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Occurrence of secondary fracture around intramedullary nails used for trochanteric hip fractures: A systematic review of 13,568 patients



A sliding hip screw (SHS) is currently the treatment of choice for trochanteric hip fractures, largely due to the low incidence of complications. An alternative treatment is the use of intramedullary proximal femoral nails. Unfortunately these implants have been associated with a risk of later fracture around the implant. The aim of this study was to see if any improvements have been made to the current intramedullary nails, to reduce the incidence of secondary fracture around the distal tip of the nail. We analysed data related to 13,568 patients from 89 studies, focusing on the incidence of post operative secondary femoral shaft fracture following the use of intramedullary nails in the fixation of trochanteric hip fractures. The overall reported incidence of secondary fracture around the nail was 1.7%. The incidence of fracture has reduced in the 3rd generation Gamma nails when compared to the older Gamma nail (1.7% versus 2.6%, p value 0.03). However, the incidence of secondary fracture in the 3rd generation Gamma nails is still significantly higher than the other brands of short nail (1.7% versus 0.7%, p value 0.0005). Long nails had a slight tendency towards a lower risk of fracture although the difference was not statistically significant (1.1% versus 1.7%, p value 0.28). There was a significantly lower risk of fracture for those nails with a biaxial fixation as opposed to uniaxial fixation (0.6% versus 1.9%, p value <0.0001). Secondary fracture around a proximal femoral nail is one of the most significant of fracture healing complications, and this study suggests that continuing design changes to this method of fixation has reduced the risk of this complication occurring.
102 Abstracts / Injury Extra 42 (2011) 95–169
grade, p= 0.01. The mean length of anaesthesia was longer in the
sepsis group (76 min) compared to the no sepsis group (65 min),
this was significant, p= 0.01. The patient’s ASA grade and fracture
type were not significant factors. The rate of infection in intracapsu-
lar fractures treated by hemiarthroplasty was significantly greater
than those that had internal fixation, p= 0.001. The rate of infec-
tion in extracapsular fractures fixed with an extra-medullary device
was significantly greater than those fixed with an intra-medullary
device, p= 0.021. The presence of an infected ulcer on the same
leg as the fracture was not associated with a higher rate of deep
We have found that the experience (seniority) of the surgeon,
the length of anaesthesia and the type of fixation used are all sig-
nificant factors in the development of deep sepsis. These are all
potentially modifiable risk factors and should be considered in the
treatment of hip fracture patients.
The effect of changing antibiotic prophylaxis on surgical site
infection following proximal femoral fracture surgery
B. Johnson, I. Starks, G. Bancroft, P. Roberts
University Hospital of North Staffordshire, United Kingdom
Proximal femoral fracture (PFF) is the most common reason
for emergency orthopaedic admission in the UK with an annual
cost of £1.7 billion to the National Health Service. Surgical site
infection (SSI) following PFF increases patient mortality and mor-
bidity. Methicillin Resistant Staphylococcus Aureus (MRSA) poses a
particular risk in this patient cohort as a large proportion of these
patients are residents of long term care facilities and are therefore
transient or chronic carriers of MRSA. The numbers of Gentamicin-
susceptible MRSA strains are increasing. We recorded the SSI and
specifically the MRSA rate following hemiarthroplasty associated
with three different prophylactic antibiotic regimes over an eight-
year period at the University Hospital of North Staffordshire. Data
was collated from the Surgical Site Infection Surveillance Service.
This data is prospectively collected, independently collated and
published on a quarterly basis. The data was analysed using the
Chi-squared test and the normal test for differences between two
proportions. Between October 2001 and June 2009, 1830 hemi-
arthoplasties were carried out. A statistically significant difference
in infection rate and MRSA rate between the three regimes was
found following statistical analysis (pvalue = < .05). The most effec-
tive antibiotic regime consisted of a single dose of intravenous
Co-amoxicav (1.2 g) and Gentamicin (240 mg) at induction and
Gentamicin impregnated equine collagen implanted under the fas-
cial layer at wound closure. Antibiotic prophylaxis for closed neck
of femur fracture is an effective intervention for reducing the inci-
dence of SSI. Single dose regimes are not inferior to multiple dose
regimens and reduce the risk of Clostridium Difficile overgrowth.
