The quality of evidence is downgraded by study limitations (high or unclear risk of bias) and imprecision (few studies, different measures).
A Cochrane review [Abstract] 1 included 76 studies (66 RCTs, 10 quasi-RCTs) with a total of 10,979 participants. The mean ages of participants in the studies ranged from 54 to 85 years; 72% were women. The majority of the studies included a mix of fracture types. More than half of the studies were conducted before 2010 and care pathways may have differed from current standards of care. Few studies considered patient-relevant outcomes such as performance of activities of daily living, health-related quality of life, mobility, or delirium.
There was no difference in functional status or mortality T1. In addition, using a cephalomedullary nail in preference to an extramedullary device saves one superficial infection per 303 patients (RR 0.71, 95% CI 0.53 to 0.96; 35 studies, n=5087) and leads to fewer non-unions (RR 0.55, 95% CI 0.32 to 0.96; 40 studies, n=4959). However, the risk of intraoperative implant-related fractures was greater with cephalomedullary nails (RR 2.94, 95% CI 1.65 to 5.24; 35 studies, n=4872), as was the risk of later fractures (RR 3.62, 95% CI 2.07 to 6.33; 46 studies, n=7021).
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect(95% CI) | n of participants(studies), GRADE | |
|---|---|---|---|---|
| Risk with extramedullary implants | Risk with cephalomedullary nails | |||
| Functional status ≤ 4 months on Zűckerman functional recovery score (0 to 44), and 100-point functional recovery scale; higher scores = better function | SMD 0.02 higher(-0.27 lower to 0.3 higher) | 188(2 studies), C | ||
| Mobility ≤ 4 months; n of participants with independent mobility | 594 per 1,000 | 665 per 1000(600 to 730) | RR 1.12(1.01 to 1.23) | 719(7 studies), D |
| Mortality ≤ 4 months | 83 per 1,000 | 80 per 1000(66 to 98) | RR 0.96(0.79 to 1.18) | 4603(30 studies), B |
| Mortality at 12 months | 204 per 1000 | 202 per 1000(184 to 220) | RR 0.99(0.90 to 1.08) | 7618(47 studies), B |
| Unplanned return to theatre (at end of follow-up, between 3-24 months) | 43 per 1,000 | 49 per 1000(38 to 64) | RR 1.15(0.89 to 1.50) | 8398(50 studies), C |
Primary/Secondary Keywords