Cephalomedullary nailing versus sliding hip screws for Intertrochanteric and basicervical hip fractures: a propensity-matched study of short-term outcomes in over 17,000 patients

  • Jared A. Warren
  • Kavin Sundaram
  • Robert Hampton
  • John McLaughlin
  • Brendan Patterson
  • Carlos A. Higuera
  • Nicolas S. PiuzziEmail author
Original Article • HIP - FRACTURES



Hip fractures are associated with poor mortality and morbidity outcomes. Controversy exists over what the preferred treatment is between sliding hips screws (SHSs) and cephalomedullary nails (CMNs) for stable intertrochanteric (IT) and basicervical (BC) hip fractures. The purpose of this study was to compare early postoperative outcomes and complications in patients treated with SHS to those treated with CMN in IT and BC hip fractures.


We used the National Surgical Quality Improvement Program database to identify IT and BC hip fractures, excluding subtrochanteric hip fractures treated with a SHS and CMN for 2008 to 2016. After propensity score matching, there were 8505 patients in the SHS cohort and 8505 in the CMN cohort. Propensity score-adjusted multivariate regression models assed SHS as an independent risk factor for the following 30-day outcomes: mortality, postoperative major and minor complications, discharge disposition, readmission and reoperation, length of hospital stay (LOS), and operative time.


No difference in mortality was encountered between SHS and CMN (p = 0.440). Compared to CMN, the SHS cohort had an 11.6% decreased likelihood of a minor complication (p < 0.001); however, no difference was found between CMN and SHS for major complications (p = 0.117). SHS patients were less likely to have transfusion (p < 0.001), DVT (p = 0.007), and MI (0.024). SHS patients were 12.5% more likely to go home (p = 0.002). No association was discovered between being treated with a SHS and reoperation (p = 0.449) and readmission (p = 0.588). SHS patients had almost a quarter of a day longer LOS (p = 0.041). Patients treated with SHS had a statistically significant (p < 0.001), but clinically irrelevant 2-min longer procedure.

Level of evidence



Sliding hip screw Cephalomedullary nail Hip fracture Mortality Postoperative complications Discharge disposition Readmission Length of stay 


Compliance with ethical standards

Conflict of interest

The authors declare no conflicts of interest.