The prophylactic antibiotic regime we propose is a simple and cost
effective improvement in the clinical care of this vulnerable group.
It is particularly effective and well-targeted to MRSA prophylaxis.
Is the Nottingham hip fracture score (NHFS) useful in predicting
30-day mortality in hip fractures?
C. Kearsey, S. Sadiq
Department of Orthopaedics, Worcester Royal Hospital, United King-
Aim: This study assessed whether we could use the NHFS to
objectively predict our 30-day mortality in hip fractures.
Methods: This was a retrospective cross sectional survey of 104
patients. These patients were identified between 1st January 2009
and 31st August 2010. No patients who died at 30 days (n= 63)
were excluded from the study and a random sample of patients
who survived at 30 days was chosen from the national hip fracture
database (n= 41). Statistical analysis of the results was carried out
using the Chi squared test and a multiple regression analysis.
Results: Results showed our mortality rate was 12% (total admis-
sions = 528). Our mean NHFS of the combined groups was 5.2
(a 10–15% mortality rate according to the literature) (range 2–8,
2–33%). Patients who died had a mean of 5.4 (range 2–8) and those
who survived had a mean of 5.0 (range 2–7). The NHFS is consid-
ered to be significant if 5. For the purpose of Chi squared the NHFS
was split into scores 5 and <5.
It was shown that 30.8% of the dead group had a NHFS < 5,
and 29.8% had 5, But in the patients who survived the results
were 27.9% and 11.5% respectively (p= 0.044). Phi test of symmetry
was 0.198 showing little relationship between the two variables
(p= 0.044). Multiple regression analysis was performed to assess
the level to which each of the components of the NHFS contributes
to the overall mortality. R squared of the regression was 0.146
(p= 0.029) and on individual breakdown showed only one of the
components was deemed to significantly contribute to the mortal-
ity rates and that was sex (standardised coefficient 0.271, p= 0.006).
Conclusion: The NHFS does not appear to predict 30-day mor-
tality in our patients and cannot be used as an effective mortality
prediction tool.
Occurrence of secondary fracture around intramedullary nails
used for trochanteric hip fractures: A systematic review of
13,568 patients
R. Norris, D. Bhattacharjee, M. Parker
Peterborough District Hospital, United Kingdom
Introduction: A sliding hip screw (SHS) is currently the treat-
ment of choice for trochanteric hip fractures, largely due to the low
incidence of complications. An alternative treatment is the use of
intramedullary proximal femoral nails, which have had a poor rep-
utation to date, due to a relatively high incidence of complications.
The aim of this study was to see if any improvements have been
made to the current intramedullary nails, to reduce the incidence
of secondary fracture around the distal tip of the nail.
Methods: We analyzed data related to 13,568 patients from
95 studies, focusing on the incidence of post operative secondary
femoral shaft fracture following the use of intramedullary nails in
the fixation of trochanteric hip fractures.
Results: The overall reported incidence of secondary fracture
around the nail was 226/13,568(1.7%). The incidence of fracture
has reduced in the 3rd generation Gamma nails when compared
to the older Gamma nails [36/2129(1.7%) versus 131/5099(2.6%) p
Abstracts / Injury Extra 42 (2011) 95–169 103
value 0.03]. However, the incidence of secondary fracture in the
3rd generation Gamma nails is still significantly higher than any
other brand of short nail [36/2129 (1.7%) versus 30/4216 (0.7%), p
value 0.0005]. Long nails had a slight tendency towards a lower
risk of fracture although the difference was not statistically signifi-
cant [7/659(1.1%) versus 210/12909(1.7%), pvalue 0.28]. There was
a significantly lower risk of fracture for those nails with a biax-
ial fixation as opposed to uniaxial fixation [14/2425(0.6%) versus
212/11143(1.9%), pvalue < 0.0001].
