Academics vs. the Real World on Hip Fractures
While cost may be a factor, efficiency is a major element academic authors may not appreciate
What’s the Claim?
A large, randomized trial comparing a sliding hip screw to a contemporary cephalomedullary nail (the Gamma 3) among patients with stable or unstable intertrochanteric hip fractures:
- Found no differences in health-related quality of life (HRQOL), revision surgery, fracture union, adverse events, patient mobility, or hip function a year after surgery
- Posited a dubious economic benefit to wider use of the lower-cost sliding hip screw over the nail
How’s It Stack Up?
This was a high-quality randomized trial, and its main findings were generally consistent with a massive meta-analysis by the Cochrane collaboration of 66 RCTs and 10 quasi-RCTs, which evaluated results from nearly 11,000 patients. But the size of that Cochrane analysis helped it deliver a much-greater level of nuance than one can get in a single RCT:
- Although functional outcomes didn’t differ much between the implant groups, patients treated with hip screws were more likely to develop infection and nonunion, while those treated with nails were more likely to have an intraoperatiave fracture (a risk that did not disappear, as many thought it might, when newer devices were used)
Makes sense. Also relevant may be that nails are a more-generalizable approach. CORRelations' advisor in Fractures & Trauma, Jaimo Ahn, MD, points out that standard-length nails can easily fix both stable and unstable intertrochanteric fractures, high subtrochanteric fractures, and those with unseen comminution that compromises the lateral wall. Handy.
