Condylocephalic nails versus extramedullary implants for extracapsular hip fractures

  • Review
  • Intervention

Authors

  • Martyn J Parker,

    Corresponding author
    1. Peterborough and Stamford Hospitals NHS Foundation Trust, Orthopaedic Department, Peterborough, Cambridgeshire, UK
    • Martyn J Parker, Orthopaedic Department, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough District Hospital, Thorpe Road, Peterborough, Cambridgeshire, PE3 6DA, UK. martyn.parker@pbh-tr.nhs.uk.

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  • Helen HG Handoll

    1. University of Teesside, Centre for Rehabilitation Sciences (CRS), Research Institute for Health Sciences and Social Care, Middlesborough, Tees Valley, UK
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Abstract

Background

Two types of implants used for the surgical fixation of extracapsular hip fractures are condylocephalic nails (intramedullary nails that are inserted up through the femoral canal from above the knee and across the fracture) and extramedullary implants.

Objectives

To compare condylocephalic nails (e.g. Ender and Harris nails) with extramedullary implants (e.g. fixed nail plates and sliding hip screws) for the treatment of extracapsular (trochanteric and subtrochanteric) hip fracture in adults.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2004), MEDLINE (1966 to September week 1 2004), EMBASE, the UK National Research Register, orthopaedic journals, conference proceedings and reference lists of articles.

Selection criteria

Randomised or quasi-randomised trials comparing condylocephalic nails with extramedullary implants.

Data collection and analysis

We independently assessed trial quality and extracted data. Ender nails and Harris nail data were presented separately. Results from fixed nail plates and sliding hip screws were subgrouped.

Main results

Eleven trials involving 1667 people with predominantly trochanteric fractures were included. Ten compared Ender nails with either a fixed nail plate or a sliding hip screw. One compared the Harris condylocephalic nail with a sliding hip screw.

The only advantages of condylocephalic nails were a reduced deep wound sepsis rate (0.9% versus 4.2%; relative risk 0.28, 95% confidence interval 0.11 to 0.62), length of surgery and operative blood loss. However, there was an increased risk of reoperation (20.9% versus 5.5%; relative risk 3.72, 95% confidence interval 2.54 to 5.44) and later fracture of the femur when compared with extramedullary implants. There was an increased risk of cut-out of the implant from the femoral head for Ender nails compared with the sliding hip screw, but not for fixed nail plates. Backing out of the nail was a frequent complication (30%) of Ender nails and often resulted in revision surgery.

Ender nails had an increased risk of shortening of the leg and external rotation deformity and potentially a poorer return to previous walking ability. An increase in residual pain, predominantly knee pain, was also evident in patients undergoing condylocephalic nailing. There was no apparent difference in mortality between the condylocephalic nail and extramedullary implant groups.

Authors' conclusions

Any advantages in intra-operative outcomes of condylocephalic nails are outweighed by the increase in fracture healing complications, reoperation rate, residual pain and limb deformity when compared with an extramedullary implant, particularly a sliding hip screw. The use of condylocephalic nails (in particular Ender nails), for trochanteric fracture is no longer appropriate.

摘要

背景

在關節囊外的髖關節骨折中,使用髁頭釘與髓外置入物的比較釘與髓外置入物的比較

condylocephalic釘(從膝蓋上方由下往上經由股骨髓腔跨越骨折處的髓內釘)與髓外置入物,分別是兩種關節囊外髖關節骨折的手術固定中所使用的置入物

目標

比較 condylocephalic釘(例如Ender釘及哈Harris釘)與髓外置入物(例如固定的骨釘鋼板或是可滑動的髖螺釘)在治療成人關節囊外髖關節骨折(轉子間或轉子下方的骨折)的差異

搜尋策略

我們檢索了閣麟肌肉損傷組專門登記冊(2004年9月),閣中心的對照試驗註冊庫(閣麟圖書館第3期,2004年),全文(1966年至2004年9月第一週),醫學文摘庫,英國國家研究註冊,矯形期刊,會議記錄和參考文獻目錄的文章。

選擇標準

比較 condylaocephalic釘和骨髓外固定物的隨機或半隨機試驗。

資料收集與分析

我們分別評估試驗質量和提取數據,將 Ender釘和Harris釘的數據分別獨立呈現。而從固定釘板和滑動髖螺釘所得到的結果則分到同一個組別再做細分。

主要結論

在包含了1667位(主要為股骨轉子骨折)病人的11個試驗中。有十個試驗是比較Ender釘和固定的骨釘骨板或滑動髖螺釘的差異,一個比較Harris condylocephalic釘和可滑動髖螺釘的差異。使用condylocephalic釘唯一的好處在於較低的深部感染率(0.9%和4.2%;相對危險度0.28,95%可信區間 0.11至0.62)、較短的手術時間與較少的出血。此外比起使用髓外固定器,使用condylocephalic釘也有比較大的風險需要進行再次手術(20.9% versus 5.5%; relative risk 3.72, 95% confidence interval 2.54 to 5.44) ,以及更高的後續股骨骨折的風險。和可滑動髖螺釘比起來,使用Ender condylocephalic釘有較高的風險會從股骨頭穿出,但和固定骨釘骨板相比則沒有此現象。使用Ender釘有較高的併發症發生率(30%),而且這些併發症常需要再次手術來處理。Ender釘有較高的風險會造成肢體變短、外旋變形,而且可能回覆到之前行走能力的機會也較差。使用condylocephalic釘還會面臨較多的殘餘疼痛,尤其是膝蓋疼痛。不論是使用condylocephalic nail或是骨髓外固定器,兩者在死亡率上並沒有差異。

作者結論

和骨髓外固定物比起來(尤其是可滑動寬螺釘),使用condylocephalic釘在手術中所得到的優勢,會被術後增加的骨折癒合時的併發症、需要再手術的比率、殘餘疼痛和肢體畸形較所抵消。 在股骨轉子骨折使用condylocephalic釘)特別是Ender釘),不再是適當的作法了。

翻譯人

本摘要由臺灣大學附設醫院賴昆鴻翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

使用Ender釘來治療髖部骨折的病人,術後會發生較多的併發症。髖部骨折是指發生在接近大腿骨上端的骨折。若骨折位置離髖關節更遠點,我們稱為關節囊外的骨折,這類的骨折可以使用金屬固定物來進行手術治療。在此我們比較兩種固定物—Condylocephalic釘(例如Ender釘)是從膝蓋上方由下往上經由股骨髓腔跨越骨折處的髓內釘;髓外固定器則包含一個固定在骨股骨折近端的螺釘或金屬杆,跨過骨折處連結股骨遠端貼著骨頭的骨板。這篇回顧發現,儘管使用Ender釘的手術時間較短,和髓外固定器相比,他有較高的併發症發生率與較高的再手術的風險。

Plain language summary

Condylocephalic nails versus extramedullary implants for extracapsular hip fractures

A hip fracture is a break near the top of the thigh bone (femur). Those located further away from the hip joint are termed extracapsular. Such fractures may be surgically fixed using metal implants. Two types of implant are compared here. Condylocephalic nails, such as Ender nails, are inserted near the knee, and pushed up through the bone marrow of the femur and across the fracture site. Extramedullary implants consist of a screw or rod, inserted in the upper part of the femur to bridge the fracture, connected to a plate secured to the femur. This review found that, despite quicker surgery, Ender nails were associated with an increased risk of complications and reoperation when compared with extramedullary implants in common use.