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Osteotomy, compression and other modifications of surgical techniques for internal fixation of extracapsular hip fractures

  1. Martyn J Parker1,*,
  2. Helen HG Handoll2

Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

Published Online: 15 APR 2009

Assessed as up-to-date: 29 MAR 2008

DOI: 10.1002/14651858.CD000522.pub2


How to Cite

Parker MJ, Handoll HHG. Osteotomy, compression and other modifications of surgical techniques for internal fixation of extracapsular hip fractures. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD000522. DOI: 10.1002/14651858.CD000522.pub2.

Author Information

  1. 1

    Peterborough and Stamford Hospitals NHS Foundation Trust, Orthopaedic Department, Peterborough, Cambridgeshire, UK

  2. 2

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

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 15 APR 2009

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Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

Hip fracture is the general term for fracture of the proximal (upper) femur. These fractures can be subdivided into intracapsular fractures (those occurring within or proximal to the attachment of the hip joint capsule to the femur) and extracapsular (those occurring outside or distal to the hip joint capsule). Extracapsular hip fractures are defined as those fractures that occur within the area of bone bounded by the attachment of the hip joint capsule and extending down to a level which is five centimetres below the distal (lower) border of the lesser trochanter. Other terms used to describe these fractures include trochanteric, subtrochanteric, pertrochanteric and intertrochanteric fractures. These terms reflect the proximity of these fractures to the greater and lesser trochanters, which are two bony protuberances (bulges) at the upper end of the femur outside the joint capsule. These fractures can be subdivided into 'stable' and 'unstable' fractures (Evans 1949; Jenson 1980). Stable fractures are two part fractures, whilst unstable fractures are comminuted with more than two parts to the fractures.

In centres with appropriate surgical facilities, most intertrochanteric fractures are treated operatively (Handoll 2008). The most common implant used for internal fixation of these fractures is the sliding hip screw (SHS). This implant consists of a screw which is passed up the femoral neck to the femoral head connected to a plate on the femur. The SHS is equivalent to the Compression, Dynamic, Richards or Ambi hip screws. These are considered 'dynamic' implants as they have the capacity for sliding at the plate/screw junction to allow for collapse at the fracture site.

Fixed nail plates consist of a nail, which is passed up the femoral neck to the femoral head, connected to a plate on the femur. These implants have no capacity for sliding to compensate for collapse at the fracture site and hence are termed 'static' or 'fixed' implants.

The Gamma nail is an intramedullary nail used in the treatment of extracapsular proximal femoral fractures. The implant consists of a sliding lag screw which passes through a short intramedullary nail. The nail is inserted via an entry hole in the greater trochanter and passed distally. Prior to nail insertion the femur has to be reamed to accommodate the nail, with some further reaming for the sliding lag screw.

Many different technical aspects of surgical fixation exist. These include surgical approach to the femur, reduction of the fracture, osteotomy of the femur, reaming of the femur, positioning of the lag screw and compression of the fracture. In addition, there is the use of substances, either inserted at the fracture site or coated on the implant, that are used to enhance the fixation of the fracture. This review update continues to examine only those aspects of surgical fixation of an extracapsular fracture that have been studied within a randomised trial. Trials comparing different implants are considered in other Cochrane reviews of extracapsular hip fractures: extramedullary fixation (Parker 2006b), arthroplasty (Parker 2006a), condylocephalic (e.g. Ender nail) nails (Parker 1998) and cephalocondylic (e.g. Gamma nail) nails (Parker 2008).

 

Osteotomy of the femur

Prior to fixation of a displaced extracapsular fractures it is routine practice to reduce the fracture before it is fixed. This is generally achieved using traction to the injured limb applied using a fracture table. Either an anatomical or slight over reduction (valgus reduction) is generally used. In addition to fracture reduction, for unstable fractures it has been suggested that an osteotomy around the fracture site alters the fracture configuration to a more stable pattern and thereby reduces the risk of fixation failure. Two different types of osteotomy have been described. Dimon 1967 described a transverse osteotomy at the level of the lesser trochanter: the femur is then displaced medially with the medial cortex of the proximal fragment inserted into the femoral shaft. This is also termed a medial displacement osteotomy. Sarmiento 1970 described a valgus osteotomy, which is an oblique osteotomy from the greater to lesser trochanter. The theoretical benefit of these osteotomies is that they will reduce the degree of collapse that occurs at the fracture site and thereby the risk of fixation failure.

 

Compression of the fracture

Compression of the fracture site has been advocated as a method of reducing any gap at the fracture surfaces and thus reducing the time it takes for the fracture to heal and the risk of fixation failure.

 

Reaming of the femur

Reaming of the femur prior to insertion of the lag screw during SHS fixation of proximal femoral fracture is undertaken with a power drill and triple reamer. The reamers are used to create a cavity within the medullar cavity of the bone into which the fixation device can be placed. The friction caused by this will generate heat which may damage the surrounding bone (Eriksson 1984). Calder 1995a described a modification to the reaming technique where the outer cortex is drilled with the reamer set to its minimum length of 60 millimetres. The reamer is then reset as normal and the bone in the femoral neck and head reamed. This process reduces the amount of time the reamer tip is within the femoral head.

For an intramedullary nail, as well as reaming for the lag screw, the proximal femoral medullary cavity needs to be reamed to accommodate the nail. This is generally undertaken with power reamers. One effect of this reaming is that the bone marrow components are forced into the venous circulation. These emboli can be detected within the circulation by transoesophageal ultrasound as they pass through the right ventricle to the pulmonary circulation, where many of them lodge (Christie 1995). The emboli may lead to the complications of fat embolism namely hypoxia, respiratory failure, circulatory failure, mental confusion and in extreme cases cardiac arrest.

 

Cement augmentation

The fixation of the fracture with an implant may be supplemented by the addition of bone cement. This is a compound, which is injected as a liquid to the spaces around the fractures surfaces. When it sets it bonds the bone surfaces together. Different types of bone cement are used with one of the main differences being whether the cement is slowly reabsorbed by the body by ingrowth of bone or resists being absorbed. One type of absorbable cement is Norian SRS.

 

Hydroxyapatite coating of the lag screw

The implant or part of the implant may be coated with a substance such as hydroxyapatite. This substance encourages bone growth around the implant and thereby should enhance the fixation and perhaps reduce the risk of fixation failure. A possible adverse effect is that hydroxyapatite coating may make the implant more difficult to remove.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

To compare the relative effects (operative details, fracture fixation complications, post-operative complications, anatomical restoration, final outcome measures) of new or modified techniques that have been used for internal fixation of extracapsular hip fractures in adults.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms
 

Criteria for considering studies for this review

 

Types of studies

All randomised controlled trials examining operative techniques or modifications to implants used for the treatment of extracapsular hip fractures. Quasi-randomised trials and trials in which the treatment allocation was inadequately concealed were considered for inclusion.

