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Internal fixation implants for intracapsular hip fractures in adults

  1. Martyn J Parker1,*,
  2. Kurinchi Selvan Gurusamy2

Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

Published Online: 23 OCT 2001

Assessed as up-to-date: 5 NOV 2010

DOI: 10.1002/14651858.CD001467


How to Cite

Parker MJ, Gurusamy KS. Internal fixation implants for intracapsular hip fractures in adults. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD001467. DOI: 10.1002/14651858.CD001467.

Author Information

  1. 1

    Peterborough and Stamford Hospitals NHS Foundation Trust, Department of Orthopaedics, Peterborough, Cambridgeshire, UK

  2. 2

    Royal Free Campus, UCL Medical School, Department of Surgery, London, UK

*Martyn J Parker, Department of Orthopaedics, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough City Hospital, CBU PO Box 211, Bretton Gate, Peterborough, Cambridgeshire, PE3 9GZ, 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: 23 OCT 2001

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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. Differences between protocol and review
  17. Index terms

Proximal femoral fractures or, as they are more generally termed, 'hip fractures', can be subdivided into intracapsular fractures (those occurring proximal to the attachment of the hip joint capsule to the femur) and extracapsular (those occurring distal to the hip joint capsule). Intracapsular fractures can be further subdivided into those which are displaced and those which are essentially undisplaced. Undisplaced fractures include those termed impacted or adduction fractures. Many other subdivisions and classification methods exist for intracapsular fractures but these have not been shown to be of reliable clinical usefulness (Parker 1993).

Intracapsular hip fractures are generally managed surgically, either by fixing the fracture using various implants and thereby retaining the femoral head, or by replacing the femoral head with a prosthesis. The latter option is not considered in this review. The rationale for operative treatment of intracapsular fractures is to reduce the risk of the fracture displacing, for undisplaced fractures, and to maintain fracture reduction for displaced fractures. Surgery entails passing single or multiple screws or pins across the fracture site. For displaced fractures the fracture must first be reduced, which may be achieved either by an open or closed reduction.

Numerous implants have been developed over time for the internal fixation of the fracture. Tronzo identified over 100 in 1974 (Tronzo 1974). These implants are inserted under X-ray guidance using either an open or percutaneous procedure. Implants may be divided into those which are smooth (pins) and those which are threaded (screws). The type of threads used on screws may vary from narrow to wide and deep. In addition, the proportion of the screw which is threaded may vary from the tip only to the entire length. The number of pins or screws inserted across the fracture can vary from one to in excess of 10, depending on the size of the implant used. Screws or pins may also be connected to a side plate which is then fixed with screws to the side of the femur. Another variation on implant design is a small metal 'tongue' which is pushed out of the tip of a nail into the subchondral bone of the femur.

Examples of single nails are the Smith-Petersen nail, Thornton nail and Rydell four-flanged nail. Examples of a single nail with a side plate are the Holt, Jewett nail plate, Massie nail, McLaughlin nail plate, Pugh nail and Thornton nail plate. Of these implants, the Massie and Pugh nails have the capacity for sliding at the nail/plate junction, allowing for collapse at the fracture site. Examples of a single screw with a side plate are the sliding hip screw (SHS) and equivalent models such as the Ambi, Dynamic, or Richards' screws. These implants all have the capacity for sliding at the screw/plate junction.

Examples of implants with a 'tongue', which can be extruded from its tip, are the Rydell four-flanged nail and Hansson pins. Examples of implants that are normally used in pairs are Garden screws, Hansson pins, Richards' screws, Tronzo (VLF) screws, Uppsala/Olmed screws, von Bahr screws, and Ullevaal screws. Examples of implants for which three are normally inserted are AO screws, Gouffon screws, Hessel pins, Mecron screws, Nystrom nails, Ullevaal screws and Scand screws.

The main fracture healing complication after internal fixation of an intracapsular fracture is the failure of the fracture to heal. This may lead to fracture displacement and is termed either 'early fracture displacement' or 'non-union' if it occurs in the first few weeks after operation. The term 'non-union' is also used for those fractures which fail to heal in later weeks. This normally results in the fracture displacing with loss of position of the fixation device. For this review the term non-union refers to both those fractures which show early displacement plus those which later fail to heal. An incidence of non-union of five to ten per cent can be expected following an undisplaced intracapsular fracture; this rises to about 20 to 40 per cent for displaced intracapsular fractures (Lu-Yao 1994; Parker 1993).

The other main fracture healing complication is avascular necrosis (also termed segmental collapse or femoral head necrosis). This is seen as collapse of the femoral head and subsequent destruction of the hip joint. It occurs secondary to disruption of the blood supply to the femoral head. An incidence of 16 per cent for displaced intracapsular fractures has been reported (Lu-Yao 1994).

Other fracture healing complications that may occur are backing out of the implant as the fracture collapses, fracture below or around the implant and breakage of the implant.

 

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. Differences between protocol and review
  17. Index terms

To identify and summarise the evidence from randomised controlled trials of the effects of different implants for the internal fixation of intracapsular proximal femoral fractures.

 

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. Differences between protocol and review
  17. Index terms
 

Criteria for considering studies for this review

 

Types of studies

All randomised controlled trials comparing alternative implants. Quasi-randomised trials (for example, allocation by alternation or date of birth) and trials in which the treatment allocation was inadequately concealed were considered for inclusion. No language restriction was applied.

 

Types of participants

Skeletally mature patients with an intracapsular proximal femoral fracture.

 

Types of interventions

Implants used for internal fixation of an intracapsular proximal femoral fracture.

 

Types of outcome measures

The principal outcome measure was the non-union rate which includes early displacement of the fracture. Data for the following outcomes were sought:

a) Operative details

  • length of surgery (in minutes)
  • operative blood loss (in millilitres)
  • number of patients transfused
  • post-operative blood transfusion (in units)
  • radiographic screening time (in seconds)

b) Fracture fixation complications

  • non-union of the fracture within the follow-up period (the definition of non-union will be that used within each individual study and this outcome will include early re-displacement of the fracture).
  • avascular necrosis
  • fracture below the implant
  • other surgical complications of fixation (as detailed in each study)
  • total fracture fixation complications (sum of the four above outcomes)
  • 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 extends beneath the deep fascia to the site of the implant)
  • deep wound infection (infection around the implant)
  • wound haematoma

c) Post-operative complications

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

d) Anatomical restoration

  • shortening (as defined in each study)
  • varus deformity (as defined in each 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)
  • residence at final follow-up (return to living at home, discharge location)
  • mobility (use of walking aids, return of mobility)
  • regain of activities of daily living
  • health related quality of life measures

 

Search methods for identification of studies

 

Electronic searches

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (13 September 2010), the Cochrane Central Register of Controlled Trials (2010, Issue 3), MEDLINE (1950 to August week 5 2010) and EMBASE (1980 to 2010 Week 36). We searched the WHO International Clinical Trials Registry Platform Search Portal, Current Controlled Trials, and the UK National Research Register (NRR) Archive (all to April 2009) to identify ongoing and recently completed trials. No language or publication restrictions were applied.

The generic search strategies for hip fracture trials run in The Cochrane Library (Wiley Online Library) and MEDLINE (2002 onwards) are shown in Appendix 1. This MEDLINE search was combined with the sensitivity- and precision-maximizing version of the Cochrane Highly Sensitive Search Strategy for identifying randomized trials (Lefebvre 2009). The general search strategy for hip fracture trials in EMBASE (2002 onwards) is also shown in Appendix 1.

 

Searching other resources

We searched reference lists of articles and our own reference databases. We included the findings from handsearches of the British Volume of the Journal of Bone and Joint Surgery supplements (1996 to 2006), abstracts of the American Orthopaedic Trauma Association annual meetings (1996 to 2006) and American Academy of Orthopaedic Surgeons annual meetings (2004 to 2007). We also included handsearch results from the final programmes of SICOT (1996 and 1999) and SICOT/SIROT (2003), EFORT (2007) and the British Orthopaedic Association Congress (2000, 2001, 2002, 2003, 2005 and 2006). Up to 2007, we scrutinised weekly downloads of "Fracture" articles in new issues of Acta Orthopaedica Scandinavica (subsequently Acta Orthopaedica); American Journal of Orthopedics; Archives of Orthopaedic and Trauma Surgery; Clinical Orthopedics and Related Research; Injury; Journal of the American Academy of Orthopedic Surgeons; Journal of Arthroplasty; Journal of Bone and Joint Surgery (American and British Volumes); Journal of Orthopedic Trauma; Journal of Trauma; Orthopedics from AMEDEO.

 

Data collection and analysis

 

Selection of studies

Study selection was performed by one author.

 

Data extraction and management

Data for the outcomes listed above were independently extracted by both review authors using a data extraction form. Any differences were resolved by discussion.

 

Assessment of risk of bias in included studies

In the update of the review (2011), two aspects of risk of bias were assessed by one author (MJP) and reported. These were sequence generation and allocation concealment. In this assessment, incomplete or a lack of information on sequence generation or allocation concealment was judged as 'unclear' risk of bias unless the trial was quasi-randomised, in which case both were rated 'no'.

We also independently assessed 11 aspects of methodological quality using a slightly modified scheme to that used in former versions of the review (see  Table 1). There was no masking of the study names or authors. Any differences were resolved by discussion.

 

Measures of treatment effect

Risk ratios and 95% confidence limits were calculated for dichotomous outcomes, and mean differences and 95% confidence limits calculated for continuous outcomes.

 

Assessment of heterogeneity

Heterogeneity between comparable trials was assessed by visual inspection of the overlap of confidence intervals amongst included studies and tested using a standard Chi² test.

 

Data synthesis

Where appropriate, results of comparable groups of trials were pooled using the fixed-effect model. Where there was substantial heterogeneity, the results of the random-effects model were checked and presented.

 

Sensitivity analysis

We planned but did not undertake sensitivity analyses to investigate the effects of including trials which at risk of bias from lack of allocation concealment.

 

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. Differences between protocol and review
  17. Index terms
 

Description of studies

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

Thirty studies were included and details of these are given in the Characteristics of included studies. The included studies involve a total of 6334 patients (6339 fractures). Alho 1998 involved three hospitals with different randomisation of implants within each centre. Results for each centre in this study are therefore considered separately under three headings (Alho 1998(a); Alho 1998(b); Alho 1998(c)).

The majority of studies included both undisplaced and displaced fractures. Kuokkanen 1991 included only undisplaced fractures while Alho 1998 (Alho 1998(a); Alho 1998(b); Alho 1998(c)), Benterud 1997, Christie 1988, Frandsen 1981, Madsen 1987 and Paus 1986 included only displaced fractures. Dalen 1985 did not state the number of displaced fractures.

The types of implant studied differed considerably. Few studies compared the same implants. Details of comparisons can be found in the Characteristics of included studies, and are summarised under each comparison in Effects of interventions.

Four studies (Ingwersen 1992; Jukkala-Partio 2000; Poulsen 1995; Sernbo 1986) were excluded for the reasons listed in the Characteristics of excluded studies.

