title: Early results and future challenges of the Danish Fracture Database. Prospective randomised controlled trial of an intramedullary nail versus a sliding hip screw for intertrochanteric fractures of the femur Percutaneous compression plate versus proximal femoral nail anti-rotation in treating elderly patients with intertrochanteric fractures: a prospective randomized study Use of the gamma3™ nail in a teaching hospital for trochanteric fractures: mechanical complications, functional outcomes, and quality of life Dual lag screw cephalomedullary nail versus the classic sliding hip screw for the stabilization of intertrochanteric fractures. A prospective randomized study Femoral shaft medialisation and neck-shaft angle in unstable pertrochanteric femoral fractures Comparative study of the proximal femoral nail antirotation versus the reconstruction nail in the treatment of comminuted proximal femoral fracture. Is the lag screw sliding effective in the intramedullary nailing in A1 and A2 AO-OTA intertrochanteric fractures? A prospective study of Sliding and None-sliding lag screw in Gamma-III nail Time to Surgery Is Associated with Thirty-Day and Ninety-Day Mortality After Proximal Femoral Fracture: A Retrospective Observational Study on Prospectively Collected Data from the Danish Fracture Database Collaborators. Comparison of outcomes following uncemented hemiarthroplasty and dynamic hip screw in the treatment of displaced subcapital hip fractures in patients aged greater than 70 years. Is Helical Blade Nailing Superior to Locked Minimally Invasive Plating in Unstable Pertrochanteric Fractures? A randomised comparison of AMBI, TGN and PFN for treatment of unstable trochanteric fractures Internal Fixation of Intertrochanteric Hip Fractures: A Clinical Comparison of Two Implant Designs The next critical role of orthopedic registries InterTan nail versus Gamma3 nail for intramedullary nailing of unstable trochanteric fractures A prospective trial comparing the Holland nail with the dynamic hip screw in the treatment of intertrochanteric fractures of the hip. Comparing two intramedullary devices for treating trochanteric fractures: A prospective study TRIGEN INTERTAN intramedullary nail versus sliding hip screw: a prospective, randomized multicenter study on pain, function, and complications in 684 patients with an intertrochanteric or subtrochanteric fracture and one year of follow-up. Minimally invasive osteosynthesis in stable trochanteric fractures: a comparative study between Gotfried percutaneous compression plate and Gamma 3 intramedullary nail Treatment of Reverse Oblique and Transverse Intertrochanteric Fractures with Use of an Intramedullary Nail or a 95° Screw-Plate: A Prospective, Randomized Study Intramedullary fixation of intertrochanteric hip fractures: a comparison of two implant designs. A prospective randomised clinical trial. A Comparison of the Proximal Femoral Nail Antirotation Device and Dynamic Hip Screw in the Treatment of Unstable Pertrochanteric Fracture Fixation of femoral neck fracture. A randomized 2-year follow-up study of hook pins and sliding screw plate in 222 patients. Intramedullary hip screw versus sliding hip screw for unstable intertrochanteric femoral fractures in the elderly. Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur--13 year results of a prospective randomised study. The dynamics of proximal femoral nails: a clinical comparison between PFNA and Targon PF. A comparative study of trochanteric fractures treated with the Gamma nail or the proximal femoral nail Functional comparison of the dynamic hip screw and the Gamma locking nail in trochanteric hip fractures: a matched-pair study of 268 patients Use of an Intramedullary Hip-Screw Compared with a Compression Hip-Screw with a Plate for Intertrochanteric Femoral Fractures. A Prospective, Randomized Study of One Hundred Patients* Functional Outcome in Treatment of Unstable Trochanteric and Subtrochanteric Fractures With the Proximal Femoral Nail and the Medoff Sliding Plate Is the Proximal Femoral Nail a Suitable Implant for Treatment of All Trochanteric Fractures? Risk factors in cutout of sliding hip screw in intertrochanteric fractures: an evaluation of 937 patients Pertrochanteric 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 Less Invasive Stabilization System (LISS) Versus Proximal Femoral Nail Anti-rotation (PFNA) in Treating Proximal Femoral Fractures: A Prospective Randomized Study Proximal Femoral Nail Antirotation versus Gamma3 nail for intramedullary nailing of unstable trochanteric fractures. A randomised comparative study. Prospective Randomized Controlled Trial of an Intramedullary Nail Versus Dynamic Screw and Plate for Intertrochanteric Fractures of the Femur Implementing, Adapting, and Validating an Evidence-Based Algorithm for Hip Fracture Surgery Clinical results using the trochanter stabilizing plate (TSP): the modular extension of the dynamic hip screw (DHS) for internal fixation of selected unstable intertrochanteric fractures. A Comparison of Proximal Femoral Nail Antirotation and Dynamic Hip Screw Devices in Trochanteric Fractures Quality of Life After a Stable Trochanteric Fracture-A Prospective Cohort Study on 148 Patients Three cancellous bone screws versus a screw-angle plate in the treatment of Garden I and II fractures of the femoral neck. Introducing new technology: a stepwise algorithm. A prospective, randomised study comparing the percutaneous compression plate and the compression hip screw for the treatment of intertrochanteric fractures of the hip. Internal fixation of femoral neck fractures. Dynamic Hip and Gouffon screws compared in 73 patients. Intertrochanteric femoral fractures. Mechanical failure after internal fixation. The Treatment of Intertrochanteric Fractures: Results Using an Intramedullary Nail With Integrated Cephalocervical Screws and Linear Compression Which Implant Is Better for Treating Reverse Obliquity Fractures of the Proximal Femur: A Standard or Long Nail?
