Complication Rates in Intertrochanteric Fractures: A Database Analysis Comparing Sliding Hip Screw and Cephalomedullary Nail

Document Type : RESEARCH PAPER


Rutgers New Jersey Medical School Department of Orthopaedics, Newark, United States



Objectives: In the treatment of closed intertrochanteric fractures, the two most common treatment 
options are intramedullary medullary nail (IMN) and dynamic hip screw (DHS), yet the best treatment 
method remains controversial. The purpose of this study is to determine the difference in mortality and 
morbidity between IMN and DHS. Secondarily, this study determines which pre -operative risk factors 
affect rates of morbidity and mortality.
Methods: American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) 2006-2016 
database was used to search for patients with a closed intertrochanteric hip fracture. Bivariate analysis was 
performed using Pearson’s Chi Square test to determine pre-operative risk factors associated with complications in 
fixation with IMN and DHS. Significant variables in this analysis, as well as demographic data, were analyzed via 
binary logistic regression. The results were recorded as odds ratio (OR) and significant differences were based on 
a P<0.05.
Results: After adjusting for demographics and clinical covariates, patients who underwent fixation with IMN had 
higher 30-day mortality, reintubation, UTI, bleeding, prolonged length of stay, and non-home discharged destination 
rates compared to DHS. Mortality risk was increased by ascites, disseminated cancer, impaired functional status, 
history of congestive heart failure, and hypoalbuminemia. Bleeding risk was increased by previous percutaneous 
coronary (PCI) and transfusions and was decreased by impaired functional status. Myocardial infarction risk was 
increased by female gender.
Conclusion: Our study found that IMN fixation increased risk of mortality, UTI, reintubation, bleeding, prolonged 
length of stay, and a non-home discharge destination compared to DHS. This study also identified patient risk factors 
associated with several postoperative complications. These data may better inform orthopaedic surgeons treating 
closed intertrochanteric fractures.
 Level of evidence: III