The authors of this report would be pleased to receive any additional information from any of the included studies which may then be included in updates of this review.

 

Risk of bias in included studies

The risk of bias assessments for sequence generation and allocation concealment for individual trials are shown in Figure 1 and an overall summary is given in Figure 2. The majority of judgements were 'unclear', which reflected in part the poor reporting of the methods of randomisation in these trials. Sequence generation was considered adequate in six trials. Only Lykke 2003 was judged as having adequate concealment of allocation. Four quasi-randomised trials (Harper 1992, Nordkild 1985, Stromquist 1988; Stromqvist 1984) were considered at high risk of bias resulting from both inadequate sequence generation and lack of allocation concealment. Details of the randomisation methods reported in the 30 trials are given below.

 FigureFigure 1. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
 FigureFigure 2. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Lagerby 1998 used closed sealed envelopes drawn in a sequential order. Elmerson 1988 randomised patients from a table of randomised numbers at the time of surgery. Alho 1998 (Alho 1998(a); Alho 1998(b); Alho 1998(c)) used random numbers within closed envelopes. Herngren 1992 and Elmerson 1995 also used a 'random numbers table'. Rehnberg 1989 also used random numbers but also matched for age, sex and type of residence. Wihlborg 1990 used sealed envelopes opened on the day of the operation. Lykke 2003 used sealed opaque numbered envelopes. Mjorud 2006 used sealed numbered envelopes. Paus 1986 used 'coded envelopes' and Sernbo 1990 used a random number generator to randomise the patient in the operating theatre. Parker 2010 used the toss of a coin.

Both Stromquist 1988 and Stromqvist 1984 used open randomisation with odd and even dates of birth. Nordkild 1985 stated they used 'odd and even numbers'. Harper 1992 used the even or odd medical record number.

Alberts 1989, Benterud 1997, Christie 1988, Dalen 1985, Frandsen 1981, Kuokkanen 1991, Lindequist 1989, Madsen 1987, Olerud 1991, Ovesen 1997, Svenningsen 1984, Sorensen 1992, and Sorensen 1996 did not give the method of randomisation. Holmberg 1990 stated that patients were randomised in the operating theatre but did not specify the method used.

The methodological assessment scores for the included studies are shown in Appendix 2.

 

Effects of interventions

For all the included studies the outcomes measures of non-union, avascular necrosis, total fracture healing complications, re-operations (for arthroplasty or implant removal), mortality and length of surgery are shown in the analysis tables. Data are not available from all included trials on all outcomes. Where significant results are reported in trials, these are also reported here.

 

Thornton nail versus three Scand pins

Dalen 1985 compared a single Thornton nail with three Scand pins in 94 patients. The limited results presented in the analyses indicate a tendency to a lower failure rate with the Scand pins ( Analysis 1.1,  Analysis 1.2). Intracapsular pressures were measured for 21 of the cases and showed no difference in intra-operative intra-articular pressures.

 

Thornton nail versus sliding nail plate

Frandsen 1981 compared a single Thornton nail with a sliding nail plate in 383 patients. Results indicate a lower risk of non-union ( Analysis 2.1) for those fractures treated with a sliding nail plate but no statistically significant difference in avascular necrosis ( Analysis 2.2) or people with either complication ( Analysis 2.3).

 

Sliding compression screw implant versus McLaughlin nail plate

Svenningsen 1984 compared a sliding compression screw plate implant with a McLaughlin nail plate in 255 patients. Results indicate a tendency towards an increased non-union rate for those treated with the McLaughlin nail plate ( Analysis 3.1). There were no statistically significant differences between the two groups for avascular necrosis ( Analysis 3.2), all fracture healing complications ( Analysis 3.3), re-operations ( Analysis 3.4), infection ( Analysis 3.5) or mortality ( Analysis 3.6). Length of surgery was a mean of 43 minutes for the compression screw implant and 38 minutes for the McLaughlin nail plate (P < 0.001). Hospital stay and fall in haemoglobin were reported as showing no significant difference between groups.

 

Sliding hip screw (SHS) versus sliding nail plate

Nordkild 1985 compared the SHS with the sliding nail plate in 49 patients. Results indicate no difference in the incidence of fracture healing complications ( Analysis 4.1,  Analysis 4.2) or re-operations (arthroplasty) ( Analysis 4.3) but an increased number of patients having residual pain in the nail plate group ( Analysis 4.4). Other outcomes reported were range of hip movements and walking aids used which showed no significant difference between groups. Bone scintigraphy was performed in a subgroup of 35 patients and showed no statistically significant difference between groups.

 

SHS versus double divergent pins

One study of 127 patients compared these implants (Christie 1988). The results for 15 patients were not given as they had either died early within the follow-up period or had been lost to follow-up. The data for non-union, avascular necrosis, re-operations (all for revision to arthroplasty) and use of walking aids at follow-up are given in the analyses. These results indicate a trend to a lower risk of non-union ( Analysis 5.1) and fewer re-operations ( Analysis 5.4) for those fractures fixed with the double divergent pins but no difference in the other outcomes.

 

SHS versus different types of cancellous bone screws

Eight studies compared the SHS with different types of cancellous bone screws (Benterud 1997; Harper 1992; Kuokkanen 1991; Madsen 1987; Ovesen 1997; Paus 1986; Sorensen 1992; Sorensen 1996). The results for the individual comparisons are described separately below but presented together in the analyses: Non-union ( Analysis 6.1), avascular necrosis ( Analysis 6.2), fracture healing complications ( Analysis 6.3), re-operations - arthroplasty ( Analysis 6.4), re-operations - implant removal ( Analysis 6.5), deep wound infection ( Analysis 6.6), mortality ( Analysis 6.7), and pain at follow-up ( Analysis 6.8).

 

SHS versus Uppsala/ Olmed screws

Benterud 1997 reported a study of 225 patients and found no difference in the incidence of fracture healing complications. Sorensen 1996 reported a study as a conference abstract for 101 patients and found no difference in the total incidence of fracture healing complications. Ovesen 1997 also reported a similar study only as a conference abstract for 316 fractures. The incidence of fracture healing complications for those who attended follow-up was reported as 31 per cent for the SHS and 25 per cent for Uppsala screws. The difference between these groups was reported as being not statistically significant. Re-operations for arthroplasty were required in 33/108 (30.6%) of SHS cases and 31/117 (26.5%) of the Uppsala group.

Benterud 1997 also reported that two patients in the SHS group developed wound infection requiring debridement. These were classified as deep wound infections in the analyses. Benterud 1997 found no difference between the two groups in mortality nor in pain at follow-up. Ovesen 1997 reported 'no difference' in mortality between groups at three, 12 and 24 months. The average hospital stay was 18 days in the SHS group and 15 days in the Uppsala screws group.

Benterud 1997 reported a significantly reduced median anaesthetic time for Olmed screws of 74 minutes versus 100 minutes for the SHS. Median operative times were 29 versus 55 minutes respectively. Ovesen 1997 reported median operative times of 25 minutes for Uppsala screws and 45 minutes for the SHS . Median operative blood loss was 10 ml for Uppsala screws and 100 ml for the SHS - this was reported as being statistically significant.

 

SHS versus two von Bahr screws

One study (Paus 1986) compared the SHS with two von Bahr screws in 131 patients. Results indicate no significant difference in any of the outcomes other than an increased number of patients treated with von Bahr screws who had implant removal ( Analysis 6.5). Length of surgery was also reported as showing a significant increase for the SHS (52 versus 41 minutes, P < 0.05).

 

SHS versus Gouffon screws

Sorensen 1992 compared the SHS with Gouffon screws in 73 patients. The trial was stopped earlier than planned because of the higher fixation failure rate in the Gouffon screw group. Results in the analyses shows a reduced fracture healing complications rate for the SHS (RR 0.52, 95% CI 0.31 to 0.87) but a higher mortality for SHS compared to the Gouffon screws (RR 2.53, 95% CI 1.09 to 5.86).

 

SHS versus three cancellous screws

Kuokkanen 1991 compared the SHS with three cannulated Mercon screws in 33 patients. Results for non-union, avascular necrosis, re-operations, deep wound infection and mortality are shown in the analyses with no significant difference for the different implants. In addition, there was one case of screw penetration into the acetabulum for the cancellous screw group. It was also reported there was no difference in the length of surgery between groups (61 minutes in each group). Mean operative blood loss was 200 ml for the cancellous screws and 245 ml for the SHS. The surviving patients were assessed by the Harris Hip Score (Harris 1969) - the results were stated to be 'somewhat better' for the SHS group (3/14 fair or poor for the SHS versus 6/15 for cancellous screws).

Harper 1992 compared the SHS (Ambi screw) with three cancellous screws in 209 patients. Only limited outcomes were reported. The number of cases requiring arthroplasty for fracture healing complications was 9/102 in the SHS group and 11/107 in the cancellous screw group. In addition there were two cases of fracture below the cancellous screws. There was no difference in mortality between groups.

 

SHS versus four cancellous screws

Madsen 1987 compared the SHS with four cancellous AO screws in 103 patients. Results for non-union of the fracture were presented using an actuarial survival analysis from which it was not possible to determine the number of patients who had died, been lost to follow-up or developed non-union. The paper reported a two-year cumulated union rate of 64 per cent for the SHS and 84 per cent for the parallel screw group, a difference that was reported as being statistically significant (P < 0.05). Results for avascular necrosis, re-operations and deep wound infection given in the analyses show no significant differences.

Madsen 1987 also reported on length of surgery which was a mean of 130 minutes for the SHS and 108 minutes for the parallel screws. Figures for the mean operative blood loss were 350 ml versus 200 ml for the cases of SHS and parallel screws who had a general anaesthetic and 200 ml versus 150 ml for those who had a regional anaesthetic. All these differences between groups were significantly in favour of the cancellous screws. Bone scintigraphy was also measured in 87 cases in Madsen 1987. The number of femoral heads with an impaired uptake was 14/40 for the SHS and 5/47 for the cancellous screws, a difference that was reported to be statistically significant.

 

Two von Bahr screws versus Hessel pins

Lindequist 1989 compared von Bahr screws with Hessel pins for 150 patients. All the results of this study are presented in the analyses ( Analysis 7.1 to  Analysis 7.8) and indicate a reduction in fracture healing complications (RR 0.58, 95% CI 0.40 to 0.83,  Analysis 7.3) and re-operations (RR 0.47, 95% CI 0.28 to 0.79,  Analysis 7.4; RR 0.26, 95% CI 0.10 to 0.66,  Analysis 7.5) for the von Bahr screws.

 

Two von Bahr screws versus Gouffon screws

Lindequist 1989 compared von Bahr screws with Gouffon screws in 169 patients. All the results of this study are presented in the analyses ( Analysis 8.1 to  Analysis 8.8) and indicate no significant difference in the incidence of fracture healing complications but a reduction in re-operations for implant removal ( Analysis 8.5) for the von Bahr screws.

