Clinical Orthopaedics and Related Research®

, Volume 471, Issue 4, pp 1349–1355 | Cite as

Convergence of Outcomes for Hip Fracture Fixation by Nails and Plates

Clinical Research



Recent popularity of intramedullary nails over sliding hip screws for treatment of intertrochanteric fractures is concerning given the absence of evidence for clinical superiority for nailing yet the presence of reimbursement differences.


We describe the change in outcomes of both procedures across a 15-year span and address the role of reimbursements in the setting of shifting patterns in use.


A 5% sample of Medicare enrollees from 1993 to 2007 was used. Cohorts were generated along diagnostic and procedure codes. Trends in device use by hospital type, surgical times, and rate of revision surgeries were compared. Historic reimbursements were examined.


Since 2005, intramedullary nail fixation has become the more common treatment in government, nonprofit, and for-profit hospitals. Before 1999, intramedullary nailing required 36 minutes longer to perform than plate-and-screw fixation on average, and had higher revision surgery rates (hazard ratio, 2.48; CI, 1.37–4.48) and 1-year mortality (hazard ratio, 1.42; CI, 1.01–1.99). These differences were not significant since 2000. Reimbursement differences have been consistently in favor of intramedullary nails.


Intramedullary nailing of intertrochanteric fractures has become as safe and efficient as the sliding hip screws, but has been more popular since 2006. Reimbursements were favorable for intramedullary nails in times of low and high use. These results argue against the reimbursement difference as the sole driving force for use of intramedullary nails.

Level of Evidence

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.


  1. 1.
    Adams CI, Robinson CM, Court-Brown CM, McQueen MM. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma. 2001;15:394–400.PubMedCrossRefGoogle Scholar
  2. 2.
    Anglen JO, Weinstein JN; American Board of Orthopaedic Surgery Research Committee. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg Am. 2008;90:700–707.PubMedCrossRefGoogle Scholar
  3. 3.
    Aros B, Tosteson AN, Gottlieb DJ, Koval KJ. Is a sliding hip screw or IM nail the preferred implant for intertrochanteric fracture fixation? Clin Orthop Relat Res. 2008;466:2827–2832.PubMedCrossRefGoogle Scholar
  4. 4.
    Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial. J Bone Joint Surg Am. 2010;92:792–798.PubMedCrossRefGoogle Scholar
  5. 5.
    Bhandari M, Schemitsch E, Jönsson A, Zlowodzki M, Haidukewych GJ. Gamma nails revisited: gamma nails versus compression hip screws in the management of intertrochanteric fractures of the hip: a meta-analysis. J Orthop Trauma. 2009;23:460–464.PubMedCrossRefGoogle Scholar
  6. 6.
    Bozic KJ, Jacobs JJ. Technology assessment and adoption in orthopaedics: lessons learned. J Bone Joint Surg Am. 2008;90:689–690.PubMedCrossRefGoogle Scholar
  7. 7.
    Forte ML, Virnig BA, Eberly LE, Swiontkowski MF, Feldman R, Bhandari M, Kane RL. Provider factors associated with intramedullary nail use for intertrochanteric hip fractures. J Bone Joint Surg Am. 2010;92:1105–1114.PubMedCrossRefGoogle Scholar
  8. 8.
    Forte ML, Virnig BA, Kane RL, Durham S, Bhandari M, Feldman R, Swiontkowski MF. Geographic variation in device use for intertrochanteric hip fractures. J Bone Joint Surg Am. 2008;90:691–699.PubMedCrossRefGoogle Scholar
  9. 9.
    Grilli R, Guastaroba P, Taroni F. Effect of hospital ownership status and payment structure on the adoption and use of drug-eluting stents for percutaneous coronary interventions. CMAJ. 2007;176:185–190.PubMedCrossRefGoogle Scholar
  10. 10.
    Haidukewych GT, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am. 2001;83:643–650.PubMedGoogle Scholar
  11. 11.
    National Cancer Institute. Surveilance Epidemiology and End Results. Available at: Accessed October 8, 2012.
  12. 12.
    Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P; Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007;89:470–475.PubMedCrossRefGoogle Scholar
  13. 13.
    Papasimos S, Koutsojannis CM, Panagopoulos A, Megas P, Lambiris E. A randomised comparison of AMBI, TGN and PFN for treatment of unstable trochanteric fractures. Arch Orthop Trauma Surg. 2005;125:462–468.PubMedCrossRefGoogle Scholar
  14. 14.
    Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2010;9:CD000093.Google Scholar
  15. 15.
    Rogmark C, Spetz CL, Garellick G. More intramedullary nails and arthroplasties for treatment of hip fractures in Sweden. Acta Orthop. 2010;81:588–592.PubMedCrossRefGoogle Scholar
  16. 16.
    Silber JH, Rosenbaum PR, Zhang X, Even-Shoshan O. Estimating anesthesia and surgical procedure times from medicare anesthesia claims. Anesthesiology. 2007;106:346–355.PubMedCrossRefGoogle Scholar
  17. 17.
    Teno JM, Mitchell SL, Gozalo PL, Dosa D, Hsu A, Intrator O, Mor V. Hospital characteristics associated with feeding tube placement in nursing home residents with advanced cognitive impairment. JAMA. 2010;303:544–550.PubMedCrossRefGoogle Scholar
  18. 18.
    Utrilla AL, Reig JS, Munoz FM, Tufanisco CB. 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. 2005;19:229–233.PubMedCrossRefGoogle Scholar
  19. 19.
    Whang PG, Lim MR, Sasso RC, Skelton A, Brown ZB, Anderson DG, Albert TJ, Hilibrand AS, Vaccaro AR. Financial incentives for lumbar surgery: a critical analysis of physician reimbursement for decompression and fusion procedures. J Spinal Disord Tech. 2008;21:381–386.PubMedCrossRefGoogle Scholar
  20. 20.
    Zou J, Xu Y, Yang H. A comparison of proximal femoral nail antirotation and dynamic hip screw devices in trochanteric fractures. J Int Med Res. 2009;37:1057–1064.PubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2012

Authors and Affiliations

  • Foster Chen
    • 1
    • 2
  • Zhong Wang
    • 2
  • Timothy Bhattacharyya
    • 2
  1. 1.University of California, San Diego School of MedicineLa JollaUSA
  2. 2.National Institutes of HealthBethesdaUSA

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