Osteotomy, compression and reaming techniques for internal fixation of extracapsular hip fractures

Many different surgical techniques, such as osteotomy, have been used in internal fixation of extracapsular hip fractures.

To compare different aspects of surgical technique in internal fixation of extracapsular hip fractures that have been subjected to randomised trials in adults.

The Cochrane Musculoskeletal Injuries Group trials register, Medline, CENTRAL and reference lists of relevant articles were searched. Date of the most recent search: March 1999.

All randomised and quasi-randomised trials investigating operative technique for the treatment of extracapsular hip fractures.

Two reviewers independently assessed trial quality, by use of an eleven item check list, and extracted data. Wherever possible and appropriate, results of outcome measures were pooled.

All eight included trials were of only modest methodological quality. One trial of 65 patients undergoing fixation with a fixed nail-plate compared osteotomy versus anatomical reduction. There was a tendency to a reduced fixation failure rate after osteotomy. Four trials involving 465 patients undergoing fixation with a sliding hip screw (SHS) compared osteotomy versus anatomical reduction. Osteotomy was associated with an increased operative blood loss and length of surgery. There was also a tendency to an increased length of hospital stay and limb shortening for osteotomy. One trial of 200 patients undergoing fixation with a SHS compared results with or without compression across the fracture site. The only significant difference in outcomes was increased varus deformity in those fractures treated with compression. One trial of 19 patients reported reduced temperatures generated by a modified method of reaming the femoral head. Another study used oesophageal ultrasound to demonstrate reduced bone marrow intravascular embolism when a Gamma nail was inserted in 50 patients with, rather than without, a distal pressure venting hole in the femur.

There is inadequate evidence to determine if any benefits exist for the routine use of osteotomy in conjunction with a SHS for the internal fixation of an unstable trochanteric femoral fracture. Osteotomy may be relevant if used in conjunction with a fixed nail plate. Based on the evidence of one trial only, there is inadequate evidence to support the application of compression across the fracture site of a trochanteric fracture during SHS fixation. Inadequate information exists for different reaming techniques during SHS or Gamma nail fixation to make definite conclusions.