Review Question - QID 215726

Cephalomedullary nailing (CMN) would be preferred to sliding hip screw (SHS) fixation in intertrochanteric hip fractures with reverse obliquity patterns.

Intertrochanteric hip fractures are extremely common in the elderly population, with a combination of low energy trauma and osteoporosis often the culprit. Stability of these fractures is correlated with the severity, as described by the OTA (Illustration A) and Evans classifications (Illustration B). In stable intertrochanteric hip fractures there is typically inherent bony stability remaining with an intact posteromedial cortex. For this reason, both SHS and CMN implants perform well in maintaining fracture alignment and promoting healing. In intertrochanteric hip fractures with less stability, like those with subtrochanteric extension or reverse obliquity, CMN may improve failure and reoperation rates by creating a fixed angle device with favorable biomechanical properties. Another important consideration when comparing these implants is cost with SHS being cheaper than the CMN

Whale et al examined rates of complication, failure and mortality in OTA 31-A1/2 intertrochanteric hip fractures treated with either SHS or CMN. They noted that among those with unstable fracture patterns, there was an increased rate of collapse and failure with SHS compared to CMN. They finish by saying that both SHS and CMN are reasonable options for use in stable intertrochanteric hip fractures, but CMN is recommended in cases of unstable fracture.

Chou et al. looked at the outcomes regarding CMN use to treat reverse obliquity intertrochanteric hip fractures. They noted that those with reverse obliquity fractures treated with CMN demonstrated satisfactory reduction with low rates of complication. They suggested that long CMN is recommended in cases of reverse obliquity hip fractures.

Figure A demonstrates a left hip radiograph which shows an unstable, reverse obliquity intertrochanteric hip fracture. Illustration A depicts the OTA classification for intertrochanteric hip fractures. Illustration B denotes the Evans classification for intertrochanteric hip fractures based on fracture stability.

Incorrect Answers:
Answer 1: There is no evidence suggesting CMN decreases length of hospital stay after surgery compared to SHS.
Answer 3: CMN tends to cause more, not less, damage to the abductors as they are often violated during the approach and nail insertion process.
Answer 4: Eventual conversion to total hip arthroplasty (THA), if necessary, is typically more difficult after CMN compared to SHS.
Answer 5: SHS is generally understood to be a cheaper implant compared to CMN.