While nearly all areas of the country made this transition from the use of a sliding compression hip screw and side plate to intramedullary nail fixation, the transition did not occur at the same pace or to quite the same extent in all regions (Fig. 2). Surgeons in the Southeast region were quicker to change to intramedullary fixation, whereas those in the Northwest were the slowest to change.
The average pain scale rating was 3.25 for patients managed with a sliding compression hip screw and side plate, compared with 3.21 for those managed with an intramedullary nail (p < 0.0001). The average functional score was 2.94 for patients managed with a sliding compression hip screw and side plate, compared with 2.96 for those managed with an intramedullary nail (p = 0.05). The average deformity score was 3.31 for patients managed with a sliding compression hip screw and side plate, compared with 3.28 for patients managed with an intramedullary nail (p = 0.01). The average patient satisfaction score was 3.21 for patients managed with a sliding compression hip screw and side plate, compared with 3.22 for patients managed with an intramedullary nail (p = 0.47).
There was a slightly higher overall complication rate among patients managed with intramedullary nail fixation (18.6% compared with 18.1%), but this difference was not significant. There were significant (p < 0.05) increases in the rates of bone fracture, unspecified surgical complications, and procedure-related complications for patients managed with intramedullary nail fixation as compared with those managed with a compression hip screw and side plate over the entire period (Fig. 3). There was no complication category or group in which the plate fixation group had a significantly higher rate than the intramedullary nail fixation group. That is, patients managed with an intramedullary nail had a higher or equivalent rate of every complication and complication grouping analyzed. The trend over recent years suggests that complication rates for intramedullary nail fixation may be declining (Fig. 4).
While a wide range of proximal femoral fracture fixation devices have been employed over the years, the sliding compression hip screw and side plate, which has a blunt end to decrease femoral head penetration and screw threads to increase head purchase, became the implant of choice for the fixation of intertrochanteric fractures in the latter half of the twentieth century6-11.
Antegrade intramedullary nailing of intertrochanteric fractures with use of a short nail through which a large screw was inserted into the femoral neck and head for interlocking was introduced by Halder in the 1980s in the form of the Gamma nail3. This device was designed by Grosse and Kempf in Strasbourg, France. Early reports suggested some substantial advantages in association with this type of fixation, including a minimally invasive surgical technique, shortened operating times, decreased blood loss, improved biomechanics, greater stability of fixation, earlier patient mobilization, and shorter lengths of stay12-15. However, there was a high rate of technical complications, including fracture of the femur distal to the nail15-17. The device was redesigned in 1997 to become the Trochanteric Gamma nail, with a smaller lateral bend, a shorter overall length, and only one distal interlocking screw. A longer, full-length version of the nail was also developed. Several other companies have developed versions of this device.
Sliding compression hip screws have been directly compared with intramedullary fixation in many studies. The results have often been contradictory; for example, some studies have demonstrated a longer operating time in association with nail fixation16-21, whereas others have demonstrated a shorter operative time in association with nail fixation22,23. The only consistent differences found between the two fixation techniques seem to be an increased rate of complications (particularly intraoperative and postoperative fractures) and a higher rate of reoperation in association with intramedullary nailing4,16,17,24-28. The largest meta-analysis of this issue that has been published to date reviewed twenty-seven prospective randomized studies, involving a total of 4588 patients, in which short nails were compared with sliding compression hip screws29. The authors' conclusions were that sliding compression hip screw and side plate fixation resulted in fewer intraoperative and postoperative femoral fractures, fewer technical complications, and fewer reoperations. There was no difference between the two techniques in terms of cutout of the screw, nonunions, infections, or mortality. The data were inadequate for definitive statements regarding operative time, blood loss, wound complications, radiation exposure, or limb shortening, but there seems to have been no difference. There were inadequate data to comment at all on functional outcomes.
Some authors have suggested that intramedullary hip screw fixation is superior for certain subsets of patients, particularly those with fractures that are “unstable,” such as fractures with reverse obliquity patterns, fractures with lateral wall or posteromedial comminution, and fractures extending into the femoral neck or subtrochanteric regions. These types are not well controlled by the sliding compression hip screw and side plate, and they are associated with a high rate of fixation failure when treated with that type of implant30-32. The belief that intramedullary fixation will be more successful for the treatment of such fractures is based on biomechanical principles, cadaver studies33,34, and clinical series13,26,35. One meta-analysis of eleven studies that specifically focused on unstable fractures (Orthopaedic Trauma Association classification 31-A3) suggested that the failure rate associated with trochanteric nails was significantly lower than that associated with plate and screw fixation36, although that finding was based on only two studies and the strength of recommendation was graded “B.” Another meta-analysis of twenty-four studies involving 3279 fractures in which the sliding compression hip screw and side plate was compared with the short femoral nail demonstrated no evidence of a reduced rate of failure in association with the use of intramedullary nail fixation for unstable fractures37. Although it is a common expert opinion that nail fixation is superior to sliding compression hip screw and side plate fixation for the treatment of unstable fractures, this point is not well proven.