 

Two von Bahr screws versus two Uppsala screws

One study of 222 patients compared these two implants (Rehnberg 1989). Results indicate a higher risk of non-union and fracture healing complications for the von Bahr screws (RR 3.18, 95% CI 1.70 to 5.94,  Analysis 9.1; RR 2.17, 95% CI 1.32 to 3.55,  Analysis 9.3). In addition to the complications shown in the analyses there were two cases of screw penetration in the Uppsala group and one in the von Bahr group. Other outcomes reported were for mortality  Analysis 9.6), mean length of surgery and mean operative blood loss for which there was no significant difference between groups. Pain was assessed at four and 12 months and reported to be significantly reduced for those treated with Uppsala screws (P < 0.001 at 4 months, P < 0.01 at 12 months). Use of walking aids was reported to be significantly more common (P < 0.01) after von Bahr screws at four months, but no significant difference was noted at 12 months. There was no significant difference in the change in residential status between groups for four and 12 months.

 

Three Richard screws versus two Uppsala screws

Lagerby 1998 studied 268 fractures in 266 patients. Results for non-union ( Analysis 10.1), avascular necrosis ( Analysis 10.2), fracture healing complications ( Analysis 10.3) and pain at follow-up ( Analysis 10.4) show no significant difference between the two implants. Re-operations, mortality and use of walking aids were reported as showing 'no difference' between groups.

 

Three Ullevaal screws versus two Olmed screws

Alho 1998(a) and Alho 1998(c) compared three Ullevaal screws with two Olmed screws in 358 patients. The limited results as presented in the analyses show a lower re-operation rate for conversion to arthroplasty for those patients treated at Ullevaal hospital (Alho 1998(c); RR 0.42, 95% CI 0.22 to 0.83,  Analysis 11.1). No difference in this re-operation rate was seen at the other centre (Alho 1998(a)). There was no difference between the two interventions in the implant removal rate ( Analysis 11.2). Three patients in the Ullevaal screw group and one in the Olmed screw group suffered fracture below the screws, necessitating revision fixation ( Analysis 11.3). No other outcomes were reported.

 

Three Ullevaal screws versus two Tronzo screws

Alho 1998(b) compared three Ullevaal screws with two Tronzo screws in 249 patients. The limited results, as presented in the analyses, indicate no difference in the number of patients needing conversion to arthroplasty ( Analysis 12.1), but a tendency to a lower removal of the implant for the Tronzo screws, although the result did not reach statistical significance (RR 2.05, 95% CI 0.90 to 4.66,  Analysis 12.2). One patient in the Ullevaal screw group suffered fracture below the screws, necessitating revision fixation ( Analysis 12.3). No other outcomes were reported.

 

Three screws of any type versus two screws of any type

Exploratory analysis was undertaken to combine all studies which compared three screws with two screws (Alho 1998(a); Alho 1998(b); Alho 1998(c); Lagerby 1998). Results as indicated in the analyses ( Analysis 13.1 to  Analysis 13.8) show no significant difference between three or two screws except for re-operation for arthroplasty. For this outcome there was a significant reduction for the three screws (32/302 versus 52/305: RR 0.64, 95% CI 0.43 to 0.97,  Analysis 13.4). However, when those cases of non-union in Lagerby 1998 are considered as well, the difference in major fracture healing complications between three and two screws becomes statistically insignificant ( Analysis 13.7).

 

Three short threaded AO screws versus three long threaded AO screws

Parker 2010 compared three AO screws with 16 mm of threads with three AO screws of 32 mm threads in 432 patients. Results as presented in the analyses showed no statistically significant differences in the occurrence of fracture healing complications ( Analysis 14.1,  Analysis 14.2,  Analysis 14.3), re-operations ( Analysis 14.4,  Analysis 14.5), mortality ( Analysis 14.6), residual pain ( Analysis 14.7) or change in residential status ( Analysis 14.8) between the two methods of fixation. In addition there was no difference between groups for the regain of mobility and mean pain scores at one year from injury.

 

Three Scand screws versus three Nystrom nails

Alberts 1989 compared three Nystrom nails with three Scand screws in 133 patients. Results as presented in the analyses showed no difference for fracture healing complications ( Analysis 15.1,  Analysis 15.2,  Analysis 15.3), infection ( Analysis 15.4,  Analysis 15.5) and mortality ( Analysis 15.6,  Analysis 15.7). Extrusion of the implant was more common with the Nystrom nails. Mean length of surgery was 18 minutes for the Nystrom nails and 30 minutes for the Scand screws (P value reported as < 0.001).

 

Three Gouffon screws with a Rydell four-flanged nail

Two studies compared these two implants. Elmerson 1988 reported a study of 223 patients and Wihlborg 1990 a study of 200 patients. Results as presented in the analyses showed no difference between the two implants for the outcome measures of non-union ( Analysis 16.1), avascular necrosis ( Analysis 16.2), fracture healing complications ( Analysis 16.3), re-operations (for arthroplasty) ( Analysis 16.4), infection ( Analysis 16.5,  Analysis 16.6) or mortality ( Analysis 16.7,  Analysis 16.8).

Elmerson 1988 also indicated that the mean length of surgery was 38 minutes for Gouffon screws and 28 minutes for the Rydell nail, a difference that was reported to be statistically significant (P < 0.001).

 

Two Hansson pins versus a Rydell four-flanged nail

Three studies compared these implants: Holmberg 1990 reported a study of 220 patients; Sernbo 1990 of 410 patients and Stromqvist 1984 of 152 patients. The outcomes measures, where reported, for non-union ( Analysis 17.1), avascular necrosis ( Analysis 17.2), fracture healing complications ( Analysis 17.3), re-operations ( Analysis 17.4,  Analysis 17.5) and mortality at two years ( Analysis 17.6) are shown in the analyses. Results indicated no significant difference in outcomes between the two implants for any of the outcomes listed above; the random-effects model was used for the first five analyses because of clearly significant heterogeneity.

Holmberg 1990 reported that a similar number of patients in each group (27/110 and 26/110) failed to return to the same residential status. Sernbo 1990 also gave figures for the mean length of surgery, radiographic screening time, length of hospital stay and numbers going back to the same residential state. There was no significant difference between groups for any of these outcomes. Stromqvist 1984 reported no cases of deep wound infection in either group and also presented the results of bone scintimetric evaluation for 138 of the patients. This indicated a statistically significant reduction of uptake of isotope for those fractures treated with the four-flanged nail.

 

Two Hansson pins versus Sliding Hip Screw (SHS)

Both Elmerson 1995 (222 patients) and Sorensen 1996 (99 patients) found no difference in the incidence of fracture healing complications ( Analysis 18.1,  Analysis 18.2,  Analysis 18.3), or re-operations ( Analysis 18.4). Mortality was reported in Elmerson 1995 with no difference between implants ( Analysis 18.5). Elmerson 1995 also reported on the length of surgery, which was significantly lower for the Hansson pins (24 versus 34 minutes,  Analysis 18.6).

 

Two Hansson hook pins versus cancellous screws

Six studies compared two Hansson hook pins with different types of cancellous bone screws (Herngren 1992; Lykke 2003; Mjorud 2006; Olerud 1991; Sorensen 1996; Stromquist 1988). The results for the individual comparisons are described separately below but presented together in the analyses: Non-union ( Analysis 19.1), avascular necrosis ( Analysis 19.2), fracture healing complications ( Analysis 19.3), re-operations - arthroplasty ( Analysis 19.4), re-operations - arthroplasty or need for arthroplasty ( Analysis 19.5), re-operations - implant removal ( Analysis 19.6), re-operations - type not specified ( Analysis 19.7), deep wound infection ( Analysis 19.8), superficial wound infection ( Analysis 19.9), and mortality ( Analysis 19.10).

 

Two Hansson pins versus two Uppsala screws

Three studies compared these implants: Herngren 1992 (179 patients, 180 fractures), Olerud 1991 (115 patients) and Sorensen 1996 (100 patients). Pooled results using the random-effects model for non-union, avascular necrosis and all fracture healing complications show no significant differences between the two implants. Notably, Olerud 1991 reported a significant reduction in the incidence of non-union for those treated with the Uppsala screws (RR 3.79, 95% CI 1.51 to 9.53), while the two trials (Herngren 1992; Sorensen 1996) found no difference between implants for the incidence of fracture healing complications. Herngren 1992 also reported three cases of trochanteric fracture of the same hip in those treated with the Hansson pins and one case with Uppsala screws. Pooled data for mortality from two trials showed trend to lower mortality in the Hansson pin group.

Length of surgery reported by Herngren 1992 was a mean of 33 minutes for the Hansson pins and 38 minutes for the Uppsala screws.

Olerud 1991 also reported, without figures, that at the four and 12 month follow-up there was a statistically significant increased incidence of pain (P = 0.0007 at 4 months, P = 0.007 at 12 months), failure to regain residential status (P = 0.028 at 4 months, P = 0.03 at 12 months) and reduction in mobility (P = 0.008 at 4 months, P = 0.097 at 12 months) for those treated by the Hansson pins.

Herngren 1992 noted there was local discomfort to lateral protrusion of the implant in six out of 96 Uppsala screw cases but in no patients of the Hansson group.

 

Two Hansson hook pins versus two AO screws

Stromquist 1988 studied 110 cases. Follow-up of patients was for only four months and the trial methodology was poor. Non-union and avascular rates were not given but re-operations within the follow-up period were stated as fewer for the Hansson pins. However, it was reported that more patients in the Hansson pin group were scheduled for arthroplasty, such that the difference between groups for those who had re-operations and needed re-operation was not significantly different (Analysis 19.5). Mortality and bone scintimetry results showed no significant difference between the two implants.

 

Two Hansson hook pins versus three AO screws

Mjorud 2006 studied 199 cases. Follow-up of patients was for two years. Outcomes reported and detailed in the analyses were fracture healing complications and re-operations. None of these outcomes showed any difference between groups. Mean length of surgery was 36 minutes for the Hansson pins and 40 minutes for the AO screws, a difference that was reported as not statistically significant. Mortality reported at up to two years from surgery showed no difference between groups. Other outcomes reported which also showed no statistically significant difference between groups were inability to walk at discharge and later walking ability.

 

Two Hansson hook pins versus three Ullevaal screws

Lykke 2003 compared two Hansson pins with three Ullevaal screws in 278 fractures. Results as indicated in the analyses show no significant difference in non-union, fracture healing complications, re-operations, wound infections or mortality between treatment groups. There appeared, however, a potential trend to a lower rate of avascular necrosis in the Hansson pin group. In addition the study reported there was no differences in the degree of residual pain at follow-up between groups (31% versus 23%), mean or median length of hospital stay (12 versus 10 days, 8 versus 8 days), or proportion of patients discharged to rehabilitation homes (47% versus 49%). The complication of deep vein thrombosis was similar between groups (one in each) as was that from pneumonia (one in the Hansson pin group versus three in the Ullevaal group). Fracture healing complications were more common in those cases in which drill penetration into the hip joint occurred during surgery. Drill penetration was more common in the Ullevaal screw group (7 versus 16 cases).

