Cephalomedullary Nailing has a Higher Reoperation Rate Compared to Sliding Hip Screw Fixation in the Treatment of Intertrochanteric Femur Fractures: A Systematic Literature Review and Meta-analysis

Document Type : SYSTEMATIC REVIEW

Authors

Rutgers New Jersey Medical School Department of Orthopaedics, Newark, USA

Abstract

Objectives: Intertrochanteric hip fractures are a common orthopaedic injury in the United States. 
Complications of surgical treatment include nonunion, lag screw cutout, implant failure, post -operative 
pain, risk of refracture or reoperation, and infection. The purpose of this study was to compare the rate 
of complications of sliding hip screw fixation (SHS) compared to cephalomedullary nailing (CMN) for 
the treatment of closed intertrochanteric femur fractures in adult patients.
Methods: PubMed, CINAHL, and Cochrane Library databases were searched for studies comparing SHS to CMN 
in the treatment of closed intertrochanteric femur fractures in adults. Data were compiled to observe the rate of 
nonunion, cutout failure, infection, refracture, perioperative blood loss, reoperation, postoperative pain, pulmonary 
embolism/deep venous thrombosis (DVT), length of hospital stay, and mortality.
Results: Seventeen studies were included comprising 1,500 patients treated with SHS and 1,890 patients treated 
with CMN. Treatment of intertrochanteric femur fractures with SHS demonstrated significantly fewer refractures and 
reoperations. There was no significant difference in other variables between SHS and CMN treated groups.
Conclusion: This meta-analysis shows that the only notable difference in outcomes is patients treated with CMN 
have a higher rate of refracture and reoperation. With new advances in the development of both CMNs and SHS, 
further studies will be required to see if these differences persist in the coming years.
 Level of evidence: II

