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Meta-Analysis
. 2013 Feb 28;2013(2):CD000339.
doi: 10.1002/14651858.CD000339.pub3.

Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults

Martyn J Parker  1 , Avishek Das
Affiliations
Meta-Analysis

Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults

Martyn J Parker et al. Cochrane Database Syst Rev. .

Abstract

Background: Extramedullary fixation of hip fractures involves the application of a plate and screws to the lateral side of the proximal femur. In external fixators, the stabilising component is held outside the thigh by pins or screws driven into the bone. This is an update of a Cochrane review first published in 1998, and last updated in 2005.

Objectives: To assess the relative effects of different types of extramedullary fixation implant, as well as external fixators, for treating extracapsular proximal femoral (hip) fractures in adults.

Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 2), MEDLINE (1966 to June Week 4 2011), EMBASE (1988 to 2011 Week 25), various other databases, conference proceedings and reference lists.

Selection criteria: Randomised or quasi-randomised controlled trials comparing extramedullary implants or external fixators for fixing extracapsular hip fracture in adults were included.

Data collection and analysis: Two review authors independently selected trials, assessed risk of bias and extracted data. Data were pooled where appropriate.

Main results: The 18 included trials tested seven comparisons in a total of 2615 mainly female and older participants with a total of 2619 fractures. All trials had methodological flaws that may affect the validity of their results.Three trials of 355 participants comparing a fixed nail plate (Jewett or McLaughlin) with the sliding hip screw (SHS) found an increased risk of fixation failure for fixed nail plates.The two trials of 433 participants comparing the Resistance Augmented Bateaux (RAB) plate with the SHS had contrasting results, notably in terms of operative complications, fixation failure and anatomical restoration.One trial of 100 participants comparing the Pugh nail and the SHS found no significant difference between implants.Three trials of 458 participants compared the Medoff plate with the SHS. There was a trend to higher blood losses and longer operation times for the Medoff plate along with a trend to a lower risk of fixation failure with the Medoff plate for unstable trochanteric fractures.Two trials of 676 participants compared the Medoff plate with three different screw-plate systems. There were no statistically significant differences in outcome for trochanteric fractures. For subtrochanteric fractures, there was a lower fixation failure rate for the Medoff plate but no evidence for differences in longer-term outcomes.Four trials of 396 participants comparing the Gotfried percutaneous compression plate (PCCP) with a SHS found a trend to lower blood loss and transfusion requirements for the PCCP but no other confirmed differences in outcomes between implants. Three of the trials reported intra-operative problems with the PCCP, some of which precluded its use.Three trials of 200 participants comparing external fixation with a SHS found less operative trauma for the external fixation. Final outcome appeared similar.

Authors' conclusions: The markedly increased fixation failure rate of fixed nail plates compared with the SHS is a major consideration and thus the SHS appears preferable.There was insufficient evidence from other comparisons of extramedullary implants or on the use of external fixators to draw definite conclusions.

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Conflict of interest statement

None known.