 

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. Differences between protocol and review
  17. Index terms

Thirty studies using a wide variety of orthopaedic implants were identified and included within the analysis. The methodology of the studies varied considerably and most trials scored poorly, although in some of these cases the low score may reflect a poor reporting of trial methods rather than poor trial methodology. Additionally, risk of bias assessment relating to sequence generation and allocation concealment found only six trials were at low risk of bias for the first item and only one trial at low risk of bias for the second. The main outcome measures reported were fracture healing complications, re-operations and mortality. The reporting of functional outcomes was poor and only documented in a small number of studies. The few significant differences observed after multiple analyses may have arisen by chance. Taken in conjunction with the generally low methodological quality of the studies as reported, caution needs to be adopted in drawing any definite conclusions. Most of the reported trials enrolled less than 300 participants. Thus, they were likely to be underpowered to provide evidence of significant difference between devices unless these differences had been expected to be large. Biologically or mechanically plausible differences between devices compared, and thus the hypotheses apparently being tested in the trials, were often unclear.

A significant potential for bias within the studies may have occurred in those centres which were evaluating an implant that was developed in their own institution, or by one of the authors of the study. The studies concerned were for Hansson pins (Stromqvist 1984), Uppsala screws (Olerud 1991; Rehnberg 1989), sliding compression screw plate (Svenningsen 1984) and Ullevaal screws (Alho 1998(c)). All these reported better outcomes for their own implants. The problems are highlighted in Alho 1998 who recommends that evaluation of implants by centres with a particular interest or expertise in one of the implants, is strongly prone to biases even within the context of a randomised trial. The cause for these biases is difficult to explain.

The conclusions for the different implants are summarised in the following.

 

Double divergent pins; fixed (static) nail plate; sliding compression screw plate; Hessel pins and Nystrom nails

For all these implants, only one randomised trial was found evaluating each implant (Alberts 1989: Nystrom nails; Christie 1988: double divergent pins; Lindequist 1989: Hessel pins; Svenningsen 1984: fixed nail plate and sliding compression screw plate). None of these studies showed a clear difference between the implants under investigation. Therefore, no conclusions can be made for the use of these implants from the randomised trials undertaken to date.

 

Single Thornton nail

This implant was found to have been evaluated in two randomised studies; one against three cancellous screws (Dalen 1985) and another against a sliding nail plate (Frandsen 1981). Both studies reported a tendency to a lower risk of fracture healing complications with the comparison implant. While there are limited data on the use of this implant, its use cannot be recommended given the tendency to inferior results in both comparisons.

 

Sliding nail plate

This implant has been evaluated in two randomised studies, one against a single Thornton nail (Frandsen 1981), where a lower rate of non-union was found for the nail plate, and the other against an SHS (Nordkild 1985), where more patients had residual pain in the nail plate group. However, the small number of patients evaluated within these two trials means that no definite conclusions can be made regarding the use of a sliding nail plate.

 

Rydell four-flanged nail

This implant was found to have been evaluated in five randomised studies, two comparing against Gouffon pins (Elmerson 1988; Wihlborg 1990) and three studies comparing against Hansson pins (Holmberg 1990; Sernbo 1990; Stromqvist 1984). No difference for the incidence of fracture healing complications or mortality between groups was found. As exception was found for Stromqvist 1984, where the results favoured the Hansson pin but, as stated already, this trial is potentially biased given the implant had been developed in the same institution.

 

Hansson hook (LIH) pins

This implant has been evaluated in 10 randomised trials. Bias may have occurred in these studies, possibly due to greater experience with one of the implants under investigation. A strong trend to improved outcomes with the Hansson pins was found in the study from Lund, Sweden (Stromqvist 1984), where the pins were developed by one of the paper's authors. The study from Uppsala, Sweden (Holmberg 1990) was from a unit where the Rydell nail was the implant used before the start of the study. This study showed a tendency to lower complications with the Rydell nail. A study from Uppsala (Olerud 1991) compared Hansson pins with Uppsala screws and found better outcomes with the latter group. The difference in results between studies may therefore be due to familiarity or special expertise with the use of one of the implants under investigation.

Three studies compared Hansson pins with the Rydell nail (Holmberg 1990; Sernbo 1990; Stromqvist 1984). Although, as described above, Stromqvist 1984 showed better outcomes after the Hansson pins, overall there were no notable differences between implants. Three studies compared Hansson pins with Uppsala screws (Herngren 1992; Olerud 1991; Sorensen 1996), two with two AO screws (Mjorud 2006; Stromquist 1988), one with Ullevaal screws (Lykke 2003) and two with the SHS (Elmerson 1995; Sorensen 1996). Overall there were no notable differences in fracture healing complications between implants.

 

Sliding hip screw (SHS)

This implant has been evaluated more extensively within 11 randomised studies. Christie 1988 compared the SHS with double divergent pins. There was a tendency to lower fracture healing complications after double divergent pins, but due to the low numbers of patients reported, no definite conclusions can be made about the comparison of these two implants. Nordkild 1985 compared the SHS with the sliding nail plate. Results indicated no difference in the incidence of fracture healing complications, but more patients had residual pain in the nail plate group. Two studies compared the SHS with Hansson pins (Elmerson 1995; Sorensen 1996). Neither study found any significant difference in the incidence of fracture healing complications.

Eight studies compared the SHS with different types of cancellous bone screws (Benterud 1997; Harper 1992; Kuokkanen 1991; Madsen 1987; Ovesen 1997; Paus 1986; Sorensen 1992; Sorensen 1996). Summation of results showed an increased incidence of avascular necrosis and also a tendency to a higher fixation failure rate with the cancellous screws, although the overall re-operation rate for fixation failure did not differ between implants. Those studies that reported on operative blood loss and operative time noted an increase for the SHS. The findings of a significantly higher mortality in the SHS group of Sorensen 1992 were not found in the other five trials providing data for this outcome.

 

Multiple screws

Implants consisting of multiple screws were the most prevalent type of implant studied. Eighteen studies compared a multiple parallel screw technique against an alternative type of implant. As summarised above, for those studies that compared multiple screws against the SHS (Benterud 1997; Harper 1992; Kuokkanen 1991; Madsen 1987; Ovesen 1997; Paus 1986; Sorensen 1992; Sorensen 1996), there was no overall difference in the number of fracture healing complications between implants aside from an increased incidence of avascular necrosis for the screws, but some studies noted that the SHS fixation took longer and had an increased blood loss. For those studies, which compared parallel screws with another type of implant, no study demonstrated notable differences for these comparisons. These studies were those comparing Gouffon screws with the Rydell nail (Elmerson 1988; Wihlborg 1990), Uppsala/Olmed screws with Hansson pins (Olerud 1991; Sorensen 1996; Herngren 1992), AO screws with Hansson pins (Mjorud 2006; Stromquist 1988), Ullevaal screws with Hansson pins (Lykke 2003), Scand hip pins with the Thornton nail (Dalen 1985), Scand hip pins with Nystrom nails (Alberts 1989) and von Bahr screws with Hessel pins (Lindequist 1989).

A further five studies compared different screw types (Alho 1998 (Alho 1998(a); Alho 1998(b); Alho 1998(c)); Lagerby 1998; Lindequist 1989; Rehnberg 1989; Parker 2010). For these studies it was not possible to make any notable conclusions between the different screw types affecting the incidence of fracture healing complications. This included those studies which compared two versus three screws.

 

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. Differences between protocol and review
  17. Index terms

 

Implications for practice

There is insufficient evidence from randomised controlled trials to determine the best implant for internal fixation of intracapsular fractures.

 
Implications for research

Further studies are required to determine the choice of implant for internal fixation of intracapsular fractures. Future studies should be adequately powered to detect any clinically important difference between implant types; in the light of the evidence from this review, they may require recruiting thousands rather than hundreds of participants, and to be multi-centre in order to increase generalisability and avoid biases which may have arisen in the past from single centre studies. These trials should have appropriate methodology with a minimum of one year follow-up of cases and always report the results in full, even if the difference between implants is not significant. The current ongoing multi-centre FAITH trial (FAITH) does address these issues and is comparing the two most commonly used implants of the SHS and multiple screws.

 

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. Differences between protocol and review
  17. Index terms

Glyn Stockton was co-author for the first edition of this review. Helen Handoll independently extracted data and checked the study of Parker 2010. We are indebted to Prof William Gillespie, Leeann Morton and Dr Helen Handoll for their help. We would also like to thank the following for useful comments from editorial review: Prof Rajan Madhok, Prof Gordon Murray, Prof Marc Swiontkowski, Dr Janet Wale, Peter Herbison, Prof James Hutchison, Dr Dicky Lam and Dr Jean-Claude Theis.

 

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. Differences between protocol and review
  17. Index terms
Download statistical data

 
Comparison 1. Thornton nail versus three Scand pins

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

 1 All fracture healing complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Re-operations1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 2. Thornton nail versus sliding nail plate

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

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

 2 Avascular necrosis1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 All fracture healing complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 3. Sliding compression screw plate versus fixed nail plate

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

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

 2 Avascular necrosis1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 All fracture healing complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Re-operations - implant removal1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 5 Superficial wound infection1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 6 Deep wound infection1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 7 Mortality - 1 year1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 4. Sliding hip screw versus sliding nail plate

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

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

 2 Avascular necrosis1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 Re-operations - arthroplasty1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Pain at follow-up1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 5. Sliding hip screw versus double divergent pins

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

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

 2 Avascular necrosis1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 All fracture healing complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Re-operations1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 5 Use of walking aids at follow-up1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 6. Sliding hip screw versus cancellous screws

