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. 2000;1998(2):CD000338.
doi: 10.1002/14651858.CD000338.

Condylocephalic nails versus extramedullary implants for extracapsular hip fractures

M J Parker  1 , H H Handoll, S Bhonsle, W J Gillespie
Affiliations

Condylocephalic nails versus extramedullary implants for extracapsular hip fractures

M J Parker et al. Cochrane Database Syst Rev. 2000.

Abstract

Background: Condylocephalic nails are intramedullary nails which are inserted up through the femoral canal from above the knee, for example Ender and Harris nails.

Objectives: To compare condylocephalic nails with alternative implants (extramedullary implants such as fixed nail plates and sliding hip screws, or other intramedullary nails) for the treatment of extracapsular hip fracture in adults.

Search strategy: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline (1983 to August 1999) and reference lists of relevant articles. Date of the most recent search: August 1999.

Selection criteria: Randomised or quasi-randomised trials comparing condylocephalic nails with other implants.

Data collection and analysis: All reviewers independently assessed trial quality and extracted data. Data were pooled where relevant and possible. Ender nails and Harris nail data were presented separately. Results from fixed nail plates and sliding hip screws were sub-grouped to explore differences in these two implant types.

Main results: Eleven trials were included. Ten compared Ender nails with either a fixed nail plate or a sliding hip screw. One compared the Harris condylocephalic nail with a sliding hip screw. The only advantages of condylocephalic nails were a reduced deep wound sepsis rate (0.9% versus 4.2%; odds ratio 0.26, 95% confidence interval 0.12 to 0.56), length of surgery and operative blood loss. However there was an increased risk of re-operation (20.9% versus 5. 5%; odds ratio 3.78, 95% confidence interval 2.67 to 5.36) and later fracture of the femur when compared with extramedullary implants. There was also an increased risk of cut-out of the implant from the femoral head for Ender nails compared with the sliding hip screw, but not for fixed nail plates. Backing out of the nail was a frequent complication (30%) of Ender nails and often resulted in revision surgery. Ender nails also had an increased risk of shortening of the leg and external rotation deformity and potentially a poorer return to previous walking ability. An increase in residual pain resulting from an excess of knee pain was also evident in patients undergoing condylocephalic nailing. There was no apparent difference in mortality between the condylocephalic nail and extramedullary implant groups.

Reviewer's conclusions: Any advantages in intra-operative outcomes of condylocephalic nails are outweighed by the increase in fracture healing complications, re-operation rate, residual pain and limb deformity when compared with an extramedullary implant, particularly a sliding hip screw. The use of condylocephalic nails (in particular Ender nails), for trochanteric fracture is no longer appropriate.

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Conflict of interest statement

None known

Figures

1.1
1.1. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 1 Length of surgery (minutes).
1.2
1.2. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 2 Operative blood loss (ml).
1.3
1.3. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 3 Radiographic screening time (seconds).
1.4
1.4. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 4 Cut‐out of implant.
1.5
1.5. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 5 Cut‐out of implant (odds ratio results).
1.6
1.6. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 6 Backing out of the nail.
1.7
1.7. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 7 Non‐union.
1.8
1.8. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 8 Fracture of the femur.
1.9
1.9. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 9 Reoperation.
1.10
1.10. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 10 Reoperation: by allocation concealment (quality score).
1.11
1.11. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 11 Reoperation: by overall trial quality (total score).
1.12
1.12. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 12 Superficial wound infection.
1.13
1.13. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 13 Deep wound infection.
1.14
1.14. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 14 Pneumonia.
1.15
1.15. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 15 Pressure sores.
1.16
1.16. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 16 DVT (deep vein thrombosis).
1.17
1.17. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 17 Pulmonary embolism.
1.18
1.18. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 18 Any medical complications.
1.19
1.19. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 19 External rotation deformity.
1.20
1.20. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 20 Shortening of leg.
1.21
1.21. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 21 Mortality: short term (<2 months).
1.22
1.22. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 22 Mortality: long term follow up.
1.23
1.23. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 23 Pain at follow up: any (knee, hip).
1.24
1.24. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 24 Pain at follow up: hip pain.
1.25
1.25. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 25 Failure to return previous residence.
1.26
1.26. Analysis
Comparison 1 Ender nails versus extramedullary fixation implants, Outcome 26 Deterioration in walking function.
2.1
2.1. Analysis
Comparison 2 Harris nail versus extramedullary fixation implants, Outcome 1 Non‐union.
2.2
2.2. Analysis
Comparison 2 Harris nail versus extramedullary fixation implants, Outcome 2 Fixation failure rate.
2.3
2.3. Analysis
Comparison 2 Harris nail versus extramedullary fixation implants, Outcome 3 Reoperation.
2.4
2.4. Analysis
Comparison 2 Harris nail versus extramedullary fixation implants, Outcome 4 Mortality: long term.
2.5
2.5. Analysis
Comparison 2 Harris nail versus extramedullary fixation implants, Outcome 5 Failure to regain mobility.
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References

