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Is the Best Plate a Nail? A Review of 3230 Unstable Intertrochanteric Fractures of the Proximal Femur

Tucker, Adam, MB BCh BAO, MRCS, MPhil*; Donnelly, Kevin, J., MB BCh BAO, MRCS*; Rowan, Clare, FRCS (Tr+Orth); McDonald, Sinead, RGN, PgDip; Foster, Andrew, P., FRCS (Tr+Orth)*

doi: 10.1097/BOT.0000000000001038
Original Article

Objectives: To evaluate the functional outcomes, revision, and mortality rates of 3 implants used for unstable intertrochanteric hip fractures; the sliding hip screw (SHS), with or without a trochanteric stabilization plate (TSP); and a cephalomedullary nail (CMN).

Design: Multicentre National Prospective Cohort Study.

Setting: Northern Ireland.

Patient/Participants: Patients were identified from a prospective database. Fractures were classified according to OTA/AO A31A2.2, A2.3, and A3. All patients had a minimum of 12 months of follow-up.

Intervention: Patients received either an SHS, an SHS in combination with a TSP, or a CMN. Implant choice was at the discretion of the operating surgeon.

Outcome Measure: Primary outcome was 12-month mortality analyzed by the Kaplan–Meier survival analysis. Secondary outcomes included 12-month functional status using a validated score and all time revision of implants for any reason.

Results: In total, 3230 patients met the inclusion criteria (2474 SHS, 158 SHS + TSP, and 598 CMN). CMN use increased over time, with concomitant reduction in SHS use. There was no significant difference in functional outcomes at 12 months (analysis of variance, P = 0.177). Although men were significantly younger, they were at a higher risk of 12-month mortality. CMNs had statistically significantly lower 12-month mortality rates (P = 0.0148). The highest revision rate (4.04%) was seen in patients treated with SHS alone (P = 0.041).

Conclusions: The use of a CMN in unstable intertrochanteric hip fractures conveys the best results in functional outcomes, 12-month mortality, and has lower revision rates compared with an SHS ± TSP.

Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

*Department of Trauma and Orthopaedics, Altnagelvin Area Hospital, Londonderry, Northern Ireland;

Department of Trauma and Orthopaedics, Royal Victoria Hospital, Belfast, Northern Ireland; and

Fracture Outcomes and Research Department (FORD), Royal Victoria Hospital, Belfast, Northern Ireland.

Reprints: Adam Tucker, MB BCh BAO, MRCS, MPhil, Trauma and Orthopaedics, Altnagelvin Area Hospital, Glenshane Rd, Londonderry BT47 6SB, Northern Ireland (e-mail:

The authors report no conflict of interest.

Internal review board: Royal Victoria Hospital Trauma and Orthopaedic Research Group (TORG) approval.

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Accepted September 18, 2017

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