Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures.

BACKGROUND: Cephalocondylic intramedullary nails which are inserted proximally to distally (cephalocondylic) have been used for the surgical treatment of extracapsular hip fractures.

OBJECTIVES: To compare all cephalocondylic intramedullary nails with extramedullary implants for the surgical treatment of extracapsular hip fractures in adults. This is the third substantive update of our original review which compared the Gamma nail with the sliding hip screw (SHS).

SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE, select orthopaedic journals and conference proceedings, and reference lists of relevant articles. We contacted trialists, colleagues and implant manufacturers. Date of the most recent search: August 2002.

SELECTION CRITERIA: All randomised and quasi-randomised trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures.

DATA COLLECTION AND ANALYSIS: Both reviewers independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, results were pooled.

MAIN RESULTS: Seventeen trials comparing the Gamma nail with the SHS were included, with data available for 2472 patients. The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased re-operation rate. There were no major differences in the incidence of wound infection, mortality or medical complications between implants. Data were inadequate for other outcomes. Five trials involving 623 patients compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group: all cases of operative and later fracture of the femur occurred in this group. Results for post-operative complications, mortality and functional outcomes were similar in the two groups. One study of 206 patients with a trochanteric fracture showed no advantages for proximal femoral nail (PFN) compared with the SHS. One trial of 60 patients reported favourable preliminary results for an experimental mini-invasive static intramedullary nail compared with the SHS. The one trial of 230 patients comparing the Kuntscher-Y nail with the SHS, reported no major difference the outcome aside from a significantly increased number of patients with leg shortening, and a tendency for poorer recovery of mobility in the Kuntscher-Y nail group. Two trials, involving 65 patients with reverse and transverse fractures at the level of the lesser trochanter, compared an intramedullary nail (Gamma or PFN nail) with an extramedullary implant (a 90-degree blade plate or dynamic condylar plate). The intramedullary nails were associated with better intra-operative results and fewer fracture fixation complications for these rare fractures.

REVIEWER'S CONCLUSIONS: Given the lower complication rate of the SHS in comparison with intramedullary nails, it appears that for trochanteric fractures the SHS is superior. Further studies will be required to determine if different types of intramedullary nail produce the same results, or if intramedullary nails have advantages for selected fracture types, for example, reversed fracture lines and subtrochanteric fractures. From the evidence available, IMHS appears to have the same problems as the Gamma nail, but other theoretical advantages of the IHMS cannot be ruled out.