 

Types of participants

Skeletally mature patients with an extracapsular proximal femoral fracture.

 

Types of interventions

All forms of modification of the surgical technique for the internal fixation of intracapsular fracture compared with treatment with a standard technique (here the control group). Included were methods, including bone substitutes, used to enhance the fixation of the implant within the bone. Systemically-applied interventions such as the use of bisphosphates were excluded.

 

Types of outcome measures

All clinically relevant outcome measures as detailed within any of the included studies were considered, including those listed below.

 

a) Operative details

  • length of surgery (in minutes)
  • operative blood loss (in millilitres)
  • post-operative blood transfusion (in units)
  • radiographic screening time (in seconds)
  • temperature of the femoral head during reaming
  • extent of bone marrow embolisation as determined by transoesophageal cardiac ultrasound

 

b) Fracture fixation complications

  • cut-out of the implant proximally (penetration of the implant from the proximal femur either into the hip joint or external to the femur).
  • non-union of the fracture within the follow-up period (the definition of non-union was that used within each individual study).
  • other surgical complications of fixation (as detailed in each study)
  • fracture fixation failure rate (sum of the above three)
  • re-operation (within the follow-up period of the study)
  • superficial wound infection (infection of the wound in which there is no evidence that the infection is deep to the deep fascia layer or extends to the site of the implant)
  • deep wound infection (infection below the deep fascia layer)

 

c) Post-operative complications

  • pneumonia
  • deep vein thrombosis
  • pulmonary embolism
  • thromboembolic complications (summation of the above two)
  • any medical complication (as detailed in each individual study)
  • length of hospital stay (in days)

 

d) Anatomical restoration

  • shortening (> 2 cm)
  • varus deformity of the femoral neck (as detailed in each individual study)
  • external rotation deformity ( > 20 degrees)

 

e) Final outcome measures

  • mortality (within the follow-up period of the study)
  • pain (persistent pain at the final follow-up assessment)
  • failure to return to living at home
  • failure to regain mobility
  • functional activities of daily living
  • composite function and hip scores
  • quality of life scores

 

Search methods for identification of studies

 

Electronic searches

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 1), MEDLINE (1966 to January Week 4 2008), EMBASE (1988 to 2008 Week 4) and CINAHL - Cumulative Index to Nursing & Allied Health Literature (1982 to December Week 1 2007). We searched Current Controlled Trials (accessed January 2008) for ongoing and recently completed trials. No language or publication restriction was applied.

The Cochrane Library (Wiley InterScience), MEDLINE (OVID-WEB), EMBASE (OVID-WEB) and CINAHL (OVID-WEB) search strategies are shown in Appendix 1. The MEDLINE search was combined with all three stages of the optimal trial search strategy (Higgins 2006).

 

Searching other resources

We searched reference lists of articles and our own reference databases. We checked the findings from handsearches of the British Volume of the Journal of Bone and Joint Surgery supplements (1996 to 2006) and abstracts of the American Orthopaedic Trauma Association annual meetings (1996 to 2007) and American Academy of Orthopaedic Surgeons annual meeting (2004 to 2007). We also included handsearch results from the final programmes of SICOT (1996 & 1999) and SICOT/SIROT (2003), EFFORT (2007) and the British Orthopaedic Association Congress (2000, 2001, 2002, 2003, 2005 and 2006). We scrutinised weekly downloads of "Fracture" articles in new issues of 15 journals (Acta Orthop Scand; Am J Orthop; Arch Orthop Trauma Surg; Clin J Sport Med; Clin Orthop; Foot Ankle Int; Injury; J Am Acad Orthop Surg; J Arthroplasty; J Bone Joint Surg Am; J Bone Joint Surg Br; J Foot Ankle Surg; J Orthop Trauma; J Trauma; Orthopedics) from AMEDEO.

 

Data collection and analysis

 

Selection of studies

Two review authors independently assessed potentially eligible trials for inclusion. Any disagreement was resolved by discussion.

 

Data extraction and management

Data for the outcomes listed above were independently extracted by two review authors and any differences resolved by discussion. Where necessary and practical, we contacted trialists for additional data and clarification of trial methods and results.

 

Assessment of risk of bias in included studies

In this review, risk of bias is implicitly assessed in terms of methodological quality. Each trial was assessed independently, without masking of authors or source, for its quality of methodology by two review authors. All differences were resolved by discussion. In total, 11 aspects of methodology were rated (see  Table 1). Summation of the scores for individual items was discontinued in the update published in Issue 2, 2009.

 

Assessment of heterogeneity

Heterogeneity between comparable trials was assessed by visual inspection of the forest plot, and consideration of the standard chi² test and I² statistic (Higgins 2003).

 

Data synthesis

For each study, risk ratios (RR) and 95% confidence intervals (CI) were calculated for dichotomous outcomes; and mean differences and 95% confidence intervals for continuous outcomes. Where appropriate, data were pooled using the fixed-effect model using 95% confidence intervals (CI). Where there was substantial clinical heterogeneity, we additionally planned to look at the results using the random-effects model.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies.

In all, 16 trials were identified of which 11 are included (see the Characteristics of included studies for details) and five are excluded (see the Characteristics of excluded studies for reasons for exclusion).

Three new trials were included in this update, and formed the basis of two new comparisons. Two of these (Mattsson 2004; Mattsson 2005) evaluated the use of calcium-phosphate cement for fractures fixed with the sliding hip screw (SHS). The remaining trial (Moroni 2004, formerly excluded as Moroni 2002) tested the use of hydroxyapatite coating of the lag screw for SHS fixation.

Three other newly identified studies were excluded (Acharya 2003; Alobaid 2004; Moroni 2007). We revised the reasons for excluding Bong 1981, which compared two types of osteotomy with conservative treatment and appears in another review (Handoll 2008).

The study populations were predominantly female with the reported mean age being 80 years or over in nine trials. All participants in Calder 1995 were female and over 60 years old. Exceptionally, more participants were male with an average age of 58 years in Kumar 1996, a study conducted in India. The seven comparisons covered by the included trials are summarised below.

 

Osteotomy with anatomical reduction using a fixed nail plate

One study of 65 participants (Hubbard 1980) compared osteotomy with anatomical reduction in conjunction with a fixed nail plate.

