
==== Front
Bone Jt Open
Bone Jt Open
BJO
Bone & Joint Open
2633-1462
The British Editorial Society of Bone & Joint Surgery London

10.1302/2633-1462.59.BJO-2024-0102
BJO-2024-0102
Editorial
Knowledge Translation
Social Media
Research
Impact
bj17439Traumabj11386Orthopaedic devicesbj9776Medical specialistsbj11416Orthopaedic treatmentsbj17570Trochanteric hip fracturebj13736Randomized controlled trialsbj17569Trochanteric fracturesbj11412Orthopaedic surgeonsbj5431Extracapsular hip fracturebj5443Extramedullary fixationbj15865Superficial infectionsbj9769Medical complicationsbj7814Intramedullary nailbj15089Sliding hip screwNail or plate for trochanteric hip fractures?
Parker Martyn J. MD, FRCS(Edin) Orthopaedic Consultant 1 Martyn.parker1@nhs.net

1 Department of Orthopaedics, Peterborough and Stamford Hospital NHS Foundation Trust, Peterborough City Hospital, Peterborough, UK
Correspondence should be sent to Martyn J. Parker. E-mail: Martyn.parker1@nhs.net
M. J. Parker received royalties from BBrawn related to the design and development of the Targon FN implant used for the treatment of intracapsular hip fractures, which are not included in this paper.

13 9 2024
9 2024
5 9 766767
© 2024 Parker.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ https://online.boneandjoint.org.uk/TDM This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/

Trochanteric hip fractures
trochanteric hip fractures
randomized controlled trials
trochanteric fractures
Orthopaedic surgeons
extracapsular hip fractures
extramedullary fixation
superficial infections
medical complications
intramedullary nail
sliding hip screw
odf2nlm-version2.0
price$2.00
principal-institutionPeterborough City Hospital, Peterborough, UK
article-typeEditorial
coi-statementM. J. Parker received royalties from BBrawn related to the design and development of the Targon FN implant used for the treatment of intracapsular hip fractures, which are not included in this paper.
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pmc­

Orthopaedic surgeons may be forgiven for being confused over the current advice on the preferred implant for trochanteric hip fractures; this is an area where there is ongoing research along with continual changes in implant design and surgical technique. In addition to the numerous case series reports, to date, 78 different randomized controlled trials (RCTs) involving 12,642 participants have compared nail versus plate fixation.1,2 National guidelines on this topic give conflicting advice, with the USA recommending an intramedullary nail for most extracapsular hip fractures,3 the National Institute for Health and Care Excellence (NICE) guidance from the UK recommending the sliding hip screw (SHS),4 and others recommending either method of treatment.5,6

Prior to 2000, there were clear advantages for the SHS with an increased risk of complications of surgical fixation for the nail. This was related primarily to implant breakage and fracture around the tip of the nail. With changes to the nail design, these differences have been reduced and there is a trend now, albeit not statistically significant, to fewer fixation failures with the nails.1

A notable finding that has emerged from a number of the RCTs is an improved recovery of mobility and a reduced dependence on walking aids for those treated with the nail fixation.1,2,7-12 The improvement is present for all fractures types (stable and unstable),13 and is more significant for those of good mobility prior to the injury. For those of limited mobility, those living in institutional care, or those with signifiant mental impairment prior to the fall, the differences are probably inconsequential.11,14 This improved recovery of mobility may be either due to the reduced tissue damage at surgery or, more likely, the presence of the proximal part of the nail within the femur limiting collapse occurring at the fracture site, enabling the fracture to heal in a closer to anatomical position. 15

A further proven benefit for the nails is the reduced risk of both superficial and deep wound infections. Summation of data from the RCTs gives figures for superficial infections of 73/2,853 (2.6%) versus 107/2,967 (3.6%) (risk ratio (RR) 0.71, 95% CI 0.53 to 0.95; p = 0.026) and for deep sepsis of 17/3,653 (0.47%) versus 30/3,654 (0.82%) (RR 0.57, 95% CI 0.31 to 1.03; p = 0.08).1 Other potential benefits that have been reported for nail fixation in some of the randomized studies are an improved Harris Hip Score,16 reduced operating blood loss, reduced blood transfusion, reduced operating times, and reduced nonunion rates. No difference in other outcomes for mortality, health-related quality of life measures, residual pain, hospital stay, and general medical complications have been identified.1

Concerns have been expressed about a possible increase in mortality for nail fixation.17 This risk does not apply for short nails used for trochanteric fractures, as the summation of the randomized trials clearly indicates no difference in mortality at any timepoints (one-year mortality nails 753/3,784 (19.9%) for nails vs 782/3,834 (20.4%) for plates (RR 0.99, 95% CI 0.90 to 1.08)).1 It is possible that any differences in mortality between nails and plates may be an issue for more complex fracture types and longer nail lengths, for which further studies are warranted.

