Intramedullary Nailing versus Sliding Hip Screw Fixation for Intertrochanteric Femoral Fractures: A Systematic Review and Meta-Analysis of Clinical and Radiological Outcomes

Sachin N C; Tejal V V; Vedavathi H

doi:10.51168/krkdnn16

Authors

Dr Sachin N C Senior Registrar, Apollo Hospital, Bannerghatta Road, Bangalore -560076, Karnataka, India
Dr. Tejal.VV Resident, Indira Maternity and Skin Laser Center, Station Road, Tumkur- 572102, Karnataka, India
Dr. Vedavathi H Professor and Head, Department of Pharmacology, Shimoga Institute of Medical Sciences, Shimoga 577201, Karnataka, India

DOI:

https://doi.org/10.51168/krkdnn16

Keywords:

cephalomedullary nail, dynamic hip screw, intertrochanteric fracture, intramedullary nail, meta-analysis, pertrochanteric fracture, sliding hip screw

Abstract

Background: Intertrochanteric femoral fractures are commonly fixed with a cephalomedullary intramedullary nail (IMN) or a sliding hip screw (SHS). Implant use has shifted toward IMN despite persistent uncertainty regarding patient-important benefit, particularly for stable fracture patterns.

Objective: To update randomized evidence comparing IMN and SHS fixation and to synthesize clinical, functional, and radiological outcomes reported in high-quality reviews published through 2025.

Methods: A focused systematic update used the 21-randomized-trial corpus reported by Shin and colleagues as the anchor evidence set. Targeted PubMed/MEDLINE, Cochrane, trial-registry, with eligible publications restricted to 31 December 2025. A subsequent multicentre randomized trial was added. Revision or surgical failure was pooled as an odds ratio (OR) using inverse-variance methods. Secondary outcomes were synthesized from the contemporary trial and high-quality systematic reviews. Risk of bias, heterogeneity, small-study effects, and certainty were considered outcome specifically.

Results: Twenty-two randomized trials contributed 4,431 participants to the revision/surgical-failure analysis. Events occurred in 100 of 2,204 SHS-treated and 93 of 2,227 IMN-treated participants. The pooled estimate did not demonstrate a clear difference (OR 1.14, 95% CI 0.84-1.54; I²=0%; P=0.401). The 2023 INSITE trial found no clinically meaningful 1-year EQ-5D difference (mean difference 0.02, 95% CI -0.03 to 0.07), no significant revision difference, and no interaction by fracture stability. Broader evidence showed little difference in mortality, return to theatre, or quality of life; older nail designs were associated with more implant-related femoral fractures. Small pooled differences in mobility scores favouring IMN were of uncertain clinical importance.

Conclusion: For stable or reducible AO/OTA 31-A1 and selected 31-A2 fractures, SHS remains an evidence-supported, lower-cost option, while IMN does not provide a consistent patient-important advantage. For unstable A2, reverse-obliquity, or subtrochanteric-extension patterns, fracture mechanics and current guidelines favour cephalomedullary fixation, although direct comparative certainty for several outcomes remains limited.

References

1. American Academy of Orthopaedic Surgeons. Management of Hip Fractures in Older Adults: Evidence-Based Clinical Practice Guideline. Rosemont, IL: AAOS; 2021.

2. Lewis SR, Macey R, Gill JR, Parker MJ, Griffin XL. Cephalomedullary nails versus extramedullary implants for extracapsular hip fractures in older adults. Cochrane Database Syst Rev. 2022;1(1):CD000093. doi:10.1002/14651858.CD000093.pub6.

3. Shin WC, Lee SM, Moon NH, Jang JH, Choi MJ. Comparison of cephalomedullary nails with sliding hip screws in surgical treatment of intertrochanteric fractures: a cumulative meta-analysis of randomized controlled trials. Clin Orthop Surg. 2023;15(2):192-202. doi:10.4055/cios22103.

4. Schemitsch EH, et al. Intramedullary nailing vs sliding hip screw in trochanteric fracture management: the INSITE randomized clinical trial. JAMA Netw Open. 2023;6(6):e2317164. doi:10.1001/jamanetworkopen.2023.17164.

5. Backman C, Lam A, Papp R, Kolle AT, Engel FD, Li W, et al. Comparing intramedullary nails versus dynamic hip screws in the treatment of intertrochanteric hip fractures on post-operative rehabilitation outcomes: a systematic review and meta-analysis. Geriatr Orthop Surg Rehabil. 2025;16:21514593251350490. doi:10.1177/21514593251350490.

6. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71.

7. Rethlefsen ML, Kirtley S, Waffenschmidt S, Ayala AP, Moher D, Page MJ, et al. PRISMA-S: an extension to the PRISMA statement for reporting literature searches in systematic reviews. Syst Rev. 2021;10:39. doi:10.1186/s13643-020-01542-z.

8. Yu F, Tang YW, Wang J, Lin ZC, Liu YB. Does intramedullary nail have advantages over dynamic hip screw for the treatment of AO/OTA 31A1-A3? A meta-analysis. BMC Musculoskelet Disord. 2023;24:588. doi:10.1186/s12891-023-06715-0.

9. Raj S, Grover S, Bola H, Pradhan A, Fazal MA, Patel A. Dynamic hip screws versus cephalocondylic intramedullary nails for unstable extracapsular hip fractures in 2021: a systematic review and meta-analysis of randomised trials. J Orthop. 2023;36:88-98. doi:10.1016/j.jor.2022.12.015.

10. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editors. Cochrane Handbook for Systematic Reviews of Interventions. Version 6.5 (updated August 2024). Cochrane; 2024.

11. Sterne JAC, Savovic J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. doi:10.1136/bmj.l4898.

12. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924-926. doi:10.1136/bmj.39489.470347.AD.

13. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629-634. doi:10.1136/bmj.315.7109.629.

14. Bridle SH, Patel AD, Bircher M, Calvert PT. Fixation of intertrochanteric fractures of the femur: a randomised prospective comparison of the Gamma nail and the dynamic hip screw. J Bone Joint Surg Br. 1991;73(2):330-334.https://doi.org/10.1302/0301-620X.73B2.2005167

15. Leung KS, So WS, Shen WY, Hui PW. Gamma nails and dynamic hip screws for peritrochanteric fractures: a randomised prospective study in elderly patients. J Bone Joint Surg Br. 1992;74(3):345-351.https://doi.org/10.1302/0301-620X.74B3.1587874

16. Radford PJ, Needoff M, Webb JK. A prospective randomised comparison of the dynamic hip screw and the Gamma locking nail. J Bone Joint Surg Br. 1993;75(5):789-793.https://doi.org/10.1302/0301-620X.75B5.8376441

17. Butt MS, Krikler SJ, Nafie S, Ali MS. Comparison of dynamic hip screw and Gamma nail: a prospective, randomized, controlled trial. Injury. 1995;26(9):615-618.https://doi.org/10.1016/0020-1383(95)00126-T

18. Park SR, Kang JS, Kim HS, Lee WH, Kim YH. Treatment of intertrochanteric fracture with the Gamma AP locking nail or by a compression hip screw: a randomised prospective trial. Int Orthop. 1998;22(3):157-160.https://doi.org/10.1007/s002640050231

19. Madsen JE, Naess L, Aune AK, Alho A, Ekeland A, Stromsoe K. Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral fractures: a comparative study with the Gamma nail and compression hip screw. J Orthop Trauma. 1998;12(4):241-248.https://doi.org/10.1097/00005131-199805000-00005

20. Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures. Clin Orthop Relat Res. 1998;(348):87-94. https://doi.org/10.1097/00003086-199803000-00015

21. Saudan M, Lubbeke A, Sadowski C, Riand N, Stern R, Hoffmeyer P. Intertrochanteric fractures: is there an advantage to an intramedullary nail? A randomized, prospective study of 206 patients comparing the dynamic hip screw and proximal femoral nail. J Orthop Trauma. 2002;16(6):386-393.https://doi.org/10.1097/00005131-200207000-00004

22. Harrington P, Nihal A, Singhania AK, Howell FR. Intramedullary hip screw versus sliding hip screw for unstable intertrochanteric femoral fractures in the elderly. Injury. 2002;33(1):23-28.https://doi.org/10.1016/S0020-1383(79)80119-9

https://doi.org/10.1016/S0020-1383(01)00106-1

23. Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Intertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail: a randomised study comparing post-operative rehabilitation. J Bone Joint Surg Br. 2005;87(1):76-81.https://doi.org/10.1302/0301-620X.87B1.15249

24. 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(7):462-468.https://doi.org/10.1007/s00402-005-0021-5

25. 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(4):229-233.https://doi.org/10.1097/01.bot.0000151819.95075.ad

26. Ekstrom W, Karlsson-Thur C, Larsson S, Ragnarsson B, Alberts KA. Functional outcome in treatment of unstable trochanteric and subtrochanteric fractures with the proximal femoral nail and the Medoff sliding plate. J Orthop Trauma. 2007;21(1):18-25.https://doi.org/10.1097/BOT.0b013e31802b41cf

27. 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(4):1057-1064.https://doi.org/10.1177/147323000903700410

28. Xu YZ, Geng DC, Mao HQ, Zhu XS, Yang HL. A comparison of the proximal femoral nail antirotation device and dynamic hip screw in the treatment of unstable pertrochanteric fracture. J Int Med Res. 2010;38(4):1266-1275.https://doi.org/10.1177/147323001003800408

29. 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(4):792-798.https://doi.org/10.2106/JBJS.I.00508

30. Stern R, Lubbeke A, Suva D, Miozzari H, Hoffmeyer P. Prospective randomised study comparing screw versus helical blade in the treatment of low-energy trochanteric fractures. Int Orthop. 2011;35(12):1855-1861.https://doi.org/10.1007/s00264-011-1232-8

31. Parker MJ, Bowers TR, Pryor GA. Sliding hip screw versus the Targon PF nail in the treatment of trochanteric fractures of the hip: a randomised trial of 600 fractures. J Bone Joint Surg Br. 2012;94(3):391-397.https://doi.org/10.1302/0301-620X.94B3.28406

32. Aktselis I, Kokoroghiannis C, Fragkomichalos E, et al. Prospective randomised controlled trial of an intramedullary nail versus a sliding hip screw for intertrochanteric fractures of the femur. Int Orthop. 2014;38(1):155-161.https://doi.org/10.1007/s00264-013-2196-7

33. Zehir S, Zehir R, Zehir S, Azboy I, Haykir N. Proximal femoral nail antirotation against dynamic hip screw for unstable trochanteric fractures: a prospective randomized comparison. Eur J Trauma Emerg Surg. 2015;41(4):393-400.https://doi.org/10.1007/s00068-014-0463-y

34. Reindl R, Harvey EJ, Berry GK, Rahme E; Canadian Orthopaedic Trauma Society. Intramedullary versus extramedullary fixation for unstable intertrochanteric fractures: a prospective randomized controlled trial. J Bone Joint Surg Am. 2015;97(23):1905-1912.https://doi.org/10.2106/JBJS.N.01007

35. Selim A, Ponugoti N, Naqvi AZ, Magill H. Cephalomedullary nailing versus dynamic hip screw with trochanteric stabilisation plate for the treatment of unstable peritrochanteric hip fractures: a meta-analysis. J Orthop Surg Res. 2021;16(1):47. doi:10.1186/s13018-020-02193-5.