Main Subjects

1. Makers R. Hip fractures among the elderly: causes, 
consequences and control. Ageing Res Rev. 2003;2(1):57-93. 
doi: 10.1016/s1568-1637(02)00045-4.
2. Zeng C, Wang YR, Wei J, et al. Treatment of trochanteric 
fractures with proximal femoral nail antirotation or dynamic 
hip screw systems: a meta-analysis. J Int Med Res. 
2012;40(3):839-851. doi: 10.1177/147323001204000302.
3. Morri M, Ambrosi E, Chiari P, et al. One-year mortality after 
hip fracture surgery and prognostic factors: a prospective 
cohort study. Sci Rep. 2019;9(1):18718. doi: 
4. Ozkan K, Turkmen I, Sahin A, Yildiz Y, Erturk S, Soylemez MS. 
A biomechanical comparison of proximal femoral nails and 
locking proximal anatomic femoral plates in femoral fracture 
fixation: A study on synthetic bones. Indian J Orthop. 
2015;49(3):347-351. doi: 10.4103/0019-5413.156220.
5. Ahn J, Bernstein J. Fractures in brief: intertrochanteric hip 
fractures. Clin Orthop Relat Res. 2010;468(5):1450-1452. doi: 
6. Yu J, Zhang C, Li L, et al. Internal fixation treatments for 
intertrochanteric fracture: a systematic review and metaanalysis of randomized evidence. Sci Rep. 2015;5:18195. doi: 
7. Sharma A, Sethi A, Sharma S. Treatment of stable 
intertrochanteric fractures of the femur with proximal 
femoral nail versus dynamic hip screw: a comparative study. 
Rev Bras Ortop. 2018;53(4):477-481. doi: 
8. Zehir S, Zehir R, Zehir S, Azboy I, Haykir N. Proximal femoral 
nail antirotation against dynamic hip screw for unstable 
trochanteric fractures; a prospective randomized 
comparison. Eur J Trauma Emerg Surg. 2015;41(4):393-400. 
doi: 10.1007/s00068-014-0463-y.
9. Huang X, Leung F, Xiang Z, et al. Proximal femoral nail versus 
dynamic hip screw fixation for trochanteric fractures: a metaanalysis of randomized controlled trials. 
ScientificWorldJournal. 2013;2013:805805. doi: 
10. Papasimos S, Koutsojannis CM, Panagopoulos A, Megas P, 
Lambiris E. A randomised comparison of AMBI, TGN and PFN 
for treatment of unstable trochanteric fractures. Arch Orthop 
Trauma Surg. 2005;125(7):462-468. doi: 10.1007/s00402-
11. Jiang LS, Shen L, Dai LY. Intramedullary fixation of 
subtrochanteric fractures with long proximal femoral nail or 
long gamma nail: technical notes and preliminary results. Ann 
Acad Med Singapore. 2007;36(10):821-826.
12. Liu M, Yang Z, Pei F, Huang F, Chen S, Xiang Z. A meta-analysis 
of the Gamma nail and dynamic hip screw in treating 
peritrochanteric fractures. Int Orthop. 2010;34(3):323-328. 
doi: 10.1007/s00264-009-0783-4.
13. Fuchshuber PR, Greif W, Tidwell CR, et al. The power of the 
National Surgical Quality Improvement Program--achieving a 
zero pneumonia rate in general surgery patients. Perm J. 2012;16(1):39-45. doi: 10.7812/TPP/11-127.
14. Anil M. The use of an Intramedullary Nail vs. Dynamic Hip 
Screw in the treatment of Intertrochantric fractures; a case 
cohort study. Kerala Journal of Orthopaedics. 2012;25:6-13.
15. Parker MJ, Handoll HH. Gamma and other cephalocondylic 
intramedullary nails versus extramedullary implants for 
extracapsular hip fractures in adults. Cochrane Database Syst 
Rev. 2008(3):CD000093. doi: 
16. Surgeons A. National Surgical Quality Improvement Program 
(NSQIP). Available at:
17. Luchetti TJ, Chung A, Olmscheid N, Bohl DD, Hustedt JW. 
Hypoalbuminemia Is Associated With Increased 
Postoperative Mortality and Complications in Hand Surgery. 
Hand (N Y). 2019:1558944718820959. doi: 
18. 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: 
19. 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.
20. 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: 
21. 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.
22. Ryan S, Politzer C, Fletcher A, Bolognesi M, Seyler T. 
Preoperative Hypoalbuminemia Predicts Poor Short-term 
Outcomes for Hip Fracture Surgery. Orthopedics. 
2018;41(6):e789-e796. doi: 10.3928/01477447-20180912-
23. Ma KL, Wang X, Luan FJ, et al. Proximal femoral nails 
antirotation, Gamma nails, and dynamic hip screws for 
fixation of intertrochanteric fractures of femur: A metaanalysis. Orthop Traumatol Surg Res. 2014;100(8):859-866. 
doi: 10.1016/j.otsr.2014.07.023.
24. Hao Z, Wang X, Zhang X. Comparing surgical interventions for 
intertrochanteric hip fracture by blood loss and operation 
time: a network meta-analysis. J Orthop Surg Res. 
2018;13(1):157. doi: 10.1186/s13018-018-0852-8.
25. Saudan M, Lubbeke A, Sadowski C, Riand N, Stern R, 
Hoffmeyer P. Pertrochanteric fractures: is there an advantage 
to an intramedullary nail?: a randomized, prospective study 
of 206 patients comparing the dynamic hip screw and 
proximal femoral nail. J Orthop Trauma. 2002;16(6):386-393.
doi: 10.1097/00005131-200207000-00004.
26. Giraud B, Dehoux E, Jovenin N, et al. [Pertrochanteric 
fractures: a randomized prospective study comparing 
dynamic screw plate and intramedullary fixation]. Rev Chir 
Orthop Reparatrice Appar Mot. 2005;91(8):732-736. doi: 
27. Jonnes C, Sm S, Najimudeen S. Type II Intertrochanteric 
Fractures: Proximal Femoral Nailing (PFN) Versus Dynamic 
Hip Screw (DHS). Arch Bone Jt Surg. 2016;4(1):23-28.
28. Hoffmann R, Schmidmaier G, Schulz R, Schutz M, Sudkamp 
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.
29. Verettas DA, Ifantidis P, Chatzipapas CN, et al. Systematic 
effects of surgical treatment of hip fractures: gliding screwplating vs intramedullary nailing. Injury. 2010;41(3):279-
284. doi: 10.1016/j.injury.2009.09.012.
30. Foundation KF. Hospital Adjusted Expenses per Inpatient 
Day. Available at:
22:%22asc%22%7D. 2017.
31. Avakian Z, Shiraev T, Lam L, Hope N. Dynamic hip screws 
versus proximal femoral nails for intertrochanteric fractures. 
ANZ J Surg. 2012;82(1-2):56-59. doi: 10.1111/j.1445-
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):3647-55. doi: 
33. Alluri RK, Leland H, Heckmann N. Surgical research using 
national databases. Ann Transl Med. 2016;4(20):393. doi: