Extramedullary fixation implants for extracapsular hip fractures.

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

objectivesTo 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 trials register and reference lists of relevant articles. Date of the most recent search: October 1999. 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: All three reviewers independently assessed trial quality, using a ten item scale, and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, results of outcome measures were pooled by comparison. MAIN

resultsAll seven included trials 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. One trial involving 233 patients compared the RAB plate (a fixed angle blade plate with an oblique connecting strut) with the SHS. In this trial both implants had a high incidence of fixation failure. There was a tendency to a lower incidence of cut-out, re-operation, fixation failure, leg shortening, varus deformity and mortality for the RAB plate. None of the differences in these outcomes were statistically significant. One trial involving 100 patients compared the Pugh nail and the SHS. There was no significant difference between implants for the outcome measures reported. One trial involving 178 patients with 182 fractures, compared the Medoff plate with the SHS. A significantly higher mean operative blood loss and longer mean operative time were reported for the Medoff plate. There was however a tendency to a lower risk of fixation failure for unstable trochanteric fractures fixed with the Medoff plate. One trial involving 107 patients with subtrochanteric fractures compared the Medoff plate with three different screw plate systems. 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

conclusionsThe 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.