Extracapsular Hip Fractures In Adults Research Articles

Surgical interventions for treating extracapsular hip fractures in adults: a network meta-analysis

Surgical interventions for treating extracapsular hip fractures in adults: a network meta-analysis

Cochrane in CORR ®: Intramedullary nails for extracapsular hip fractures in adults (review).

M ore than 1.5 million patients suffer hip fractures worldwide each year [3], and annual direct and indirect costs are projected to exceed USD 130 billion globally by 2050 [6]. Thirty-day mortality approaches 5% in males and 9% in females, and many more patients experience significant functional loss and debilitation [4]. Approximately 50% of all hip fractures are extracapsular, which surgeons can treat using a wide variety of possible internal fixation strategies. Extramedullary sliding hip screws were the standard of care from the 1950s to the 1990s, but many surgeons now prefer intramedullary nails that interlock proximally in the femoral head [2]. There has been a more than 20-fold relative increase in the utilization of intramedullary nails since 1999, and approximately two-thirds of new orthopaedic surgeons now select them routinely [1]. Several designs are on the market from different manufacturers, each varying in length, diameter, neckshaft angle, number of locking screws or blades, ability to slide and/or compress, ability to control rotation, construction materials, start-point, and surgical technique. This review aimed to determine whether different nail designs are associated with unique benefits or harms in patients with extracapsular hip fractures. Twelve designs were evaluated among 2130 patients from 17 separate trials. The authors concluded that there were no important differences in function, mobility, pain, death, fracture fixation complications, or rates of revision surgery between most of the implants that were studied. A Note from the Editor-In-Chief: We are pleased to publish the next installment of Cochrane in CORR, our partnership between CORR, The Cochrane Collaboration, and McMaster University’s Evidence-Based Orthopaedics Group. In it, researchers from McMaster University will provide expert perspective on an abstract originally published in The Cochrane Library that we think is especially important. (Queally JM, Harris E, Handoll HHG, Parker MJ. Intramedullary nails for extracapsular hip fractures in adults. Cochrane Database of Systematic Reviews 2014, Issue 9. Art. No.: CD004961. DOI: 10.1002/ 14651858.CD004961.pub4). Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Reproduced with permission. NE certifies that he, or a member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. One of the authors certifies that he (MB), or a member of his or her immediate family, has received or may receive payments or benefits, during the study period, an amount of less than USD 10,000 from Stryker Corporation (Kalamazoo, MI, USA). All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or the Association of Bone and Joint Surgeons. Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and The Cochrane Library (http:// www.thecochranelibrary.com) should be consulted for the most recent version of the review. This Cochrane in CORR column refers to the abstract available at: DOI: 10.1002/ 14651858.CD004961.pub4.

Intramedullary nails for extracapsular hip fractures in adults.