Conclusion: Secondary fracture around a proximal femoral nail
is one of the most significant of fracture healing complications, and
this study suggests that continuing design changes to this method
of fixation has reduced the risk of this complication occurring.
The incidence and significance of post-traumatic femoral CAM
deformity following internal fixation of intra-capsular fractures
of the hip
B.A. Hickey, S.A. Jones
University Hospital of Wales, Cardiff, United Kingdom
Femoro-acetabular impingement (FAI) is a condition whereby
abnormal hip morphology leads to a pathological abutment result-
ing in pain and hyaline cartilage damage. We investigated the
incidence of post-traumatic CAM deformity and its correlation with
revision surgery.
A consecutive cases series of all patients treated with inter-
nal fixation for intra-capsular hip fractures between 2003 and
2005 (n= 107) was identified. Clinical notes and radiographs were
reviewed. Two patients died peri-operatively and 18 had no lat-
eral radiograph were excluded. As a best-case scenario, the lateral
radiograph at one-week post-operative was reviewed for all 87
patients included by an investigator who was blinded to outcome
of revision. Using the definition of CAM deformity by Eijer, defined
as an anterior offset ratio of less than 0.17 we determined the inci-
dence of femoral neck CAM deformity.
87 patients of mean age 74 years (39–95) were included, 74%
were female. 67% of fractures were undisplaced and the majority
(92%) of fractures were treated with internal fixation using three
cannulated screws.
Mean radiographic follow up was 2.25 years. The overall revision
rate was 21% (15 total hip replacements, 3 cemented hemi-
arthroplasty). 55% of patients with displaced fractures required
revisio compared with 15.8% of patients with undisplaced fractures
(p= 0.009). CAM deformity was present in 67% of all patients.
In patients who required revision surgery 28% had CAM defor-
mity compared to 7% of those without (p= 0.02).
Our findings show that CAM deformity is common following
internal fixation for intra-capsular fractured neck of femur and that
the presence of this deformity is associated with higher rate of revi-
sion surgery. We concur that post-traumatic CAM deformity and
the pathological abutment that occurs is significant cause of failure
following the internal fixation of hip fractures.
Radiation exposure during internal fixation of extracapsular
femoral neck fractures by trainees
P.R.P. Rushton, C.M.S. Srinivasan
Kingsmill Hospital, Sutton in Ashfield, UK
Background: Open reduction and internal fixation of extracapsu-
lar hip fractures is a common operation, with around 32,000 being
carried out annually in the UK. The dynamic hip screw (DHS) is often
used to achieve fixation under fluoroscopic guidance. This exposes
both the patient and theatre staff to potentially damaging radia-
tion. DHS operations are often carried out by surgeons in training
with variable levels of supervision.
Objective: To ascertain whether complexity of fracture, surgical
experience and level of supervision of trainees impacts on the radi-
ation dose to patients during DHS fixation of femoral neck fractures.
Study design: Retrospective study of radiographs, case notes and
radiation exposure records.
Subject: 123 patients (83 female) who underwent DHS fixation
between February 2009 and February 2010 at a district general
hospital. Mean age 83 years.
Outcome measures:
Radiation dose: Dose area product, DAP (Gycm2)
Fracture fragments (Simplified Jenson classification): 2, 3 and 4
part fracture
Seniority of surgeon: CT1-2/ registrar/senior (consultant or
associate specialist)
Analysis: Radiation dose exposure between groups was com-
pared using Mann–Whitney Utests. The null hypothesis was
rejected if p< 0.05.
Results: There was a non significant sequential increase in radi-
ation exposure as the number of fracture fragments increased.
Controlling for the number of fracture fragments and length of DHS
barrel plate used, CT1-2 grades exposed patients to significantly
more radiation than registrars and senior surgeons (p= 0.004).
There was no significant difference between radiation exposure
from registrars and senior surgeons. Radiation exposure by CT1-2
doctors was similar if supervised by a registrar or senior surgeon.
