RecommendationUse extramedullary implants such as a sliding hip screw in preference to an intramedullary nail in patients with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2).
Relative values of different outcomesThe most important outcomes considered by the GDG include early and late mortality, re-operation, postoperative fracture, length of hospital stay and post fracture mobility.
Trade off between clinical benefits and harmsNone of the studies reported have shown any advantage of intramedullary devices over extramedullary devices. Intramedullary devices had been shown to have a higher re-operation rate due to an increased incidence of periprosthetic fracture both in the perioperative period and the postoperative period (risk ratio 5.61). This may be due to the inclusion of studies with original nail designs no longer implanted. All other outcomes have been reported as similar. An additional meta-analysis is included in Appendix G, page 504. By grouping studies using a cut off of publication after 2000, no changes to the existing evidence statement are made.
Economic considerationsIn patients with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2) the price of intramedullary fixation devices varies but on average is three times the price of sliding hip screws for short nails and five times the price for long nails. As pointed out in the clinical evidence statement, no significant benefit has been proven of the advantages of intramedullary devices over extramedullary devices, so that the GDG agreed to consider extramedullary implants cost-effective for hip fracture patients.
Quality of evidenceThe level of evidence is high with numerous studies producing very similar findings.
Other considerationsAll patients should be allowed to be mobilised full weight bearing after hip fracture surgery (see section 10.2). All modern implants are designed to be load sharing devices to facilitate this. Full weight bearing allows early mobilisation and rehabilitation.

The GDG highlighted this recommendation as a key priority for implementation.

From: 10, Surgical procedures

Cover of The Management of Hip Fracture in Adults
The Management of Hip Fracture in Adults [Internet].
NICE Clinical Guidelines, No. 124.
National Clinical Guideline Centre (UK).
Copyright © 2011, National Clinical Guideline Centre.

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