Keywords

Main Subjects

References

  1. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. 2009; 302(14):1573-1579. doi: 10.1001/jama.2009.1462.
  2. Goldacre MJ, Roberts SE, Yeates D. Mortality after admission to hospital with fractured neck of femur: database study. BMJ. 2002; 325(7369):868-869. doi: 10.1136/bmj.325.7369.868.
  3. Melton LJ 3rd, Gabriel SE, Crowson CS, Tosteson AN, Johnell O, Kanis JA. Cost-equivalence of different osteoporotic fractures. Osteoporos Int. 2003; 14(5):383-388. doi: 10.1007/s00198-003-1385-4.
  4. Tosounidis TH, Castillo R, Kanakaris NK, Giannoudis PV. Common complications in hip fracture surgery: Tips/tricks and solutions to avoid them. Injury. 2015; 46 Suppl 5:S3-11. doi: 10.1016/j.injury.2015.08.006.
  5. Tsang ST, Aitken SA, Golay SK, Silverwood RK, Biant LC. When does hip fracture surgery fail? Injury. 2014; 45(7):1059-1065. doi: 10.1016/j.injury.2014.03.019.
  6. Ortman JM, Velkoff VA, Hogan H. An Aging Nation: The Older Population in the United States. ProQuest, Ann Arbor. 2014.
  7. Kaplan K, Miyamoto R, Levine BR, Egol KA, Zuckerman JD. Surgical management of hip fractures: an evidence-based review of the literature. II: intertrochanteric fractures. J Am Acad Orthop Surg. 2008;16(11):665-673. doi: 10.5435/00124635-200811000-00007.
  8. Kokoroghiannis C, Aktselis I, Deligeorgis A, Fragkomichalos E, Papadimas D, Pappadas I. Evolving concepts of stability and intramedullary fixation of intertrochanteric fractures--a review. Injury. 2012; 43(6):686-693. doi: 10.1016/j.injury.2011.05.031.
  9. Swart E, Makhni EC, Macaulay W, Rosenwasser MP, Bozic KJ. Cost-effectiveness analysis of fixation options for intertrochanteric hip fractures. J Bone Joint Surg Am. 2014; 96(19):1612-1620. doi: 10.2106/JBJS.M.00603.
  10. Asif N, Ahmad S, Qureshi OA, Jilani LZ, Hamesh T, Jameel T. Unstable Intertrochanteric Fracture Fixation - Is Proximal Femoral Locked Compression Plate Better Than Dynamic Hip Screw. J Clin Diagn Res. 2016; 10(1):RC09-13. doi: 10.7860/JCDR/2016/11179.7084.
  11. Knobe M, Drescher W, Heussen N, Sellei RM, Pape HC. Is helical blade nailing superior to locked minimally invasive plating in unstable pertrochanteric fractures? Clin Orthop Relat Res. 2012; 470(8):2302-2312. doi: 10.1007/s11999-012-2268-9.
  12. Bohl DD, Basques BA, Golinvaux NS, Miller CP, Baumgaertner MR, Grauer JN. Extramedullary compared with intramedullary implants for intertrochanteric hip fractures: thirty-day outcomes of 4432 procedures from the ACS NSQIP database. J Bone Joint Surg Am. 2014;96(22):1871-1877. doi: 10.2106/JBJS.N.00041.
  13. Chua IT, Rajamoney GN, Kwek EB. Cephalomedullary nail versus sliding hip screw for unstable intertrochanteric fractures in elderly patients. J Orthop Surg (Hong Kong). 2013; 21(3):308-312. doi: 10.1177/230949901302100309.
  14. Adams CI, Robinson CM, Court-Brown CM, McQueen MM. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma. 2001; 15(6):394-400. doi: 10.1097/00005131-200108000-00003.
  15. Ahrengart L, Törnkvist H, Fornander P, et al. A randomized study of the compression hip screw and Gamma nail in 426 fractures. Clin Orthop Relat Res. 2002 ;( 401):209-222. doi: 10.1097/00003086-200208000-00024.
  16. Aktselis I, Kokoroghiannis C, Fragkomichalos E, et al. Prospective randomised controlled trial of an intramedullary nail versus a sliding hip screw for intertrochanteric fractures of the femur. Int Orthop. 2014; 38(1):155-161. doi: 10.1007/s00264-013-2196-7.
  17. Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial. J Bone Joint Surg Am. 2010; 92(4):792-798. doi: 10.2106/JBJS.I.00508.
  18. Bridle SH, Patel AD, Bircher M, Calvert PT. Fixation of intertrochanteric fractures of the femur. A randomised prospective comparison of the gamma nail and the dynamic hip screw. J Bone Joint Surg Br. 1991; 73(2):330-334. doi: 10.1302/0301-620X.73B2.2005167.
  19. Crawford CH, Malkani AL, Cordray S, Roberts CS, Sligar W. The trochanteric nail versus the sliding hip screw for intertrochanteric hip fractures: a review of 93 cases. J Trauma. 2006; 60(2):325-328; discussion 328-329. doi: 10.1097/01.ta.0000197872.87439.f9.
  20. Foulongne E, Gilleron M, Roussignol X, Lenoble E, Dujardin F. Mini-invasive nail versus DHS to fix pertrochanteric fractures: a case-control study. Orthop Traumatol Surg Res. 2009; 95(8):592-598. doi: 10.1016/j.otsr.2009.08.007.
  21. Hoffman CW, Lynskey TG. Intertrochanteric fractures of the femur: a randomized prospective comparison of the Gamma nail and the Ambi hip screw. Aust N Z J Surg. 1996; 66(3):151-155. doi: 10.1111/j.1445-2197.1996.tb01144.x.
  22. Leung KS, So WS, Shen WY, Hui PW. Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised prospective study in elderly patients. J Bone Joint Surg Br. 1992; 74(3):345-351. doi: 10.1302/0301-620X.74B3.1587874.
  23. Morvan A, Boddaert J, Cohen-Bittan J, Picard H, Pascal-Mousselard H, Khiami F. Risk factors for cut-out after internal fixation of trochanteric fractures in elderly subjects. Orthop Traumatol Surg Res. 2018; 104(8):1183-1187. doi: 10.1016/j.otsr.2018.06.021.
  24. Ovesen O, Andersen M, Poulsen T, Nymark T, Overgaard S, Rock ND. The trochanteric gamma nail versus the dynamic hip screw: a prospective randomised study. One-year follow-up of 146 intertrochanteric fractures. Hip Int. 2006; 16(4):293-298. doi: 10.5301/hip.2008.2820.
  25. Park SR, Kang JS, Kim HS, Lee WH, Kim YH. Treatment of intertrochanteric fracture with the Gamma AP locking nail or by a compression hip screw--a randomised prospective trial. Int Orthop. 1998; 22(3):157-160. doi: 10.1007/s002640050231.