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

 1 Non-union4462Risk Ratio (M-H, Random, 95% CI)0.94 [0.57, 1.57]

    1.1 Sliding hip screw versus two Uppsala/Olmed screws
1225Risk Ratio (M-H, Random, 95% CI)1.34 [0.89, 2.03]

    1.2 Sliding hip screw versus two von Bahr screws
1131Risk Ratio (M-H, Random, 95% CI)0.98 [0.55, 1.76]

    1.3 Sliding hip screw versus three Gouffon screws
173Risk Ratio (M-H, Random, 95% CI)0.54 [0.28, 1.05]

    1.4 Sliding hip screw versus three cancellous screws
133Risk Ratio (M-H, Random, 95% CI)Not estimable

 2 Avascular necrosis5565Risk Ratio (M-H, Fixed, 95% CI)0.62 [0.38, 1.01]

    2.1 Sliding hip screw versus two Uppsala/Olmed screws
1225Risk Ratio (M-H, Fixed, 95% CI)0.79 [0.38, 1.65]

    2.2 Sliding hip screw versus two von Bahr screws
1131Risk Ratio (M-H, Fixed, 95% CI)0.59 [0.23, 1.53]

    2.3 Sliding hip screw versus three Gouffon screws
173Risk Ratio (M-H, Fixed, 95% CI)0.47 [0.13, 1.66]

    2.4 Sliding hip screw versus three cancellous screws
133Risk Ratio (M-H, Fixed, 95% CI)0.19 [0.01, 3.66]

    2.5 Sliding hip screw versus four cancellous screws
1103Risk Ratio (M-H, Fixed, 95% CI)0.61 [0.15, 2.43]

 3 All fracture healing complications6772Risk Ratio (M-H, Fixed, 95% CI)0.86 [0.70, 1.05]

    3.1 Sliding hip screw versus two Uppsala/Olmed screws
2326Risk Ratio (M-H, Fixed, 95% CI)1.07 [0.81, 1.40]

    3.2 Sliding hip screw versus two von Bahr screws
1131Risk Ratio (M-H, Fixed, 95% CI)0.84 [0.54, 1.30]

    3.3 Sliding hip screw versus three Gouffon screws
173Risk Ratio (M-H, Fixed, 95% CI)0.52 [0.31, 0.87]

    3.4 Sliding hip screw versus three cancellous screws
2242Risk Ratio (M-H, Fixed, 95% CI)0.60 [0.28, 1.27]

 4 Re-operations - arthroplasty5565Risk Ratio (M-H, Fixed, 95% CI)0.99 [0.74, 1.33]

    4.1 Sliding hip screw versus two Uppsala/Olmed screws
1225Risk Ratio (M-H, Fixed, 95% CI)1.15 [0.76, 1.75]

    4.2 Sliding hip screw versus two von Bahr screws
1131Risk Ratio (M-H, Fixed, 95% CI)0.98 [0.53, 1.85]

    4.3 Sliding hip screw versus three Gouffon screws
173Risk Ratio (M-H, Fixed, 95% CI)0.60 [0.32, 1.12]

    4.4 Sliding hip screw versus three cancellous screws
133Risk Ratio (M-H, Fixed, 95% CI)0.19 [0.01, 3.66]

    4.5 Sliding hip screw versus four cancellous screws
1103Risk Ratio (M-H, Fixed, 95% CI)2.38 [0.65, 8.70]

 5 Re-operations - implant removal5565Risk Ratio (M-H, Random, 95% CI)0.86 [0.30, 2.45]

    5.1 Sliding hip screw versus two Uppsala/Olmed screws
1225Risk Ratio (M-H, Random, 95% CI)2.17 [0.56, 8.45]

    5.2 Sliding hip screw versus two von Bahr screws
1131Risk Ratio (M-H, Random, 95% CI)0.20 [0.04, 0.86]

    5.3 Sliding hip screw versus three Gouffon screws
173Risk Ratio (M-H, Random, 95% CI)0.54 [0.05, 5.73]

    5.4 Sliding hip screw versus three cancellous screws
133Risk Ratio (M-H, Random, 95% CI)3.29 [0.80, 13.57]

    5.5 Sliding hip screw versus four cancellous screws
1103Risk Ratio (M-H, Random, 95% CI)0.51 [0.16, 1.59]

 6 Deep wound infection4492Risk Ratio (M-H, Fixed, 95% CI)2.66 [0.63, 11.25]

    6.1 Sliding hip screw versus two Uppsala/Olmed screws
1225Risk Ratio (M-H, Fixed, 95% CI)5.41 [0.26, 111.49]

    6.2 Sliding hip screw versus two von Bahr screws
1131Risk Ratio (M-H, Fixed, 95% CI)1.97 [0.18, 21.20]

    6.3 Sliding hip screw versus three cancellous screws
133Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    6.4 Sliding hip screw versus four cancellous screws
1103Risk Ratio (M-H, Fixed, 95% CI)2.04 [0.19, 21.80]

 7 Mortality5671Risk Ratio (M-H, Fixed, 95% CI)1.25 [0.83, 1.89]

    7.1 Sliding hip screw versus two Uppsala/Olmed screws
1225Risk Ratio (M-H, Fixed, 95% CI)1.08 [0.49, 2.40]

    7.2 Sliding hip screw versus two von Bahr screws
1131Risk Ratio (M-H, Fixed, 95% CI)0.55 [0.19, 1.55]

    7.3 Sliding hip screw versus three Gouffon screws
173Risk Ratio (M-H, Fixed, 95% CI)2.53 [1.09, 5.86]

    7.4 Sliding hip screw versus three cancellous screws
2242Risk Ratio (M-H, Fixed, 95% CI)1.34 [0.61, 2.95]

 8 Pain at follow-up2298Risk Ratio (M-H, Fixed, 95% CI)0.81 [0.58, 1.12]

    8.1 Sliding hip screw versus two Uppsala/Olmed screws
1225Risk Ratio (M-H, Fixed, 95% CI)0.94 [0.55, 1.62]

    8.2 Sliding hip screw versus three Gouffon screws
173Risk Ratio (M-H, Fixed, 95% CI)0.70 [0.48, 1.01]

 
Comparison 7. von Bahr screws versus Hessel pins

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

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

 2 Avascular necrosis1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 All fracture healing complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Re-operations - arthroplasty1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 5 Re-operations - implant removal1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 6 Superficial wound infection1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 7 Deep wound infection1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 8 Mortality - 2 years1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 8. von Bahr screws versus Gouffon screws

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

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

 2 Avascular necrosis1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 All fracture healing complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Re-operations - arthroplasty1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 5 Re-operations - implant removal1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 6 Superficial wound infection1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 7 Deep wound infection1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 8 Mortality - 2 years1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 9. Two von Bahr screws versus two Uppsala screws

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

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

 2 Avascular necrosis1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 All fracture healing complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Re-operations - arthroplasty1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 5 Re-operations - implant removal1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 6 Mortality - 12 months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 10. Three Richards screws versus two Uppsala screws

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

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

 2 Avascular necrosis1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 All fracture healing complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Pain (moderate/severe) at one year1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 11. Three Ullevaal screws versus two Uppsala/Olmed screws

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

 1 Re-operations - arthroplasty2358Risk Ratio (M-H, Fixed, 95% CI)0.54 [0.30, 0.95]

 2 Re-operations - implant removal2358Risk Ratio (M-H, Fixed, 95% CI)0.94 [0.52, 1.70]

 3 Fracture below screws (requiring re-operation)2358Risk Ratio (M-H, Fixed, 95% CI)2.19 [0.33, 14.53]

 
Comparison 12. Three Ullevaal screws versus two Tronzo screws

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

 1 Re-operations - arthroplasty1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Re-operations - implant removal1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 Fracture below screws (requiring re-operation)1Peto Odds Ratio (Peto, Fixed, 95% CI)Totals not selected

 
Comparison 13. Three screws (any type) versus two screws (any type)

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

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

 2 Avascular necrosis1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 All fracture healing complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Re-operations - arthroplasty3607Risk Ratio (M-H, Fixed, 95% CI)0.64 [0.43, 0.97]

 5 Re-operations - implant removal3607Risk Ratio (M-H, Fixed, 95% CI)1.26 [0.78, 2.02]

 6 Fracture below screws (requiring re-operation)3607Risk Ratio (M-H, Fixed, 95% CI)2.45 [0.48, 12.38]

 7 Re-operation for arthroplasty or non-union4875Risk Ratio (M-H, Fixed, 95% CI)0.85 [0.62, 1.17]

 8 Pain (moderate/severe) at one year1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 14. Three short thread AO screws versus three long threaded AO screws

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

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

 2 Avascular necrosis1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 Fracture below screws1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Re-operations - all types1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 5 Re-operations - implant removal1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 6 Mortality - one year1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 7 Pain at one year follow-up1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 8 Failure to return to same residential status at one year (survivors)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 15. Three Scand screws versus three Nystrom nails

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

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

 2 Avascular necrosis1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 All fracture healing complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Superficial wound infection1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 5 Deep wound infection1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 6 Mortality - one year1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 7 Mortality - two years1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 16. Three Gouffon screws versus Rydell four-flanged nail

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

 1 Non-union2423Risk Ratio (M-H, Fixed, 95% CI)0.92 [0.65, 1.30]

 2 Avascular necrosis2423Risk Ratio (M-H, Fixed, 95% CI)1.09 [0.57, 2.08]

 3 All fracture healing complications2423Risk Ratio (M-H, Fixed, 95% CI)0.96 [0.73, 1.27]

 4 Re-operations2423Risk Ratio (M-H, Fixed, 95% CI)1.12 [0.74, 1.71]

 5 Superficial wound infection1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 6 Deep wound infection1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 7 Mortality - one year2423Risk Ratio (M-H, Fixed, 95% CI)1.13 [0.66, 1.94]

 8 Mortality - two years2423Risk Ratio (M-H, Fixed, 95% CI)0.87 [0.60, 1.28]

 
Comparison 17. Two Hansson pins versus Rydell four-flanged nail

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

 1 Non-union3782Risk Ratio (M-H, Random, 95% CI)0.92 [0.54, 1.58]

 2 Avascular necrosis3782Risk Ratio (M-H, Random, 95% CI)0.59 [0.28, 1.24]

 3 All fracture healing complications3782Risk Ratio (M-H, Random, 95% CI)0.77 [0.48, 1.23]

 4 Re-operations - arthroplasty3782Risk Ratio (M-H, Random, 95% CI)0.83 [0.43, 1.61]

 5 Re-operations - implant removal2630Risk Ratio (M-H, Fixed, 95% CI)1.0 [0.51, 1.96]

 6 Mortality - 2 years2372Risk Ratio (M-H, Fixed, 95% CI)1.10 [0.81, 1.48]

 
Comparison 18. Two Hansson pins versus sliding hip screw

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

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

 2 Avascular necrosis1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 All fracture healing complications2321Risk Ratio (M-H, Fixed, 95% CI)0.93 [0.70, 1.25]

 4 Re-operations - arthroplasty1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 5 Mortality - 2 years1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 6 Length of surgery1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 
Comparison 19. Two Hansson pins versus cancellous screws

