A Cochrane review [Abstract] 1 included 18 trials testing seven comparisons with a total of 2 619 mainly female and older participants. Trials comparing a fixed nail plate (Jewett or McLaughlin) with the sliding hip screw (SHS, the 'standard' extramedullary device for these fractures) found an increased risk of fixation failure for fixed nail plates (3 trials, n=355). Two trials (n=433) comparing the RAB (resistance augmented bateaux) plate with the SHS gave contrasting results. In one trial (n=100) comparing the Pugh nail and the SHS there were no gross differences in any of the outcome measures. Three trials (n= 458) compared the Medoff plate with the SHS. There was a trend to higher blood losses and longer operation times for the Medoff plate along with a trend to a lower risk of fixation failure with the Medoff plate for unstable trochanteric fractures. Two trials (n=676) compared Medoff sliding plate with any of three screw-plate systems (SHS, SHS with a trochanteric stabilising plate, and dynamic compression screw, DCS). There was no statistically significant differences for trochanteric fractures. For subtrochanteric fractures, there was a tendency to a lower fixation failure rate and reoperation rate for the Medoff plate, but the conclusions remain to be confirmed. In general, less invasive implants, such as the external fixator, which require smaller incisions resulted in less blood loss and often quicker operations than the sliding hip screw. Four trials of 396 participants comparing the Gotfried percutaneous compression plate (PCCP) with a SHS found a trend to lower blood loss and transfusion requirements for the PCCP but no other confirmed differences in outcomes between implants. Three of the trials reported intra-operative problems with the PCCP, some of which precluded its use.Three trials of 200 participants comparing external fixation with a SHS found less operative trauma for the external fixation. Final outcome appeared similar.
Comment:The markedly increased fixation failure rate of fixed nail plates compared with the SHS is a major consideration and thus the SHS appears preferable.There was insufficient evidence from other comparisons of extramedullary implants or on the use of external fixators to draw definite conclusions.
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