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

BACKGROUND: Two types of implants used for the surgical fixation of extracapsular hip fractures are cephalocondylic intramedullary nails, which are inserted into the femoral canal proximally to distally across the fracture, and extramedullary implants.

OBJECTIVES: To compare cephalocondylic intramedullary nails with extramedullary implants (e.g. the sliding hip screw) for extracapsular hip fractures in adults.

SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (June 2005), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the UK National Research Register, orthopaedic journals, conference proceedings and reference lists of articles.

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

DATA COLLECTION AND ANALYSIS: Both authors independently assessed trial quality and extracted data. Wherever appropriate, results were pooled.

MAIN RESULTS: Predominantly older people with mainly trochanteric fractures were treated in the 32 included trials. Twenty trials, involving 3646 people, compared the Gamma nail with the sliding hip screw (SHS). The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased reoperation rate. There were no major differences between implants in the wound infection, mortality or medical complications. Data were inadequate for other outcomes. Five trials, involving 623 people, 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. Two trials involving 314 people showed no difference in fracture fixation complications, reoperation, wound infection and length of hospital stay for proximal femoral nail (PFN) compared with the SHS. Single trial comparisons (experimental mini-invasive static intramedullary nail compared with the SHS: 60 participants; Kuntscher-Y nail with the SHS: 230 participants; Gamma nail and the Medoff sliding plate: 217 participants) failed to provide sufficient evidence to establish differences between implants in outcome. Two trials, involving 65 people with reverse and transverse fractures at the level of the lesser trochanter, found intramedullary nails (Gamma nail or PFN) were associated with better intra-operative results and fewer fracture fixation complications than extramedullary implants (a 90-degree blade plate or dynamic condylar plate) for these fractures.

AUTHORS' CONCLUSIONS: Given the lower complication rate of the SHS in comparison with intramedullary nails, SHS appears superior for trochanteric fractures. Further studies are required to determine if different types of intramedullary nail produce similar results, or if intramedullary nails have advantages for selected fracture types (for example, subtrochanteric fractures).