A prospective comparative evaluation for the use of an intramedullary hip-screw versus a compression hip-screw with a plate for intertrochanteric femoral fractures

Background
Combining the advantages of intramedullary fixation with those of a sliding screw theoretically overcomes the usual complications of dynamic hip-screw fixation. A comparative study was conducted to evaluate the credibility of the use of intramedullary screw over the conventional dynamic hip-screw.
Patients and methods
A total of 100 elderly patients who had an intertrochanteric femoral fracture were randomized to treatment with a compression hip-screw with a plate (50 patients) or intramedullary hip-screw (50 patients). All patients were followed up prospectively for 1 year. A detailed assessment of the functional status and the plain radiographs of the hip was performed at 1, 3, 6, and 12 months postoperatively. The two treatment groups were strictly comparable.
Results
The operative time needed to insert the intramedullary hip-screw was significantly greater than that needed to insert the compression hip-screw with the plate, but use of the intramedullary hip-screw was associated with less estimated intraoperative blood loss. There were one intraoperative fracture of the femoral shaft and two intraoperative fractures of the greater trochanter in the group managed with the intramedullary hip-screw. One patient had pulling-out of the compression hip-screw on the seventh postoperative day. Four patients had a wound hematoma after insertion of an intramedullary hip-screw. All but one of the fractures healed. The one nonunion, which was in a patient who had a compression hip-screw, was treated with a hemiarthroplasty. Fourteen patients who had an intramedullary hip-screw had cortical hypertrophy at the level of the tip of the nail at 12 months postoperatively. Six of these patients also had pain in the mid-portion of the thigh; three of the six patients had the hardware removed because of the pain, and the symptoms resolved.
Conclusion
Routine use of intramedullary hip-screws cannot be recommended for the treatment of intertrochanteric femoral fractures because of the reported complications. However, the intramedullary device is a promising alternative, especially for a comminuted fracture with subtrochanteric extension or a reverse oblique pattern.