Extramedullary fixation implants for extracapsular hip fractures.

BACKGROUND

Extramedullary fixation of hip fractures refers to the application of a plate and screws to the lateral side of the proximal femur.

OBJECTIVES

To compare different types of extramedullary fixation implants for the surgical treatment of extracapsular hip fracture in adults.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register and reference lists of relevant articles. Date of the most recent search: October 2001.

SELECTION CRITERIA

All randomised or quasi-randomised trials comparing extramedullary implants used in the fixation of extracapsular hip fracture in adults.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality, using a ten item scale, and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, data from comparable trials were pooled.

MAIN RESULTS

Two new trials investigating the Medoff plate are included in this update. All ten included trials (involving 1856 participants) had methodological flaws which may have resulted in serious bias. Three trials involving 355 patients compared a fixed nail plate (Jewett or McLaughlin) with the sliding hip screw (SHS). The limited data presented indicated an increased risk of fixation failure outcomes for fixed nail plates. The two trials, involving 433 patients, comparing the RAB plate with the SHS had contrasting results, notably in terms of operative complications, fixation failure and anatomical restoration. One trial involving 100 patients compared the Pugh nail and the SHS. There was no significant difference between implants for the outcome measures reported. Two trials involving 292 patients with 296 fractures, compared the Medoff plate with the SHS. Higher mean operative blood loss and longer mean operative time were reported for the Medoff plate in one trial. There was a lower risk of fixation failure for unstable trochanteric fractures fixed with the Medoff plate. Two trials involving, respectively, 569 patients with unstable trochanteric fractures and 107 with subtrochanteric fractures 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 tendency to a lower fixation failure rate for the Medoff plate, but no evidence for differences in longer-term outcomes.

REVIEWER'S CONCLUSIONS: The fixed nail plate has higher risks of implant breakage and fixation failure than the SHS. Though insufficient evidence on other outcomes is available from randomised trials, the increased fixation failure rate is a major consideration and thus the SHS appears preferable. Insufficient information is available to draw firm conclusions of the clinical significance of differences between the SHS and either the RAB plate, the Pugh nail or the Medoff plate.