The scientific evidence, at least in the English-language literature, does not support the superiority of intramedullary nail fixation over standard sliding compression hip screw and side plate fixation for the treatment of intertrochanteric femoral fractures29. In fact, the consensus from the orthopaedic literature is that intramedullary nail fixation is associated with a higher complication rate and no better outcomes4,16,17,24-29,37. Our data, which were collected from young orthopaedic surgeons in the beginning of their careers, confirm a higher rate of fracture and procedure-related complications and, at best, equivalent pain and deformity scores at the time of follow-up for patients managed with intramedullary nail fixation. However, our data show that intramedullary nail fixation has overtaken plate fixation rapidly among younger orthopaedic surgeons. Due to the higher rate of surgical complications, it is possible that some patients have had adverse effects because of this change in practice. In addition, implant costs alone are estimated to be two to four times higher for intramedullary nail fixation38,39. Thus, the change in fixation method had come in the face of equivalent or worse outcomes and higher implant costs and surgeon reimbursement rates (as discussed below).
We do not know for sure why these practices have changed so dramatically in such a short period. There are many possible influences, and the cause is probably multifactorial. Many surgeons believe that intramedullary fixation is quicker, easier, and more stable and offers improved patient mobility, despite the fact that the English-language literature does not support these claims. It is possible that there has been a change in the nature of intertrochanteric fractures and that the changed practice patterns reflect a difference in the patient population. Perhaps more unstable or comminuted fractures have been seen in recent years because of an aging active population. Unfortunately, we cannot evaluate this possibility because we do not have any details about the fractures beyond the ICD-9 codes.
It may be that younger surgeons are responding to a change in training and that for some reason residents are currently being trained preferentially in intramedullary fixation of intertrochanteric fractures. There may be an intrinsic attraction to new fixation devices and surgical techniques. Younger surgeons may be under certain pressures to offer new techniques in a medical market that is constantly searching for the latest in technology. It is possible that concerns about medical liability may cause some surgeons to use intramedullary fixation in all cases, lest they be faulted for misjudging the stability of a fracture that displaced after plate treatment.
It is also possible that one factor driving this change may be the difference in the relative value units associated with the two techniques. According to the 2007 Relative Value Scale, plate fixation (CPT code 27244) is worth 29.61 total relative value units, whereas nail fixation (CPT code 27245) is worth 36.14 total relative value units40. With use of a Medicare conversion factor of approximately $36 per relative value unit, the difference between the two procedures results in a pay differential of approximately $235 in favor of intramedullary nail fixation.
Our study has multiple limitations. The data were obtained from the practices of young surgeons who had completed five years of surgical training and had been, on the average, in independent practice for two to three years. It would be hazardous to generalize any of the findings to the entire body of practicing orthopaedic surgeons. A major limitation is the portion of the study that relies on outcomes data entered by the candidates. As noted above, the four outcome scales (pain, function, deformity, and patient satisfaction) are not clearly defined, are not scientifically validated, and are dependent on subjective judgments that are reported by the candidate surgeon. The outcome scales are applied by the surgeons, who may have a stake in better outcomes, and they are applied at variable, but short, times after surgery. While these limitations are true, we believe that they would apply equally to patients managed with an intramedullary nail or a compression hip screw. There is no reason to suspect that candidates would apply judgments in a selective way to favor one implant over another. The criticism of subjectivity and bias may also apply to the surgeons' reporting of complications. Since the follow-up of these patients is variable and short, it is quite possible that all complications were not detected and that outcomes would change with time. We do believe that, because of the rather high-stakes nature of the American Board of Orthopaedic Surgery examination and the awareness that they will have to present and defend a certain number of cases, candidates likely go to great length to be accurate and honest. The candidates know that twelve of their cases will be selected for intense scrutiny and that they will have to produce radiographs and medical records. Should they be found to have falsified an outcome, the consequences could be a failure to become Board-certified and a prohibition from reapplying for some time.
In conclusion, a striking shift in fixation strategy for intertrochanteric femoral fractures has occurred over a brief period of time among younger orthopaedic surgeons. This has resulted in higher implant costs and surgeon fees, with no improvement in patient outcomes. We believe that the difference in relative value units between the two surgical technique alternatives for the same condition should be carefully scrutinized and that any differences should be based solely on measured differences in work.
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
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