 

Osteotomy with anatomical reduction using a SHS

Four studies with a total of 465 participants (Clark 1990; Desjardins 1993; Gargan 1994, Kumar 1996) compared osteotomy with anatomical reduction in conjunction with SHS fixation.

 

Bone cement augmentation at the fracture site

Two studies involving a total of 138 participants (Mattsson 2004 and Mattsson 2005) studied the augmentation of a SHS fixation with bone cement.

 

Compression of the fracture

Sernbo 1994 tested the use of compression in 200 participants treated with a SHS fixation. Compression was applied using a compression screw inserted during the surgery.

 

Hydroxyapatite coating of the lag screw

One study of 120 participants (Moroni 2004) tested the use of a lag screw coated with hydroxyapatite for SHS fixation against a control group in which a standard lag screw was used.

 

Modified reaming method

Calder 1995 tested the application of a modified reaming method versus the usual method in 19 participants. For this study the outer cortex of the femur is reamed first prior to reaming of the femoral head and neck for the lag screw.

 

Use of a venting hole when reaming

One study (Roder 1995), published in German, compared reaming of the femur for intramedullary nail insertion with versus without a venting hole in 50 participants.

 

Risk of bias in included studies

Based on our already established methods, we evaluated various aspects of methodological quality of the included trials rather than risk of bias. However, as well as presenting the results of our assessment, we highlight two key sources of bias associated with lack of blinding. These are selection bias from the failure to conceal allocation, and detection bias from the failure to blind outcome assessment.

Some details of the method of randomisation were given in 7 of the 11 studies. Moroni 2004 used numbered sealed envelopes containing the randomisation from a computer generated list. Gargan 1994 used sealed envelopes with the type of operation being determined from a table of random numbers. Mattsson 2004, Mattsson 2005 and Sernbo 1994 used sealed envelopes. Desjardins 1993 and Hubbard 1980 used a computer generated list. Clark 1990 was quasi-randomised and used the patient's date of birth. No method was stated by Calder 1995, Kumar 1996 or Roder 1995. We considered the risk of selection bias associated with the failure to conceal allocation at randomisation was high in the only quasi-randomised trial (Clark 1990), low in Moroni 2004 where an independent person opened the envelopes, and unclear in the remaining trials.

There was a risk of detection bias, particularly for clinician-rated outcomes, in all the included trials given that there was no assessor blinding.

The results of the methodological assessment for individual trials are given below. See  Table 1 for the descriptions of the criteria for items 1 to 11.

1 2 3 4 5 6 7 8 9 10 11 Trial
1 0 1 0 1 1 1 1 0 0 1 Calder 1995
0 0 0 0 1 0 1 1 0 0 1 Clark 1990
2 1 0 1 1 0 0 0 0 1 0 Desjardins 1993
2 1 0 1 0 0 0 0 0 0 1 Gargan 1994
2 0 0 0 1 0 1 0 0 0 1 Hubbard 1980
1 1 0 0 0 0 0 0 0 1 0 Kumar 1996
2 1 0 0 1 0 1 1 0 1 1 Mattsson 2004
2 1 0 1 1 1 1 1 0 1 0 Mattsson 2005
3 1 0 1 1 1 1 1 0 1 1 Moroni 2004
1 1 0 0 1 1 1 1 0 0 1 Roder 1995
2 0 0 1 1 1 0 0 0 0 1 Sernbo 1994

 

Effects of interventions

Where appropriate, data from each trial are presented in the analyses and by treatment comparison in the following section. Further unpublished details from the authors of each study would be welcomed by the reviewers.

 

Osteotomy (treatment group) versus anatomical reduction (control group) for fixed nail plate

One study (Hubbard 1980, 65 patients), all with unstable trochanteric fractures, was included. Three patients who were considered unfit for surgery were withdrawn from the trial.

 

a) Operative details

Hubbard 1980 reported only that the operating procedure for osteotomy took "no longer" and caused "no more bleeding" than for the control group".

 

b) Fracture fixation complications (Analysis 1.1)

There was no statistically significant differences between the two groups in the fixation failure rate (0/30 versus 4/32; risk ratio (RR) 0.12; 95% confidence interval (CI) 0.01 to 2.11). Of the four cases of fixation failure in the anatomical reduction group, there were two cases of cut-out and two cases of bending and breakage of the implant requiring reoperation. The only fracture fixation complication reported for the osteotomy group was a deep wound infection.

 

c) Post-operative complications

These outcomes were not reported.

 

d) Anatomical restoration

These outcomes were not reported.

 

e) Final outcome measures (Analysis 1.2)

There was no significant difference in mortality (8/32 versus 7/32; RR 1.22, 95% CI 0.50 to 2.95) or the number of participants who were unable to regain their pre-fracture mobility (11/22 versus 16/25; RR 0.78, 95% CI 0.47 to 1.30).

 

Sliding hip screw (SHS) using an osteotomy (treatment group) or anatomical reduction (control group)

Four studies (Clark 1990; Desjardins 1993; Gargan 1994; Kumar 1996) with a total of 465 patients were identified and included in the review.

 

a) Operative details

Data from Clark 1990 and Desjardins 1993 for length of surgery are presented in the analyses ( Analysis 2.1). In including the data from Clark 1990, we have assumed that standard deviations were provided in their paper. Pooled data for length of surgery were heterogeneous with Clark 1990 finding no significant difference (56 versus 53 minutes) between the two groups, whereas Desjardins 1993 found a significantly increased operation time for osteotomy of 103 versus 83 minutes. Both Gargan 1994 and Kumar 1996 found similarly increased operative times for osteotomy group (respectively: 70 versus 47 minutes; 180 versus 120 minutes).

Pooled data for operative blood loss showed a significantly increased mean operative blood loss in the osteotomy group (mean difference (MD) 85.56 ml, 95% CI 35.52 to 135.61 ml). Kumar 1996 reported, without statistical analysis, an increased mean blood loss for osteotomy (500 ml versus 300 ml). Gargan 1994 found that, on average, 2.0 units of blood were transfused after osteotomy compared with 1.6 units after anatomic reduction. These findings of greater blood loss with osteotomy are consistent with the more invasive nature of the operation.

No study reported radiographic screening time.

 

b) Fracture fixation complications

From the limited results available, there was no significant differences in the outcome measures of cut-out, non-union (this also includes "delayed union" in Desjardins 1993), fixation failure rate or reoperation rate (see  Analysis 2.2). Gargan 1994 did not provide separate data by group for the 12 cases of fixation failure: in nine cases, the screw had penetrated the joint; in two cases, it had cut-out of the neck; and in one case, the plate had pulled off the femoral shaft. Out of 110 patients followed up in Kumar 1996, there were 12 cases of fixation failure. Overall, there was a tendency to an increased overall fixation failure rate after osteotomy (20/190 versus 16/229; RR 1.51, 95% CI 0.81 to 2.83).