Intramedullary nails may be used for the surgical fixation of extracapsular hip fractures in adults. This is an update of a Cochrane review first published in 2005 and last updated in 2008. To assess the effects (benefits and harms) of different designs of intramedullary nails for treating extracapsular hip fractures in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (6 January 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 12, 2013), MEDLINE (1966 to November Week 3, 2013), MEDLINE In-Process & Other Non-Indexed Citations (3 January 2014), EMBASE (1988 to 2014, Week 1) and the World Health Organization (WHO) International Clinical Trials Registry Platform (accessed January 2014). All randomised or quasi-randomised trials comparing different types, or design modifications, of intramedullary nails in the treatment of extracapsular hip fractures in adults. At least two review authors independently selected studies, assessed risk of bias and extracted data. We performed limited meta-analysis using the fixed-effect model. We included eight new trials, testing seven new comparisons in this update. Overall, we included 17 trials, testing 12 comparisons of different cephalocondylic nail designs. The trials involved a total of 2130 adults (predominantly female and older people) with mainly unstable trochanteric fractures.All trials were at unclear risk of bias for most domains, with the majority at high risk of detection bias for subjective outcomes. The three quasi-randomised trials were at high risk for selection bias.Four trials (910 participants) compared the proximal femoral nail (PFN) with the Gamma nail. There was no significant difference between the two implants in functional outcome (the very low quality evidence being limited to results from single trials), mortality (low quality evidence: 86/415 versus 80/415; risk ratio (RR) 1.08, 95% confidence interval (CI) 0.82 to 1.41), serious fixation complications (operative fracture of the femur, cut-out, non-union and later fracture of the femur) nor re-operations (low quality evidence: 45/455 versus 36/455; RR 1.25, 95% CI 0.83 to 1.90).Two trials (185 participants) provided very low quality evidence of a lack of clinically significant difference in outcome (functional score, mortality, fracture fixation complications and re-operation) between the ACE trochanteric nail and the Gamma nail.Two trials (200 participants) provided very low quality evidence of a lack of significant difference in outcome (mobility score, pain, fracture fixation complications or re-operations) between the proximal femoral nail antirotation (PFNA) nail and the Gamma 3 nail.Seven of the nine trials evaluating different comparisons provided very low quality evidence of a lack of significant between-group differences in all of the reported main outcomes for the following comparisons: ACE trochanteric nail versus Gamma 3 nail (112 participants); gliding nail versus Gamma nail (80 participants); Russell-Taylor Recon nail versus long Gamma nail (34 participants, all under 50 years); proximal femoral nail antirotation (PFNA) nail versus Targon PF nail (80 participants); dynamically versus statically locked intramedullary hip screw (IMHS) nail (81 participants); sliding versus non-sliding Gamma 3 nail (80 participants, all under 60 years); and long versus standard PFNA nails (40 participants with reverse oblique fractures).The other two single comparison trials also provided very low quality evidence of a lack of significant between-group differences in all of the main outcomes with single exceptions. The trial (215 participants) comparing the ENDOVIS nail versus the IMHS nail found low quality evidence of poorer mobility in the ENDOVIS nail group, where more participants in this group were bedridden after their operation (29/105 versus 18/110; RR 1.69, 95% CI 1.00 to 2.85; P = 0.05). The trial (113 participants) comparing the InterTan nail versus the PFNA II nail found very low quality evidence that more PFNA II group participants experienced thigh pain (3/47 versus 12/46; RR: 0.24, 95% CI 0.07 to 0.81). The limited evidence from the randomised trials undertaken to date is insufficient to determine whether there are important differences in outcome between different designs of intramedullary nails used in treating 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.

Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults.

Extramedullary fixation of hip fractures involves the application of a plate and screws to the lateral side of the proximal femur. In external fixators, the stabilising component is held outside the thigh by pins or screws driven into the bone. ThisisanupdateofaCochranereviewfirstpublishedin1998, and last updated in 2005. To assess the relative effects of different types of extramedullary fixation implant, as well as external fixators, for treating extracapsular proximal femoral (hip) fractures in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 2), MEDLINE (1966 to June Week 4 2011), EMBASE (1988 to 2011 Week 25), various other databases, conference proceedings and reference lists. Randomised or quasi-randomised controlled trials comparing extramedullary implants or external fixators for fixing extracapsular hip fracture in adults were included. Two review authors independently selected trials, assessed risk of bias and extracted data. Data were pooled where appropriate. The 18 included trials tested seven comparisons in a total of 2615 mainly female and older participants with a total of 2619 fractures. All trials had methodological flaws that may affect the validity of their results.Three trials of 355 participants comparing a fixed nail plate (Jewett or McLaughlin) with the sliding hip screw (SHS) found an increased risk of fixation failure for fixed nail plates.The two trials of 433 participants comparing the Resistance Augmented Bateaux (RAB) plate with the SHS had contrasting results, notably in terms of operative complications, fixation failure and anatomical restoration.One trial of 100 participants comparing the Pugh nail and the SHS found no significant difference between implants.Three trials of 458 participants compared the Medoff plate with the SHS. There was a trend to higher blood losses and longer operation times for the Medoff plate along with a trend to a lower risk of fixation failure with the Medoff plate for unstable trochanteric fractures.Two trials of 676 participants compared the Medoff plate with three different screw-plate systems. There were no statistically significant differences in outcome for trochanteric fractures. For subtrochanteric fractures, there was a lower fixation failure rate for the Medoff plate but no evidence for differences in longer-term outcomes.Four trials of 396 participants comparing the Gotfried percutaneous compression plate (PCCP) with a SHS found a trend to lower blood loss and transfusion requirements for the PCCP but no other confirmed differences in outcomes between implants. Three of the trials reported intra-operative problems with the PCCP, some of which precluded its use.Three trials of 200 participants comparing external fixation with a SHS found less operative trauma for the external fixation. Final outcome appeared similar. The markedly increased fixation failure rate of fixed nail plates compared with the SHS is a major consideration and thus the SHS appears preferable.There was insufficient evidence from other comparisons of extramedullary implants or on the use of external fixators to draw definite conclusions.

Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults

Two types of implants used for the surgical fixation of extracapsular hip fractures are cephalocondylic intramedullary nails, which are inserted into the femoral canal proximally to distally across the fracture, and extramedullary implants (e.g. the sliding hip screw). To compare cephalocondylic intramedullary nails with extramedullary implants for extracapsular hip fractures in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2010), The Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 1), MEDLINE (1950 to March 2010), EMBASE (1980 to 2010 Week 13), and other sources. All randomised and quasi-randomised controlled trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures. Both authors independently assessed trial quality and extracted data. Wherever appropriate, results were pooled. We included 43 trials containing predominantly older people with mainly trochanteric fractures. Twenty-two trials (3749 participants) compared the Gamma nail with the sliding hip screw (SHS). The Gamma nail was associated with increased risk of operative and later fracture of the femur and increased reoperation rate. There were no major differences between implants in wound infection, mortality or medical complications.Five trials (623 participants) compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group. Results for post-operative complications, mortality and functional outcomes were similar in both groups.Three trials (394 participants) showed no difference in fracture fixation complications, reoperation, wound infection and length of hospital stay for proximal femoral nail (PFN) versus the SHS.None of the 10 trials (1491 participants) of other nail versus extramedullary implant comparisons for trochanteric fractures provided sufficient evidence to establish definite differences between the implants under test.Two trials (65 participants) found intramedullary nails were associated with fewer fracture fixation complications than fixed nail plates for unstable fractures at the level of the lesser trochanter.Two trials (124 participants) found a tendency to less fracture healing complications with the intramedullary nails compared with fixed nail plates for subtrochanteric fractures. With its lower complication rate in comparison with intramedullary nails, and absence of functional outcome data to the contrary, the SHS appears superior for trochanteric fractures. Further studies are required to confirm whether more recently developed designs of intramedullary nail avoid the complications of previous nails. Intramedullary nails may have advantages over fixed angle plates for subtrochanteric and some unstable trochanteric fractures, but further studies are required.

Osteotomy, compression and other modifications of surgical techniques for internal fixation of extracapsular hip fractures.

Many different surgical techniques have been described for the internal fixation of extracapsular hip fractures. To compare different aspects of surgical technique used in operations for internal fixation of extracapsular hip fractures in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 1), MEDLINE, EMBASE, CINAHL, Current Controlled Trials, orthopaedic journals, conference proceedings and reference lists of articles. Date of last search was January 2008. No language restriction was applied. All randomised and quasi-randomised trials investigating operative techniques used in operations for the treatment of extracapsular hip fractures in adults. Two review authors independently selected trials, assessed trial quality and extracted data. Wherever appropriate, data were pooled. Predominantly older people with trochanteric fractures were treated in the 11 included trials.One trial (65 participants undergoing fixation with a fixed nail-plate) found no statistically significant differences between osteotomy versus anatomical reduction. Four trials, involving 465 participants undergoing fixation with a sliding hip screw (SHS), compared osteotomy versus anatomical reduction. Osteotomy was associated with an increased operative blood loss and length of surgery. There were no statistically significant differences for mortality, morbidity or measures of anatomical deformity.Two trials (138 participants) compared SHS fixation of a trochanteric hip fracture augmented with cement against a standard fixation. There were no reoperations even for the four cases of fixation failure in the cement group. The cement group had significantly better quality of life scores at six months. One trial (200 participants) comparing compression versus no compression of a trochanteric fracture in conjunction with SHS fixation found no significant differences between the two groups. One trial (120 participants) found a tendency to improved outcomes with a hydroxyapatite coated lag screw, but none reached statistical significance. One trial (19 participants) reported reduced temperatures when using a modified reaming method. Another trial (50 participants) found reduced bone marrow intravascular embolism, detected by oesophageal ultrasound, when a Gamma nail was inserted with a distal pressure venting hole in the femur. There is inadequate evidence to support the use of osteotomy for internal fixation of a trochanteric hip fracture. Similarly, there is insufficient evidence to support the use of the other techniques examined in the trials included in this review.

Extramedullary fixation implants and external fixators for extracapsular hip fractures.

