Archives of Orthopaedic and Trauma Surgery

, Volume 133, Issue 7, pp 961–968 | Cite as

Intramedullary nail versus extramedullary plate fixation for unstable intertrochanteric fractures: decision analysis

  • Young-Kyun Lee
  • Chin Youb Chung
  • Moon Seok ParkEmail author
  • Kyoung Min Lee
  • Kyung-Hoi Koo
Trauma Surgery



The best options of internal fixation for unstable intertrochanteric femoral fractures in elderly osteoporotic patients remain controversial. We determined whether intramedullary nail or extramedullary plate provides better treatment for unstable intertrochanteric fractures using a decision analysis tool that considers quality of life.


A decision analysis model was constructed containing final outcome score and the probability of mortality within 1 year, infection, and mechanical complications. Final outcome was defined as health-related quality of life and was used as a utility in the decision tree. Probabilities were obtained by literature review, and health-related quality of life was evaluated by asking 30 orthopedic experts to complete a questionnaire. A roll back tool was used to determine the best surgical option, and sensitivity analysis was performed to compensate for decision model uncertainty.


The decision model favored intramedullary nailing in terms of quality of life. In one-way sensitivity analysis, intramedullary nailing was more beneficial than the extramedullary plating, when probability of mechanical complication after intramedullary nailing was below 0.258.


In terms of quality of life, the decision analysis model showed that intramedullary nailing was more beneficial for patients with an unstable intertrochanteric fracture.


Unstable intertrochanteric fracture Internal fixation Intramedullary nail Extramedullary plate Decision analysis 