Median values for 2 and 3 fragment fractures for different grades
(table) could be used for feedback to trainees and trainers.
Training grade Median DAP (Gycm2)
CT1-2 0.65
Registrar 0.41
Consultant 0.41
Conclusions: Our results agree with previous studies that junior
surgeons exposure patients to greater amounts of radiation than
more senior surgeons during DHS fixation of hip fractures. As the
dosage is well within the safe range this is acceptable as surgeons
learn their craft. Appropriate supervision according to complex-
ity of the fracture and experience of trainee surgeon will help in
keeping the dose to a minimum. Knowledge of typical radiation
exposure for different levels of training may also help facilitate this.
... In addition, an open reduction with implantation of a wire cerclage is commonly described in the literature-however clinical studies show no advantage of a long compared to a short nail [15][16][17][18]. Until now, a systematic biomechanical comparison of stability after long or short intramedullary nail osteosynthesis of subtrochanteric fractures is lacking [19,20]. The high clinical relevance of the implant choice results not least from the prolonged surgery time, the extensive blood loss and the pronounced soft tissue trauma when choosing a long intramedullary implant in stable as well as unstable pertrochanteric femur fractures [15,16,21,22]. ...
... Matching the results of the above-mentioned clinical study, a meta-analysis on the question whether to use short or long intramedullary nails best for proximal femur fractures was also unable to show any significant advantage of long nails [20]. ...
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Purpose Due to the demographic change towards an older society, osteoporosis-related proximal femur fractures are steadily increasing. Intramedullary nail osteosyntheses are available in different lengths, where the field of application overlaps. The aim of this study was to investigate whether subtrochanteric fractures can also be treated stably using a short femoral intramedullary nail in cadaveric bones. Methods A short PFNA and a long PFNA were implanted in both seven artificial bones and osteoporotic human specimens. A standardized AO 31-A3 (reverse-oblique) fracture was placed in the specimens with a lateral fracture spur 2 cm proximal to the distal locking screw (short PFNA) and embedded. The simulated iliotibial tract was preloaded to 50 N. The force was applied at 10 mm/min up to a force of 200–800 N (artificial bones) and 200–400 N (human specimens). The dislocation of the fracture gap, the axial bone stiffness of bone construct and the force curve of the tractus iliotibialis were measured. Results There is no difference in the use of a short versus long PFNA in terms of stiffness of the overall construct and only a slight increase in dislocation in the fracture gap results with short PFNA compared to a long intramedullary nail. Conclusion In summary of the available literature, the present study supports the thesis that there is no clinical difference between long versus short nails in A3 femur fractures. Furthermore, the present study defines a safe biomechanical range of fracture extension above the locking screw of the short intramedullary nail. Level of Evidence III
... Despite the biomechanical benefits, IMNs have been associated with an increased risk of ipsilateral Sffx, although this appears to be less frequent with contemporary nail designs [18,19]. The choice of implant may influence the incidence, localisation and morphology of a Sffx [20,21]. In a recent retrospective study, no differences could be found when comparing the incidence of a contralateral Sffx after an initial trochanteric fracture treated with either an IMN or an SHS [22]. ...
... To the best of our knowledge, no previous study has compared the impact of IMN in the treatment of trochanteric or subtrochanteric fractures in elderly patients with no previous implant in either femur at the time of surgery. The incidence of peri-implant femoral fractures distal to an IMN has been described [20,26]. Although the incidence has decreased with the evolution of new generations of IMNs, peri-implant fractures still represent a challenge to the orthopaedic surgeon. ...
