Fixation devices secured across the fracture that are placed either directly or externally for treating hip fractures located outside the hip joint

Hip fractures located outside the hip joint capsule (extracapsular hip fractures) may be surgically fixed using metal implants. Often these are extramedullary devices consisting of a screw or rod, inserted in the upper part of the thigh bone (femur) to bridge (fix) the fracture, connected to a plate secured to the femur. Sometimes external fixators are used. In these, the stabilising component is held outside the thigh by pins or screws driven into the bone on either side of the fracture.

The 18 randomised controlled trials included in this review tested seven comparisons in a total of 2615 mainly female and older participants. All trials had methodological flaws that may affect the validity of their results and there was a general lack of evidence on long-term effects and functional recovery. Some extramedullary implants appeared to be associated with an increased risk of fixation complications and reoperation. In particular, three trials comparing a fixed nail plate (Jewett or McLaughlin) with the sliding hip screw (the 'standard' extramedullary device for these fractures) found an increased risk of fixation failure for fixed nail plates. Less invasive implants, such as the external fixator, which require smaller incisions resulted in less blood loss and often quicker operations than the sliding hip screw.

We concluded that the sliding hip screw seems preferable to older types of fixed nail plates given their high rate of implant and fixation failure. However, there was not enough evidence to draw conclusions for other comparisons of extramedullary implants or on the use of external fixators.

Authors' conclusions: 

The markedly increased fixation failure rate of fixed nail plates compared with the SHS is a major consideration and thus the SHS appears preferable.

There was insufficient evidence from other comparisons of extramedullary implants or on the use of external fixators to draw definite conclusions.

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Background: 

Extramedullary fixation of hip fractures involves the application of a plate and screws to the lateral side of the proximal femur. In external fixators, the stabilising component is held outside the thigh by pins or screws driven into the bone. This is an update of a Cochrane review first published in 1998, and last updated in 2005.

Objectives: 

To assess the relative effects of different types of extramedullary fixation implant, as well as external fixators, for treating extracapsular proximal femoral (hip) fractures in adults.

Search strategy: 

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 2), MEDLINE (1966 to June Week 4 2011), EMBASE (1988 to 2011 Week 25), various other databases, conference proceedings and reference lists.

Selection criteria: 

Randomised or quasi-randomised controlled trials comparing extramedullary implants or external fixators for fixing extracapsular hip fracture in adults were included.

Data collection and analysis: 

Two review authors independently selected trials, assessed risk of bias and extracted data. Data were pooled where appropriate.

Main results: 

The 18 included trials tested seven comparisons in a total of 2615 mainly female and older participants with a total of 2619 fractures. All trials had methodological flaws that may affect the validity of their results.

Three trials of 355 participants comparing a fixed nail plate (Jewett or McLaughlin) with the sliding hip screw (SHS) found an increased risk of fixation failure for fixed nail plates.

The two trials of 433 participants comparing the Resistance Augmented Bateaux (RAB) plate with the SHS had contrasting results, notably in terms of operative complications, fixation failure and anatomical restoration.

One trial of 100 participants comparing the Pugh nail and the SHS found no significant difference between implants.

Three trials of 458 participants compared the Medoff plate with the SHS. There was a trend to higher blood losses and longer operation times for the Medoff plate along with a trend to a lower risk of fixation failure with the Medoff plate for unstable trochanteric fractures.

Two trials of 676 participants compared the Medoff plate with three different screw-plate systems. There were no statistically significant differences in outcome for trochanteric fractures. For subtrochanteric fractures, there was a lower fixation failure rate for the Medoff plate but no evidence for differences in longer-term outcomes.

Four trials of 396 participants comparing the Gotfried percutaneous compression plate (PCCP) with a SHS found a trend to lower blood loss and transfusion requirements for the PCCP but no other confirmed differences in outcomes between implants. Three of the trials reported intra-operative problems with the PCCP, some of which precluded its use.

Three trials of 200 participants comparing external fixation with a SHS found less operative trauma for the external fixation. Final outcome appeared similar.

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