26.              Radford PJ, Needoff M, Webb JK. A prospective randomised comparison of the dynamic hip screw and the gamma locking nail. J Bone Joint Surg Br. 1993; 75(5):789-793. doi: 

  1. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. 2009; 302(14):1573-1579. doi: 10.1001/jama.2009.1462.
  2. Goldacre MJ, Roberts SE, Yeates D. Mortality after admission to hospital with fractured neck of femur: database study. BMJ. 2002; 325(7369):868-869. doi: 10.1136/bmj.325.7369.868.
  3. Melton LJ 3rd, Gabriel SE, Crowson CS, Tosteson AN, Johnell O, Kanis JA. Cost-equivalence of different osteoporotic fractures. Osteoporos Int. 2003; 14(5):383-388. doi: 10.1007/s00198-003-1385-4.
  4. Tosounidis TH, Castillo R, Kanakaris NK, Giannoudis PV. Common complications in hip fracture surgery: Tips/tricks and solutions to avoid them. Injury. 2015; 46 Suppl 5:S3-11. doi: 10.1016/j.injury.2015.08.006.
  5. Tsang ST, Aitken SA, Golay SK, Silverwood RK, Biant LC. When does hip fracture surgery fail? Injury. 2014; 45(7):1059-1065. doi: 10.1016/j.injury.2014.03.019.
  6. Ortman JM, Velkoff VA, Hogan H. An Aging Nation: The Older Population in the United States. ProQuest, Ann Arbor. 2014.
  7. Kaplan K, Miyamoto R, Levine BR, Egol KA, Zuckerman JD. Surgical management of hip fractures: an evidence-based review of the literature. II: intertrochanteric fractures. J Am Acad Orthop Surg. 2008;16(11):665-673. doi: 10.5435/00124635-200811000-00007.
  8. Kokoroghiannis C, Aktselis I, Deligeorgis A, Fragkomichalos E, Papadimas D, Pappadas I. Evolving concepts of stability and intramedullary fixation of intertrochanteric fractures--a review. Injury. 2012; 43(6):686-693. doi: 10.1016/j.injury.2011.05.031.
  9. Swart E, Makhni EC, Macaulay W, Rosenwasser MP, Bozic KJ. Cost-effectiveness analysis of fixation options for intertrochanteric hip fractures. J Bone Joint Surg Am. 2014; 96(19):1612-1620. doi: 10.2106/JBJS.M.00603.
  10. Asif N, Ahmad S, Qureshi OA, Jilani LZ, Hamesh T, Jameel T. Unstable Intertrochanteric Fracture Fixation - Is Proximal Femoral Locked Compression Plate Better Than Dynamic Hip Screw. J Clin Diagn Res. 2016; 10(1):RC09-13. doi: 10.7860/JCDR/2016/11179.7084.
  11. Knobe M, Drescher W, Heussen N, Sellei RM, Pape HC. Is helical blade nailing superior to locked minimally invasive plating in unstable pertrochanteric fractures? Clin Orthop Relat Res. 2012; 470(8):2302-2312. doi: 10.1007/s11999-012-2268-9.
  12. Bohl DD, Basques BA, Golinvaux NS, Miller CP, Baumgaertner MR, Grauer JN. Extramedullary compared with intramedullary implants for intertrochanteric hip fractures: thirty-day outcomes of 4432 procedures from the ACS NSQIP database. J Bone Joint Surg Am. 2014;96(22):1871-1877. doi: 10.2106/JBJS.N.00041.
  13. Chua IT, Rajamoney GN, Kwek EB. Cephalomedullary nail versus sliding hip screw for unstable intertrochanteric fractures in elderly patients. J Orthop Surg (Hong Kong). 2013; 21(3):308-312. doi: 10.1177/230949901302100309.
  14. Adams CI, Robinson CM, Court-Brown CM, McQueen MM. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma. 2001; 15(6):394-400. doi: 10.1097/00005131-200108000-00003.
