Background: 

The widespread use of intramedullary nails (IMNs) compared with sliding hip screws (SHSs) in extracapsular hip fractures (AO/OTA 31-A1, 31-A2, 31-A3) has been questioned because of a higher complication rate, although the outcome might have improved through more recent implant designs and the learning curve. This study aimed to investigate if there is a difference with regard to the cumulative incidence of conversion to arthroplasty or any reoperation during the first 5 years after IMN or SHS fixation of extracapsular hip fractures.

Methods: 

In this nationwide, observational cohort study, individuals who were ≥60 years of age and were registered in the Swedish Fracture Register (SFR) from 2012 to 2018 due to extracapsular fracture and were primarily treated with an IMN or SHS were followed in the SFR and the Swedish Arthroplasty Register (SAR) for a minimum of 1 year. The primary outcome was the cumulative incidence of conversion to arthroplasty (conversion rate). The secondary outcome was the cumulative incidence of all reoperations (reoperation rate). Both were calculated in a competing risk analysis during the first 5 years.

Results: 

We included 19,604 individuals (70% women), with a median age of 85 years (range, 60 to 107 years). The 31-A2 fracture was most prevalent (52%), followed by the 31-A1 fracture (28%). No significant differences were seen in the 1-year conversion rate after IMN or SHS use (1.0% compared with 0.9% in the 31-A1 fractures, 1.7% compared with 1.3% in the 31-A2 fractures, and 1.3% compared with 1.5% in the 31-A3 fractures) or in the 1-year reoperation rate (1.9% compared with 1.9% in the type-A1 fractures, 3.4% compared with 2.5% in the type-A2 fractures, and 4.0% compared with 5.2% in the type-A3 fractures). Only in 31-A2 fractures were more reoperations seen after IMN use at 2 and 5 years (p < 0.05). The crude 1-year-mortality was 26.4% (5,178 of 19,604), without significant differences between implants.

Conclusions: 

Considering conversion arthroplasty, IMNs and SHSs performed equally well in general. IMN use was associated with more reoperations than SHS use in 31-A2 fractures at 2 years. However, from a clinical perspective, the differences between the implants were small, in particular when considering the competing risk of dying.

Level of Evidence: 

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

中文翻译：

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髓内钉或滑动髋螺钉治疗髋关节囊外骨折后，髋关节置换术的转换率没有差​​异：一项针对 19,604 名个体的观察性队列研究

背景： 

与滑动髋螺钉（SHS）相比，髓内钉（IMN）在髋关节囊外骨折（AO/OTA 31-A1、31-A2、31-A3）中的广泛使用受到质疑，因为其并发症发生率较高，尽管结果通过最近的种植体设计和学习曲线可能会有所改善。本研究旨在调查 IMN 或 SHS 固定髋关节囊外骨折后的前 5 年内，转为关节置换术或任何再次手术的累积发生率是否存在差异。

方法： 

在这项全国性观察性队列研究中，年龄≥60 岁、2012 年至 2018 年间因囊外骨折在瑞典骨折登记处 (SFR) 登记、主要接受 IMN 或 SHS 治疗的个体在 SFR 中进行了随访，瑞典关节置换术注册 (SAR) 至少 1 年。主要结果是转为关节置换术的累积发生率（转为率）。次要结果是所有再手术的累积发生率（再手术率）。两者都是在前 5 年的竞争风险分析中计算得出的。

结果： 

我们纳入了 19,604 人（70% 为女性），中位年龄为 85 岁（范围为 60 至 107 岁）。31-A2 骨折最为常见 (52%)，其次是 31-A1 骨折 (28%)。使用 IMN 或 SHS 后 1 年转换率没有显着差异（31-A1 骨折为 1.0% 与 0.9%，31-A2 骨折为 1.7% 与 1.3%，1.3% 与 1.5%）。 %（31-A3 骨折）或 1 年再手术率（A1 型骨折为 1.9% 与 1.9%，A2 型骨折为 3.4% 与 2.5%，A2 型骨折为 4.0% 与 5.2%）在 A3 型骨折中）。仅在 31-A2 骨折中，使用 IMN 后第 2 年和第 5 年再次手术次数较多 (p < 0.05)。1 年粗死亡率为 26.4%（19,604 例中的 5,178 例），不同植入物之间没有显着差异。

结论： 

考虑到转换关节成形术，IMN 和 SHS 总体表现同样出色。对于 31-A2 骨折，2 年时使用 IMN 比使用 SHS 导致更多的再次手术。然而，从临床角度来看，植入物之间的差异很小，特别是考虑到死亡的竞争风险时。

证据级别： 

预后III 级。有关证据级别的完整描述，请参阅作者须知。