Review Question - QID 219558

Intertrochanteric femur fractures can be treated with both short and long cephalomedullary nails. Intertrochanteric femur fractures treated with a long cephalomedullary nail when compared to a short nail, have a higher rate of postoperative anemia requiring transfusion.

Intertrochanteric femur fractures are common extracapsular fractures that typically occur in the elderly and are generally managed operatively. There are a variety of implants that can be used to treat this fracture pattern. If the fracture line has less than 3 cm of subtrochanteric extension a short or long cephalomedullary nail can be employed. Short and long nails have similar benefits of being load-sharing devices that limit shaft medialization with intramedullary buttress. Patients treated with a short or long nail for an intertrochanteric femur fracture have similar functional outcomes, no observed difference in periprosthetic fracture, and no differences in reoperation. However, patients treated with long nails have a higher rate of postoperative anemia (hgb<10g/dL) and blood transfusion.

Shannon et al published the results of a prospective randomized trial that compared short versus long cephalomedullary nails in intertrochanteric femur fractures with less than 3 cm of subtrochanteric extension. This study examined 168 patients (short nail =80, long nail =88) with a minimum of 3-month follow-up. They found no difference in SF-36 or Harris hip scores at 3 months. There was also no difference in implant cutout, post-operative infection, or peri-implant fractures.

Womble et al published a retrospective study of 247 patients over 8 years treated with cephalomedullary nails. They excluded patients younger than 65 or less than 1-year follow-up. They found that increasing the length of the nail had no significant effect on pneumonia, acute kidney injury, pulmonary embolism, 30-day or 1-year mortality, or 30-day return to the operating room. However, they observed that patients treated with long nails had an increased rate of anemia, defined as Hgb < 10g/dL, (p=0.0491) and blood transfusion (p=0.0044).

Figure A shows a left hip plain film with an intertrochanteric femur fracture. Figure B shows the immediate post-operative left hip plain film of the same fracture seen in Figure A.

Incorrect Answers:
Answer 1: Short-term functional outcomes are equivalent in patients treated with a short or long cephalomedullary nail.
Answer 2: Re-operation rates are equivalent in patients treated with a short or long cephalomedullary nail.
Answer 4: Patients treated with a long cephalomedullary nail are more likely to get a post-operative blood transfusion.
Answer 5: The observed periprosthetic fracture rate is equivalent in patients treated with a short or long cephalomedullary nail.