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Background The literature is inconclusive as to whether an intramedullary nail changes the distribution of a subsequent ipsi- or contralateral fracture of the femur. We have compared the incidence, localisation, and fracture pattern of subsequent femoral fractures after intramedullary nailing of trochanteric or subtrochanteric fractures in patients without previous implants in either femur at the time of surgery. Methods Retrospective analysis was performed of a two-centre cohort of 2012 patients treated with a short or long intramedullary nail for the management of trochanteric or subtrochanteric fracture between January 2005 and December 2018. Subsequent presentations with ipsi- and contralateral femoral fractures were documented. Only patients with no previous femoral surgery performed, other than the index nailing were followed. Odds ratios (ORs) for subsequent femoral fracture were calculated using robust variance estimates in logistic regression. Results The mean age of the cohort was 82.4 years and 72.1% were female. The total number of patients presenting with subsequent femoral fractures was 299 (14.9%). The number of patients presenting with subsequent ipsilateral and contralateral femoral fractures was 51 (2.5%) and 248 (12.3%) respectively (OR 5.0; CI 3.7–6.9). Twenty-six (8.7%) of all subsequent femoral fractures occured in the ipsilateral shaft, 14 (4.7%) in the ipsilateral metaphyseal area, one (0.33%) in the contralateral shaft, and three (1.0%) in the contralateral metaphysis (OR 10; CI 3.6–29). Conclusion An intramedullary nail significantly changes the fracture pattern in the event of a second low-energy trauma, reducing the risk of subsequent proximal ipsilateral femoral fractures and increasing the risk of subsequent ipsilateral femoral fractures in the shaft and distal metaphyseal area compared with the native contralateral femur.
... With the increasing use of intramedullary nailing, problems regarding peri-implant fractures (PIFs) have been brought up. Although reported incidence for PIFs has been as high as 2.6% [7], no distinct guidelines have been established for the treatment of PIFs. Previous studies do not report outcomes of salvage operations done after PIF. ...
... The rate of PIF (1.4%) in our study was similar to earlier reports, with 1.6-2.1% reported for PFNA and 1.7% for all cephalomedullary nails together [7,12]. Previously, Skala-Rosenbaum et al. reported an incidence of 2.0% (n = 17) for PIFs in their series of 849 trochanteric fractures treated with intermediate-length (240 mm) cephalomedullary nails [13]. ...
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Introduction Trochanteric femoral fractures are among the most common operatively treated fractures. Intramedullary fixation has become the treatment of choice in many centers around the world. Nevertheless, the knowledge of rare complications of these fractures is limited. In this study, the incidence and treatment strategies for peri-implant fractures (PIF) were assessed. Materials and methods A single-center retrospective cohort study was done on 987 consecutive operatively treated trochanteric fractures. PFNA cephalomedullary nail was used as a fixation method. All patients were followed up from patient records for peri-implant fractures. Plain radiographs as well as different salvage methods were analyzed and compared. Results The total rate of peri-implant fractures was 1.4% ( n = 14). The rate of PIF for patients treated with short (200 mm) nails, intermediate-length (240 mm) nails, and long nails was 2.7% ( n = 2), 1.5% ( n = 11), and 0.7% ( n = 1), respectively (ns, p > 0.05 for difference). Treatment of choice for PIF was either ORIF with locking plate (57%, n = 8) or exchange nailing (43%, n = 6). None of the PIF patients needed additional surgeries for non-union, malunion, or delayed union. Conclusions A PIF is a rare complication of intramedullary fixation of trochanteric fractures. It can be treated with either locking plates or exchange nailing with sufficient results. There are no grounds for favoring long nails to avoid PIFs.
... However, advances in the technology of intramedullary nails have improved the rate of a second fracture following internal fixation. Based on a systematic review by Norris et al., hip fractures must be treated individually and in correlation with the fragility of the bone as well as the fragility of the patient (13). Gotfried argued that the percutaneous compression plating (PCCP) can be beneficial toward this objective (14). ...
... [8] Historically, fracture at the tip of the implant was a concern with short nails, but the incidence of this has decreased with modern nail designs. [9,10] Recent studies show no difference in peri-implant fracture rate, complication rate, or reoperation rate between short and long nails. [11][12][13][14][15][16][17] In addition, studies have found shorter surgical times and lower costs with the use of short nails. ...