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

 1 Non-union4772Risk Ratio (M-H, Random, 95% CI)1.25 [0.73, 2.13]

    1.1 Two Hansson pins versus two Uppsala screws
2295Risk Ratio (M-H, Random, 95% CI)2.04 [0.66, 6.24]

    1.2 Two Hansson pins versus three AO screws
1199Risk Ratio (M-H, Random, 95% CI)0.79 [0.40, 1.53]

    1.3 Two Hansson pins versus three Ullevaal screws
1278Risk Ratio (M-H, Random, 95% CI)0.95 [0.61, 1.49]

 2 Avascular necrosis4772Risk Ratio (M-H, Random, 95% CI)0.94 [0.43, 2.05]

    2.1 Two Hansson pins versus two Uppsala screws
2295Risk Ratio (M-H, Random, 95% CI)1.49 [0.69, 3.21]

    2.2 Two Hansson pins versus three AO screws
1199Risk Ratio (M-H, Random, 95% CI)1.29 [0.36, 4.66]

    2.3 Two Hansson pins versus three Ullevaal screws
1278Risk Ratio (M-H, Random, 95% CI)0.48 [0.21, 1.08]

 3 All fracture healing complications5872Risk Ratio (M-H, Random, 95% CI)1.14 [0.77, 1.67]

    3.1 Two Hansson pins versus two Uppsala screws
3395Risk Ratio (M-H, Random, 95% CI)1.50 [0.79, 2.84]

    3.2 Two Hansson pins versus three AO screws
1199Risk Ratio (M-H, Random, 95% CI)0.94 [0.56, 1.59]

    3.3 Two Hansson pins versus three Ullevaal screws
1278Risk Ratio (M-H, Random, 95% CI)0.79 [0.55, 1.13]

 4 Re-operations - arthroplasty3587Risk Ratio (M-H, Fixed, 95% CI)0.74 [0.52, 1.04]

    4.1 Two Hansson pins versus two cancellous AO
1110Risk Ratio (M-H, Fixed, 95% CI)0.15 [0.02, 1.25]

    4.2 Two Hansson pins versus three AO screws
1199Risk Ratio (M-H, Fixed, 95% CI)0.76 [0.43, 1.34]

    4.3 Two Hansson pins versus three Ullevaal screws
1278Risk Ratio (M-H, Fixed, 95% CI)0.83 [0.53, 1.31]

 5 Re-operation - arthroplasty or need for arthroplasty3587Risk Ratio (M-H, Fixed, 95% CI)0.80 [0.58, 1.12]

    5.1 Two Hansson pins versus two cancellous AO
1110Risk Ratio (M-H, Fixed, 95% CI)0.80 [0.29, 2.22]

    5.2 Two Hansson pins versus three AO screws
1199Risk Ratio (M-H, Fixed, 95% CI)0.76 [0.43, 1.34]

    5.3 Two Hansson pins versus three Ullevaal screws
1278Risk Ratio (M-H, Fixed, 95% CI)0.83 [0.53, 1.31]

 6 Re-operations - implant removal1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    6.1 Two Hansson pins versus three AO screws
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 7 Re-operations - type not specified2379Risk Ratio (M-H, Fixed, 95% CI)1.05 [0.73, 1.51]

    7.1 Two Hansson pins versus two Uppsala screws
1180Risk Ratio (M-H, Fixed, 95% CI)1.33 [0.76, 2.33]

    7.2 Two Hansson pins versus three AO screws
1199Risk Ratio (M-H, Fixed, 95% CI)0.88 [0.54, 1.42]

 8 Deep wound infection2458Risk Ratio (M-H, Fixed, 95% CI)0.76 [0.13, 4.45]

    8.1 Two Hansson pins versus two Uppsala screws
1180Risk Ratio (M-H, Fixed, 95% CI)0.76 [0.13, 4.45]

    8.2 Two Hansson pins versus three Ullevaal screws
1278Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 9 Superficial wound infection1278Risk Ratio (M-H, Fixed, 95% CI)1.78 [0.16, 19.43]

    9.1 Two Hansson pins versus three Ullevaal screws
1278Risk Ratio (M-H, Fixed, 95% CI)1.78 [0.16, 19.43]

 10 Mortality5882Risk Ratio (M-H, Fixed, 95% CI)0.85 [0.68, 1.06]

    10.1 Two Hansson pins versus two Uppsala screws
2295Risk Ratio (M-H, Fixed, 95% CI)0.63 [0.38, 1.04]

    10.2 Two Hansson pins versus two cancellous AO
1110Risk Ratio (M-H, Fixed, 95% CI)0.93 [0.29, 3.03]

    10.3 Two Hansson pins versus three AO screws
1199Risk Ratio (M-H, Fixed, 95% CI)0.87 [0.57, 1.33]

    10.4 Two Hansson pins versus three Ullevaal screws
1278Risk Ratio (M-H, Fixed, 95% CI)0.97 [0.70, 1.35]

 

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. Differences between protocol and review
  17. Index terms
 

Appendix 1. Search strategies

 

Cochrane Central Register of Controlled Trials (Wiley Online Library)

#1   MeSH descriptor Hip Fractures explode all trees (927)
#2   ((hip* or femur* or femoral* or intracapsular* or subcapital or transcervical) NEAR/4 fracture*):ti,ab,kw (1952)
#3   (#1 OR #2) (1952)
#4   (pin or pins or pinned or pinning or nail* or screw* or plate* or arthroplast* or fix* or prosthes*):ti,ab,kw (29319)
#5   MeSH descriptor Internal Fixators, this term only (98)
#6   MeSH descriptor Bone Screws, this term only (394)
#7   MeSH descriptor Fracture Fixation, Internal explode all trees (652)
#8   MeSH descriptor Bone Plates, this term only (212)
#9   MeSH descriptor Bone Nails, this term only (250)
#10 MeSH descriptor Arthroplasty, this term only (139)
#11 MeSH descriptor Arthroplasty, Replacement, Hip, this term only (1172)
#12 (#4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11) (29319)
#13 (#3 AND #12) (745)
#14 (extracapsular or trochanteric or subtrochanteric or pertrochanteric or intertrochanteric):ti (389)
#15 (intracapsular or subcapital or transcervical):ti (225)
#16 (#14 AND NOT #15) (379)
#17 (#13 AND NOT #16) (499)

 

MEDLINE (Ovid Web)

1 exp Hip Fractures/ (14794)
2 ((hip$ or femur$ or femoral$ or intracapsular$ or subcapital or transcervical) adj4 fracture$).tw. (20570)
3 or/1-2 (24920)
4 (pin$1 or nail$ or screw$1 or plate$1 or arthroplast$ or fix$ or prosthes$).tw. (385604)
5 Internal Fixators/ or Bone Screws/ or Fracture Fixation, Internal/ or Bone Plates/ or Bone Nails/ (40241)
6 Arthroplasty/ or Arthroplasty, Replacement, Hip/ (17548)
7 or/4-6 (404588)
8 and/3,7 (10370)
9 (extracapsular or trochanteric or subtrochanteric or pertrochanteric or intertrochanteric).ti. (3536)
10 (intracapsular or subcapital or transcervical).ti. (1753)
11 9 not 10 (3458)
12 8 not 11 (9105)
13 Randomized Controlled Trial.pt. (298721)
14 Controlled Clinical Trial.pt. (82422)
15 randomized.ab. (205154)
16 placebo.ab. (121719)
17 Clinical Trials as Topic.sh. (150826)
18 randomly.ab. (149185)
19 trial.ti. (88477)
20 13 or 14 or 15 or 16 or 17 or 18 or 19 (692318)
21 exp Animals/ not Humans/ (3531211)
22 20 not 21 (640356)
23 12 and 22 (461)

 

EMBASE (Ovid Web)

1 exp Hip Fracture/ (20636)
2 ((hip$ or femur$ or femoral or intracapsular$ or subcapital or transcervical) adj4 fracture$).tw. (23792)
3 or/1-2 (31432)
4 (pin$1 or nail$ or screw$1 or plate$1 or arthroplast$ or fix$ or prosthes$).tw. (434374)
5 Bone Nail/ or Bone Plate/ or Bone Screw/ or Ender Nail/ or External Fixator/ or Fixation Device/ or Interlocking Nail/ or Internal Fixator/ or Osteosynthesis Material/ (26043)
6 exp Fracture Fixation/ (52878)
7 Arthroplasty/ or Hip Arthroplasty/ (18137)
8 or/4-7 (465804)
9 and/3,8 (13255)
10 (extracapsular or trochanteric or subtrochanteric or pertrochanteric or intertrochanteric).ti. (4058)
11 (intracapsular or subcapital or transcervical).ti. (1907)
12 10 not 11 (3967)
13 9 not 12 (11698)
14 Randomized Controlled Trial/ (280313)
15 Clinical Trial/ (804967)
16 Controlled Clinical Trial/ (161695)
17 Randomization/ (52313)
18 Single Blind Procedure/ (13269)
19 Double Blind Procedure/ (98937)
20 Prospective Study/ (154609)
21 ((clinical or controlled or comparative or prospective$ or randomi#ed) adj3 (trial or study)).tw. (508940)
22 (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).tw. (126704)
23 ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).tw. (126329)
24 ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or group$)).tw. (150805)
25 RCT.tw. (5874)
26 or/14-25 (1373779)
27 Case Study/ or Abstract Report/ or Letter/ (762331)
28 26 not 27 (1345199)
29 13 and 28 (1397)

 

Appendix 2. Methodological quality assessment results


 Study IDItem 1Item 2Item 3Item 4Item 5Item 6Item 7Item 8Item 9Item 10Item 11

Thornton nail versus three Scand pins

Dalen 198500000010000

Thornton nail versus sliding nail plate

Frandsen 198100010001101

Sliding compression screw plate versus McLaughlin nail plate

Svenningsen 198401010011101

Sliding hip screw versus sliding nail plate

Nordkild 198500011010101

Sliding hip screw versus double divergent pins

Christie 198800011001101

Sliding hip screw versus two von Bahr screws

Paus 198600010111101

Sliding hip screw versus Gouffon screws

Sorensen 199200011111101

Sliding hip screw versus cancellous screws

Harper 199200010101011

Madsen 198700010001101

Kuokkanen 199100011011100

Sliding hip screw versus Hansson pins versus Uppsala screws

Sorensen 199600000001000

Sliding hip screw versus two Uppsala or Olmed screws

Benterud 199700011001000

Ovesen 199700000001000

Sliding hip screw versus two Hansson pins

Elmerson 199510011011101

Three Gouffon pins versus a Rydell four flanged nail

Elmerson 198810010011101

Wihlborg 199000001011111

Two Hansson pins versus a Rydell four flanged nail

Holmberg 199000001111111

Sernbo 199010011111100

Stromqvist 198400011011101

Two Hansson pins versus two Uppsala screws

Herngren 199210011011111

Olerud 199100000011101

Two Hansson hook pins versus three Ullevaal screws

Lykke 200301010101110

Two Hansson hook pins versus two AO screws

Stromquist 198800000010100

Two Hansson hook pins versus three AO screws

Mjorud 200600110101101

Three Richard screws versus two Uppsala screws

Lagerby 199800011101101

Two von Bahr screws versus two Uppsala screws

Rehnberg 198910011111101

Three Ullevaal screws versus two Olmed screws

 Alho 1998(a)10011111001

Three Ullevaal screws versus two Tronzo screws

Alho 1998(b)10011111001

Three Ullevaal screws versus two Olmed screws

Alho 1998(c)10011111001

Three Nystrom nails versus three Scand screws

Alberts 198900011011100

von Bahr screws versus Hessel pins versus Gouffon screws

Lindequist 198900000111101

Three short thread AO screws versus three long threaded AO screws

Parker 201010011111111



 

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. Differences between protocol and review
  17. Index terms

Last assessed as up-to-date: 5 November 2010.


DateEventDescription

18 January 2011New search has been performedFor this update, published in Issue 2, 2011, the following amendments were made:

1. Title changed from 'Internal fixation implants for intracapsular proximal femoral fractures in adults' to 'Internal fixation implants for intracapsular hip fractures in adults'
2. New studies of Mjorud 2006 and Parker 2010 included.
3. Ongoing study of FAITH added.
4. Risk of bias assessment implemented for sequence generation and allocation concealment.
5. Additional reference to studies of Stromqvist 1984 and Sernbo 1990 added.
There were no changes to the conclusions of the review.



