Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults
Abstract
Background
Extramedullary fixation of hip fractures involves the application of a plate and screws to the lateral side of the proximal femur. In external fixators, the stabilising component is held outside the thigh by pins or screws driven into the bone.
Objectives
To compare different types of extramedullary fixation implants and external fixators for fixing extracapsular hip fracture in adults.
Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2005), various other databases, conference proceedings and reference lists.
Selection criteria
All randomised or quasi‐randomised controlled trials comparing extramedullary implants or external fixators for fixing extracapsular hip fracture in adults.
Data collection and analysis
Two authors independently selected trials, assessed trial quality and extracted data. Data were pooled where appropriate.
Main results
The 14 included trials tested seven comparisons in a total of 2222 mainly female and older participants. All trials had methodological flaws that may affect the validity of their results.
Three trials comparing a fixed nail plate (Jewett or McLaughlin) with the sliding hip screw (SHS) found an increased risk of fixation failure for fixed nail plates.
The two trials comparing the Resistance Augmented Bateaux (RAB) plate with the SHS had contrasting results, notably in terms of operative complications, fixation failure and anatomical restoration.
One trial comparing the Pugh nail and the SHS found no significant difference between implants.
Two trials compared the Medoff plate with the SHS. One trial reported higher blood losses and longer operation times for the Medoff plate. There was a lower risk of fixation failure with the Medoff plate for unstable trochanteric fractures.
Two trials compared the Medoff plate with three different screw‐plate systems. There were no statistically significant differences in outcome for trochanteric fractures. For subtrochanteric fractures, there was a lower fixation failure rate for the Medoff plate, but no evidence for differences in longer‐term outcomes.
Two trials comparing the Gotfried percutaneous plate with a SHS found a reduced blood loss with the Gotfried plate. A higher intra‐operative fixation failure rate of the Gotfried plate may indicate some restriction to its use.
Two trials found less operative trauma for external fixation when compared with the SHS. Final outcome appeared similar.
Authors' conclusions
The markedly increased fixation failure rate of fixed nail plates compared with the SHS is a major consideration and thus the SHS appears preferable.
There was insufficient evidence from other comparisons to draw definite conclusions.
Plain language summary
Fracture fixation devices secured across the fracture that are placed either directly or externally for treating hip fractures located outside the hip joint
Hip fractures located outside the hip joint capsule (extracapsular hip fractures) may be surgically fixed using metal implants. Often these are extramedullary devices consisting of a screw or rod, inserted in the upper part of the thigh bone (femur) to bridge (fix) the fracture, connected to a plate secured to the femur. Sometimes external fixators are used. In these, the stabilising component is held outside the thigh by pins or screws driven into the bone on either side of the fracture.
The 14 randomised controlled trials included in this review tested seven comparisons in a total of 2222 mainly female and older participants. All trials had methodological flaws that may affect the validity of their results and there was a general lack of evidence on long‐term effects and functional recovery. Some extramedullary implants appeared to be associated with an increased risk of fixation complications and reoperation. In particular, three trials comparing a fixed nail plate (Jewett or McLaughlin) with the sliding hip screw (the 'standard' extramedullary device for these fractures) found an increased risk of fixation failure for fixed nail plates. Less invasive implants, such as the external fixator, which require smaller incisions resulted in less blood loss and often quicker operations than the sliding hip screw.
We concluded that the sliding hip screw seems preferable to older types of fixed nail plates given their high rate of implant and fixation failure. However, there was not enough evidence to draw conclusions for other comparisons of extramedullary implants or on the use of external fixators.
