A prospective trial comparing the Holland nail with the dynamic hip screw in the treatment of intertrochanteric fractures of the hip

Abstract

We compared the outcome of patients treated for an intertrochanteric fracture of the femoral neck with a locked, long intramedullary nail with those treated with a dynamic hip screw (DHS) in a prospective randomised study. Each patient who presented with an extra-capsular hip fracture was randomised to operative stabilisation with either a long intramedullary Holland nail or a DHS. We treated 92 patients with a Holland nail and 98 with a DHS. Pre-operative variables included the Mini Mental test score, patient mobility, fracture pattern and American Society of Anesthesiologists grading. Peri-operative variables were anaesthetic time, operating time, radiation time and blood loss. Post-operative variables were time to mobilising with a frame, wound infection, time to discharge, time to fracture union, and mortality. We found no significant difference in the pre-operative variables. The mean anaesthetic and operation times were shorter in the DHS group than in the Holland nail group (29.7 vs 40.4 minutes, p < 0.001; and 40.3 vs 54 minutes, p < 0.001, respectively). There was an increased mean blood loss within the DHS group versus the Holland nail group (160 ml vs 78 ml, respectively, p < 0.001). The mean time to mobilisation with a frame was shorter in the Holland nail group (DHS 4.3 days, Holland nail 3.6 days, p = 0.012). More patients needed a post-operative blood transfusion in the DHS group (23 vs seven, p = 0.003) and the mean radiation time was shorter in this group (DHS 0.9 minutes vs Holland nail 1.56 minutes, p < 0.001). The screw of the DHS cut out in two patients, one of whom underwent revision to a Holland nail. There were no revisions in the Holland nail group. All fractures in both groups were united when followed up after one year. We conclude that the DHS can be implanted more quickly and with less exposure to radiation than the Holland nail. However, the resultant blood loss and need for transfusion is greater. The Holland nail allows patients to mobilise faster and to a greater extent. We have therefore adopted the Holland nail as our preferred method of treating intertrochanteric fractures of the hip.

Comparative evaluation of dynamic hip screw and proximal femoral nail for fracture of intertrochanteric femur

“…18 Little et al have suggested medical comorbidities and post-operative factors like pain and muscle dysfunction to be factors determining time to mobilization. 19 Nuber et al have reported full weight bearing immediately after the operation for 97% of PFN patients and 88% of DHS patients. 20 Little et al have reported mean time to mobilization of 3.6 days for Holland nail and 4.3 days for DHS patients.…”

CORR Insights™: Intramedullary Nails Result in More Reoperations Than Sliding Hip Screws in Two-part Intertrochanteric Fractures

“…Multiple studies have provided somewhat conflicting data [1][2][3][5][6][7][8][9][10][11][12].When all fracture patterns are considered, however, there does not appear to be any significant difference in blood loss, transfusion requirements, or operative times [1][2][3][5][6][7][8][9][10][11][12]. Postoperative complications, such as infection and thromboembolic phenomena, also are similar for the two groups [1][2][3][5][6][7][8][9][10][11][12].…”

“…Postoperative complications, such as infection and thromboembolic phenomena, also are similar for the two groups [1][2][3][5][6][7][8][9][10][11][12]. The presence of nonunions and fracture healing appear to be similar with the two types of implants as well [1][2][3][5][6][7][8][9][10][11][12].…”

“…Likewise, there does not appear to be any differences between the two methods regarding leg-length discrepancy, external rotation, or varus femoral neck deformity (although few studies look at these outcomes) [1-3, 7, 11, 12]. Operative fracture of the femur has been significantly worse when using the shorter cephalomedullary device, necessitating reoperation or changing the implant to a longer device [1][2][3][5][6][7][8][9][10][11][12]. This last finding was disputed by Bhandari et al [4], who performed a meta-analysis of more recent studies.…”

“…Short nails were used with 96% of the patients who had a cephalomedullary device, thus increasing the possibility of fracture around the implant. The main weakness of this study is that it does not compare the devices with the less stable fracture patterns, which is the primary indication for using a cephalomedullary device [1][2][3][4][5][6][7][8][9][10][11][12].…”