Three deep wound infections were reported: all were after anatomic reduction ( Analysis 2.3).

 

c) Post-operative complications

There was no mention of these in either Gargan 1994 or Kumar 1996 with only limited data presented in the other two reported studies (Clark 1990; Desjardins 1993). Overall there was no evidence of a difference in the incidence of complications between the two groups (30/97 versus 36/112; RR 0.98, 95 % CI 0.66 to 1.45). Only Desjardins 1993 gave some details of these complications from which it could be seen that the incidence of thromboembolic complications and pressure sores was the same in both groups.

Clark 1990 reported a significant increase in hospital stay in the osteotomy group (31 days versus 21 days in the anatomical reduction group). This was not the case when the data (we have assumed that standard deviations were provided in their paper) were included in the analysis.  Analysis 2.5 also shows data from Desjardins 1993, who found no significant difference in the length of hospital stay between groups.

 

d) Anatomical restoration

Only Clark 1990 reported adequately on leg shortening (defined as more than 1 cm) and external rotational deformity (more than 10 degrees). Neither of these nor the pooled results for varus deformity showed a significant difference between the two groups ( Analysis 2.6).

 

e) Final outcome measures (Analysis 2.7)

Pooled data for mortality from three studies (Clark 1990; Desjardins 1993; Gargan 1994) showed no significant difference between the treatment groups (25/142 versus 32/167; RR 0.92, 95% CI 0.57 to 1.47). Kumar 1996 reported that 10 patients died post-operatively within six weeks but did not provide separate data by treatment group.

No study provided data for pain at follow up although Kumar 1996 reported that there was no difference in pain at follow up between the two treatment groups. Both Clark 1990 and Desjardins 1993 found no significant difference in the number of patients who were unable to return to their former residence (24/80 versus 19/87; RR 1.38, 95% CI 0.83 to 2.28) or regain their former mobility (42/77 versus 44/84; RR 1.04, 95% CI 0.78 to 1.39). Kumar 1996 stated there was no difference between the two groups in mobility, limping or walking distance at follow up.

 

Bone cement augmentation at the fracture site

Two studies (Mattsson 2004; Mattsson 2005) compared SHS fixation augmented with an absorbable calcium phosphate bone cement, versus standard SHS fixation in 138 patients with an unstable trochanteric fracture. Very little data on clinical outcomes were available from Mattsson 2004.

 

a) Operative details

Mattsson 2005 reported the difference in the mean length of surgery (68.7 versus 56.7 minutes) between the two groups was not statistically significant. Conversely, the difference in the mean blood loss (405 ml versus 281 ml) was significantly in favour of the control group (reported P < 0.05).

 

b) Fracture fixation complications (Analysis 3.1)

There were no cases of cut-out in Mattsson 2005. Mattsson 2005 reported two cases in the cement group where fracture union was delayed more than six months (both fractures united subsequently). In addition, the plate became detached from the femur in two cases in the cement group. No treatment was required. There were no reoperations in either Mattsson 2004 or Mattsson 2005. Mattsson 2004 reported no cases of wound infection.

 

c) Post-operative complications

There was no reporting of medical complications in either trial. Mattsson 2005 found no significant difference between the two groups in the length of hospital stay ( Analysis 3.3: MD 0.50 days, 95% CI -0.84 to 1.84 days).

 

d) Anatomical restoration

Mattsson 2004 reported a statistically significant difference (P < 0.02) in favour of augmentation in the mean varus angulation at the fracture site at six months (5.89 versus 10.57 degrees). Mattsson 2004 also measured movement or translation of the fracture site with tantalum markers inserted into the bone at the time of surgery: these data are not presented in the review analyses. At six months the total translation was significantly less in the cement group (7.77 mm versus 13.24 mm; P = 0.02). Mattsson 2005 reported the mean sliding distance of the lag screw was statistically significantly lower in the cement group (13.5 mm versus 15.9 mm). The clinical consequences of these outcomes were not reported in either trial.

 

e) Final outcome measures

These outcomes were only reported in Mattsson 2005 who found no significant difference between the groups in mortality ( Analysis 3.4: 3/55 versus 2/57; RR 1.55, 95% CI 0.27 to 8.95). There was no statistically significant differences in global pain visual analogue scale scores at six months ( Analysis 3.5). Although there was a statistically significant reduced level of pain during walking in the cement group at six months, the clinical significance of this result is not clear ( Analysis 3.5: MD -5.00 mm, 95% CI -9.70 to -0.30 mm). No statistically significant differences were found for activities of daily living at six months. However, Mattsson 2005 reported improved abilities at six weeks in the cement group for rising from the chair (P < 0.003), getting off the toilet (P < 0.05) and climbing a step (P < 0.03). Mattsson 2005 reported, without providing full data, statistically significantly better quality of life at six months in the cement group as measured by the SF-36 score: SF-36 scores for general health (80.9 versus 66.3; reported P < 0.02); physical functioning domain (42.1 versus 28.0; P < 0.04); physical health domain (30.7 versus 22.8; not significant (NS)); role emotional domain (58.6 versus 52.3; NS); social functioning domain (83.7 versus 64.2; P < 0.002); vitality domain (62.9 versus 51.3; P < 0.02); mental health domain (77.9 versus 67.0; P < 0.03). There was no statistically significant difference in the abductor strength between the two groups at six months ( Analysis 3.6).

 

Compression of a trochanteric fracture in conjunction with a SHS

One study of 200 participants was included (Sernbo 1994).

 

a) Operative details

The study demonstrated no difference in operative times or operative blood loss between the two techniques ( Analysis 4.1).

 

b) Fracture fixation complications

There was no significant difference in non-union, the only outcome measure in this category reported ( Analysis 4.2).

 

c) Post-operative complications

There was no report of these outcomes.

 

d) Anatomical restoration

Varus angulation of the fracture by more than 10 degrees was more frequent but not statistically significantly so after compression ( Analysis 4.3: 6/71 versus 1/82; RR 6.93, 95% CI 0.85 to 56.19).

 

e) Final outcome measures

There was no report of these outcomes.

 

Hydroxyapatite coating of the lag screw

One study (Moroni 2004) of 120 participants was included.

 

a) Operative details

There was no report of these outcomes.

 

b) Fracture fixation complications

No cut-out or reoperations occurred in the coated screw group compared with four and three respectively for the uncoated group. However, the differences between the two groups in these outcomes were not statistically significant ( Analysis 5.1: cut-out, RR 0.11, 95%CI 0.01 to 2.02; reoperation, RR 0.14, 95% CI 0.01 to 2.71).