The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Conflict of interest



  1. 1.
    Zhang B, Chiu KY, Wang M (2004) Hip arthroplasty for failed internal fixation of intertrochanteric fractures. J Arthroplasty 19:329–333PubMedCrossRefGoogle Scholar
  2. 2.
    Hsu CJ, Chou WY, Chiou CP, Chang WN, Wong CY (2008) Hemi-arthroplasty with supplemental fixation of greater trochanter to treat failed hip screws of femoral intertrochanteric fracture. Arch Orthop Trauma Surg 128:841–845PubMedCrossRefGoogle Scholar
  3. 3.
    Haidukewych GJ, Berry DJ (2003) Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg Am 85-A:899–904Google Scholar
  4. 4.
    Little NJ, Verma V, Fernando C, Elliott DS, Khaleel A (2008) A prospective trial comparing the Holland nail with the dynamic hip screw in the treatment of intertrochanteric fractures of the hip. J Bone Joint Surg Br 90:1073–1078PubMedGoogle Scholar
  5. 5.
    Anglen JO, Weinstein JN (2008) 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 90:700–707PubMedCrossRefGoogle Scholar
  6. 6.
    Aros B, Tosteson AN, Gottlieb DJ, Koval KJ (2008) Is a sliding hip screw or im nail the preferred implant for intertrochanteric fracture fixation? Clin Orthop Relat Res 466:2827–2832PubMedCrossRefGoogle Scholar
  7. 7.
    Geiger F, Zimmermann-Stenzel M, Heisel C, Lehner B, Daecke W (2007) Trochanteric fractures in the elderly: the influence of primary hip arthroplasty on 1-year mortality. Arch Orthop Trauma Surg 127:959–966PubMedCrossRefGoogle Scholar
  8. 8.
    Parker MJ, Handoll HH (2005) Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev CD000093Google Scholar
  9. 9.
    Brauer CA, Bozic KJ (2009) Using observational data for decision analysis and economic analysis. J Bone Joint Surg Am 91(Suppl 3):73–79PubMedCrossRefGoogle Scholar
  10. 10.
    Bernstein J (1997) Decision analysis. J Bone Joint Surg Am 79:1404–1414PubMedGoogle Scholar
  11. 11.
    Brauer CA, Neumann PJ, Rosen AB (2007) Trends in cost effectiveness analyses in orthopaedic surgery. Clin Orthop Relat Res 457:42–48PubMedGoogle Scholar
  12. 12.
    Chen CM, Chiu FY, Lo WH (2001) Avascular necrosis of femoral head after gamma-nailing for unstable intertrochanteric fractures. Arch Orthop Trauma Surg 121:505–507PubMedCrossRefGoogle Scholar
  13. 13.
    Al-yassari G, Langstaff RJ, Jones JW, Al-Lami M (2002) The AO/ASIF proximal femoral nail (PFN) for the treatment of unstable trochanteric femoral fracture. Injury 33:395–399PubMedCrossRefGoogle Scholar
  14. 14.
    Harrington P, Nihal A, Singhania AK, Howell FR (2002) Intramedullary hip screw versus sliding hip screw for unstable intertrochanteric femoral fractures in the elderly. Injury 33:23–28PubMedCrossRefGoogle Scholar
  15. 15.
    Sadowski C, Lubbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P (2002) Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a prospective, randomized study. J Bone Joint Surg Am 84-A:372–381Google Scholar
  16. 16.
    Pajarinen J, Lindahl J, Savolainen V, Michelsson O, Hirvensalo E (2004) Femoral shaft medialisation and neck-shaft angle in unstable pertrochanteric femoral fractures. Int Orthop 28:347–353PubMedGoogle Scholar
  17. 17.
    Schipper IB, Steyerberg EW, Castelein RM, van der Heijden FH, den Hoed PT, Kerver AJ, van Vugt AB (2004) Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail. J Bone Joint Surg Br 86:86–94PubMedGoogle Scholar
  18. 18.
    Kim SY, Kim YG, Hwang JK (2005) Cementless calcar-replacement hemiarthroplasty compared with intramedullary fixation of unstable intertrochanteric fractures. A prospective, randomized study. J Bone Joint Surg Am 87:2186–2192PubMedCrossRefGoogle Scholar
  19. 19.
    Min WK, Kim SY, Kim TK, Lee KB, Cho MR, Ha YC, Koo KH (2007) Proximal femoral nail for the treatment of reverse obliquity intertrochanteric fractures compared with gamma nail. J Trauma 63:1054–1060PubMedCrossRefGoogle Scholar
  20. 20.
    Vidyadhara S, Rao SK (2007) One and two femoral neck screws with intramedullary nails for unstable trochanteric fractures of femur in the elderly—randomised clinical trial. Injury 38:806–814PubMedCrossRefGoogle Scholar
  21. 21.
    Park SY, Yang KH, Yoo JH, Yoon HK, Park HW (2008) The treatment of reverse obliquity intertrochanteric fractures with the intramedullary hip nail. J Trauma 65:852–857PubMedCrossRefGoogle Scholar
