From the Guidelines
The primary difference between sliding hip screws (SHS) and cephalomedullary nails (CMN) for intertrochanteric (IT) hip fractures is their design and biomechanical properties, with CMNs offering better stability and resistance to femoral shaft medialization in unstable fractures, as recommended by the AAOS clinical practice guideline summary 1. The design of SHS consists of a side plate attached to the femoral shaft with a large screw that slides within a barrel, allowing controlled fracture compression. On the other hand, CMNs are intramedullary devices with a nail inserted into the femoral canal and a lag screw extending into the femoral head. For stable IT fractures, both devices perform similarly with comparable outcomes, as indicated by the strong recommendation in the AAOS clinical practice guideline summary 1. However, for unstable fractures (reverse oblique patterns, subtrochanteric extension, or significant comminution), CMNs offer better biomechanical advantages, allowing for earlier weight-bearing, lower cut-out rates in unstable patterns, and generally requiring less surgical exposure, as supported by the strong strength of evidence and recommendation in the AAOS management of hip fractures in older adults evidence-based clinical practice guideline 1. Key considerations for choosing between these implants include:
- Fracture pattern stability
- Patient factors like bone quality
- Surgeon experience
- Institutional resources In the context of real-life clinical medicine, prioritizing morbidity, mortality, and quality of life, the choice between SHS and CMN should be based on the individual patient's needs and fracture characteristics, with a strong consideration for the use of CMN in unstable fractures, as recommended by the most recent and highest quality study 1.
From the Research
Comparison of SHS and CMN for IT Hip Fractures
- The choice between sliding hip screws (SHS) and cephalomedullary nails (CMN) for intertrochanteric (IT) hip fractures is controversial, with studies showing varying results [ 2 , 3 , 4 , 5 , 6 ].
Outcomes and Complications
- A study found that SHS was associated with a decreased likelihood of minor complications, but no difference in major complications compared to CMN [ 2 ].
- Another study found that CMN was the preferred treatment among orthopaedic surgeons, with 68% primarily using CMN and 19% primarily using SHS [ 3 ].
- A retrospective study found that TFN (a type of CMN) had shorter operative times and was used in more complex fracture patterns, while SHS had fewer blood transfusions [ 4 ].
- A prospective randomized study found no statistically significant difference in functional recovery, reoperation, and mortality rates between SHS and CMN [ 5 ].
Surgical Considerations
- The sliding hip screw is the most commonly used device for fracture stabilization, with secure placement within the femoral head being the most important aspect of its insertion [ 6 ].
- Intramedullary hip screws may have selected indications, but have not been shown to be superior to the sliding hip screw [ 6 ].