There were 3 high (Miedel 2005, Schipper 2004, Zehir 2015), and 6 moderate quality (Arktelis 2014, Fernandez 2017, Griffin 2016, Hardy 1998, Reindle 2015, Tao 2013) studies evaluating the use of cephalomedullary devices in the treatment of unstable intertrochanteric and subtrochanteric fractures. Although many comparative studies have been done, the variability of fracture classification systems and implants used makes interpretation of the literature challenging. Evaluation of these studies shows an apparent treatment benefit with cephalomedullary devices for unstable peritrochanteric fractures compared to extramedullary devices.
One high strength comparative study (Schipper 2004) showed similar results and outcomes between different cephalomedullary devices in unstable fractures.
Another high strength study (Miedel 2005) demonstrated a lower complication rate with use of a cephalomedullary versus an extramedullary device in treatment of unstable intertrochanteric and subtrochanteric fractures. Another moderate strength study (Hardy 1998) showed improved mobility and decreased limb shortening in unstable intertrochanteric fractures treated with a cephalomedullary device versus a sliding hip screw.
Benefits/Harms of Implementation
There are no known harms associated with implementing this recommendation.
Future Research
Continued comparative studies between modern cephalomedullary and extramedullary devices in unstable subtrochanteric and reverse obliquity fractures (OTA 31.A3) which control for fracture reduction and implant position (specifically tip-to-apex distance) may further clarify the utility of cephalomedullary devices for this fracture cohort.
- Tao, R., Lu, Y., Xu, H., Zhou, Z. Y., Wang, Y. H., Liu, F. Internal fixation of intertrochanteric hip fractures: a clinical comparison of two implant designs. Thescientificworldjournal 2013; 0: 834825
- Reindl, R., Harvey, E. J., Berry, G. K., Rahme, E., Canadian Orthopaedic Trauma, Society Intramedullary Versus Extramedullary Fixation for Unstable Intertrochanteric Fractures: A Prospective Randomized Controlled Trial. Journal of Bone & Joint Surgery - American Volume 2015; 23: 1905-12
- Hardy, D. C., Descamps, P. Y., Krallis, P., Fabeck, L., Smets, P., Bertens, C. L., Delince, P. E. Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures. A prospective, randomized study of one hundred patients. Journal of Bone & Joint Surgery - American Volume 1998; 5: 618-30
- Griffin, X. L., Parsons, N., McArthur, J., Achten, J., Costa, M. L. The Warwick Hip Trauma Evaluation One: a randomised pilot trial comparing the X-Bolt Dynamic Hip Plating System with sliding hip screw fixation in complex extracapsular hip fractures: WHiTE (One). Bone & Joint Journal 2016; 5: 686-9
- Fernandez, M. A., Aquilina, A., Achten, J., Parsons, N., Costa, M. L., Griffin, X. L. The tip-apex distance in the X-Bolt dynamic plating system. 2017; 4: 204-207
- Aktselis, I., Kokoroghiannis, C., Fragkomichalos, E., Koundis, G., Deligeorgis, A., Daskalakis, E., Vlamis, J., Papaioannou, N. Prospective randomised controlled trial of an intramedullary nail versus a sliding hip screw for intertrochanteric fractures of the femur. International Orthopaedics 2014; 1: 155-61
- Zehir, S., Zehir, R., Zehir, S., Azboy, I., Haykir, N. Proximal femoral nail antirotation against dynamic hip screw for unstable trochanteric fractures; a prospective randomized comparison. European Journal of Trauma & Emergency Surgery 2015; 4: 393-400
- Schipper, I. B., Steyerberg, E. W., Castelein, R. M., van der Heijden, F. H., den Hoed, P. T., Kerver, A. J., van Vugt, A. B. Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail. Journal of Bone & Joint Surgery - British Volume 2004; 1: 86-94
- Miedel, R., Ponzer, S., Törnkvist, H., Söderqvist, A., Tidermark, J. The standard Gamma nail or the Medoff sliding plate for unstable trochanteric and subtrochanteric fractures. A randomised, controlled trial. Journal of Bone & Joint Surgery - British Volume 2005; 1: 68-75