  1. 1.
    Landefeld C (2011) Goals of care for hip fracture: promoting independence and reducing mortality. Arch Intern Med 171:1837–1838CrossRefGoogle Scholar
  2. 2.
    Magazine P, Haentjen J, Colón-Emeri C, Vanderschueren D, Milise K, Velkeniers B, Boone B (2009) Meta-analysis: excess mortality after hip fracture among older. Ann Intern Med 152:380–390Google Scholar
  3. 3.
    Kiriakopoulos E, McCormick F, Nwachukwu BU et al (2017) In-hospital mortality risk of intertrochanteric hip fractures: a comprehensive review of the US Medicare database from 2005 to 2010. Musculoskelet Surg 101:213–218. CrossRefGoogle Scholar
  4. 4.
    Prieto-Alhambra D, Reyes C, Sainz MS et al (2018) In-hospital care, complications, and 4-month mortality following a hip or proximal femur fracture: the Spanish registry of osteoporotic femur fractures prospective cohort study. Arch Osteoporos 13:96. CrossRefGoogle Scholar
  5. 5.
    Chow SK-H, Qin J, Wong RM-Y et al (2018) One-year mortality in displaced intracapsular hip fractures and associated risk: a report of Chinese-based fragility fracture registry. J Orthop Surg Res 13:235. CrossRefGoogle Scholar
  6. 6.
    Hu F, Jiang C, Shen J et al (2012) Preoperative predictors for mortality following hip fracture surgery: a systematic review and meta-analysis. Injury 43:676–685. CrossRefGoogle Scholar
  7. 7.
    Moyet J, Deschasse G, Marquant B et al (2018) Which is the optimal orthogeriatric care model to prevent mortality of elderly subjects post hip fractures? A systematic review and meta-analysis based on current clinical practice. Int Orthop. Google Scholar
  8. 8.
    Oñativia I, Slulittel PAI, Diaz Dilernia F et al (2018) Outcomes of nondisplaced intracapsular femoral neck fractures with internal screw fixation in elderly patients: a systematic review. Hip Int 28:18–28CrossRefGoogle Scholar
  9. 9.
    Mundi S, Pindiprolu B, Simunovic N, Bhandari M (2014) Similar mortality rates in hip fracture patients over the past 31 years. Acta Orthop 85:54–59. CrossRefGoogle Scholar
  10. 10.
    Judd KT, Christianson E (2015) Expedited operative care of hip fractures results in significantly lower cost of treatment. Iowa Orthop J 35:62–64Google Scholar
  11. 11.
    Aktselis I, Kokoroghiannis C, Fragkomichalos E et al (2014) Prospective randomised controlled trial of an intramedullary nail versus a sliding hip screw for intertrochanteric fractures of the femur. Int Orthop 38:155–161. CrossRefGoogle Scholar
  12. 12.
    Hao Z, Wang X, Zhang X (2018) Comparing surgical interventions for intertrochanteric hip fracture by blood loss and operation time: a network meta-analysis. J Orthop Surg Res 13:1–8. CrossRefGoogle Scholar
  13. 13.
    Henzman C, Ong K, Lau E et al (2015) Complication risk after treatment of intertrochanteric hip fractures in the medicare population. Orthopedics 38:e799–e805. CrossRefGoogle Scholar
  14. 14.
    Kouvidis G, Sakellariou VI, Mavrogenis AF et al (2012) Dual lag screw cephalomedullary nail versus the classic sliding hip screw for the stabilization of intertrochanteric fractures. A prospective randomized study. Strateg Trauma Limb Reconstr 7:155–162. CrossRefGoogle Scholar
  15. 15.
    Matre K, Havelin LI, Gjertsen JE et al (2013) Intramedullary nails result in more reoperations than sliding hip screws in two-part intertrochanteric fractures trauma. Clin Orthop Relat Res 471:1379–1386. CrossRefGoogle Scholar
  16. 16.
    Parker MJ (2017) Sliding hip screw versus intramedullary nail for trochanteric hip fractures; a randomised trial of 1000 patients with presentation of results related to fracture stability. Injury 48:2762–2767. CrossRefGoogle Scholar
  17. 17.
    Socci AR, Casemyr NE, Leslie MP, Baumgaertner MR (2017) Implant options for the treatment of intertrochanteric fractures of the hip rationale, evidence, and recommendations. Bone Joint J 99-B:128–133. CrossRefGoogle Scholar
  18. 18.
    Kani KK, Porrino JA, Mulcahy H, Chew FS (2019) Fragility fractures of the proximal femur: review and update for radiologists. Skeletal Radiol 48:29–45. CrossRefGoogle Scholar
  19. 19.
    Khan AZ, Rames RD, Miller AN (2018) Clinical management of osteoporotic fractures. Curr Osteoporos Rep 16:299–311. CrossRefGoogle Scholar
  20. 20.
    Pandarinath R, Amdur R, DeBritz JN, Rao RD (2018) Comparison of short-term complication rates between cephalomedullary hip screw devices and sliding hip screws: an analysis of the national surgical quality improvement program database. J Am Acad Orthop Surg 26:845–851. CrossRefGoogle Scholar
  21. 21.
    Huang X, Leung F, Xiang Z et al (2013) Proximal femoral nail versus dynamic hip screw fixation for trochanteric fractures : a meta-analysis of randomized controlled trials. Sci World J 2013:80580Google Scholar
  22. 22.
    National Institute for Health and Clinical Excellence (2014) Hip fracture: management. National Institute for Health and Clinical Excellence, LondonGoogle Scholar
  23. 23.
    Li J, Zhang L, Zhang H et al (2018) Effect of reduction quality on post-operative outcomes in 31-A2 intertrochanteric fractures following intramedullary fixation: a retrospective study based on computerised tomography findings. Int Orthop. Google Scholar
  24. 24.
    Morochovic R, Takacova K, Tomocovcivk L et al (2019) Factors influencing femoral neck fracture healing after internal fixation with dynamic locking plate. Arch Orthop Trauma Surg 139:629–638CrossRefGoogle Scholar
  25. 25.
    Avakian Z, Shiraev T, Lam L, Hope N (2012) Dynamic hip screws versus proximal femoral nails for intertrochanteric fractures. ANZ J Surg 82:56–59. CrossRefGoogle Scholar
  26. 26.
    Bohl DD, Basques BA, Golinvaux NS et al (2014) Extramedullary compared with intramedullary implants for intertrochanteric hip fractures thirty-day outcomes of 4432 procedures from the ACS NSQIP database. J Bone Joint Surg Am 96:1871–1877. CrossRefGoogle Scholar
  27. 27.
    Parker MJ, Cawley S (2017) Sliding hip screw versus the Targon PFT nail for trochanteric hip fractures. Bone Joint J 99B:1210–1215. CrossRefGoogle Scholar
  28. 28.
    Parker MJ, Handol H (2010) Gamma and other cephalocondylic intramedullary nails versus extramedullary. Acta Radiol 51:828–831. CrossRefGoogle Scholar
  29. 29.
    Zhu Q, Xu X, Yang X et al (2017) Intramedullary nails versus sliding hip screws for AO/OTA 31-A2 trochanteric fractures in adults: a meta-analysis. Int J Surg 43:67–74. CrossRefGoogle Scholar
  30. 30.
    Cho HM, Lee K et al (2016) Clinical and functional outcomes of treatment for type A1 intertrochanteric femoral fracture in elderly patients: comparison of dynamic hip screw and proximal femoral nail antirotation. Hip Pelvis 28:232–242. CrossRefGoogle Scholar
  31. 31.
    Kumar R, Singh RN, Singh BN (2012) Comparative prospective study of proximal femoral nail and dynamic hip screw in treatment of intertrochanteric fracture femur. J Clin Orthop Trauma 3:28–36. CrossRefGoogle Scholar
  32. 32.
    Swart E, Makhni EC, Macaulay W et al (2014) Cost-effectiveness analysis of fixation options for intertrochanteric hip fractures. J Bone Joint Surg 96:1612–1620CrossRefGoogle Scholar
  33. 33.
    Krigbaum H, Takemoto S, Kim HT, Kuo AC (2016) Costs and complications of short versus long cephalomedullary nailing of OTA 31-A2 proximal femur fractures in U.S. Veterans. J Orthop Trauma 30:125–129. CrossRefGoogle Scholar
  34. 34.
    Pollmann CT, Røtterud JH, Gjertsen JE et al (2019) Fast track hip fracture care and mortality—an observational study of 2230 patients. BMC Musculoskelet Disord 20:1–10. CrossRefGoogle Scholar
  35. 35.
    NSQIP (n.d.) American College of Surgeons National Surgical Quality Improvement Program. Accessed 25 Aug 2018
  36. 36.
    Cohen ME, Ko CY, Bilimoria KY et al (2013) Optimizing ACS NSQIP modeling for evaluation of surgical quality and risk: patient risk adjustment, procedure mix adjustment, shrinkage adjustment, and surgical focus. J Am Coll Surg 217:336–346.e1. CrossRefGoogle Scholar
  37. 37.
    Durand WM, Goodman AD, Johnson JP, Daniels AH (2018) Assessment of 30-day mortality and complication rates associated with extended deep vein thrombosis prophylaxis following hip fracture surgery. Injury 49:1141–1148. CrossRefGoogle Scholar
  38. 38.
    Haughom BD, Basques BA, Hellman MD et al (2018) Do mortality and complication rates differ between periprosthetic and native hip fractures? J Arthroplasty 33:1914–1918. CrossRefGoogle Scholar
  39. 39.
    Neufeld ME, O’Hara NN, Zhan M et al (2016) Timing of hip fracture surgery and 30-day outcomes. Orthopedics 39:361–368. CrossRefGoogle Scholar
  40. 40.
    Pulido L, Parvizi J, Macgibeny M et al (2008) Hospital complications after total joint arthroplasty. J Arthroplasty. Google Scholar
  41. 41.
    Harrell FEJ (2015) rms: regression modeling strategies. R package version 4.4-0Google Scholar
  42. 42.
    Bovbjerg P, Froberg L, Schmal H (2019) Short versus long intramedullary nails for treatment of intertrochanteric femur fractures (AO 31-A1 and AO 31-A2): a systematic review. Eur J Orthop Surg Traumatol. Google Scholar
  43. 43.
    Gill J, Jensen L, Chin P et al (2007) Intertrochanteric hip fractures treated with the trochanteric fixation nail and sliding hip screw. J Surg Orthop Adv Summer 16:62–66Google Scholar
  44. 44.
    Wang Q, Yang X, He HZ et al (2014) Comparative study of interTAN and dynamic hip screw in treatment of femoral intertrochanteric injury and wound. Int J Clin Exp Med 7:5578–5582Google Scholar
  45. 45.
    Bhandari M, Schemitsch E, Jönsson A et al (2009) Gamma nails revisited: gamma nails versus compression hip screws in the management of intertrochanteric fractures of the hip: a meta-analysis. J Orthop Trauma 23:460–464. CrossRefGoogle Scholar
  46. 46.
    Utrilla AL, Reig JS, Muñoz FM, Tufanisco CB (2005) Trochanteric Gamma nail and compression hip screw for trochanteric fractures: a randomized, prospective, comparative study in 210 elderly patients with a new design of the gamma nail. J Orthop Trauma 19:229–233. CrossRefGoogle Scholar
  47. 47.
    Ahrengart L, Törnkvist H, Fornander P et al (2002) A randomized study of the compression hip screw and gamma nail in 426 fractures. Clin Orthop Relat Res. Google Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Orthopedic SurgeryCleveland Clinic, Orthopaedic and Rheumatology InstituteClevelandUSA
  2. 2.Department of Orthopedic SurgeryCleveland Clinic FloridaWestonUSA

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