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 (e.g. the sliding hip screw). OBJECTIVES To compare cephalocondylic intramedullary nails with extramedullary implants for extracapsular hip fractures in adults. SEARCH STRATEGY We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (June 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to June week 3 2007), EMBASE (1988 to 2007 Week 27), 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 36 included trials.Twenty-two trials (3871 participants) 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.Five trials (623 participants) 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. Three trials (394 participants) 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 trials compared the Targon PF nail versus SHS (60 participants); experimental mini-invasive static intramedullary nail versus SHS (60 participants); Kuntscher-Y nail versus SHS (230 participants); Gamma nail versus Medoff sliding plate (217 participants); and PFN versus Medoff sliding plate (203 participants). These trials provided insufficient evidence to establish differences between these implants. Two trials (65 participants 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 screw) 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).