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Meta-Analysis
. 2014 Sep 12;2014(9):CD004961.
doi: 10.1002/14651858.CD004961.pub4.

Intramedullary nails for extracapsular hip fractures in adults

Joseph M Queally  1 , Ella Harris, Helen H G Handoll, Martyn J Parker
Affiliations
Meta-Analysis

Intramedullary nails for extracapsular hip fractures in adults

Joseph M Queally et al. Cochrane Database Syst Rev. .

Abstract

Background: Intramedullary nails may be used for the surgical fixation of extracapsular hip fractures in adults. This is an update of a Cochrane review first published in 2005 and last updated in 2008.

Objectives: To assess the effects (benefits and harms) of different designs of intramedullary nails for treating extracapsular hip fractures in adults.

Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (6 January 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 12, 2013), MEDLINE (1966 to November Week 3, 2013), MEDLINE In-Process & Other Non-Indexed Citations (3 January 2014), EMBASE (1988 to 2014, Week 1) and the World Health Organization (WHO) International Clinical Trials Registry Platform (accessed January 2014).

Selection criteria: All randomised or quasi-randomised trials comparing different types, or design modifications, of intramedullary nails in the treatment of extracapsular hip fractures in adults.

Data collection and analysis: At least two review authors independently selected studies, assessed risk of bias and extracted data. We performed limited meta-analysis using the fixed-effect model.

Main results: We included eight new trials, testing seven new comparisons in this update. Overall, we included 17 trials, testing 12 comparisons of different cephalocondylic nail designs. The trials involved a total of 2130 adults (predominantly female and older people) with mainly unstable trochanteric fractures.All trials were at unclear risk of bias for most domains, with the majority at high risk of detection bias for subjective outcomes. The three quasi-randomised trials were at high risk for selection bias.Four trials (910 participants) compared the proximal femoral nail (PFN) with the Gamma nail. There was no significant difference between the two implants in functional outcome (the very low quality evidence being limited to results from single trials), mortality (low quality evidence: 86/415 versus 80/415; risk ratio (RR) 1.08, 95% confidence interval (CI) 0.82 to 1.41), serious fixation complications (operative fracture of the femur, cut-out, non-union and later fracture of the femur) nor re-operations (low quality evidence: 45/455 versus 36/455; RR 1.25, 95% CI 0.83 to 1.90).Two trials (185 participants) provided very low quality evidence of a lack of clinically significant difference in outcome (functional score, mortality, fracture fixation complications and re-operation) between the ACE trochanteric nail and the Gamma nail.Two trials (200 participants) provided very low quality evidence of a lack of significant difference in outcome (mobility score, pain, fracture fixation complications or re-operations) between the proximal femoral nail antirotation (PFNA) nail and the Gamma 3 nail.Seven of the nine trials evaluating different comparisons provided very low quality evidence of a lack of significant between-group differences in all of the reported main outcomes for the following comparisons: ACE trochanteric nail versus Gamma 3 nail (112 participants); gliding nail versus Gamma nail (80 participants); Russell-Taylor Recon nail versus long Gamma nail (34 participants, all under 50 years); proximal femoral nail antirotation (PFNA) nail versus Targon PF nail (80 participants); dynamically versus statically locked intramedullary hip screw (IMHS) nail (81 participants); sliding versus non-sliding Gamma 3 nail (80 participants, all under 60 years); and long versus standard PFNA nails (40 participants with reverse oblique fractures).The other two single comparison trials also provided very low quality evidence of a lack of significant between-group differences in all of the main outcomes with single exceptions. The trial (215 participants) comparing the ENDOVIS nail versus the IMHS nail found low quality evidence of poorer mobility in the ENDOVIS nail group, where more participants in this group were bedridden after their operation (29/105 versus 18/110; RR 1.69, 95% CI 1.00 to 2.85; P = 0.05). The trial (113 participants) comparing the InterTan nail versus the PFNA II nail found very low quality evidence that more PFNA II group participants experienced thigh pain (3/47 versus 12/46; RR: 0.24, 95% CI 0.07 to 0.81).

Authors' conclusions: The limited evidence from the randomised trials undertaken to date is insufficient to determine whether there are important differences in outcome between different designs of intramedullary nails used in treating extracapsular hip fractures. Given the evidence of superiority of the sliding hip screw compared with intramedullary nails for extracapsular hip fractures, further studies comparing different designs of intramedullary nails are not a priority. Any new design should be evaluated in a randomised comparison with the sliding hip screw.

PubMed Disclaimer

Conflict of interest statement

JQ: None known EH: None known HH: None known MJP: Has received royalties from B.Braun Ltd related to the design and development of an implant used for the internal fixation of intracapsular hip fractures. This implant and fracture type is not considered in this review.

