intertrochanteric hip fractures was associated with a higher but nonsignificant risk of postoperative complications.  By controlling for tip-to-apex distance, there was no statistical difference between the types of the implants with regard to fracture reduction and the fracture stability during the healing phase.

Benefits/Harms of Implementation

There are no known harms associated with implementing this recommendation 

Future Research 

The current trend is for increasing use of cephalomedullary devices in the treatment of intertrochanteric fractures (Yli-Kyyny 2012;Jeffery Anglen 2008). Concerns regarding increased complication rates with conversion of failed cephalomedullary implants to total hip arthroplasty (Pui 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 pain, 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.