In the United States, ~341,000 hip fractures occur each year and the frequency of hip fractures doubles every 5-6 years after sixty years old. The American Academy of Orthopedic Surgeons provide guidelines for providers managing hip fractures over the age of 65, which is not only supported by strong evidence, but also helpful in the Subacute Rehab / Long Term Care setting. One of these recommendations includes the ‘use of cephalomedullary device is recommended for the treatment of patients with subtrochanteric or reverse obliquity fractures.’ The article included highlights the type of fixation device best utilized for treatment.
During my Long Term Care rotation, I saw numerous patients each week who were admitted to the Subacute Rehab facility for physical therapy and occupational therapy following surgical fixation of a hip fracture. These patients required care and planning following their discharge and the surgical fixation type was an important aspect of that planning. Reading the patients hospital charts prompted me to look into the various ways these fractures were treated and I was surprised to see how many patients had intertrochanteric hip fractures. In my reading, I learned there are several ways intertrochanteric fractures are treated and tailored my research to reflect that fracture type.
One patient in particular prompted this search as the hospital chart repeatedly referenced the ‘CM Nail.’ I knew these nails existed, but in my mind, I always thought when there was a hip fracture the preferred method was partial or complete arthroplasty, which is not always the case. The article found that the CM nail or cephalomedullary nail ’emerged as the preferred construct, with majority of surgeons believing that CM nail is easier to use, associated with improved outcomes, or is biomechanically superior to a sliding hip screw.’ What I found to be very interesting in this article (and something that the authors addressed) is that these practices reflect more personal experience than evidence-based medicine.
The researchers addressed the use of the CM nail and sliding hip screws in both a teaching hospital as well as in a non-academic setting. The evidence found that the CM nail is the dominant approach regardless of experience level or practice setting. I found this particularly interesting because a majority of the surgeons included in this study practiced with the CM nail, even though they were trained with the sliding nail. It shows that as their practice evolves they work with the treatment modality that they believes to provide the best outcomes for their patients, which may skew the results.
The article concludes, although, the CM nail is used more frequently, there is no definitive ‘best practice’ for the treatment of hip fractures. Patients who undergo surgery to treat an intertrochanteric fracture have similar outcomes regardless of intervention. Both the CM nail and the sliding hip screw lead to are equivalent healing and outcomes for patients. As medicine continues to evolve, it is essential that there are ‘better defined roles of sliding hip screws and cephalomedullary nails’ to ensure providers give the highest level of care and patients have the best outcomes following an intertrochanteric fracture.
https://emedicine.medscape.com/article/825363-overview
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