Figures

1
1
Study flow diagram
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1 Proximal femoral nail (PFN) versus Gamma nail, Outcome 1 Mortality.
1.2
1.2. Analysis
Comparison 1 Proximal femoral nail (PFN) versus Gamma nail, Outcome 2 Final functional outcomes.
1.3
1.3. Analysis
Comparison 1 Proximal femoral nail (PFN) versus Gamma nail, Outcome 3 Harris hip scores (0 to 100: high values = best function).
1.4
1.4. Analysis
Comparison 1 Proximal femoral nail (PFN) versus Gamma nail, Outcome 4 Intra‐operative complications.
1.5
1.5. Analysis
Comparison 1 Proximal femoral nail (PFN) versus Gamma nail, Outcome 5 Fracture healing complications.
1.6
1.6. Analysis
Comparison 1 Proximal femoral nail (PFN) versus Gamma nail, Outcome 6 Re‐operation.
1.7
1.7. Analysis
Comparison 1 Proximal femoral nail (PFN) versus Gamma nail, Outcome 7 Wound complications.
1.8
1.8. Analysis
Comparison 1 Proximal femoral nail (PFN) versus Gamma nail, Outcome 8 Post‐operative complications.
1.9
1.9. Analysis
Comparison 1 Proximal femoral nail (PFN) versus Gamma nail, Outcome 9 Length of hospital stay (days).
1.10
1.10. Analysis
Comparison 1 Proximal femoral nail (PFN) versus Gamma nail, Outcome 10 Operative details: length of surgery and blood loss.
1.11
1.11. Analysis
Comparison 1 Proximal femoral nail (PFN) versus Gamma nail, Outcome 11 Number of patients transfused.
2.1
2.1. Analysis
Comparison 2 ACE trochanteric nail versus Gamma nail, Outcome 1 Mortality.
2.2
2.2. Analysis
Comparison 2 ACE trochanteric nail versus Gamma nail, Outcome 2 Final functional outcomes.
2.3
2.3. Analysis
Comparison 2 ACE trochanteric nail versus Gamma nail, Outcome 3 Mobility score (0: no difficulties to 9: most difficulties).
2.4
2.4. Analysis
Comparison 2 ACE trochanteric nail versus Gamma nail, Outcome 4 Harris hip score (1 to 100: high values = best function).
2.5
2.5. Analysis
Comparison 2 ACE trochanteric nail versus Gamma nail, Outcome 5 Fracture healing complications.
2.6
2.6. Analysis
Comparison 2 ACE trochanteric nail versus Gamma nail, Outcome 6 Wound complications.
2.7
2.7. Analysis
Comparison 2 ACE trochanteric nail versus Gamma nail, Outcome 7 Post‐operative complications.
2.8
2.8. Analysis
Comparison 2 ACE trochanteric nail versus Gamma nail, Outcome 8 Anatomical restoration.
2.9
2.9. Analysis
Comparison 2 ACE trochanteric nail versus Gamma nail, Outcome 9 Operative details: length of surgery, blood loss and radiographic screening time.
2.10
2.10. Analysis
Comparison 2 ACE trochanteric nail versus Gamma nail, Outcome 10 Number of patients transfused.
3.1
3.1. Analysis
Comparison 3 ACE trochanteric nail versus the Gamma 3 nail, Outcome 1 Mortality at 1 year.
3.2
3.2. Analysis
Comparison 3 ACE trochanteric nail versus the Gamma 3 nail, Outcome 2 Fracture healing complications.
3.3
3.3. Analysis
Comparison 3 ACE trochanteric nail versus the Gamma 3 nail, Outcome 3 Post‐operative complications.
4.1
4.1. Analysis
Comparison 4 Gliding nail versus Gamma nail, Outcome 1 Mortality at 6 months.
4.2
4.2. Analysis
Comparison 4 Gliding nail versus Gamma nail, Outcome 2 Residence and unfavourable outcome (geriatric institution or death) at 6 months.
4.3
4.3. Analysis
Comparison 4 Gliding nail versus Gamma nail, Outcome 3 Fracture fixation complications.
4.4
4.4. Analysis
Comparison 4 Gliding nail versus Gamma nail, Outcome 4 Post‐operative complications.
4.5
4.5. Analysis
Comparison 4 Gliding nail versus Gamma nail, Outcome 5 Anatomical deformity.
5.1
5.1. Analysis
Comparison 5 ENDOVIS nail versus intramedullary hip screw (IMHS), Outcome 1 Unable to walk (bedridden) post‐operatively.
5.2
5.2. Analysis
Comparison 5 ENDOVIS nail versus intramedullary hip screw (IMHS), Outcome 2 Mortality.
5.3
5.3. Analysis
Comparison 5 ENDOVIS nail versus intramedullary hip screw (IMHS), Outcome 3 Fracture fixation complications.
5.4
5.4. Analysis
Comparison 5 ENDOVIS nail versus intramedullary hip screw (IMHS), Outcome 4 Number of patients transfused.
6.1
6.1. Analysis
Comparison 6 Russell‐Taylor Recon nail versus long Gamma nail, Outcome 1 Final outcome measures.
6.2
6.2. Analysis
Comparison 6 Russell‐Taylor Recon nail versus long Gamma nail, Outcome 2 Fracture healing and wound healing complications.
7.1
7.1. Analysis
Comparison 7 PFNA versus Targon PF nail, Outcome 1 Fracture fixation complications.
8.1
8.1. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 1 Mortality (12 months).
8.2
8.2. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 2 Harris hip score (1 to 100; higher values = best function).
8.3
8.3. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 3 Mobility at 12+ months (Parker and Palmer mobility score: 0 to 9: best).
8.4
