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
This is my first Editor’s Choice for OrthoBuzz as new Editor-in-Chief of JBJS. I am following the example of my esteemed predecessor, Vern Tolo, who recently issued an Editor’s Choice warning about our failure to improve the management of patients with fragility fractures in terms of appropriate diagnosis and treatment of underlying osteoporosis. That is a failure of under-treatment. I want to focus on a potential issue of overtreatment.
In the July 2, 2014 JBJS, Leroux et al. describe the risk factors for repeat surgery after ORIF of midshaft clavicle fractures. The study analyzed 1,350 patients treated with surgery between 2002 and 2010 in Ontario. It is important to note that this analysis includes years after 2007, when JBJS published the seminal multicenter RCT on this topic by the Canadian Orthopaedic Trauma Society (COTS). The essence of that study was that ORIF with plate fixation results in a lower rate of nonunion and better functional outcomes predominantly in patients who have completely displaced fractures with about 2 cm of shortening or displacement.
Since that publication, we have seen an explosion in the operative treatment of midshaft clavicle fractures in North America. However, all too often the inclusion criteria derived from the seminal RCT are not referenced in individual patient decision making, and the presence of a clavicle fracture–regardless of degree of displacement–becomes an indication for surgical management.
The findings of the Leroux study should help put a hard stop to this! These researchers found a 24.6% incidence of repeat surgery in this cohort of patients. The most common reoperation was isolated implant removal (18.8%), and the incidence of major complications included nonunion (2.6%), deep infection (2.6%), pneumothoraces (1.2%), and malunion (1.1%). Risk of reoperation was increased in female patients and in those with major medical comorbidities. Limited surgeon experience increased the risk of reoperation for infection.
The orthopaedic surgery community must heed these data and act upon them. We should not misinterpret the COTS study to “encourage” a patient to opt for surgery if he or she has a midshaft clavicle fracture with less than 2 cm of shortening or displacement. The technical aspects of surgery for midshaft clavicle nonunion is not that different than that for a fresh fracture, so avoidance of nonunion must be thoughtfully discussed with the patient before recommending surgical fixation.
The bottom line that Leroux et al. provide is that surgery for a midshaft clavicle fracture is not a guaranteed success and that surgeon experience matters. And beyond clavicle fractures, let’s be sure we use our literature during shared decision making in an accurate and appropriate manner. That is a basic tenet of professionalism that we all should subscribe to.