Intramedullary Nailing vs Sliding Hip Screw in Trochanteric Fracture Management

Abstract

ImportanceFractures of the hip have devastating effects on function and quality of life. Intramedullary nails (IMN) are the dominant implant choice for the treatment of trochanteric fractures of the hip. Higher costs of IMNs and inconclusive benefit in comparison with sliding hip screws (SHSs) convey the need for definitive evidence.ObjectiveTo compare 1-year outcomes of patients with trochanteric fractures treated with the IMN vs an SHS.Design, Setting, and ParticipantsThis randomized clinical trial was conducted at 25 international sites across 12 countries. Participants included ambulatory patients aged 18 years and older with low-energy trochanteric (AO Foundation and Orthopaedic Trauma Association [AO/OTA] type 31-A1 or 31-A2) fractures. Patient recruitment occurred between January 2012 and January 2016, and patients were followed up for 52 weeks (primary end point). Follow-up was completed in January 2017. The analysis was performed in July 2018 and confirmed in January 2022.InterventionsSurgical fixation with a Gamma3 IMN or an SHS.Main Outcomes and MeasuresThe primary outcome was health-related quality of life (HRQOL), measured by the EuroQol–5 Dimension (EQ5D) at 1-year postsurgery. Secondary outcomes included revision surgical procedure, fracture healing, adverse events, patient mobility (measured by the Parker mobility score), and hip function (measured by the Harris hip score).ResultsIn this randomized clinical trial, 850 patients were randomized (mean [range] age, 78.5 [18-102] years; 549 [64.6% female) with trochanteric fractures to undergo fixation with either the IMN (n = 423) or an SHS (n = 427). A total of 621 patients completed follow-up at 1 year postsurgery (304 treated with the IMN [71.9%], 317 treated with an SHS [74.2%]). There were no significant differences between groups in EQ5D scores (mean difference, 0.02 points; 95% CI, −0.03 to 0.07 points; P = .42). Furthermore, after adjusting for relevant covariables, there were no between-group differences in EQ5D scores (regression coefficient, 0.00; 95% CI, −0.04 to 0.05; P = .81). There were no between-group differences for any secondary outcomes. There were also no significant interactions for fracture stability (β [SE] , 0.01 [0.05]; P = .82) or previous fracture (β [SE], 0.01 [0.10]; P = .88) and treatment group.Conclusions and RelevanceThis randomized clinical trial found that IMNs for the treatment of trochanteric fractures had similar 1-year outcomes compared with SHSs. These results suggest that the SHS is an acceptable lower-cost alternative for trochanteric fractures of the hip.Trial RegistrationClinicalTrials.gov Identifier: NCT01380444

Equivalent mortality after operation with sliding hip screw or intramedullary nail for trochanteric AO/OTA A1 and A2 fractures reported in the Norwegian Hip Fracture Register 2008 to 2020

“…7 However, two large randomized clinical trials have reported no difference in mortality at one year postoperatively. 6,9 On the other hand, higher 30-day mortality associated with IMN compared to SHS has been reported in two earlier large observational studies. 10,11…”

“…1 While most guidelines recommend the use of IMNs for unstable trochanteric fractures (AO/OTA 31A3) 2 and subtrochanteric fractures, 3-5 there is growing evidence that SHSs and IMNs provide similar outcomes for stable trochanteric fractures (AO/OTA 31A1 and 31A2). 6,7 There is, however, an increasing trend internationally to use IMNs also for A1 and A2 fractures. 1,3,4,8…”

Trauma

“…Authors from London (Canada) asked the question: Could the increased implant cost be justified by significantly superior outcomes of IMN fixation over SHS fixation? 1 A multinational team from the INSITE investigators set out to answer this question using a randomized controlled trial design. Their study was undertaken at 25 sites across 12 countries.…”

“…The systematic review and meta-analysis, led by researchers from Boston (Massachusetts, USA), aimed to fill this gap by evaluating existing studies and collating robust evidence on this issue. 1 The study followed the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered in PROSPERO (ID: 380459). Searches were carried out in the studies with the I2 statistic.…”

Single-centre results of a randomised controlled trial comparing the Gamma3 nail and a sliding hip screw to treat AO type 31-A1 and 31-A2 trochanteric fractures

“…We participated in a multicentric randomised controlled study (Identi cation No. : DRKS00003342) [30] to establish whether the Gamma3 nailing system has a positive impact on the quality of life of the patients compared with a SHS. We evaluated the EQ-5D Index and Visual Analogue Scale (VAS) scores, the Parker Mobility Score, the Harris Hip Score, the mortality rate and the change in the living situation and the use of walking aids 1 year after surgery.…”