In the December 2, 2015 issue of The Journal, Reindl et al. report on the results of a multicenter randomized trial comparing intramedullary (IM) fixation versus sliding hip screws for stabilization of type A2 unstable intertrochanteric fractures. This trial is yet another product of the Canadian Orthopaedic Trauma Society (COTS), which has collaborated on high-quality clinical trials for more than a decade.
There have been more than 20 RCTs comparing intramedullary fixation with sliding hip screws. Many of these trials exclusively investigated stable fracture patterns or included both stable and unstable fractures. These studies generally concluded that nails provide no clear outcome benefits, except perhaps in unstable fractures. Several meta-analyses have also been published that identified no significant difference in clinical or functional outcomes.
Up until now, there has been little dispute with the recommendation that unstable intertrochanteric fractures be fixed with intramedullary implants. While this current trial confirms radiographic advantages to IM fixation (significantly less femoral-neck shortening) after 12 months, Reindl et al. found but no significant functional advantage (in terms of Lower Extremity Measures, Functional Independence Measures, or timed up-and-go tests) with IM fixation in unstable A2 fractures. These findings add more evidence to the claim that IM implants for both stable and unstable patterns are overused in North America.
The question now becomes how many more trials do we need to further make the point? We know that powerful surgeon-behavior influences exist in academic medical centers that continue to use intramedullary implants routinely for intertrochanteric hip fractures (see the 2010 JBJS prognostic study by Forte et al.). Considering the much higher cost of intramedullary nails relative to hip screws, it is high time that these same centers teach appropriate use of IM implants for these fractures so that trainees become facile with both implant types.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
It’s about time! Before retiring from active practice 6 years ago, I questioned what I felt was the overuse of IM nails for I-T hip fxs. The indication seemed to be the old “If I got a new hammer everything looks like a nail” way of thinking. We physicians need to consider the cost as well as the quality of the health care delivered. Bravo to the authors and to Dr. Swiontkowski.
I trained on DHS compression hip screws so learning to use IM nails was new for me. However, anyone who has finished in the past 15 years probably has little of no exposure to compression hip screws. It should be left up to the surgeon’s discretion what he or she feels comfortable to provide the best outcome. For me there is considerably less soft tissue trauma with the IM nails.
Dr Richard Stern, Geneva, Switzerland, says: Why did JBJS accept this article for publication since it does not shed any new light with regards to these two implants? The study comes to the same conclusion as so many others over so many years. When is enough, enough?
This manuscript was accepted for publication because it was a well-conducted RCT that focused on a fracture type (unstable A2 fractures) about which there is/was ongoing debate about which implant resulted in superior outcomes.The results support your notion that we may not need more controlled trials in this area.
Marc Swiontkowski, MD
So, I should use a cheaper implant and a bigger incision and allow more blood loss when I can get away with it because the fracture isn’t that bad? Instead, perhaps we should always use the implant with the best results and the least morbidity even if more expensive.
I love the judgmental indictments being rendered. IM nails overused in whose opinion? We are supposed to overlook the fact that IM nails can be inserted in half the time of compression plates through much smaller incisions with less blood loss and anesthesia time in patients who in many cases are medically marginal. Have any of the studies that claim the costs are less factored in the added costs of longer anesthesia and blood transfusions into the cost picture? If cost is the only consideration, perhaps we should all go back to the Austin-Moore prostheses as well. They are much cheaper too. Then we can once again see the old folks come in with the prosthesis burrowed into the pelvis as frequently happened, something I have never seen once in 30 years of using bipolar prostheses.
To Drs. Pollock, Striplin, and Prager:
Thank you for your postings regarding my OrthoBuzz Editor’s Choice about the manuscript by Reindl et al. I appreciate you taking the time to write, as this is what we envisioned for OrthoBuzz: a place to debate the appropriate role of peer-reviewed findings in our clinical decision making.
Unfortunately, multiple RCTs and subsequent meta-analyses do not confirm your opinions that IM nails are quicker and result in less blood loss. That may be due in part to the fact that with the IM nail, the fracture hematoma is not evacuated as it is with the placement of a sliding hip screw, but the loss of blood from circulation is the same.
Marc Swiontkowski, MD
It is well and good to cite scientific studies when dealing with issues but I think scientific studies in the field of medicine are often not truly scientific because there are factors that cannot completely be controlled when dealing with human beings (both patients and physicians). The only way this issue could be entirely scientific is for the same surgeon to perform the same operation on the same patient in the same facility. I worked with a surgeon years ago who routinely took 4-6 hours to do an ACL reconstruction. I work with a surgeon now who routinely takes 4-5 hours to do an ulnar nerve transposition. Should we draw conclusions about operative time and blood loss if patients of these surgeons are included? Are any of the cited studies done in facilities where residents were doing the cases? We were all slower in those days. It is grossly unfair to imply that there is no justification for a particular procedure just because some surgeons do not perform it faster or with less blood loss. And I think people do not realize the unintended effects of articles like this on those of us out practicing orthopaedics in the community. Hospitals and insurance companies are constantly looking for ways to save their own money at the expense of the physician. They are not above seizing on information like this to refuse to let us perform certain procedures, even if they are in the best interests of the patients. I experienced this personally with patient-specific guides for knee arthroplasty. I am happy to hear that some surgeons do not get any faster times or better results with them. In my hands, the surgery time was considerably less and the patients routinely left the hospital a day earlier (again, were these factors considered in the published articles?) but because of the published studies my current hospital will not let me use the guides.
Science should always be the basis of medicine, but recognize the limitations of studies, present the evidence, and allow us to decide what is best for our own patients in our own hands.
I heartily agree with the points raised by Drs. Pollock and Prager. While I trained with the extra medullary devices (DHS et al) for intertrochanteric fractures, once the improved intramedullary devices were introduced (Gamma Nail, etc.), I found that in the real world, community hospital setting, I could do any IT fx procedure in half the time and with less soft tissue damage and blood loss (perceived, at least), and with fewer complications in fracture healing. So I’ve never looked back.
We’re talking a few hundred bucks in implant cost which can be easily overshadowed by an extra 30 minutes of OR/anesthesia time, or an extra day’s stay in hospital, or a wound complication which CMS extracts from your bundled payment.
I use both implants on a routine basis. In my hands, they both are pretty efficient with regards to time. In my fellows hands, the IM nail is much quicker. Once the nail is in the canal pin placement in the head is easy. SHSs require more 3D visualization by the surgeon and that takes time and experience to develop. As for the blood loss, unless someone has taken advanced imaging and looked at hematoma size I don’t believe anyone’s blood loss estimate. Looking at sponges, suction canisters and the OR floor is not a viable measure of blood loss. I believe most of the blood loss is in the hematoma at the fracture site pre and post op. We never see that. Both devices work well, but in my experience teaching the use of both implants, more people become facile with nails more quickly. Also, when you consider the cost of the care of a hip, the cost of the device we use is minor. People should use what they are most comfortable with as it really doesn’t matter with regard to overall cost of care or risk to the patient.