 

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. Differences between protocol and review
  17. Index terms

Protocol first published: Issue 2, 1999
Review first published: Issue 4, 2001


DateEventDescription

27 June 2008AmendedConverted to new review format.

27 August 2003New search has been performedFor the first update in Issue 4, 2003 the following changes were made:
1. New study of Lykke 2003 included.
2. Sernbo 1986 and Jukkala-Partio 2000 added to excluded studies.
3. Extra reference to studies of Olerud 1991 and Sorensen 1992 added.
There were no changes to the conclusions of the review.



 

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. Differences between protocol and review
  17. Index terms

Martyn Parker initiated and designed the review, read all studies, extracted data and compiled the first drafts. Kurinchi Gurusamy checked data from the newly studies identified for the first and second update. 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. Differences between protocol and review
  17. Index terms

Martyn Parker was the lead author of one of the studies included in this review (Parker 2010). The assessment of this study was undertaken by Kurinchi Gurusamy and Helen Handoll. Martyn Parker has received and may continue to receive financial payment from manufacturing companies of orthopaedic implants used for the internal fixation of hip fractures and for attending meeting organised by these companies and for advising on the design and use of hip fracture implants. Kurinchi Gurusamy has no connection with any manufacturing company.

 

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. Differences between protocol and review
  17. Index terms
 

Internal sources

  • Scottish Home and Health Department, UK.

 

External sources

  • No sources of support supplied

 

Differences between protocol and review

  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. Differences between protocol and review
  17. Index terms

In the update of the review (2011), two aspects of risk of bias were assessed and reported: sequence generation and allocation concealment. We also modified our former scheme for assessment methodological quality, mainly adding in an item for sequence generation.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé scientifiqueアブストラクト
  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. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to ongoing studies
  22. Additional references
Alberts 1989 {published data only}
  • Alberts KA, Jaerveus J, Zyto K. Nail versus screw fixation of femoral neck fractures. A 2-year radiological and clinical prospective study. Annales Chirurgiae et Gynaecologiae 1989;78:298-303.
Alho 1998(a) {published data only}
  • Alho A, Austdal S, Benterud JG, Blikra G, Lerud P, Raugstad TS. Biases in a randomized comparison of three types of screw fixation in displaced femoral neck fractures. Acta Orthopaedica Scandinavica 1998;69(5):463-8.
  • Alho A, Austdal S, Benterud JG, Blikra G, Lerud P, Raugstad TS. Problems in orthopedic multicenter studies - screw fixation of displaced femoral neck fracture [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1998;282:11.
  • Austdal S, Benterud JG, Blikra G, Kuokkanen H, Lindequist S, Lerud P, et al. Osteosynthesis of displaced femoral neck fractures with multiple screws - a randomised multicenter study [abstract]. Journal of Bone and Joint Surgery. British Volume 1993;75 Suppl 2:199.
  • Benterud J, Alho A. Multiple screw fixation for displaced femoral neck fractures - a multicentre study [abstract]. Journal of Bone and Joint Surgery. British Volume 1995;77 Suppl 2:214.
  • Benterud JG, Blikra G, Lerud P, Raugstad TS, Austdal S, Lindequist S, et al. Multicentre randomized study on osteosynthesis of femoral neck fractures [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1994;260:32-3.
  • Benterud JG, Blikra G, Lerud P, Raugstad TS, Austdal S, Lindequist S, et al. Multicentric randomized study on screw osteosynthesis of femoral neck fractures [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1992;248:85.
Alho 1998(b) {published data only}
  • Alho A, Austdal S, Benterud JG, Blikra G, Lerud P, Raugstad TS. Biases in a randomized comparison of three types of screw fixation in displaced femoral neck fractures. Acta Orthopaedica Scandinavica 1998;69(5):463-8.
  • Alho A, Austdal S, Benterud JG, Blikra G, Lerud P, Raugstad TS. Problems in orthopedic multicenter studies - screw fixation of displaced femoral neck fracture [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1998;282:11.
  • Austdal S, Benterud JG, Blikra G, Kuokkanen H, Lindequist S, Lerud P, et al. Osteosynthesis of displaced femoral neck fractures with multiple screws - a randomised multicenter study [abstract]. Journal of Bone and Joint Surgery. British Volume 1993;75 Suppl 2:199.
  • Benterud J, Alho A. Multiple screw fixation for displaced femoral neck fractures - a multicentre study [abstract]. Journal of Bone and Joint Surgery. British Volume 1995;77 Suppl 2:214.
  • Benterud JG, Blikra G, Lerud P, Raugstad TS, Austdal S, Lindequist S, et al. Multicentre randomized study on osteosynthesis of femoral neck fractures [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1994;260:32-3.
  • Benterud JG, Blikra G, Lerud P, Raugstad TS, Austdal S, Lindequist S, et al. Multicentric randomized study on screw osteosynthesis of femoral neck fractures [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1992;248:85.
Alho 1998(c) {published data only}
  • Alho A, Austdal S, Benterud JG, Blikra G, Lerud P, Raugstad TS. Biases in a randomized comparison of three types of screw fixation in displaced femoral neck fractures. Acta Orthopaedica Scandinavica 1998;69(5):463-8.
  • Alho A, Austdal S, Benterud JG, Blikra G, Lerud P, Raugstad TS. Problems in orthopedic multicenter studies - screw fixation of displaced femoral neck fracture [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1998;282:11.
  • Austdal S, Benterud JG, Blikra G, Kuokkanen H, Lindequist S, Lerud P, Raugstad TS, Alho A. Osteosynthesis of displaced femoral neck fractures with multiple screws - a randomised multicenter study [abstract]. Journal of Bone and Joint Surgery. British Volume 1993;75 Suppl 2:199.
  • Benterud J, Alho A. Multiple screw fixation for displaced femoral neck fractures - a multicentre study [abstract]. Journal of Bone and Joint Surgery. British Volume 1995;77 Suppl 2:214.
  • Benterud JG, Blikra G, Lerud P, Raugstad TS, Austdal S, Lindequist S, et al. Multicentre randomized study on osteosynthesis of femoral neck fractures [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1994;260:32-3.
  • Benterud JG, Blikra G, Lerud P, Raugstad TS, Austdal S, Lindequist S, et al. Multicentric randomized study on screw osteosynthesis of femoral neck fractures [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1992;248:85.
Benterud 1997 {published data only}
  • Alho A, Benterud JG, Ronningen H, Hoiseth A. Prediction of disturbed healing in femoral neck fracture: radiographic analysis of 149 cases. Acta Orthopaedica Scandinavica 1992;63(6):639-44.
  • Benterud JG, Alho A. Displaced femoral neck fracture treated with HCS or Olmed screws - 225 randomized patients followed for 3 years [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1994;256:18.
  • Benterud JG, Husby T, Nordsletten L, Alho A. Fixation of displaced femoral neck fractures with a sliding screw plate and a cancellous screw or two Olmed screws - A prospective, randomized study of 225 elderly patients with a 3-year follow-up. Annales Chirurgiae et Gynaecologiae 1997;86(4):338-42.
Christie 1988 {published data only}
  • Christie J, Howie CR, Armour PC. Fixation of displaced subcapital femoral fractures. Compression screw fixation versus double divergent pins. Journal of Bone and Joint Surgery. British Volume 1988;70(2):199-201.
  • Howie CR, Christie J, Watson H. A prospective randomised trial of compression screw fixation versus double divergent pin fixation for displaced subcapital fracture of the femur [abstract]. Journal of Bone and Joint Surgery. British Volume 1987;69(3):490.
Dalen 1985 {published data only}
Elmerson 1988 {published data only}
  • Elmerson S, Gunnar BJ, Andersson J, Irstam L, Zetterberg C. Internal fixation of femoral neck fracture. No difference between the Rydell four-flanged nail and Gouffon's pins. Acta Orthopaedica Scandinavica 1988;59(4):372-6.
Elmerson 1995 {published data only}
  • Elmerson S, Sjostedt A, Zetterberg C. Fixation of femoral neck fracture. A randomized 2-year follow-up study of hook pins and sliding screw plate in 222 patients. Acta Orthopaedica Scandinavica 1995;66(6):507-10.
Frandsen 1981 {published data only}
  • Frandsen PA. Osteosynthesis of displaced fractures of the femoral neck. A comparison between Smith-Petersen Osteosynthesis and sliding-nail-plate osteosynthesis - a radiological study. Acta Orthopaedica Scandinavica 1979;50(4):443-9.
  • Frandsen PA, Andersen Jr PE. Treatment of displaced fractures of the femoral neck. Smith-Petersen osteosynthesis versus sliding-nail-plate osteosynthesis. Acta Orthopaedica Scandinavica 1981;52(5):547-52.
Harper 1992 {published data only}
  • Harper WM. A prospective randomised trial comparing multiple parallel cannulated screws with a sliding hip screw and plate. In 'Treatment of intracapsular proximal femoral fractures'. Thesis. Leicester: University of Leicester, 1994:158-86.
  • Harper WM, Gregg PJ. The treatment of intracapsular proximal femoral fractures: a randomized prospective trial [abstract]. Journal of Bone and Joint Surgery. British Volume 1992;74 Suppl 3:282.
Herngren 1992 {published data only}
  • Herngren B, Mork-Petersen F, Bauer M. Uppsala screws or Hansson pins for internal fixation of femoral neck fractures? A prospective study of 180 cases. Acta Orthopaedica Scandinavica 1992;63(1):41-6.
Holmberg 1990 {published data only}
  • Holmberg S, Mattsson P, Dahlborn M, Ersmark H. Fixation of 220 femoral neck fractures. A prospective comparison of the Rydell nail and the LIH hook pins. Acta Orthopaedica Scandinavica 1990;61(2):154-7.
Kuokkanen 1991 {published data only}
  • Kuokkanen H, Korkala O, Antti-Poika I, Tolonen J, Lehtimaki MY, Silvennoinen T. Three cancellous bone screws versus a screw-angle plate in the treatment of Garden I and II fractures of the femoral neck. Acta Orthopaedica Belgica 1991;57:53-7.
Lagerby 1998 {published data only}
  • Lagerby M, Asplund S, Ringqvist I. Cannulated screws for fixation of femoral neck fractures: No difference between Uppsala screws and Richards screws in a randomized prospective study of 268 cases. Acta Orthopaedica Scandinavica 1998;69(4):387-91.
Lindequist 1989 {published data only}
  • Lindequist S, Malmqvist B, Ullmark G. Fixation of femoral neck fracture. Prospective comparison of von Bahr screws, Gouffon screws and Hessel pins [published erratum appears in Acta Orthopaedica Scandinavica 1989 Aug;60(4):507-508]. Acta Orthopaedica Scandinavica 1989;60(3):293-8.
Lykke 2003 {published data only}
  • Lykke N, Lerud PJ, Stromsoe K, Thorngren K-G. Fixation of fracture of the femoral neck: a prospective, randomised trial of three Ullevaal hip screws versus two Hansson hook-pins. Journal of Bone Joint Surgery. British Volume 2003;85:426-30.
Madsen 1987 {published data only}
  • Linde F, Andersen E, Hvass I, Madsen F, Pallesen R. Avascular femoral head necrosis following fracture fixation. Injury 1986;17:159-63.
  • Madsen F, Linde F, Andersen E, Birke H, Hvass I, Poulsen TD. Fixation of displaced femoral neck fractures. A comparison between sliding screw plate and four cancellous bone screws. Acta Orthopaedica Scandinavica 1987;58:212-6.
  • Madsen F, Linde F, Andersen E, Birke H, Hvass I, Poulsen TD. Sliding screw plate versus four ASIF cancellous bone screws in the treatment of displaced femoral neck fractures [abstract]. Acta Orthopaedica Scandinavica 1986;57:598-9.
Mjorud 2006 {published data only}
  • Mjorud J, Skaro O, Solhaug JH, Thorngren K-G. A randomised study in all cervical hip fractures. Osteosynthesis with Hansson hook-pins versus AO-screws in 199 consecutive patients followed for two years. Injury 2006;37(8):768-77.
Nordkild 1985 {published data only}
  • Nordkild P, Sonne-Holm S, Jensen JS. Femoral neck fracture: sliding screw plate versus sliding nail plate -a randomized trial. Injury 1985;16:449-54.
  • Sonne-Holm S, Nordkild P, Dyrbye M, Jensen JS. The predictive value of bone scintigraphy after internal fixation of femoral neck fractures. Injury 1987;18:33-5.
  • Sonne-Holm S, Nordkild P, Dyrbye M, Jensen JS. The predictive value of bone scintigraphy after internal fixation of femoral neck fractures [abstract]. Acta Orthopaedica Scandinavica 1986;57:181.
Olerud 1991 {published data only}
  • Hellqvist E, Olerud C, Rehnberg L. Hansson pins vs Uppsala screws in treating femoral neck fractures [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1990;61(237):56.
  • Olerud C, Rehnberg L. Femoral neck fractures: Swedish experience. In: Marti RK, Dunki Jacobs PB editor(s). Proximal femoral fractures: operative techniques and complications. Vol. 1, London: Medical Press, 1993:219-40.
  • Olerud C, Rehnberg L, Hellquist E. Internal fixation of femoral neck fractures. Two methods compared. Journal of Bone and Joint Surgery. British Volume 1991;73:16-9.
Ovesen 1997 {published data only}
  • Ovesen O, Poulsen TD, Andersen I. Uppsala screws versus dynamic hip screw for internal fixation of femoral neck fractures [abstract]. Journal of Bone and Joint Surgery. British Volume 1997;79 Suppl 2:244.
  • Ovesen O, Poulsen TD, Andersen I, Jensen PE, Damholt UW. Uppsala screws versus dynamic hip screw for internal fixation of femoral neck fractures [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1997;274:40.
Parker 2010 {published data only}
  • Parker MJ. personal communication October 29 2010.
  • Parker MJ, Ali SM. Short versus long thread cannulated cancellous screws for intracapsular hip fractures: a randomised trial of 432 patients. Injury 2010;41(4):382-4.
Paus 1986 {published data only}
  • Paus A, Gjengedal E, Hareide A, Jorgensen JJ. Dislocated fractures of the femoral neck treated with von Bahr screws or hip compression screw. Results of a prospective, randomized study. Journal of the Oslo City Hospitals 1986;36:55-61.
Rehnberg 1989 {published data only}
  • Olerud C, Rehnberg L. Femoral neck fractures: Swedish experience. In: Marti Rk, Dunki Jacobs PB editor(s). Proximal femoral fractures: operative techniques and complications. Vol. 1, London: Medical Press, 1993:207-19.
  • Rehnberg L, Olerud C. A new method for osteosynthesis prevents early complications in cervical hip fractures [Ny osteosyntesmetod minskar de tidiga komplikationerna vid cervikala hoftfrakturer]. Lakartidningen 1988;85:3820-1. [MEDLINE: 89038721 89038721]
  • Rehnberg L, Olerud C. Femoral neck fractures: A prospective randomized comparison of von Bahr and Uppsala screws [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1990;237:55.
  • Rehnberg L, Olerud C. Fixation of femoral neck fractures. Comparison of the Uppsala and von Bahr screws. Acta Orthopaedica Scandinavica 1989;60:579-84.
Sernbo 1990 {published data only}
  • Sernbo I, Holmquist H, Redlund-Johnell I, Johnell O. Radiographic prediction of failure after fixation of cervical hip fracture. Acta Orthopaedica Scandinavica 1994;65(3):295-8.
  • Sernbo I, Johnell O, Baath L, Nilsson JA. Internal fixation of 410 cervical hip fractures. A randomized comparison of a single nail versus two hook-pins. Acta Orthopaedica Scandinavica 1990;61(5):411-4.
Sorensen 1992 {published data only}
  • Sorensen JL, Varmarken JE, Bomler J. Internal fixation of femoral neck fractures. Dynamic Hip and Gouffon screws compared in 73 patients. Acta Orthopaedica Scandinavica 1992;63(3):288-92.
  • Varmarken JE, Sorensen JL, Bomler J. Internal fixation of femoral neck fractures; a randomised comparison of Dynamic Hip Screw and Gouffon Pins [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1992;63(247):35-6.
Sorensen 1996 {published data only}
  • Sorensen AI, Scavenius M, Aagaard H, Ronnebech J, Torholm C. Dynamic hip screw versus Hook-pins versus Uppsala screws in treatment of fracture of the cervical neck [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1996;267:30.
Stromquist 1988 {published data only}
  • Roos H, Hansson LI, Ohlin P, Stromquist B. Screws or hook pins in femoral neck fracture fixation? [abstract]. Acta Orthopaedica Scandinavica 1986;57:250.
  • Stromquist B, Roos H, Hansson LI, Ohlin P. Fixation of fractures of the femoral neck using screws or hook-pins. Radionuclide study and short-term results [Fixation des fractures du col femoral par vissage ou "broches en crochet". Etude scintimetrique et resultats a court terme. Fixation des fractures du col femoral par vissage ou "broches en crochet". Etude scintimetrique et resultats a court terme.]. Revue de Chirurgie Orthopedique et Reparatrice de L'appareil Moteur 1988;74:609-13. [MEDLINE: 89202939 89202939]
Stromqvist 1984 {published data only}
  • Stromqvist B. Femoral head vitality after intracapsular hip fracture. 490 cases studied by intravital tetracycline labelling and Tc-MDP radionuclide imaging. Acta Orthopaedica Scandinavica 1983;54(Suppl 200):17.
  • Stromqvist B, Hansson LI, Nilsson LT, Thorngren KG. Two-year follow-up of femoral neck fractures. Comparison of osteosynthesis methods. Acta Orthopaedica Scandinavica 1984;55:521-5.
  • Stromqvist B, Hansson LI, Nilsson LT, Thorngren K-G. Two-year follow-up of femoral neck fractures with special reference to type of osteosynthesis. Acta Orthopaedica Scandinavica 1984;55:712-3.
  • Stromqvist B, Hansson LI, Palmer J, Ceder L, Thorngren KG. Scintimetric evaluation of nailed femoral neck fractures with special reference to type of osteosynthesis. Acta Orthopaedica Scandinavica 1983;54:340-7.
Svenningsen 1984 {published data only}
  • Benum P, Nesse O, Svenningsen S. Fracture of the neck of the femur. A randomized prospective study [abstract]. Acta Orthopaedica Scandinavica 1980;51:371.
  • Svenningsen S, Benum P, Nesse O, Furset OI. Femoral neck fractures in the elderly. A comparison of 3 therapeutic methods [Larhalsbrudd hos eldre. En sammenligning av tre behandlingsmetoder]. Tidsskr for den Norske Laegeforening 1985;105(7):492-5. [MEDLINE: 85193171]
  • Svenningsen S, Benum P, Nesse O, Furset OI. Femoral neck fractures in the elderly - a comparison of 3 treatment methods [Larhalsbrudd hos eldre--en sammenligning av tre behandlingsmetoder]. Nordisk Medicin 1985;100:256-9. [MEDLINE: 86176685 86176685]
  • Svenningsen S, Benum P, Nesse O, Furset OI. Internal fixation of femoral neck fractures. Compression screw compared with nail plate fixation. Acta Orthopaedica Scandinavica 1984;55:423-9.
Wihlborg 1990 {published data only}