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Objectives: In patients with wide femoral canals, an undersized short nail may not provide adequate stability, leading to toggling of the nail around the distal interlocking screw and subsequent loss of reduction. The purpose of this study was to identify risk factors associated with nail toggle and to examine whether increased nail toggle is associated with increased varus collapse. Design: Retrospective cohort study. Setting: Level 1 and level 3 trauma center. Patients/participants: Seventy-one patients with intertrochanteric femur fractures treated with short cephalomedullary nails (CMN) from October 2013 to December 2017. Intervention: Short CMN. Main outcome measurements: Nail toggle and varus collapse were measured on intraoperative and final follow-up radiographs. Risk factors for nail toggle including demographics, fracture classification, quality of reduction, Dorr type, nail/canal diameter ratio, lag screw engaging the lateral cortex, and tip-apex distance (TAD) were recorded. Results: On multivariate regression analysis, shorter TAD (P = .005) and smaller nail/canal ratio (P < .001) were associated with increased nail toggle. Seven patients (10%) sustained nail toggle >4 degrees. They had a smaller nail/canal ratio (0.54 vs 0.74, P < .001), more commonly Dorr C (57% vs 14%, P = .025), lower incidence of lag screw engaging the lateral cortex (29% vs 73%, P = .026), shorter TAD (13.4 mm vs 18.5 mm, P = .042), and greater varus collapse (6.2 degrees vs 1.3 degrees, P < .001) compared to patients with nail toggle < 4 degrees. Conclusions: Lower percentage nail fill of the canal and shorter TAD are risk factors for increased nail toggle in short CMNs. Increased nail toggle is associated with increased varus collapse.Level of evidence: Therapeutic Level III.
Background: The widespread use of intramedullary nails (IMNs) compared with sliding hip screws (SHSs) in extracapsular hip fractures (AO/OTA 31-A1, 31-A2, 31-A3) has been questioned because of a higher complication rate, although the outcome might have improved through more recent implant designs and the learning curve. This study aimed to investigate if there is a difference with regard to the cumulative incidence of conversion to arthroplasty or any reoperation during the first 5 years after IMN or SHS fixation of extracapsular hip fractures. Methods: In this nationwide, observational cohort study, individuals who were ≥60 years of age and were registered in the Swedish Fracture Register (SFR) from 2012 to 2018 due to extracapsular fracture and were primarily treated with an IMN or SHS were followed in the SFR and the Swedish Arthroplasty Register (SAR) for a minimum of 1 year. The primary outcome was the cumulative incidence of conversion to arthroplasty (conversion rate). The secondary outcome was the cumulative incidence of all reoperations (reoperation rate). Both were calculated in a competing risk analysis during the first 5 years. Results: We included 19,604 individuals (70% women), with a median age of 85 years (range, 60 to 107 years). The 31-A2 fracture was most prevalent (52%), followed by the 31-A1 fracture (28%). No significant differences were seen in the 1-year conversion rate after IMN or SHS use (1.0% compared with 0.9% in the 31-A1 fractures, 1.7% compared with 1.3% in the 31-A2 fractures, and 1.3% compared with 1.5% in the 31-A3 fractures) or in the 1-year reoperation rate (1.9% compared with 1.9% in the type-A1 fractures, 3.4% compared with 2.5% in the type-A2 fractures, and 4.0% compared with 5.2% in the type-A3 fractures). Only in 31-A2 fractures were more reoperations seen after IMN use at 2 and 5 years (p < 0.05). The crude 1-year-mortality was 26.4% (5,178 of 19,604), without significant differences between implants. Conclusions: Considering conversion arthroplasty, IMNs and SHSs performed equally well in general. IMN use was associated with more reoperations than SHS use in 31-A2 fractures at 2 years. However, from a clinical perspective, the differences between the implants were small, in particular when considering the competing risk of dying. Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Purpose The purpose of this study was to investigate differences in aseptic reoperation rates between single or dual lag screw femoral nails,in the treatment of intertrochanteric fractures (ITF) in elderly patients. Methods Electronic databases were searched for RCTs and prospective cohort studies treating elderly ITF patients with a single or dual screw femoral nails. Data for aseptic reoperation rates between single screw, dual separated screw and dual integrated screw devices were pooled using a random-effects meta-analysis with 95% CIs. Pooled proportions were compared using a N-1 chi-squared test. Complications contributing to aseptic reoperation rates were extracted, and the contribution of cut-out and periprosthetic fracture as a proportion of reoperations was analysed using a negative binomial regression model. Results Forty-two ( n = 42) studies were evaluated, including 2795 patients treated with a single screw device, 1309 patients treated with a dual separated screw device and 303 patients treated with a dual integrated screw device. There was no significant difference in aseptic reoperation rates between single and dual lag screw femoral nails of both separated and integrated lag screw designs. Moreover, complications of cut-out and periprosthetic fracture as a proportion of reoperations did not differ significantly between devices. Conclusion The current evidence showed that aseptic reoperation rates were not significantly different between single and dual screw nails of a separated lag screw design. For dual integrated screw devices, due to insufficient evidence available, further high quality RCTs are required to allow for decisive comparisons with these newer devices.