8.4. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 4 Recovery of pre‐operative mobility (12+ months).
8.5
8.5. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 5 SF‐36 Physical Health (0 to 100; higher scores = best function).
8.6
8.6. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 6 SF‐36 Mental Health (0 to 100; higher scores = best function).
8.7
8.7. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 7 Katz ADL score at 12 months (0 to 6; higher score = best function).
8.8
8.8. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 8 Range of hip flexion (degrees).
8.9
8.9. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 9 Thigh pain at 12 months (Numeric pain scale, 1 to 10, higher scores = most pain).
8.10
8.10. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 10 Hip or thigh pain (12+ months).
8.11
8.11. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 11 Fracture fixation complications.
8.12
8.12. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 12 Post‐operative complications.
8.13
8.13. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 13 Sangha Score at 1 year (1 to 6; higher score = more comorbidity).
8.14
8.14. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 14 Length of stay (days).
8.15
8.15. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 15 Femoral shortening.
8.16
8.16. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 16 Operative details.
8.17
8.17. Analysis
Comparison 8 PFNA versus Gamma 3 nail, Outcome 17 Number of patients transfused.
9.1
9.1. Analysis
Comparison 9 Dynamic versus static locked intramedullary nail, Outcome 1 Mortality at 1 year.
9.2
9.2. Analysis
Comparison 9 Dynamic versus static locked intramedullary nail, Outcome 2 Pain and cortical hypertrophy.
9.3
9.3. Analysis
Comparison 9 Dynamic versus static locked intramedullary nail, Outcome 3 Fracture fixation complications.
9.4
9.4. Analysis
Comparison 9 Dynamic versus static locked intramedullary nail, Outcome 4 Leg shortening (mm) in those able to undergo a radiographic assessment.
9.5
9.5. Analysis
Comparison 9 Dynamic versus static locked intramedullary nail, Outcome 5 Operative details.
10.1
10.1. Analysis
Comparison 10 Sliding versus non‐sliding lag screw for Gamma 3 nail, Outcome 1 Harris hip score (0 to 100: high values = best function).
10.2
10.2. Analysis
Comparison 10 Sliding versus non‐sliding lag screw for Gamma 3 nail, Outcome 2 Fracture fixation complications.
10.3
10.3. Analysis
Comparison 10 Sliding versus non‐sliding lag screw for Gamma 3 nail, Outcome 3 Average healing time (months).
10.4
10.4. Analysis
Comparison 10 Sliding versus non‐sliding lag screw for Gamma 3 nail, Outcome 4 Operative details.
10.5
10.5. Analysis
Comparison 10 Sliding versus non‐sliding lag screw for Gamma 3 nail, Outcome 5 Length of stay (days).
10.6
10.6. Analysis
Comparison 10 Sliding versus non‐sliding lag screw for Gamma 3 nail, Outcome 6 Leg length discrepancy (mm) ('Group C' ‐ unstable fractures ‐ only).
11.1
11.1. Analysis
Comparison 11 InterTan nail versus the PFNA II nail, Outcome 1 Mortality (1 year).
11.2
11.2. Analysis
Comparison 11 InterTan nail versus the PFNA II nail, Outcome 2 Final functional outcomes.
11.3
11.3. Analysis
Comparison 11 InterTan nail versus the PFNA II nail, Outcome 3 Hip and thigh pain.
11.4
11.4. Analysis
Comparison 11 InterTan nail versus the PFNA II nail, Outcome 4 Fracture fixation complications.
11.5
11.5. Analysis
Comparison 11 InterTan nail versus the PFNA II nail, Outcome 5 Time to fracture healing (weeks).
11.6
11.6. Analysis
Comparison 11 InterTan nail versus the PFNA II nail, Outcome 6 Post‐operative complications.
11.7
11.7. Analysis
Comparison 11 InterTan nail versus the PFNA II nail, Outcome 7 Length of stay (days).
11.8
11.8. Analysis
Comparison 11 InterTan nail versus the PFNA II nail, Outcome 8 Operative details.
12.1
12.1. Analysis
Comparison 12 Long versus standard proximal femoral nail antirotation (PFNA nail), Outcome 1 Mortality (1 year).
12.2
12.2. Analysis
Comparison 12 Long versus standard proximal femoral nail antirotation (PFNA nail), Outcome 2 Final functional outcomes.
12.3
12.3. Analysis
Comparison 12 Long versus standard proximal femoral nail antirotation (PFNA nail), Outcome 3 Fracture fixation complications.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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References to studies excluded from this review

Cao 2009 {published data only}
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References to studies awaiting assessment

Mora 2011 {published data only}
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NCT01437176 {unpublished data only}
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