 

c) Post-operative complications

There was no report of these outcomes.

 

d) Anatomical restoration

Clinical deformity was not reported. However, there was a statistically significant difference between the two groups in mean femoral neck angle at six months (133 degrees versus 127 degrees; P = 0.003).

 

e) Final outcome measures

There was no significant difference between the two groups in six months mortality ( Analysis 5.2: 4/65 versus 6/68; RR 0.70, 95% CI 0.21 to 2.36). At six months, both the Harris hip score and the SF-36 scores were better in the coated screw group but the differences were not statistically significant for both outcome measures ( Analysis 5.3).

 

Reaming of the femur for SHS fixation using a modified reaming method or a standard method

The only study identified (Calder 1995) did not record data for any of the clinical outcome measures sought. The only outcome reported was the temperature within the femoral head. There was no statistically significant different in the mean peak temperature recorded in the two groups (modified reamer: n = 10; mean 46.3 degrees, standard deviation (SD) 8.4 versus standard reamer: n = 9; mean 51.9 degrees, standard deviation 3.3). However, the difference in the time (5.7 versus 17.4 seconds) the temperature remained above 44 degrees centigrade was reported to be statistically significant (P < 0.05) between methods.

 

Provision of a distal femoral venting hole to reduce the risk of bone marrow embolisation during reaming

Roder 1995 recorded the degree of bone marrow embolisation, as measured by transoesophageal oesophageal ultrasound, during reaming and insertion of a Gamma nail with or without a femoral venting hole in 50 patients. A 4.5 millimetre vent hole was drilled in the lateral femoral cortex approximately 25 centimetres distal to the tip of the greater trochanter before opening the bone marrow cavity in 25 Gamma nail patients. The amount of embolisation was graded, in a semi-quantitative way, into four groups from none (grade 0) through to heavy (grade three). Results of observations made during operations were presented by intervention group rather than by individual patients. No patient of the 25 Gamma nail patients with a vent hole had grade three embolisation but grade two embolisation was observed during reaming for 25 out of 575 observations (4.3%). For the 25 patients treated with the Gamma nail without a vent hole, grade three embolisation was observed for 365 out of 575 observations (63.5%) and grade two embolisation in 74 out of 575 observations (12.9%). No other outcomes were reported.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

This review involves a mixed collection of studies testing various aspects of surgical fixation. It reports on the comparisons that have been evaluated in randomised or quasi-randomised controlled clinical trials that we have identified so far. It can be viewed as a 'work in progress', and we will continue to assess and report on new trials that arise in this area. The relevance of some included trials to current practice can and should be questioned. An example is those trials using the fixed nail plate, which is an inferior implant to sliding hip screw (Parker 2006b). Overall, the available evidence from these small trials, with only modest methodological quality or worse, is limited and thus only tentative conclusions can be drawn for each of the seven comparisons.

 

Fixed nail plate using an osteotomy (treatment group) or anatomical reduction (control group)

Osteotomy of the proximal femur for an unstable trochanteric fracture was originally described with the use of a fixed nail plate. The theory was that collapse at the fracture site would be reduced as bone to bone contact was restored medially. This would reduce the risk of the implant penetrating through the femoral head into the joint. The one included trial comparing osteotomy with anatomical reduction for a fixed nail plate presented only limited results for a small number of patients. While none of the differences between the two groups for fracture fixation complications, mortality and mobility were statistically significant, all four cases of fixation failure occurred in the anatomical reduction group. An osteotomy may therefore be appropriate if a fixed nail plate is used to fix an unstable trochanteric fracture. As noted above, physicians should however be aware that a fixed nail plate may not be the choice of implant for this type of fracture (Parker 2006b).

 

Sliding hip screw (SHS) using an osteotomy (treatment group) or anatomical reduction (control group)

The dynamic nature of the SHS, when used for trochanteric fractures, allows for collapse at the fracture site. Thus theoretically, this reduces the possible benefits of osteotomy. Osteotomy appears to have no beneficial effect on reducing the risk of implant cut-out or the overall fixation failure rate. Gargan 1994 observed that the incidence of fixation failure within the osteotomy group was reduced when a short barrel SHS was used; they reported that they had only one failure out of 11 osteotomy cases after the short barrel plate was introduced as opposed to seven out of 34 prior to this.

As would be expected, the addition of osteotomy as part of the surgical procedure increased the length of surgery and operative blood loss. Few data were presented on the incidence of post-operative complications but overall there was no significant difference in complications between groups. Neither was there any significant difference for mortality or morbidity. Nor was there for measures of anatomical deformity. However, the increased tendency for leg shortening with osteotomy found in Clark 1990 is consistent with the results from theoretical studies.

 

Bone cement augmentation at the fracture site

The limited number of patients and incomplete recording and reporting of outcome in the two trials mean that no definite conclusions can be made. Movement at the fracture site appeared less in the cement augmented group as demonstrated by the reduced translation at the fracture site and slide of the lag screw within the barrel. The clinical significance of this difference was not demonstrated. Of concern were the two cases of delayed union and the two cases of detachment of the plate from the femur in the cement augmented group of Mattsson 2005. In addition, removal of the implant when cement is used may be more difficult should a reoperation be required. The favourable results for cement augmentation in terms of pain, earlier recovery of basic activities of living at six weeks, and quality of life at six months also need confirmation. In all, further good quality randomised trials with larger number of patients are required. Blinding of some outcome assessors and participants should also be possible.

 

Compression of a trochanteric fracture in conjunction with a SHS

The one study identified indicated that compression of a trochanteric fracture internally fixed with a SHS may offer no benefit and may increase the risk of varus angulation of the fracture.

 

Hydroxyapatite coating of the lag screw

The one study identified on this topic suggested that coating the lag screw with hydroxyapatite reduced the occurrence of cut-out of the femur and improved the function at six months. However, these findings were not statistically significant and thus no definite conclusions should be drawn. Removal of the screws that are hydroxyapatite coated, should it be required subsequently, may be more difficult and this was not discussed in this study. Given that the lead investigator of this study has conducted several studies evaluating hydroxyapatite-coated screws in other fractures that show promising results also, it is important (particularly for reasons of applicability) that further trials are carried out by other investigators.

 

Reaming of the femur for SHS fixation using a modified reaming method

The data presented on this small study indicated that the modified reaming method reduced the temperature generated within the femoral head. However there was no measurement of clinical outcomes, even those which may be directly affected by the high temperatures within the femoral head such as non-union or avascular necrosis. Thus, the clinical relevance of this is open to question.

