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Surgical approaches and ancillary techniques for internal fixation of intracapsular proximal femoral fractures

  1. Martyn J Parker*,
  2. Abhijit Banerjee

Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

Published Online: 20 APR 2005

Assessed as up-to-date: 17 FEB 2005

DOI: 10.1002/14651858.CD001705.pub2


How to Cite

Parker MJ, Banerjee A. Surgical approaches and ancillary techniques for internal fixation of intracapsular proximal femoral fractures. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD001705. DOI: 10.1002/14651858.CD001705.pub2.

Author Information

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

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

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 20 APR 2005

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Characteristics of included studies [ordered by study ID]
Frandsen 1984

MethodsQuasi-randomised trial: method of randomisation by alternating days.


Participants220 patients with a displaced intracapsular fracture treated by internal fixation with a compression hip screw.
University Hospital, Odense, Denmark.
Median ages: 77/79 years (range 40-94)
18% male
Follow up: median follow up was 24 and 28 months for the surviving patients of the two groups. The healing complications results for the 64 participants who died before one year from injury were not included. None of the survivors were lost to follow up.


InterventionsIntra-operative compression of the fracture using the compression hip screw versus no compression (control group). Fractures in the control group were 'heavily impacted' at the time of surgery. The method of impaction was not stated.


OutcomesNon union
Avascular necrosis
Mortality


NotesThe study was based on 234 consecutive admissions with a displaced intracapsular fracture to two orthopaedic departments within one hospital. Of the 14 excluded patients, one had a pathological fracture, two died before surgery, one was treated with a hemiarthroplasty, one under local anaesthetic with a Thornton nail, three lived outside the area and six refused to participate. The results for 64 patients who died before one year from injury were not given: some fracture healing complications had occurred in some of these patients.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?NoC - Inadequate

Gray 1988

MethodsRandomised trial: method of randomisation by sealed envelopes opened in the operating theatre.


Participants49 people with an intracapsular fracture treated by internal fixation with a sliding hip screw.
Middlemore Hospital, Auckland, New Zealand.
Mean age: 77.7/80.6 years. All over 65 years
% male: not stated
Follow up: two years. Number lost to follow up: not stated.


InterventionsOpen versus closed reduction of the fracture at the time of internal fixation.


OutcomesLength of surgery
Post-operative transfusion
Failure rate
Fracture reduction alignment angles
Distance of screws to hip joint
Mortality


NotesAdditional details provided by the authors. Results within the conference abstract were given as percentages but indicated a larger number (134 patients) were included in the study. The additional information from the authors was more detailed and used in the review.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

Jacobsson 1985

MethodsRandomised trial: method of randomisation not stated.


Participants103 people with an intracapsular fracture treated by internal fixation with three Scand pins or a Thornton nail.
Skovde Hospital, Skovde, Sweden.
Mean age: 79 years
24% male
Follow up: only until time of post-operative scintimetry: at 10 days (+/-1.2 days) after surgery. Nine people were excluded: three because of hip disease, four due to uninterpretable examinations and two due to the use of different implants.


InterventionsImpaction of the fracture with a 1 kg mallet after release of traction at the end of surgery versus no impaction (control group)


OutcomesPost-operative isotope scintimetry


NotesParticipants were also randomly allocated to fracture fixation with three Scand pins or a Thornton nail.
The paper of Dalen 1985 contains no results for impaction but is the same groups of patients used for comparing Thornton nails and Scand pins. All patients were randomised into two studies.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

Upadhyay 2004

MethodsRandomised trial: method of randomisation by closed envelopes.


Participants102 people with displaced intracapsular fracture treated by internal fixation with three cannulated screws.
Two major trauma centres in New Delhi, India.
Mean age: 37.2/38.3 years. All between 15-50 years
% male: 83%
Follow up: two years.
Number lost to follow up: none.


InterventionsOpen versus closed reduction of the fracture at the time of internal fixation.


OutcomesLength of surgery
Non union of fracture
Avascular necrosis
Wound infections
Poor fracture reduction
Poor screw positioning
Mean time to fracture union
Deep vein thrombosis


NotesTen randomised patients were not included in the presentation of the results: four had follow up of less than two years, four for whom an accurate closed reduction could not be obtained were managed by open reduction and excluded and a further two with injuries to other organs systems or limbs.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

 
Comparison 1. Fracture compression versus no compression

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

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

 2 Non-union of the fracture at one year1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 Fracture non-union or dead at one year1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Avascular necrosis at two years (in united fractures)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 2. Open versus closed reduction

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

 1 Length of surgery (minutes)2Mean Difference (IV, Fixed, 95% CI)Totals not selected

 2 Post-operative transfusion1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 Mean time to fracture union (weeks)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 4 Poor quality fracture reduction1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 5 Poor screw placement1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 6 Non-union of fracture1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

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

 8 Fracture healing failure rate2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

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

 10 Mortality at six months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected