PRO: Why I use compression hip screws
Douglas W. Lundy, MD, FACS

As orthopaedic surgeons, we are fascinated by the “new and improved.” We are drawn to the newest ideas like moths to a flame. This characteristic pervades the orthopaedic community, and those who wish to sell us things know it all too well.

Despite the fact that compression hip screws have been the mainstay and gold standard in the fixation of intertrochanteric femoral fractures, orthopaedic surgeons have extensively left this faithful device in search of something newer. According to one study, the use of intramedullary nails used to stabilize intertrochanteric femoral fractures by orthopaedic surgeons sitting for the American Board of Orthopaedic Surgery Part II exam increased from 3 percent in 1999 to 67 percent in 2006. This is a dramatic shift in treatment over a relatively short period of time.

Anecdotally, it certainly seems that the increase in use of cephalomedullary nails may be due to the fact that younger surgeons are more comfortable with the nail technique than with using the compression hip screw. A 2010 study on provider factors associated with the use of intramedullary nails found that younger surgeon age (younger than age 45), teaching hospital status, and resident assistance during surgery were among the associated factors.

The same study also commented on another interesting point. It is well-recognized that cephalomedullary nails cost more than compression hips screws. The authors did not anticipate that any significant change in implant utilization would occur until the surgeons selecting the implants were no longer insulated from the true cost data. Only when surgeons are held accountable for the costs that they incur while treating patients will they place more attention on the expense of these high-priced implants.

Some surgeons advocate that stabilizing these injuries with cephalomedullary nails takes less time than compression hip screws. Others say that blood loss is less, and some claim that cephalomedullary nails are mechanically superior to the plate-screw constructs. In the treatment of intertrochanteric femoral fractures, clinical studies have not supported any of these claims. It is time that these “differences” are recognized as being purely anecdotal and not based in the orthopaedic literature.

Do intramedullary nails perform better in the stabilization of intertrochanteric femoral fractures? Comparative effectiveness research is being used more often to examine how much certain treatments are really worth. A 2012 study on the use and associated outcomes of intramedullary nailing compared with sliding hip screws in Veterans Affairs (VA) hospitals looked at the crux of the issue: that is, is the increase in quality brought by using cephalomedullary nails in the treatment of intertrochanteric femoral fractures worth the increased cost? These authors did not find any decrease in complications between patients stabilized with cephalomedullary nails or compression hip screws. This comparative effectiveness study did not find a compelling reason why these fractures should be stabilized with anything other than compression hip screws.

The true benefit of compression hip screws may finally be reported in the literature. A recent study found a higher reoperation rate for patients treated with cephalomedullary nails compared to those stabilized with compression hip screws. Patients treated with nails required reoperation 4.2 percent of the time compared to a reoperation rate of only 2.4 percent in patients treated with compression hip screws. The tried-and-true compression hip screw not only can hold its own with the newer devices, but some studies are demonstrating that it may actually be better.

Disclosure information: Dr. Lundy—Synthes; Livengood Engineering; Clinical Orthopaedics and Related Research; Journal of Orthopaedic Trauma; Orthopedics; American Board of Orthopaedic Surgery; American College of Surgeons; Orthopaedic Trauma Association; Georgia Orthopaedic Society

Douglas W. Lundy, MD, is a member of the AAOS Now editorial board. He is in private practice with Resurgens Orthopaedics in Atlanta.

References

1. Anglen JO, Weinstein JN, American Board of Orthopaedic Surgery Research Committee: Nail or plate fixation of intertrochanteric hip fractures: Changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg Am 2008 Apr;90(4):700–707.
2. Forte ML, Virnig BA, Eberly LE, Swiontkowski MF, Feldman R, Bhandari M, Kane RL: Provider factors associated with intramedullary nail use for intertrochanteric hip fractures. J Bone Joint Surg Am 2010 May;92(5):1105–1114.
3. Radcliff TA, Regan E, Cowper Ripley DC, Hutt E: Increased use of intramedullary nails for intertrochanteric proximal femoral fractures in veterans affairs hospitals: A comparative effectiveness study. J Bone Joint Surg Am 2012 May 2;94(9):833–840.
4. Matre K, Havelin LI, Gjertsen JE, Espehaug B, Fevang JM: Intramedullary nails result in more reoperations than sliding hip screws in two-part intertrochanteric fractures. Clin Orthop Relat Res 2013 Apr;471(4):1379–1386.

CON: Nails are superior
George V. Russell Jr, MD

I cannot believe there is any controversy in 2013 regarding plates and nails for pertrochanteric hip fractures. The controversy reminds me of asking the question: Are cell phones better than rotary phones? Of course, cell phones are better than rotary phones, just as cephalomedullary nails are better than plates for pertrochanteric hip fractures.

Cephalomedullary nails are biomechanically superior to plates simply by the design of the implant. Plates, which are anchored to the lateral femoral shaft, have a larger lever arm than cephalomedullary devices. An intramedullary rod decreases the lever arm from device to fracture, thereby decreasing the risk of implant failure.

Cephalomedullary nails have another design benefit: They reduce the degree of collapse at the fracture site—a tremendous patient benefit, especially in the case of a comminuted fracture.

Traditional plate designs permit compression until the neck and head fragments impact the calcar in the best case; if there are fractures out to the lateral wall, impaction is to the lateral shaft of the femur. Cephalomedullary nails permit impaction only to the position of the medullary rod. In situations where comminution is present, the difference in shortening is considerable, with the cephalomedullary implants proving superior.

Unlike plate designs, cephalomedullary rods may be used with every type of pertrochanteric fracture—from the most stable to the most unstable. Fractures with extension to the lateral shoulder or fractures with comminution in the calcar prove very difficult to stabilize with plate devices. Not only is excessive femoral neck shortening problematical, but side plates may not prove sufficient to stabilize the shaft component of the fracture if the unstable fracture runs lengthwise.

Another benefit of cephalomedullary nailing is the ability to splint the entire pathologic femur by inserting a long medullary rod. No plate device can perform better than a rod in this capacity.

Although the amount of blood loss has proven to be equivocal with either type of device, theoretically, blood loss would be less with a percutaneously placed cephalomedullary nail. Three or four small portals are required to place a cephalomedullary nail; placing a plate device requires a formal incision on the thigh. Common sense says that blood loss would be less with a medullary implant.

To return to my original question, few people would suggest that a rotary phone is better than a cell phone. A rotary phone may have some uses, but they are few and far between. If the cephalomedullary nail is a cell phone, and the plates and screws are a rotary phone, the answer will be clear.

Disclosure information: Dr. Russell—AONA; Acumed, LLC; Zimmer; Synthes; METRC; Journal of Bone and Joint Surgery; AAOS; Orthopaedic Trauma Association

George V. Russell Jr, MD, is a professor and chairman of the department of orthopaedic surgery and rehabilitation at the University of Mississippi Medical Center.