 

The provision of a distal femoral venting hole during reaming for Gamma nail fixation

The data presented for 50 patients undergoing Gamma nail fixation indicated that vascular embolisation of bone marrow can be reduced by drilling a vent hole in the distal femoral cortex. However, as there were no measures of clinical outcome the clinical relevance of this is open to question. Furthermore, given that one of the problems of Gamma nail fixation is fracture of the femur below the implant, the vent hole would weaken the bone in this area and the extra risk of fracture would need to be assessed.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

 

Implications for practice

There is no evidence available to support the routine use of either osteotomy or intra-operative fracture compression when a SHS is used for the internal fixation of a trochanteric proximal femoral fracture.

Insufficient evidence exists to support use of bone cement augmentation, hydroxyapatite coating of the lag screw, the reaming of the femur using a modified technique for SHS fixation or the use of a vent hole in the femur for Gamma nail fixation.

 
Implications for research

The evidence base from these small trials often with flawed methodology is insufficient to draw conclusions of the effects of the different techniques tested so far. Any new or modified technique should be tested in good quality randomised trials against the best standard procedure, collecting clinically relevant outcomes. Many other aspects of the surgical fixation of extracapsular fracture have not been studied within randomised trials, but it is important to establish beforehand that any proposed change in technique would have sufficient impact on clinical outcome to merit further research.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

We thank our two co-authors (G Tripuraneni and J McGreggor-Riley) who were involved with the first two versions of this review. We thank Dr Joanne Elliott for her help with the search for trials and Mrs Lindsey Elstub and Ms Amy Kavanagh for editorial support.

We would also like to thank the following for useful comments from editorial and external review: Dr Vicki Livingstone, Dr Janet Wale, Assoc Prof Leif Ceder and Prof Rajan Madhok.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms
Download statistical data

 
Comparison 1. Osteotomy versus anatomical reduction: fixed nail plate

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Fracture fixation complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Cut-out
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Fixation failure rate
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.3 Deep sepsis
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 2 Final outcome measures (at 3 months)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Mortality
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 Failure to regain former mobility
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 2. Osteotomy versus anatomical reduction: sliding hip screw

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Operative details: length of surgery and blood loss2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    1.1 Length of surgery (minutes)
2209Mean Difference (IV, Fixed, 95% CI)6.97 [1.47, 12.46]

    1.2 Operative blood loss (ml)
2209Mean Difference (IV, Fixed, 95% CI)85.56 [35.52, 135.61]

 2 Fracture fixation complications4Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    2.1 Cut-out rate
2209Risk Ratio (M-H, Fixed, 95% CI)1.13 [0.29, 4.36]

    2.2 Non-union
2209Risk Ratio (M-H, Fixed, 95% CI)5.47 [0.27, 111.39]

    2.3 Fixation failure rate
4419Risk Ratio (M-H, Fixed, 95% CI)1.51 [0.81, 2.83]

    2.4 Reoperation
2209Risk Ratio (M-H, Fixed, 95% CI)0.82 [0.16, 4.19]

 3 Deep sepsis2209Risk Ratio (M-H, Fixed, 95% CI)0.29 [0.03, 2.50]

 4 Medical complications2209Risk Ratio (M-H, Fixed, 95% CI)0.98 [0.66, 1.45]

 5 Length of hospital stay (days)2Mean Difference (IV, Fixed, 95% CI)Totals not selected

 6 Anatomical deformity2Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    6.1 Leg shortening (> 1 cm)
175Risk Ratio (M-H, Fixed, 95% CI)2.17 [0.71, 6.58]

    6.2 Varus deformity
2163Risk Ratio (M-H, Fixed, 95% CI)0.37 [0.10, 1.32]

    6.3 External rotation deformity
175Risk Ratio (M-H, Fixed, 95% CI)3.25 [0.35, 29.85]

 7 Final outcome measures3Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    7.1 Mortality
3309Risk Ratio (M-H, Fixed, 95% CI)0.92 [0.57, 1.47]

    7.2 Failure to return to same residential status
2167Risk Ratio (M-H, Fixed, 95% CI)1.38 [0.83, 2.28]

    7.3 Failure to regain mobility
2161Risk Ratio (M-H, Fixed, 95% CI)1.04 [0.78, 1.39]

 
Comparison 3. SHS fixation with cement versus standard SHS (no cement)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Fracture fixation complications2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Cut-out
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Loosening of the plate
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.3 Delayed union
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.4 Reoperation
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 2 Wound infection1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 Length of hospital stay1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 4 Mortality1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 5 Pain at 6 months (visual analogue scale: 0 none to 100 worst)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 Global pain
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    5.2 On walking 50 feet
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 6 Hip abductor strength (% of unaffected side)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 
Comparison 4. Compression of trochanteric fractures in sliding hip screw fixation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Operative details: length of surgery and blood loss1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 Length of surgery (minutes)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    1.2 Operative blood loss (ml)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 2 Non-union1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 Varus deformity1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 5. Hydroxyapatite-coated screws versus standard screws: SHS

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Fracture fixation complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Cut-out
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Reoperation
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 2 Mortality1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

 3 Functional and activity of daily living scores1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 Harris hip score (0: worst to 100: best function)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    3.2 SF-36 (0: worst to 100: best)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms
 

Appendix 1. Search strategies

 

The Cochrane Library (Wiley InterScience)

#1MeSH descriptor Hip Fractures explode all trees
#2((hip* or pertrochant* or intertrochant* or trochanteric or subtrochanteric or extracapsular* or ((femur* or femoral*) NEAR/3 (neck or proximal))) NEAR/4 fracture*):ti,ab,kw
#3(#1 OR #2)
#4MeSH descriptor Orthopedics, this term only
#5MeSH descriptor Fracture Fixation, Internal explode all trees
#6MeSH descriptor Internal Fixators, this term only
#7MeSH descriptor Osteotomy, this term only
#8MeSH descriptor Bone Nails, this term only
#9MeSH descriptor Bone Screws, this term only
#10MeSH descriptor Bone Plates, this term only
#11(#4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10)
#12(#3 AND #11)

 

MEDLINE (OVID-WEB)

1 exp Femoral Fractures/
2 ((hip$ or pertrochant$ or intertrochant$ or trochanteric or subtrochanteric or extracapsular$ or ((femur$ or femoral$) adj3 (neck or proximal))) adj4 fracture$).tw.
3 or/1-2
4 Surgery/ or Osteotomy/ or Internal Fixators/ or Bone Screws/ or exp Fracture Fixation, Internal/ or Bone Plates/ or Bone Nails/
5 (osteotom$ or ream$ or compression or pin$1 or nail$ or screw$1 or plate$1).tw.
6 or/4-5
7 and/3,6