Purposes: Femoral implant related fractures (IRF) are a growing pathology in an increasingly elderly and frail population. A series of IRF after cephalomedullary nail (CMN) fixation of a femoral fracture is analyzed and an algorithm described to guide the management of such fractures. Methods: All eligible patients operated on for IRF fixation after CMN were reviewed regarding their demographics, comorbidities, injury pattern, and treatment. Primary outcomes were mortality and local complications. Secondary outcomes were time to consolidation, time to weight-bearing initiation, length of hospitalization, and discharge destination. Results: The incidence of IRF requiring fixation was 1.3% after 3401 CMN implantation procedures. Elderly women with comorbidities and plate fixation predominated. One-year mortality was 18.6%, being higher for patients presenting with infection and those unable to walk at the end of follow-up. Local complications occurred in 25.6%. Median time to weight-bearing was 9.1 weeks, but longer for patients with plate fixation or complications. Patients presenting with an infection and those discharged to nursing facilities had more comorbidity. Conclusions: Following an algorithm presented here, patients were treated either with nail exchange or lateral locking plate fixation, permitting straightforward evaluations and acceptable results in a very high-risk population.
Proximal femoral fractures (PFF) are one of the most common reasons for admission of patients to a traumatological and orthopedic hospital. For the vast majority of patients with PFF, such injury means a loss of the previous degree of mobility. Clinical guidelines are the main working tool of a practicing physician, both a specialist and a narrow practice doctor. Conciseness, structuredness of information about a particular nosology, methods of its diagnosis and treatment, based on the principles of evidence-based medicine, allow to give in a short time one or another answer to a question of interest to a specialist, to achieve maximum efficiency and personalization of treatment. These clinical guidelines include data on the classification, clinical presentation, diagnosis, and treatment of proximal femoral fractures. In addition, they provide methods for the rehabilitation of patients with this pathology.
Background: Hip fractures are a major healthcare problem, presenting a substantial challenge and burden to patients, healthcare systems and society. The increased proportion of older adults in the world population means that the absolute number of hip fractures is rising rapidly across the globe. Most hip fractures are treated surgically. This Cochrane Review evaluates evidence for implants used to treat extracapsular hip fractures. Objectives: To assess the relative effects of cephalomedullary nails versus extramedullary fixation implants for treating extracapsular hip fractures in older adults. Search methods: We searched CENTRAL, MEDLINE, Embase, Web of Science, the Cochrane Database of Systematic Reviews, Epistemonikos, ProQuest Dissertations & Theses, and the National Technical Information Service in July 2020. We also searched clinical trials databases, conference proceedings, reference lists of retrieved articles, and conducted backward-citation searches. Selection criteria: We included randomised controlled trials (RCTs) and quasi-RCTs comparing cephalomedullary nails with extramedullary implants for treating fragility extracapsular hip fractures in older adults. We excluded studies in which all or most fractures were caused by a high-energy trauma or specific pathologies other than osteoporosis. Data collection and analysis: We used standard methodological procedures expected by Cochrane. We collected data for seven critical outcomes: performance of activities of daily living (ADL), delirium, functional status, health-related quality of life, mobility, mortality (reported within four months of surgery as 'early mortality'; and reported from four months onwards, with priority given to data at 12 months, as '12 months since surgery'), and unplanned return to theatre for treating a complication resulting directly or indirectly from the primary procedure (such as deep infection or non-union). We assessed the certainty