  22. 22.
    Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ (2010) 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 92:792–798PubMedCrossRefGoogle Scholar
  23. 23.
    Verettas DA, Ifantidis P, Chatzipapas CN, Drosos GI, Xarchas KC, Chloropoulou P, Kazakos KI, Trypsianis G, Ververidis A (2010) Systematic effects of surgical treatment of hip fractures: gliding screw-plating vs intramedullary nailing. Injury 41:279–284PubMedCrossRefGoogle Scholar
  24. 24.
    Dall’Oca C, Maluta T, Moscolo A, Lavini F, Bartolozzi P (2010) Cement augmentation of intertrochanteric fractures stabilised with intramedullary nailing. Injury 41:1150–1155PubMedCrossRefGoogle Scholar
  25. 25.
    Lunsjo K, Ceder L, Thorngren KG, Skytting B, Tidermark J, Berntson PO, Allvin I, Norberg S, Hjalmars K, Larsson S, Knebel R, Hauggaard A, Stigsson L (2001) Extramedullary fixation of 569 unstable intertrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus three other screw-plate systems. Acta Orthop Scand 72:133–140Google Scholar
  26. 26.
    Mattsson P, Larsson S (2004) Unstable trochanteric fractures augmented with calcium phosphate cement. A prospective randomized study using radiostereometry to measure fracture stability. Scand J Surg 93:223–228PubMedGoogle Scholar
  27. 27.
    Mattsson P, Alberts A, Dahlberg G, Sohlman M, Hyldahl HC, Larsson S (2005) Resorbable cement for the augmentation of internally-fixed unstable trochanteric fractures. A prospective, randomised multicentre study. J Bone Joint Surg Br 87:1203–1209PubMedGoogle Scholar
  28. 28.
    Willig R, Keinanen-Kiukaaniemi S, Jalovaara P (2001) Mortality and quality of life after trochanteric hip fracture. Public Health 115:323–327PubMedCrossRefGoogle Scholar
  29. 29.
    Mendonca TM, Silva CH, Canto RS, Morales Nde M, Pinto Rde M, Morales Rde R (2008) Evaluation of the health-related quality of life in elderly patients according to the type of hip fracture: femoral neck or trochanteric. Clinics 63:607–612PubMedCrossRefGoogle Scholar
  30. 30.
    Ekstrom W, Miedel R, Ponzer S, Hedstrom M, Samnegard E, Tidermark J (2009) Quality of life after a stable trochanteric fracture–a prospective cohort study on 148 patients. J Orthop Trauma 23:39–44PubMedCrossRefGoogle Scholar
  31. 31.
    Wolf CF, Gu NY, Doctor JN, Manner PA, Leopold SS (2011) Comparison of one and two-stage revision of total hip arthroplasty complicated by infection: a markov expected-utility decision analysis. J Bone Joint Surg Am 93:631–639PubMedCrossRefGoogle Scholar
  32. 32.
    Aleem IS, Karanicolas PJ, Bhandari M (2009) Arthroplasty versus internal fixation of femoral neck fractures: a clinical decision analysis. Ortop Traumatol Rehabil 11:233–241PubMedGoogle Scholar
  33. 33.
    Yoon HK, Park C, Jang S, Lee YK, Ha YC (2011) Incidence and mortality following hip fracture in Korea. J Korean Med Sci 26:1087–1092PubMedCrossRefGoogle Scholar
  34. 34.
    Lee YK, Ha YC, Chang BK, Kim KC, Kim TY, Koo KH (2011) Cementless bipolar hemiarthroplasty using a hydroxyapatite-coated long stem for osteoporotic unstable intertrochanteric fractures. J Arthroplasty 26:626–632PubMedCrossRefGoogle Scholar
  35. 35.
    Rodop O, Kiral A, Kaplan H, Akmaz I (2002) Primary bipolar hemiprosthesis for unstable intertrochanteric fractures. Int Orthop 26:233–237PubMedCrossRefGoogle Scholar
  36. 36.
    Grimsrud C, Monzon RJ, Richman J, Ries MD (2005) Cemented hip arthroplasty with a novel cerclage cable technique for unstable intertrochanteric hip fractures. J Arthroplasty 20:337–343PubMedCrossRefGoogle Scholar
  37. 37.
    Liu XZ, Yang W, Yang SH, Xu WH, Ye SN (2008) Total hip arthroplasty for treatment of elderly patients with comminuted intertrochanteric fracture accompanied by femoral head necrosis. Chin J Traumatol 11:359–363PubMedGoogle Scholar
  38. 38.
    Sidhu AS, Singh AP, Singh S (2010) Total hip replacement as primary treatment of unstable intertrochanteric fractures in elderly patients. Int Orthop 34:789–792PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Young-Kyun Lee
    • 1
  • Chin Youb Chung
    • 1
  • Moon Seok Park
    • 1
    Email author
  • Kyoung Min Lee
    • 1
  • Kyung-Hoi Koo
    • 1
  1. 1.Department of Orthopaedic SurgerySeoul National University Bundang HospitalSeongnam-siSouth Korea

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