 

EMBASE (OVID-WEB)

1 exp Hip Fracture/
2 ((hip$ or pertrochant$ or intertrochant$ or trochanteric or subtrochanteric or extracapsular$ or ((femur$ or femoral$) adj3 (neck or proximal))) adj4 fracture$).tw.
3 or/1-2
4 Fracture Treatment/ or Hip Surgery/ or Femur Intertrochanteric Osteotomy/ or Femur Osteotomy/ or Hip Osteotomy/ or exp Fracture Fixation/ or Bone Screw/ or Bone Plate/ or Bone Nail/ or ender Nail/ or Interlocking Nail/ or Osteosynthesis Material/
5 (osteotom$ or ream$ or compression or pin$1 or nail$ or screw$1 or plate$1).tw.
6 or/4-5
7 and/3,6
8 Clinical trial/
9 Randomized controlled trial/
10 Randomization/
11 Single blind procedure/
12 Double blind procedure/
13 Crossover procedure/
14 Placebo/
15 Randomi?ed controlled trial$.tw.
16 Rct.tw.
17 Random allocation.tw.
18 Randomly allocated.tw.
19 Allocated randomly.tw.
20 (allocated adj2 random).tw.
21 Single blind$.tw.
22 Double blind$.tw.
23 ((treble or triple) adj blind$).tw.
24 Placebo$.tw.
25 Prospective study/
26 or/8-25
27 Case study/
28 Case report.tw.
29 Abstract report/ or letter/
30 or/27-29
31 26 not 30
32 limit 31 to human
33 and/7,32

 

CINAHL (OVID-WEB)

1 Hip Fractures/
2 ((hip$ or pertrochant$ or intertrochant$ or trochanteric or subtrochanteric or extracapsular$ or ((femur$ or femoral$) adj3 (neck or proximal))) adj4 fracture$).tw.
3 or/1-2
4 Hip Surgery/ or Fracture Fixation/ or Osteotomy/ or Orthopedic Fixation Devices/
5 (osteotom$ or ream$ or compression or pin$1 or nail$ or screw$1 or plate$1).tw.
6 or/4-5
7 and/3,6
8 exp Clinical Trials/
9 exp Evaluation Research/
10 exp Comparative Studies/
11 exp Crossover Design/
12 clinical trial.pt.
13 or/8-12
14 ((clinical or controlled or comparative or placebo or prospective or randomi#ed) adj3 (trial or study)).tw.
15 (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).tw.
16 ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).tw.
17 (cross?over$ or (cross adj1 over$)).tw.
18 ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or group$)).tw.
19 or/14-18
20 or/13,19
21 and/7,20

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

Last assessed as up-to-date: 29 March 2008.


DateEventDescription

18 February 2009New search has been performedFor the fourth review update (Issue 2, 2009), the following changes were made:
1. Review title changed from "Osteotomy, compression and reaming techniques for internal fixation of extracapsular hip fractures";
2. Search updated (January 2008);
3. Three new studies (Mattsson 2004; Mattsson 2005; Moroni 2004), generating two new comparisons, were included;
4. Three newly identified studies (Acharya 2003; Alobaid 2004; Moroni 2007) were excluded;
5. Additional reference (Pedlow 1991) found for included trial (Desjardins 1993);
6. Updated methods, including the removal of overall quality assessment scores, and formatting.

Though the conclusions were adjusted to accommodate the two new comparisons, the finding of insufficient evidence was unchanged.

18 February 2009New citation required but conclusions have not changedThe fourth review update also saw a change in authorship (see 'Contributions of authors').



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

Protocol first published: Issue 4, 1997
Review first published: Issue 3, 1998


DateEventDescription

20 October 2008AmendedConverted to new review format

28 February 2001New search has been performedIn the third update (Issue 3, 2001), the search for trials was updated to February 2001, and no new trials for inclusion were identified. One identified study, Papanikolaou 1999, was excluded. The conclusions of the review were unchanged.

For details of previous updates, please see 'Notes'.



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

Martyn Parker initiated and designed the review, performed study selection, contacted trialists, assessed study quality, extracted data and compiled the first drafts of the review and all subsequent updates. Gopi Tripuraneni and John McGreggor-Riley checked data extraction and assessed the trials for methodological quality for the versions of the review available up to 2008. Helen Handoll checked over and corrected the pre-existing review (2008), updated review methodology, performed study selection, contacted trialists, assessed study quality, extracted data and revised successive drafts. Martyn Parker is the guarantor of the review.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms
 

Internal sources

  • University of Teesside, Middlesbrough, UK.
  • Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, UK.

 

External sources

  • No sources of support supplied

 

Notes

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

Previous titles no longer in use:
1. Extracapsular hip fractures: Surgical techniques
2. Osteotomy, compression and reaming techniques for internal fixation of extracapsular hip fractures

First update (Issue 2, 1999).
1. Roder 1995 included.

