Convergence of Outcomes for Hip Fracture Fixation by Nails and Plates

Abstract

Background Recent popularity of intramedullary nails over sliding hip screws for treatment of intertrochanteric fractures is concerning given the absence of evidence for clinical superiority for nailing yet the presence of reimbursement differences.

Which Fixation Device is Preferred for Surgical Treatment of Intertrochanteric Hip Fractures in the United States? A Survey of Orthopaedic Surgeons

“…Our finding that the majority of surgeons currently use cephalomedullary nails is in agreement with the literature showing that the popularity of the cephalomedullary nails is steadily increasing [2,7,12]. Anglen and Weinstein [2] conducted a study of candidates participating in the American Board of Orthopaedics oral boards and found the use of cephalomedullary nails increased from 3% to 65% from 1999 to 2006 by newly practicing orthopaedic surgeons.…”

“…The most recent Cochrane review on the topic [28] concluded that the sliding hip screw is the superior construct for treatment of intertrochanteric fractures because of the decreased rate of surgical complications compared with cephalomedullary nails, but additional studies are necessary to determine whether newer designs of cephalomedullary nails avoid the complications of older models, such as those used for periimplant fracture. In contrast to surgeon perception of technical ease, studies have shown there is a learning curve associated with cephalomedullary nails use [7,27]. Parker et al [27] found that the intramedullary nail had slightly increased operative and anesthesia time, increased radiographic screening time, and overall was more technically challenging with respect to placement of proximal and distal interlock screws.…”

“…If a surgeon is able to perform a cephalomedullary nail procedure with much greater ease and efficiency than a sliding hip screw procedure, this potentially could offset the cost of the implant. Chen et al [7], in a study of Medicare enrollees from 1993 to 2007, found that the outcome of cephalomedullary nailing has improved with time relative to sliding hip screws. This convergence in outcomes may be attributed to improved implant design and surgeon technique.…”

“…Intertrochanteric fractures comprise approximately 50% of these. Historically, a sliding compression screw has been the preferred implant [19,28,30,34]; however, cephalomedullary nailing has become an increasingly popular fixation technique for these fractures since its introduction in the 1980s [2,7,12]. Cephalomedullary nailing has theoretical advantages of being less invasive and biomechanically superior, providing a buttress to limit fracture collapse [21].…”

Higher 30-day mortality associated with the use of intramedullary nails compared with sliding hip screws for the treatment of trochanteric hip fractures

“…18 The decline in use of the SHS has been well documented. [19][20][21] Justification usually points towards theoretical biomechanical advantages associated with IM nailing, despite the lack of robust evidence to support this. 9 It is difficult to determine the influence of industry and reimbursement practices 19 on such a precipitous change in practice.…”