Extramedullary fixation implants and external fixators for extracapsular hip fractures

Extramedullary fixation of hip fractures involves the application of a plate and screws to the lateral side of the proximal femur. In external fixators, the stabilising component is held outside the thigh by pins or screws driven into the bone on either side of the fracture.

To compare different types of extramedullary fixation implants and external fixators for treating extracapsular hip fracture in adults.

We searched the Cochrane Musculoskeletal Injuries Group specialised register and reference lists of relevant articles up to July 2002.

All randomised or quasi-randomised trials comparing these devices for the fixation of extracapsular hip fracture in adults.

Two reviewers independently assessed trial quality, using a ten item scale, and extracted data. Additional information was sought from trialists when required. Wherever appropriate, data from comparable trials were pooled.

Two trials examining the Gotfried plate and one, an external fixator, are newly included in this update. All 13 included trials had methodological flaws, which may affect the validity of their results. The limited data available for three trials (355 patients) comparing a fixed nail plate (Jewett or McLaughlin) with the sliding hip screw (SHS) indicated an increased risk of fixation failure for fixed nail plates. The two trials (433 patients) comparing the RAB plate with the SHS had contrasting results, notably in terms of operative complications, fixation failure and anatomical restoration. One trial (100 patients) found no significant difference between the Pugh nail and the SHS. Two trials (292 patients) compared the Medoff plate with the SHS. One trial reported higher operative blood loss and longer operative times for the Medoff plate. There was a lower risk of fixation failure for unstable trochanteric fractures fixed with the Medoff plate. Two trials involving, respectively, unstable trochanteric fractures (569 patients) and subtrochanteric fractures (107 patients) compared the Medoff plate with three different screw-plate systems. There were no statistically significant differences in outcome for trochanteric fractures. For subtrochanteric fractures, there was a tendency to less fixation failure for the Medoff plate, but no evidence for differences in longer-term outcomes. Two trials (226 patients) compared the Gotfried percutaneous plate with a SHS. A higher intra-operative fixation failure rate of the Gotfried plate indicated some specific restriction to its use. The Gotfried plate appeared to involve lower operative blood losses. There were insufficient data on long term outcomes. One trial (100 patients) provided some evidence of less operative trauma and speedier recovery for external fixation when compared with the SHS. Final outcomes appeared similar.

The 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 significant differences between the SHS and either the RAB, the Pugh, the Medoff or the Gotfried plates, or an external fixator.