  15. Ahrengart L, Törnkvist H, Fornander P, et al. A randomized study of the compression hip screw and Gamma nail in 426 fractures. Clin Orthop Relat Res. 2002 ;( 401):209-222. doi: 10.1097/00003086-200208000-00024.
  16. Aktselis I, Kokoroghiannis C, Fragkomichalos E, et al. Prospective randomised controlled trial of an intramedullary nail versus a sliding hip screw for intertrochanteric fractures of the femur. Int Orthop. 2014; 38(1):155-161. doi: 10.1007/s00264-013-2196-7.
  17. Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial. J Bone Joint Surg Am. 2010; 92(4):792-798. doi: 10.2106/JBJS.I.00508.
  18. Bridle SH, Patel AD, Bircher M, Calvert PT. Fixation of intertrochanteric fractures of the femur. A randomised prospective comparison of the gamma nail and the dynamic hip screw. J Bone Joint Surg Br. 1991; 73(2):330-334. doi: 10.1302/0301-620X.73B2.2005167.
  19. Crawford CH, Malkani AL, Cordray S, Roberts CS, Sligar W. The trochanteric nail versus the sliding hip screw for intertrochanteric hip fractures: a review of 93 cases. J Trauma. 2006; 60(2):325-328; discussion 328-329. doi: 10.1097/01.ta.0000197872.87439.f9.
  20. Foulongne E, Gilleron M, Roussignol X, Lenoble E, Dujardin F. Mini-invasive nail versus DHS to fix pertrochanteric fractures: a case-control study. Orthop Traumatol Surg Res. 2009; 95(8):592-598. doi: 10.1016/j.otsr.2009.08.007.
  21. Hoffman CW, Lynskey TG. Intertrochanteric fractures of the femur: a randomized prospective comparison of the Gamma nail and the Ambi hip screw. Aust N Z J Surg. 1996; 66(3):151-155. doi: 10.1111/j.1445-2197.1996.tb01144.x.
  22. Leung KS, So WS, Shen WY, Hui PW. Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised prospective study in elderly patients. J Bone Joint Surg Br. 1992; 74(3):345-351. doi: 10.1302/0301-620X.74B3.1587874.
  23. Morvan A, Boddaert J, Cohen-Bittan J, Picard H, Pascal-Mousselard H, Khiami F. Risk factors for cut-out after internal fixation of trochanteric fractures in elderly subjects. Orthop Traumatol Surg Res. 2018; 104(8):1183-1187. doi: 10.1016/j.otsr.2018.06.021.
  24. Ovesen O, Andersen M, Poulsen T, Nymark T, Overgaard S, Rock ND. The trochanteric gamma nail versus the dynamic hip screw: a prospective randomised study. One-year follow-up of 146 intertrochanteric fractures. Hip Int. 2006; 16(4):293-298. doi: 10.5301/hip.2008.2820.
  25. Park SR, Kang JS, Kim HS, Lee WH, Kim YH. Treatment of intertrochanteric fracture with the Gamma AP locking nail or by a compression hip screw--a randomised prospective trial. Int Orthop. 1998; 22(3):157-160. doi: 10.1007/s002640050231.
  26. Radford PJ, Needoff M, Webb JK. A prospective randomised comparison of the dynamic hip screw and the gamma locking nail. J Bone Joint Surg Br. 1993; 75(5):789-793. doi: 10.1302/0301-620X.75B5.8376441.
  27. Reina N, Geiss L, Pailhé R, Maubisson L, Laffosse JM, Chiron P. Traumax screw plate vs. Gamma nail. Blood loss in pertrochanteric fractures treated by minimally invasive osteosynthesis. Hip Int. 2014; 24(2):200-205. doi: 10.5301/hipint.5000096.
  28. Ronga M, Bonzini D, Valoroso M, et al. Blood loss in trochanteric fractures: multivariate analysis comparing dynamic hip screw and Gamma nail. Injury. 2017; 48 Suppl 3:S44-S47. doi: 10.1016/S0020-1383(17)30657-5.
