Surgical approaches and ancillary techniques for internal fixation of intracapsular proximal femoral fractures.

backgroundIn the fixation of intracapsular hip fractures, different implants, surgical approaches and ancillary manoeuvres have been employed to improve the reduction, and the stability of the reconstruction, in an attempt to reduce the frequency of non-union and aseptic necrosis of the femoral head.

objectivesTo compare alternative surgical approaches and ancillary techniques in internal fixation of intracapsular hip fractures which have been subjected to randomised and quasi-randomised trials in adults. SEARCH STRATEGY: The Cochrane Musculoskeletal Injuries Group Specialised Register, MEDLINE, and reference lists of relevant articles were searched. Date of the most recent search: November 2004. SELECTION CRITERIA: All randomised and quasi-randomised trials investigating operative technique for the treatment of intracapsular hip fractures. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality, by use of a 10 item checklist, and extracted data. MAIN

resultsOne trial with 103 participants studied the effect of impaction of the fracture at the time of surgery. The only outcome measure reported was bone scintimetry. There was some evidence that impaction, particularly of displaced fractures, resulted in a reduction of blood flow to the femoral head as assessed by bone scintimetry. One quasi-randomised trial with 220 participants compared compression of the fracture with no compression. Results for 156 individuals at one year showed a tendency to a lower incidence of non-union for those fractures treated without compression.Two trials, one involving 102 young adults under 50 years old and the other involving 49 older people aged 65 years or over, compared open versus closed reduction of the fracture. Both found open reduction significantly increased length of surgery. None of the other differences between open and closed reduction in the outcomes reported by the two trials were statistically significant. AUTHORS'

conclusionsInsufficient evidence exists from randomised trials to confirm the relative effects of open versus closed reduction of intracapsular fractures, or the effects of intra-operative impaction or compression of an intracapsular fracture treated by internal fixation.