Intramedullary nails for extracapsular hip fractures in adults

Abstract

Intramedullary nails may be used for the surgical fixation of extracapsular hip fractures in adults. They may be inserted from the top (cephalocondylic) or from the bottom (condylocephalic) end of the femur. To compare different types or design modifications of intramedullary nails used in the fixation of extracapsular hip fractures. We searched the Cochrane Musculoskeletal Injuries Group specialised register (September 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2004), MEDLINE (1966 to September week 1 2004), EMBASE (1988 to 2004 Week 37), the UK National Research Register Issue 2, 2004, several orthopaedic journals, conference proceedings and reference lists of articles. All randomised or quasi-randomised trials comparing different types of intramedullary nails or modifications to the design of intramedullary nails in the treatment of extracapsular hip fractures in adults. Both authors independently assessed trial quality and extracted data. Additional information was sought from all trialists. Four studies, involving a total of 834 predominantly female and older patients with mainly unstable trochanteric fractures, were included. All trials compared different designs of cephalocondylic nail. Allocation concealment was likely in one trial, not described in two and not done in the fourth. Two studies, with 674 participants, compared the proximal femoral nail versus the Gamma nail. Blood transfusion was greater for the proximal femoral nail group in one trial, yet blood loss was less in this group in the other trial. Pooled data for re-operation (relative risk 1.08, 95% confidence interval 0.65 to 1.81) and mortality (relative risk 1.24, 95% confidence interval 0.90 to 1.71) showed no statistically significant differences between the two groups. Limited data for long term function also showed no statistically significant differences. The two other studies, with 80 participants each, found respectively no differences between a gliding nail versus a Gamma nail; and a dynamically versus a statically locked intramedullary hip screw. The limited evidence from the randomised trials undertaken to date is insufficient to determine if there are important differences in outcome between different designs of intramedullary nails used in the internal fixation of extracapsular hip fractures. Given the evidence of superiority of the sliding hip screw compared with intramedullary nails for extracapsular hip fractures, further studies comparing different designs of intramedullary nails are not a priority. Any new design should be evaluated in a randomised comparison with the sliding hip screw.