Extramedullary fixation implants and external fixators for extracapsular hip fractures

Abstract

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. OBJECTIVES: To compare different types of extramedullary fixation implants and external fixators for fixing extracapsular hip fracture in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2005), various other databases, conference proceedings and reference lists. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials comparing extramedullary implants or external fixators for fixing extracapsular hip fracture in adults. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials, assessed trial quality and extracted data. Data were pooled where appropriate. MAIN RESULTS: The 14 included trials tested seven comparisons in a total of 2222 mainly female and older participants. All trials had methodological flaws that may affect the validity of their results. Three trials 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 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 comparing the Pugh nail and the SHS found no significant difference between implants. Two trials compared the Medoff plate with the SHS. One trial reported higher blood losses and longer operation times for the Medoff plate. There was a lower risk of fixation failure with the Medoff plate for unstable trochanteric fractures. Two trials 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. Two trials comparing the Gotfried percutaneous plate with a SHS found a reduced blood loss with the Gotfried plate. A higher intra-operative fixation failure rate of the Gotfried plate may indicate some restriction to its use. Two trials found less operative trauma for external fixation when compared with the SHS. Final outcome appeared similar. 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 to draw definite conclusions.