References to studies included in this review

Brostrom 1992 {published data only}
    1. Barrios C, Brostrom L‐A, Stark A, Walheim G. Factors predicting failures of internal fixation in intertrochanteric fractures ‐ a multivariate analysis comparing Ender pins and a dynamic hip screw [abstract]. Acta Orthopaedica Scandinavica Supplementum 1992;248:87.
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    1. Brostrom L‐A, Barrios C, Kronberg M, Stark A, Walheim G. Clinical features and walking ability in the early postoperative period after treatment of trochanteric hip fractures. Annales Chirurgiae et Gynaecologiae 1992;81(1):66‐71. [MEDLINE: ] - PubMed
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Chapman 1981 {published data only}
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Trafton 1984 {published data only}
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References to studies excluded from this review

Amici 1980 {published data only}
    1. Amici F Jr, Wigren A, Vollsater J. Pertrochanteric fractures of the femur treated by Ender's nails. Italian Journal of Orthopaedics and Traumatology 1980;6(2):213‐8. - PubMed
Andersson 1984 {published data only}
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Claes 1985 {published data only}
    1. Claes H, Broos P, Stappaerts K. Pertrochanteric fractures in elderly patients: treatment with Ender's nails, blade‐plate or endoprosthesis?. Injury 1985;16(4):261‐4. - PubMed
Cobelli 1985 {published data only}
    1. Cobelli NJ, Sadler AH. Ender rod versus compression screw fixation of hip fractures. Clinical Orthopaedics and Related Research 1985;(201):123‐9. - PubMed
Demartin 1984 {published data only}
    1. Demartin F, Bianchi R. Osteosynthesis with sliding‐compression screw plates or with Ender nails in pertrochanteric fractures? Comparison between 2 methods [Osteosintesi con vite‐placca a scivolamento e compressione oppure con chiodi di Ender nelle fr atture pertrocanteriche? Confronto fra due metodiche]. Chirurgia Degli Organi di Movimento 1984;69(2):159‐67. - PubMed
Geissler 1992 {published data only}
    1. Geissler N, Putzki H, Heymann H. Ender nailing versus dynamic hip screw ‐ a comparison of early postoperative results [Ender‐nagelung versus dynamische huftschraube (DHS) ‐ ein vergleich fruh postoperativer verlaufe]. Zentralblatt fur Chirurgie 1992;117(6):355‐7. - PubMed
Gratz 1978 {published data only}
    1. Gratz K, Lemberger U, Marty A. Comparison of different methods of treatment of per‐ and subtrochanteric femoral fractures [Vergleich verschiedener behandlungsmethoden der per‐ und subtrochantaren femurfraktur]. Helvetica Chirurgica Acta 1978;45(4‐5):571‐4. - PubMed
Hontzsch 1990 {published data only}
    1. Hontzsch D, Weller S, Karnatz N. The dynamic hip screw in comparison with Ender nailing [Die dynamische Huftschraube (DHS) im Vergleich zur Ender‐Nagelung]. Aktuelle Traumatologie 1990;20(1):14‐9. - PubMed
Indemini 1982 {published data only}
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Jensen 1980 {published data only}
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Jones 1977 {published data only}
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Ludtke‐Handjery 1991 {published data only}
    1. Ludtke‐Handjery A, Mau C. Has the dynamic hip screw justifiably replaced Ender nailing in the management of hip para‐articular femoral fractures of the A1‐A3 and B2 type? [Hat die dynamische huftschraube zu recht die Ender‐nagelung in der versorgung huftgelenksnaher femurfrakturen vom typ A1‐A3 und B2 verdrangt?]. Unfallchirurg 1991;94(4):157‐62. - PubMed
Merenyi 1995 {published and unpublished data}
    1. Merenyi G, Zagh I, Kovacs A. Gamma nail versus Ender nails and angle‐plate in the proximal fractures of the femur ‐ a randomised prospective study [Abstract]. Journal of Bone and Joint Surgery. British Volume 1995;77 Suppl II:215.
Muller 1994 {published data only}
    1. Muller B, Bonnaire F, Heckel T, Jaeger JH, Kempf I, Kuner EH. Ender nail with interlocking mechanism or dynamic hip screw in pertrochanteric fractures? A prospective study extending its limits [Ender‐nagel mit verriegelung oder dynamische huftschraube bei pertrochantaren frakturen]. Unfallchirurgie 1994;20(1):18‐29. - PubMed
Schottle 1975 {published data only}
    1. Schottle H, Jungbluth KH, Rudolph H. Nailing using the Ender method or AO‐angle plate in pertrochanteric fracture [Ender‐nagelung oder AO‐winkelplatte bei pertrochantarer fraktur]. Hefte zur Unfallheilkunde 1975;126:395‐7. - PubMed
Sherk 1985 {published data only}
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Tonino 1982 {published and unpublished data}
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Zukor 1985 {published data only}
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Additional references

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    1. Parker MJ, Handoll HHG. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures. Cochrane Database of Systematic Reviews 2004, Issue 3. - PubMed
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References to other published versions of this review

Brostrom 1992
    1. Brostrom L‐A, Barrios C, Kronberg M, Stark A, Walheim G. Clinical features and walking ability in the early postoperative period after treatment of trochanteric hip fractures. Annales Chirurgiae et Gynaecologiae 1992;81(1):66‐71. [MEDLINE: ] - PubMed
Parker 2004c
    1. Parker MJ, Handoll HHG, Bhonsle S, Gillespie WJ. Condylocephalic nails versus extramedullary implants for extracapsular hip fractures. Cochrane Database of Systematic Reviews 2004, Issue 3. - PMC - PubMed

Publication types