Figures

1
1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
2
2
Risk of bias summary: judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Fixed nail plate versus sliding hip screw (SHS), Outcome 1 Fracture fixation complications.
1.2
1.2. Analysis
Comparison 1 Fixed nail plate versus sliding hip screw (SHS), Outcome 2 Final outcome measures.
2.1
2.1. Analysis
Comparison 2 RAB plate versus sliding hip screw (SHS), Outcome 1 Number of patients transfused.
2.2
2.2. Analysis
Comparison 2 RAB plate versus sliding hip screw (SHS), Outcome 2 Fracture fixation complications.
2.3
2.3. Analysis
Comparison 2 RAB plate versus sliding hip screw (SHS), Outcome 3 Wound infection.
2.4
2.4. Analysis
Comparison 2 RAB plate versus sliding hip screw (SHS), Outcome 4 Thromboembolism.
2.5
2.5. Analysis
Comparison 2 RAB plate versus sliding hip screw (SHS), Outcome 5 Anatomical deformity.
2.6
2.6. Analysis
Comparison 2 RAB plate versus sliding hip screw (SHS), Outcome 6 Mortality.
3.1
3.1. Analysis
Comparison 3 Pugh nail versus sliding hip screw (SHS), Outcome 1 Fixation failure.
3.2
3.2. Analysis
Comparison 3 Pugh nail versus sliding hip screw (SHS), Outcome 2 Deep infection.
3.3
3.3. Analysis
Comparison 3 Pugh nail versus sliding hip screw (SHS), Outcome 3 Deep vein thrombosis.
3.4
3.4. Analysis
Comparison 3 Pugh nail versus sliding hip screw (SHS), Outcome 4 Final outcome measures.
4.1
4.1. Analysis
Comparison 4 Medoff sliding plate versus sliding hip screw (SHS), Outcome 1 Cut‐out.
4.2
4.2. Analysis
Comparison 4 Medoff sliding plate versus sliding hip screw (SHS), Outcome 2 Detachment of the plate from the femur.
4.3
4.3. Analysis
Comparison 4 Medoff sliding plate versus sliding hip screw (SHS), Outcome 3 Non‐union of fracture.
4.4
4.4. Analysis
Comparison 4 Medoff sliding plate versus sliding hip screw (SHS), Outcome 4 Fixation failure rate.
4.5
4.5. Analysis
Comparison 4 Medoff sliding plate versus sliding hip screw (SHS), Outcome 5 Reoperation.
4.6
4.6. Analysis
Comparison 4 Medoff sliding plate versus sliding hip screw (SHS), Outcome 6 Thromboembolic complications.
4.7
4.7. Analysis
Comparison 4 Medoff sliding plate versus sliding hip screw (SHS), Outcome 7 Final outcome measures.
5.1
5.1. Analysis
Comparison 5 Medoff sliding plate versus any of three other screw‐plate systems, Outcome 1 Cut‐out.
5.2
5.2. Analysis
Comparison 5 Medoff sliding plate versus any of three other screw‐plate systems, Outcome 2 Non‐union.
5.3
5.3. Analysis
Comparison 5 Medoff sliding plate versus any of three other screw‐plate systems, Outcome 3 Implant breakage or disassembly.
5.4
5.4. Analysis
Comparison 5 Medoff sliding plate versus any of three other screw‐plate systems, Outcome 4 Fixation failure.
5.5
5.5. Analysis
Comparison 5 Medoff sliding plate versus any of three other screw‐plate systems, Outcome 5 Reoperation.
5.6
5.6. Analysis
Comparison 5 Medoff sliding plate versus any of three other screw‐plate systems, Outcome 6 Superficial wound infection.
5.7
5.7. Analysis
Comparison 5 Medoff sliding plate versus any of three other screw‐plate systems, Outcome 7 Deep wound infection.
5.8
5.8. Analysis
Comparison 5 Medoff sliding plate versus any of three other screw‐plate systems, Outcome 8 Thromboembolic complications.
5.9
5.9. Analysis
Comparison 5 Medoff sliding plate versus any of three other screw‐plate systems, Outcome 9 Mortality (1 year).
5.10
5.10. Analysis
Comparison 5 Medoff sliding plate versus any of three other screw‐plate systems, Outcome 10 Failure to return home.
5.11
5.11. Analysis
Comparison 5 Medoff sliding plate versus any of three other screw‐plate systems, Outcome 11 Failure to regain mobility.
6.1
6.1. Analysis
Comparison 6 Gotfried percutaneous compression plate (PCCP) versus sliding hip screw (SHS), Outcome 1 Length of surgery (minutes).
6.2
6.2. Analysis
Comparison 6 Gotfried percutaneous compression plate (PCCP) versus sliding hip screw (SHS), Outcome 2 Intraoperative blood loss (ml).
6.3
6.3. Analysis
Comparison 6 Gotfried percutaneous compression plate (PCCP) versus sliding hip screw (SHS), Outcome 3 Mean fall in haemoglobin (%).
6.4
6.4. Analysis
Comparison 6 Gotfried percutaneous compression plate (PCCP) versus sliding hip screw (SHS), Outcome 4 Mean units of blood transfused.
6.5
6.5. Analysis
Comparison 6 Gotfried percutaneous compression plate (PCCP) versus sliding hip screw (SHS), Outcome 5 Number of patients transfused.
6.6
6.6. Analysis
Comparison 6 Gotfried percutaneous compression plate (PCCP) versus sliding hip screw (SHS), Outcome 6 X‐ray screening time (seconds) (approximate SDs).
6.7
6.7. Analysis
Comparison 6 Gotfried percutaneous compression plate (PCCP) versus sliding hip screw (SHS), Outcome 7 Fracture fixation complications.
6.8
6.8. Analysis
Comparison 6 Gotfried percutaneous compression plate (PCCP) versus sliding hip screw (SHS), Outcome 8 Wound infection.
6.9
6.9. Analysis
Comparison 6 Gotfried percutaneous compression plate (PCCP) versus sliding hip screw (SHS), Outcome 9 Post‐operative complications.
6.10
6.10. Analysis
Comparison 6 Gotfried percutaneous compression plate (PCCP) versus sliding hip screw (SHS), Outcome 10 Length of hospital stay (days).
6.11
6.11. Analysis
Comparison 6 Gotfried percutaneous compression plate (PCCP) versus sliding hip screw (SHS), Outcome 11 Final outcome measures.
7.1
7.1. Analysis
Comparison 7 Pertrochanteric external fixator versus sliding hip screw (SHS), Outcome 1 Length of surgery (minutes).
7.2
7.2. Analysis
Comparison 7 Pertrochanteric external fixator versus sliding hip screw (SHS), Outcome 2 Operative blood loss (ml).
7.3
7.3. Analysis
Comparison 7 Pertrochanteric external fixator versus sliding hip screw (SHS), Outcome 3 Fall in haemoglobin (mg/dl).
7.4
7.4. Analysis
Comparison 7 Pertrochanteric external fixator versus sliding hip screw (SHS), Outcome 4 Number of patients transfused.
7.5
7.5. Analysis
Comparison 7 Pertrochanteric external fixator versus sliding hip screw (SHS), Outcome 5 Fracture fixation complications.
7.6
7.6. Analysis
Comparison 7 Pertrochanteric external fixator versus sliding hip screw (SHS), Outcome 6 Wound infection.
7.7
7.7. Analysis
Comparison 7 Pertrochanteric external fixator versus sliding hip screw (SHS), Outcome 7 Length of hospital stay (days).
7.8
7.8. Analysis
Comparison 7 Pertrochanteric external fixator versus sliding hip screw (SHS), Outcome 8 Final outcome measures.
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References

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Enskog 1999 {published data only}
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ChiCTR 2011 {unpublished data only}
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