Cephalomedullary Device - Pertrochanteric Fractures

One moderate quality study (Shannon 2019) and multiple low quality studies reported lower surgical OR time, lower intraoperative blood loss (Frisch 2017, Horner 2017, Liu 2018), lower transfusion rate (Guo 2015), and less fluoroscopy (Frisch 2017, Horner 2017, Liu 2018) with short nail use. Multiple comparison studies reported no difference in adverse events (Bovbjerg 2020, Frisch 2017, Guo 2015, Horner 2017, Liu 2018, Rai 2020) nor patient reported outcomes (Rai 2020) in short versus long cephalomedullary nails.  One low quality study (Frisch 2017) reported a higher incidence of periprosthetic fractures with short nails, but other studies did not find such findings (Guo 2015). Overall, both short or long cephalomedullary nails are acceptable options in pertrochanteric femur fractures. 

Benefits/ Harms of Implementation

Benefits of implementation include shorter patient operative time and lower blood loss.  There is risk that patients may suffer periprosthetic femur fractures with short nails. 

Outcome Importance

The consequences of using a short versus long cephalomedullary nail is unaffected for adverse events such as implant cut out, infection or implant failure. A short nail may result in less operative time and lower blood loss, and possibly lower transfusion rate. 

Cost Effectiveness/Resource Utilization

Shorter cephalomedullary nails generally have lower implant costs compared to long cephalomedullary nails. Additionally, shorter operative time and lower blood loss may have intangible healthcare related savings. 

Acceptability

There are likely a large number of surgeons who are dogmatic about the use of long cephalomedullary nails, especially in the use of unstable fracture patterns such as reverse obliquity or subtrochanteric extension fractures.  Additionally, studies have not looked specifically at use of short cephalomedullary nails in these fracture patterns. 

Feasibility

No feasibility nor barriers foreseen  

Future Research

Future research with high quality studies should help elucidate short versus long in unstable intertrochanteric fracture patterns and periprosthetic fracture risk factors.