of the evidence for these outcomes using GRADE. MAIN RESULTS: We included 76 studies (66 RCTs, 10 quasi-RCTs) with a total of 10,979 participants with 10,988 extracapsular hip fractures. The mean ages of participants in the studies ranged from 54 to 85 years; 72% were women. Seventeen studies included unstable trochanteric fractures; three included stable trochanteric fractures only; one included only subtrochanteric fractures; and other studies included a mix of fracture types. More than half of the studies were conducted before 2010. Owing to limitations in the quality of reporting, we could not easily judge whether care pathways in these older studies were comparable to current standards of care. We downgraded the certainty of the outcomes because of high or unclear risk of bias; imprecision (when data were available from insufficient numbers of participants or the confidence interval (CI) was wide); and inconsistency (when we noted substantial levels of statistical heterogeneity or differences between findings when outcomes were reported using other measurement tools). There is probably little or no difference between cephalomedullary nails and extramedullary implants in terms of mortality within four months of surgery (risk ratio (RR) 0.96, 95% CI 0.79 to 1.18; 30 studies, 4603 participants) and at 12 months (RR 0.99, 95% CI 0.90 to 1.08; 47 studies, 7618 participants); this evidence was assessed to be of moderate certainty. We found low-certainty evidence for differences in unplanned return to theatre but this was imprecise and included clinically relevant benefits and harms (RR 1.15, 95% CI 0.89 to 1.50; 50 studies, 8398 participants). The effect estimate for functional status at four months also included clinically relevant benefits and harms; this evidence was derived from only two small studies and was imprecise (standardised mean difference (SMD) 0.02, 95% CI -0.27 to 0.30; 188 participants; low-certainty evidence). Similarly, the estimate for delirium was imprecise (RR 1.22, 95% CI 0.67 to 2.22; 5 studies, 1310 participants; low-certainty evidence). Mobility at four months was reported using different measures (such as the number of people with independent mobility or scores on a mobility scale); findings were not consistent between these measures and we could not be certain of the evidence for this outcome. We were also uncertain of the findings for performance in ADL at four months; we did not pool the data from four studies because of substantial heterogeneity. We found no data for health-related quality of life at four months. Using a cephalomedullary nail in preference to an extramedullary device saves one superficial infection per 303 patients (RR 0.71, 95% CI 0.53 to 0.96; 35 studies, 5087 participants; moderate-certainty evidence) and leads to fewer non-unions (RR 0.55, 95% CI 0.32 to 0.96; 40 studies, 4959 participants; moderate-certainty evidence). However, the risk of intraoperative implant-related fractures was greater with cephalomedullary nails (RR 2.94, 95% CI 1.65 to 5.24; 35 studies, 4872 participants; moderate-certainty evidence), as was the risk of later fractures (RR 3.62, 95% CI 2.07 to 6.33; 46 studies, 7021 participants; moderate-certainty evidence). Cephalomedullary nails caused one additional implant-related fracture per 67 participants. We noted no evidence of a difference in other adverse events related or unrelated to the implant, fracture or both. Subgroup analyses provided no evidence of differences between the length of cephalomedullary nail used, the stability of the fracture, or between newer and older designs of cephalomedullary nail. Authors' conclusions: Extramedullary devices, most commonly the sliding hip screw, yield very similar functional outcomes to cephalomedullary devices in the management of extracapsular fragility hip fractures. There is a reduced risk of infection and non-union with cephalomedullary nails, however there is an increased risk of implant-related fracture that is not attenuated with newer designs. Few studies considered patient-relevant outcomes such as performance of activities of daily living, health-related quality of life, mobility, or delirium. This emphasises the need to include the core outcome set for hip fracture in future RCTs.