Implant costs should also be considered as they tend to be higher for the nails. Implant prices do, however, vary substantially both nationally and locally. For the short nails used for trochanteric fractures, the differences in price between a nail and the SHS vary from being equivalent to being three to four times more for the nail. Local pricing structures will therefore dictate any cost-benefit analysis.

In summary, both the SHS and intramedullary nails are excellent and acceptable treatment methods for trochanteric fracture. In recent years, the developments in extramedullary fixation have failed to achieve any notable improvements in outcome,18 while the continued development for the nails has lead to a significant improvement, particularly in relation to the improved regain of mobility. There are still areas for research and development of the nails, including the optimum nail length, diameter, uni- versus biaxial fixation, reaming versus unreamed, and the need for distal locking. The continued increase in the use of the nails is to be expected, and we should anticipate further improvements will occur that will continue to improve the outcome for this large group of patients.

Author contributions

M. J. Parker: Writing – original draft, Writing – review & editing

Funding statement

The author received no financial or material support for the research, authorship, and/or publication of this article.

ICMJE COI statement

M. J. Parker received royalties from BBrawn related to the design and development of the Targon FN implant used for the treatment of intracapsular hip fractures, which are not included in this paper.

© 2024 Parker. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
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References

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2. Schemitsch EH Nowak LL Schulz AP et al. Intramedullary nailing vs sliding hip screw in trochanteric fracture management: the INSITE randomized clinical trial JAMA Netw Open 2023 6 6 e2317164 10.1001/jamanetworkopen.2023.17164 37278998
3. No authors listed Management of hip fractures in older adults evidence-based clinical practice guideline American Academy of Orthopaedic Surgeons 2021 https://www.aaos.org/hipfxcpg.pdf date last accessed 16 March 2023
4. No authors listed Hip fracture: management Clinical guideline (CG124) National Institute for Health and Clinical Excellence 2011 https://www.nice.org.uk/guidance/cg124 date last accessed 27 August 2024
5. Australian and New Zealand Hip Fracture Registry (ANZHFR) Steering Group 2014 https://anzhfr.org/wp-content/uploads/sites/1164/2021/12/ANZ-Guideline-for-Hip-Fracture-Care.pdf date last accessed 27 August 2024
6. Nationellt vårdprogram för höftfraktur Nationellt system for kunskapsstyrning Haslo- och sjukvard [published in Swedish] 2024 Nationellt-vardprogram-for-hoftfraktur.pdf date last accessed 19 August 2024
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12. Xu YZ Geng DC Mao HQ Zhu XS Yang HL A comparison of the proximal femoral nail antirotation device and dynamic hip screw in the treatment of unstable pertrochanteric fracture J Int Med Res 2010 38 4 1266 1275 10.1177/147323001003800408 20925999
13. Parker MJ Sliding hip screw versus intramedullary nail for trochanteric hip fractures; a randomised trial of 1000 patients with presentation of results related to fracture stability Injury 2017 48 12 2762 2767 10.1016/j.injury.2017.10.029 29102044
14. Ong JCY Gill JR Parker MJ Mobility after intertrochanteric hip fracture fixation with either a sliding hip screw or a cephalomedullary nail: sub group analysis of a randomised trial of 1000 patients Injury 2019 50 10 1709 1714 10.1016/j.injury.2019.06.015 31256911
15. Bretherton CP Parker MJ Femoral medialization, fixation failures, and functional outcome in trochanteric hip fractures treated with either a sliding hip screw or an intramedullary nail from within a randomized trial J Orthop Trauma 2016 30 12 642 646 10.1097/BOT.0000000000000689 27875489
16. Harris WH Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty: an end-result study using a new method of result evaluation J Bone Joint Surg Am 1969 51-A 4 737 755
17. Whitehouse MR Berstock JR Kelly MB et al. Higher 30-day mortality associated with the use of intramedullary nails compared with sliding hip screws for the treatment of trochanteric hip fractures Bone Joint J 2019 101-B 1 83 91 10.1302/0301-620X.101B1.BJJ-2018-0601.R2 30601043
18. Parker MJ Das A Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults Cochrane Database Syst Rev 2013 2013 2 CD000339 10.1002/14651858.CD000339.pub3 23450528