Second update (Issue 2, 2000).
1. Kumar 1996 included and Papanikolaou 1999 excluded.
2. Risk ratios were presented instead of odds ratios.
Conclusions of the review unchanged.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Notes
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. Additional references
Calder 1995 {published data only}
Clark 1990 {published data only}
Desjardins 1993 {published data only}
  • Desjardins AL, Roy A, Paiement C, Newman N, Pedlow F, Desloges D, Turcotte R. Unstable intertrochanteric fractures: A prospective randomized study comparing anatomic reduction and medial osteotomy. Journal of Bone and Joint Surgery - British Volume 1992;74 Suppl 3:281-2.
  • Desjardins AL, Roy A, Paiement G, Newman N, Pedlow F, Desloges D, Turcotte RE. Unstable intertrochanteric fracture of the femur: a prospective randomised study comparing anatomical reduction and medial displacement osteotomy. Journal of Bone and Joint Surgery - British Volume 1993;75:445-7. [MEDLINE: 1993266635]
  • Desjardins AL, Roy A, Paiement G, Newman N, Pedlow F, Desloges D, et al. Unstable intertrochanteric fracture of the femur: A prospective randomized study comparing anatomical reduction and medial displacement osteotomy. Orthopedic Transactions 1994;18(3):735.
  • Pedlow F, Desjardins AL, Roy A, Paiement G. [Instable intertrochanteric fractures: a prospective study comparing anatomic reduction and osteotomy of medialisation]. Annales de Chirurgie 1991;45(9):849.
Gargan 1994 {published data only}
Hubbard 1980 {published data only}
  • Hubbard MJS, Burke FD, Bracey DJ, Houghton GR. A prospective controlled trial of valgus osteotomy in the fixation of unstable pertrochanteric fractures of the femur [Abstract]. Journal of Bone and Joint Surgery - British Volume 1978;60:144.
  • Hubbard MJS, Burke FD, Houghton GR, Bracey DJ. A prospective controlled trial of valgus osteotomy in the fixation of unstable pertrochanteric fractures of the femur. Injury 1980;11:228-32. [MEDLINE: 1980158865]
Kumar 1996 {published data only}
  • Kumar MM, Sudhakar GM, Shar DD, Pathak RH. A study of the role of osteotomy in unstable intertrochanteric fractures. Journal of Postgraduate Medicine 1996;42(1):4-6.
Mattsson 2004 {published data only}
  • Mattsson P, Larsson S. Unstable trochanteric fractures augmented with calcium phosphate cement. A prospective randomized study using radiostereometry to measure fracture stability. Scandinavian Journal of Surgery 2004;93(3):223-8. [MEDLINE: 15544079]
Mattsson 2005 {published data only}
  • Mattsson P, Alberts A, Dahlberg G, Sohlman M, Hyldahl HC, Larsson S. Resorbable cement for the augmentation of internally-fixed unstable trochanteric fractures. A prospective, randomised multicentre study. Journal of Bone and Joint Surgery - British Volume 2005;87(9):1203-9. [MEDLINE: 16129742]
Moroni 2004 {published and unpublished data}
  • Hoque M. personal communication June 25 2008.
  • Moroni A. Surgical techniques for osteoporotic bone. Journal of Bone and Joint Surgery - British Volume 2006;88(Suppl 1):11.
  • Moroni A, Faldini C, Pegreffi F, Giannini S. Better clinical outcomes for osteoporotic trochanteric fracture patients: DHS fixed with hydroxyapatite-coated AO/ASIF screws [abstract]. Journal of Bone and Joint Surgery - British Volume 2004;86(Suppl 3):243.
  • Moroni A, Faldini C, Pegreffi F, Giannini S. HA-coated screws decrease the incidence of fixation failure in osteoporotic trochanteric fractures. Clinical Orthopaedics and Related Research 2004;(425):87-92. [MEDLINE: 15292792]
  • Moroni A, Faldini C, Pegreffi F, Giannini S. How to improve results in osteoporotic hip fractures treated with dynamic hip screw fixation: a prospective randomized study [abstract]. Hip International 2002;12(2):244-5.
Roder 1995 {published data only}
  • Roder W, Isemer F-E, Weigel TF, Zimmermann F, Peifer A. Bone marrow introvasion during operative pertrochanteric femur fracture care - Gamma nail versus DHS [Markeinschwemmung bei operativer Versorgung pertrochantarer Femurfrakturen. Vergleich Gammanagel gegen DHS]. Aktuelle Traumatologie 1995;25:67-71. [MEDLINE: 1995178296]
Sernbo 1994 {published data only}
  • Sernbo I, Johnell O, Gardsell A. A prospective randomized trial in trochanteric hip fractures treated with compression hip screw with and without locking and compression of the lag screw [Abstract]. Acta Orthopaedica Scandinavica - Supplementum 1990;237:55.
  • Sernbo I, Johnell O, Gardsell A. Locking and compression of the lag screw in trochanteric fractures is not beneficial: a prospective, randomized study of 153 cases. Acta Orthopaedica Scandinavica 1994;65:24-6. [MEDLINE: 1994205360]

References to studies excluded from this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Notes
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. Additional references
Acharya 2003 {published data only}
  • Acharya MR, Eastwood G, Bing A, Harper WH. Fixation of hip fractures with a sliding hip screw: a randomised controlled trial comparing fixation of the plate in the keyed and unkeyed position [abstract]. Injury-International Journal of the Care of the Injured 2003;34:629.
  • Acharya MR, Eastwood G, Bing A, Harper WH. Fixation of hip fractures with a sliding hip screw: a randomised controlled trial comparing fixation of the plate in the keyed and unkeyed position [abstract]. Journal of Bone and Joint Surgery - British Volume 2004;86(Suppl 1):78.
  • Acharya MR, Eastwood G, Bing A, Harper WH. Fixation of hip fractures with a sliding hip screw: a randomised controlled trial comparing fixation of the plate in the keyed and unkeyed position [abstract]. Journal of Bone and Joint Surgery - British Volume 2004;86(Suppl 3):377.
Alobaid 2004 {published data only}
  • Alobaid A, Harvey EJ, Elder GM, Lander P, Guy P, Reindl R. Minimally invasive dynamic hip screw: prospective randomized trial of two techniques of insertion of a standard dynamic fixation device. Journal of Orthopaedic Trauma 2004;18(4):207-12. [MEDLINE: 15087963]
Bong 1981 {published and unpublished data}
Moroni 2007 {published data only}
Papanikolaou 1999 {published data only}
  • Papanikolaou A, Deimedes G, Lochovitis K, Darmanis S, Antoniou N. The treatment of unstable intertrochanteric fractures: medial displacement osteotomy versus anatomical nailing [Abstract]. Journal of Bone and Joint Surgery. British Volume 1999;81 Suppl 2:64.

Additional references

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Notes
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. Additional references
Calder 1995a
Christie 1995
  • Christie J, Robinson CM, Pell AC, McBirnie J, Burnett R. Transcardiac echocardiography during invasive intramedullary procedures. Journal of Bone and Joint Surgery - British Volume 1995;77:450-5.
Dimon 1967
Eriksson 1984
Evans 1949
  • Evans EM. The treatment of trochanteric fractures of the femur. Journal of Bone and Joint Surgery - British Volume 1949;31:190-203.
Handoll 2008
Higgins 2003
Higgins 2006
  • Higgins JPT, Green S, editors. Highly sensitive search strategies for identifying reports of randomized controlled trials in MEDLINE. Cochrane Handbook for Systematic Reviews of Interventions 4.2.6 [updated September 2006]; Appendix 5b. www.cochrane.org/resources/handbook/hbook.htm (accessed 01 May 2007).
Jenson 1980
Parker 1998
  • Parker MJ, Handoll HHG. Condylocephalic nails versus extramedullary implants for extracapsular hip fractures. Cochrane Database of Systematic Reviews 1998, Issue 4. [DOI: 10.1002/14651858.CD000338]
Parker 2006a
Parker 2006b
Parker 2008
Sarmiento 1970
  • Sarmiento A, Williams EM. The unstable intertrochanteric fracture: treatment with a valgus osteotomy and I-beam nail plate. Journal of Bone and Joint Surgery - American Volume 1970;52:1309-18.