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé scientifiqueアブストラクト
  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. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to ongoing studies
  22. Additional references
Ingwersen 1992 {published data only}
  • Ingwersen J, Skoglund A, Syversen S. Early loss of fixation of cervical hip fractures [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1992;247:6-7.
Jukkala-Partio 2000 {published data only}
  • Jukkala-Partio K, Partio EK, Helevirta P, Pohjonen T, Tormala P, Rokkanen P. Treatment of subcapital femoral neck fractures with bioabsorbable or metallic screw fixation. Annals Chirurgiae et Gynaecologiae 2000;89:45-52.
Poulsen 1995 {published data only}
Sernbo 1986 {published data only}
  • Sernbo I, Edwards P, Johnell O, Baath L. Cannulated screws versus spring loaded single nail in cervical hip fractures: A prospective randomized trial [abstract]. Acta Orthopaedica Scandinavica 1986;57:598.

References to ongoing studies

  1. Top of page
  2. AbstractRésumé scientifiqueアブストラクト
  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. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to ongoing studies
  22. Additional references
FAITH {unpublished data only}
  • Bhandari M. Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH): a multi-centre randomised trial comparing sliding hip screws and cancellous screws on revision surgery rates and quality of life in the treatment of femoral neck fractures. http://apps.who.int/trialsearch/Trial.aspx?TrialID=ISRCTN25524122 (accessed 18 January 2011).

Additional references

  1. Top of page
  2. AbstractRésumé scientifiqueアブストラクト
  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. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to ongoing studies
  22. Additional references
Alho 1998
  • Alho A, Austdal S, Benterud JG, Blikra G, Lerud P, Raugstad TS. Biases in a randomized comparison of three types of screw fixation in displaced femoral neck fractures. Acta Orthopaedica Scandinavica 1998;69(5):463-8.
Harris 1969
  • Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mould arthroplasty. An end-result study using a new method of result evaluation. Journal of Bone and Joint Surgery. American Volume 1969;51-A(4):737-55.
Lefebvre 2009
  • Lefebvre C, Manheimer E, Glanville J. Chapter 6.4.11  Search filters. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2 (updated September 2009). The Cochrane Collaboration, 2009. Available from www.cochrane-handbook.org.
Lu-Yao 1994
  • Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE. Outcome after displaced fracture of the femoral neck: a meta-analysis of one hundred and six published reports. Journal of Bone and Joint Surgery. American Volume 1994;76-A:15-25.
Parker 1993
  • Parker MJ, Pryor GA. Hip fracture management. Oxford: Blackwell Scientific Publications, 1993.
Tronzo 1974