  29. Saarenpää I, Heikkinen T, Ristiniemi J, Hyvönen P, Leppilahti J, Jalovaara P. Functional comparison of the dynamic hip screw and the Gamma locking nail in trochanteric hip fractures: a matched-pair study of 268 patients. Int Orthop. 2009; 33(1):255-260. doi: 10.1007/s00264-007-0458-y.
  30. Verettas DA, Ifantidis P, Chatzipapas CN, et al. Systematic effects of surgical treatment of hip fractures: gliding screw-plating vs intramedullary nailing. Injury. 2010; 41(3):279-284. doi: 10.1016/j.injury.2009.09.012.
  31. Hung WW, Morrison RS. Hip fracture: a complex illness among complex patients. Ann Intern Med. 2011; 155(4):267-268. doi: 10.7326/0003-4819-155-4-201108160-00012.
  32. Niu E, Yang A, Harris AH, Bishop J. Which Fixation Device is Preferred for Surgical Treatment of Intertrochanteric Hip Fractures in the United States? A Survey of Orthopaedic Surgeons. Clin Orthop Relat Res. 2015; 473(11):3647-3655. doi: 10.1007/s11999-015-4469-5.
  33. Jones HW, Johnston P, Parker M. Are short femoral nails superior to the sliding hip screw? A meta-analysis of 24 studies involving 3,279 fractures. Int Orthop. 2006; 30(2):69-78. doi: 10.1007/s00264-005-0028-0.
  34. Huang X, Leung F, Xiang Z, et al. Proximal femoral nail versus dynamic hip screw fixation for trochanteric fractures: a meta-analysis of randomized controlled trials. ScientificWorldJournal. 2013; 2013:805805. doi: 10.1155/2013/805805.
  35. Jiang SD, Jiang LS, Zhao CQ, Dai LY. No advantages of Gamma nail over sliding hip screw in the management of peritrochanteric hip fractures: a meta-analysis of randomized controlled trials. Disabil Rehabil. 2008; 30(7):493-497. doi: 10.1080/09638280701355538.
  36. Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial. J Bone Joint Surg Am. 2010; 92(4):792-798. doi: 10.2106/JBJS.I.00508.
  37. Chung AS, Hustedt JW, Walker R, Jones C, Lowe J, Russell GV. Increasing Severity of Malnutrition Is Associated With Poorer 30-Day Outcomes in Patients Undergoing Hip Fracture Surgery. J Orthop Trauma. 2018; 32(4):155-160. doi: 10.1097/BOT.0000000000001081.
  38. Tiberi JV 3rd, Hansen V, El-Abbadi N, Bedair H. Increased complication rates after hip and knee arthroplasty in patients with cirrhosis of the liver. Clin Orthop Relat Res. 2014; 472(9):2774-2778. doi: 10.1007/s11999-014-3681-z.
  39. Chang W, Lv H, Feng C, et al. Preventable risk factors of mortality after hip fracture surgery: Systematic review and meta-analysis. Int J Surg. 2018; 52:320-328. doi: 10.1016/j.ijsu.2018.02.061.
  40. Hoffmann R, Schmidmaier G, Schulz R, Schütz M, Südkamp NP. [Classic nail versus DHS. A prospective randomised study of fixation of trochanteric femur fractures]. Unfallchirurg. 1999; 102(3):182-190. doi: 10.1007/s001130050391.
  41. Zhu Q, Xu X, Yang X, et al. Intramedullary nails versus sliding hip screws for AO/OTA 31-A2 trochanteric fractures in adults: A meta-analysis. Int J Surg. 2017; 43:67-74. doi: 10.1016/j.ijsu.2017.05.042.

 

 

 

 

The Archives of Bone and Joint Surgery
Volume 11, Issue 10
October 2023
Pages 595-604

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History

  • Receive Date: 14 March 2022
  • Revise Date: 30 September 2023
  • Accept Date: 13 August 2023

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