Extramedullary fixation of hip fractures involves the application of a plate and screws to the lateral side of the proximal femur. In external fixators, the stabilising component is held outside the thigh by pins or screws driven into the bone on either side of the fracture. To compare different types of extramedullary fixation implants and external fixators for treating extracapsular hip fracture in adults. We searched the Cochrane Musculoskeletal Injuries Group specialised register and reference lists of relevant articles up to July 2002. All randomised or quasi-randomised trials comparing these devices for the fixation of extracapsular hip fracture in adults. Two reviewers independently assessed trial quality, using a ten item scale, and extracted data. Additional information was sought from trialists when required. Wherever appropriate, data from comparable trials were pooled. Two trials examining the Gotfried plate and one, an external fixator, are newly included in this update. All 13 included trials had methodological flaws, which may affect the validity of their results. The limited data available for three trials (355 patients) comparing a fixed nail plate (Jewett or McLaughlin) with the sliding hip screw (SHS) indicated an increased risk of fixation failure for fixed nail plates. The two trials (433 patients) comparing the RAB plate with the SHS had contrasting results, notably in terms of operative complications, fixation failure and anatomical restoration. One trial (100 patients) found no significant difference between the Pugh nail and the SHS. Two trials (292 patients) compared the Medoff plate with the SHS. One trial reported higher operative blood loss and longer operative times for the Medoff plate. There was a lower risk of fixation failure for unstable trochanteric fractures fixed with the Medoff plate. Two trials involving, respectively, unstable trochanteric fractures (569 patients) and subtrochanteric fractures (107 patients) compared the Medoff plate with three different screw-plate systems. There were no statistically significant differences in outcome for trochanteric fractures. For subtrochanteric fractures, there was a tendency to less fixation failure for the Medoff plate, but no evidence for differences in longer-term outcomes. Two trials (226 patients) compared the Gotfried percutaneous plate with a SHS. A higher intra-operative fixation failure rate of the Gotfried plate indicated some specific restriction to its use. The Gotfried plate appeared to involve lower operative blood losses. There were insufficient data on long term outcomes. One trial (100 patients) provided some evidence of less operative trauma and speedier recovery for external fixation when compared with the SHS. Final outcomes appeared similar. The fixed nail plate has higher risks of implant breakage and fixation failure than the SHS. Though insufficient evidence on other outcomes is available from randomised trials, the increased fixation failure rate is a major consideration and thus the SHS appears preferable. Insufficient information is available to draw firm conclusions of significant differences between the SHS and either the RAB, the Pugh, the Medoff or the Gotfried plates, or an external fixator.

Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures.

Cephalocondylic intramedullary nails which are inserted proximally to distally (cephalocondylic) have been used for the surgical treatment of extracapsular hip fractures. To update and expand our review comparing the Gamma nail with the sliding hip screw (SHS) by comparing all cephalocondylic intramedullary nails with extramedullary implants for the surgical treatment of extracapsular hip fractures in adults. We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline, select orthopaedic journals and conference proceedings, and reference lists of relevant articles. We contacted trialists, colleagues and implant manufacturers. Date of the most recent search: June 1998. All randomised and quasi-randomised trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures. Both reviewers independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, results were pooled. The one trial of 230 patients comparing the Kuntscher-Y nail with the SHS, reported no major difference the outcome aside from a significantly increased number of patients with leg shortening, and a tendency for poorer recovery of mobility in the Kuntscher-Y nail group. Fourteen trials comparing the Gamma nail with the SHS were included, with data available for 1977 patients. The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased re-operation rate. There were no major differences in the incidence of wound infection, mortality or medical complications between implants. Data were inadequate to determine if there were differences for other outcomes. Two trials involving 231 patients compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group: all cases of operative and later fracture of the femur and haematoma occurred in this group. Results for post-operative complications, mortality and functional outcomes were similar in the two groups. Further evidence is required before any conclusions can be drawn on the relative merits of the Kuntscher-Y nail and the SHS. Given the lower complication rate of the SHS in comparison with the Gamma nail, it appears that for trochanteric fractures the SHS is superior. Further evidence is still required to confirm this, as well as to determine if the Gamma nail, or modifications of the Gamma nail, have advantages for selected fracture types (for example, subtrochanteric fractures). From the limited evidence available, IMHS appears to have the same problems as the Gamma nail, but other theoretical advantages of the IHMS can not be ruled out.