Which Implant Is Better for Treating Reverse Obliquity Fractures of the Proximal Femur: A Standard or Long Nail?

Background Reverse obliquity fractures of the proximal femur have biomechanical characteristics distinct from other intertrochanteric fractures and high implant failure rate when treated with sliding hip screws. Intramedullary hip nailing for these fractures reportedly has less potential for cut-out of the lag screw because of their loadbearing capacity when compared with extramedullary implants. However, it is unclear whether nail length influences healing. Questions/purposes We compared standard and long types of intramedullary hip nails in terms of (1) reoperation (fixation failure), (2) 1-year mortality rate, (3) function and mobility, and (4) union rate. Methods We conducted a pilot prospective randomized controlled trial comparing standard versus long (≥ 34 cm) intramedullary hip nails for reverse obliquity fractures of the proximal femur from January 2009 to December 2009. There were 15 patients with standard nails and 18 with long nails. Mean age was 79 years (range, 67–95 years). We determined 1-year mortality rates, reoperation rates, Parker-Palmer mobility and Harris hip scores, and radiographic findings (fracture union, blade cut-out, tip-apex distance, implant failure). Minimum followup was 12 months (mean, 14 months; range, 12–20 months). Results We found no difference in reoperation rates between groups. Two patients (both from the long-nail group) underwent revision surgery because of implant failure in one and deep infection in the other. There was no difference between the standard- and long-nail groups in mortality rate (17% versus 18%), Parker-Palmer mobility score (five versus six), Harris hip score (74 versus 79), union rate (100% in both groups), blade cut-out (zero versus one), and tip-apex distance (22 versus 24 mm). Conclusions Our preliminary data suggest reverse obliquity fractures of the trochanteric region of the femur can be treated with either standard or long intramedullary nails. Level of Evidence Level II, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.