Treatment of trochanteric and subtrochanteric hip fractures: Sliding hip screw or intramedullary nail?

Abstract

Background: Trochanteric and subtrochanteric fractures are usually treated with a sliding hip screw (SHS) or an intramedullary (IM) nail, and the question whether a SHS or an IM nail should be the preferred implant for all or subgroups of fractures has not come to a final conclusion. In recent years, there has been a trend towards more use of IM nails, but this trend has not been driven by better results in well designed clinical trials. Regardless of type of implant, complications have to be encountered and to which extent modern implants have improved results remains unclear. Aims: It was our first aim to assess whether treatment with the new TRIGEN INTERTAN intramedullary nail resulted in less postoperative pain, better function, and improved quality of life for patients with trochanteric and subtrochanteric fractures compared to treatment with the SHS (Papers I and IV). Surgical complications and reoperation rates were also assessed. Secondly, we wanted to compare postoperative pain, function, quality of life, and reoperation rates for patients operated with IM nails and SHS for different subgroups of trochanteric and subtrochanteric fractures at a national level (Papers II and III). Patients and methods: 684 elderly patients with trochanteric and subtrochanteric fractures were included and treated with a SHS or the Intertan nail in a multicenter randomized controlled trial (RCT) (Paper I). The patients were assessed during hospital stay and at 3 and 12 months postoperatively. The 159 patients with reverse oblique trochanteric (AO/OTA type A3) and subtrochanteric fractures were separately analyzed and discussed in depth (Paper IV). Using data from the Norwegian Hip Fracture Register in papers II and III, we analyzed 7643 operations for simple two-part trochanteric fractures (AO/OTA type A1) (Paper II) and 2716 operations for reverse oblique and subtrochanteric fractures (Paper III) after treatment with either a SHS or an IM nail. Results: As presented in Papers I and IV patients operated with the Intertan nail had slightly less pain at early postoperative mobilization compared to those operated with a SHS, but we found no difference at 12 months. Regardless of fracture type, mobility, hip function, quality of life, and surgical complication rates were comparable for the two groups at 12 months. In simple two-part trochanteric fractures (Paper II) the SHSs had a lower complication rate compared to IM nails one year postoperatively (2.4% and 4.2% for SHS and IM nail, respectively, p = 0.001). Only minor, and clinically insignificant differences between the groups were found for pain, patient satisfaction, and quality of life. In Paper III, conversely, we found that the patients operated with an IM nail had a significantly lower failure rate compared to the SHS one year postoperatively (3.8% vs. 6.4%, respectively, p = 0.011). Small differences regarding pain, patient satisfaction, quality of life, and mobility were also in favor of IM nailing. Conclusions: Pain, function, quality of life, and reoperation rates were similar for the Intertan nail and the SHS in trochanteric and subtrochanteric fractures 12 months postoperatively. Data from our hip fracture register, however, favored the SHS in simple two- part trochanteric fractures, whereas IM nails had the lower complication rate and better clinical results in reverse oblique and subtrochanteric fractures. Accordingly, a differentiated treatment algorithm based on fracture type could be considered.