abstract: INTRODUCTION The Danish Fracture Data base ( DFDB ) was established in 2011 to establish nationwide prospect i ve quality assessment of all fracture-related surgery . In this paper , we describe the DFDB 's setup , present preliminary data from the first annual report and discuss its future potential . MATERIAL AND METHODS The DFDB collaboration includes 13 hospitals and covers a population of 3.7 million .  Data registration is performed online by the surgeon following surgery , and it includes patient- , trauma- and surgery-related data . Primary procedures , reoperations and planned secondary procedures are registered . Indication for reoperation is also recorded . The reoperation rate and the one-year mortality are the primary indicators of quality . RESULTS Approximately 10,000 fracture-related surgical procedures were registered in the data base at the time of presentation of the first annual DFDB report ( currently 15,000 ) . 85 % of all procedures were performed on adult fractures and 15 % on paediatric fractures . Proximal femur ( 33 % ) , distal radius ( 15 % ) and malleolar fractures ( 12 % ) were the three most common primary adult fractures . Pain and discomfort from orthopaedic hardware , infection and failure of osteo synthesis were the three most common indications for reoperation and accounted for 34 % , 14 % and 13 % , respectively . CONCLUSION The DFDB is an online data base for registration of fracture-related surgery that allows for basic quality assessment of surgical fracture treatment and large-scale observational research by registering primary surgery , reoperations and planned secondary procedures . FUNDING not relevant . TRIAL REGISTRATION not relevant Purpose The purpose of this prospect i ve r and omised trial was to assess whether an intramedullary nail is superior to a sliding hip screw in the treatment of multifragmentary intertrochanteric fractures Methods Eighty patients with a 31-A2.2 or A2.3 Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association ( AO/OTA ) intertrochanteric fracture were r and omly allocated to fixation with either the Gamma nail or the AMBI sliding hip screw device . Results All patients were followed up at one , three , six and 12 months postoperatively , except for nine who died . There was no statistical difference in Parker mobility score between groups . The Gamma nail group had significantly higher Barthel Index and EuroQol-5D ( EQ-5D ) scores than the AMBI group at 12 months . At the same time , the EQ-5D score had returned to its pre-operative values in the Gamma nail group but not in the AMBI group . There were no differences in mortality , radiation time and hospital stay . Duration of the operation , incision length and hip pain occurrence were significantly less in the Gamma nail group . Conclusions Few failures occur when unstable 31-A2.2 and A2.3 AO/OTA fractures are fixed with a sliding hip screw . Nevertheless , an intramedullary nail seems superior in reconstituting patients to their pre-operative state Background The treatment and management of hip fracture poses a great challenge for clinicians in osteology and surgery . The aim of this study is to compare the clinical effectiveness of the percutaneous compression plate ( PCCP ) versus proximal femoral nail anti-rotation ( PFNA ) in the treatment of intertrochanteric fractures in elderly patients . Methods A prospect i ve r and omized study was carried out from January 2008 to October 2011 involving 90 elderly patients with intertrochanteric fractures ( 90 hips ) who underwent minimally invasive surgery using the PCCP or PFNA .  Evaluation variables , including operation time , intra- and perioperative blood loss , duration of hospital stay , incidence of postoperative complications , and final clinical outcomes by the end of follow-up , were used to compare the benefits of these two implants . Results Among 90 subjects , 45 received PCCPs and 45 received PFNAs . The baseline characteristics of the two groups were comparable . The median follow-up time was 16.9 months ( 12–24 months ) . In the PCCP group , the mean operative time was 53 min ( 40–75 min ) , and the mean intra- and perioperative blood losses were 100.7 ml ( 60–150 ml ) and 916 ml ( 433–1339 ml ) , respectively , which were significantly lower than those in the PFNA group . Nevertheless , there was no statistical difference in the incidence of postoperative complications and final clinical outcomes including pain complaints , range of motion of the hip , postoperative hip function at 12 months , and the recovery of walking ability to pre-injury status between these two implants . Conclusions Overall , the PCCP and PFNA appear to have similar clinical effects in treating elderly patients with intertrochanteric fractures , although the PCCP provided shorter operation times and less blood loss than PFNA . Both implants discussed were demonstrated to be ideal for the treatment of femoral intertrochanteric fractures in elderly patients Background Trochanteric fractures are common fractures in the elderly . Due to characteristic demographic changes , the incidence of these injuries is rapidly increasing . Treatment of these fractures is associated with high rates of complications . In addition , the long-term results remain poor , with high morbidity , declines in function , and high mortality . Therefore , in this study , complication rates and patients ’ outcomes were evaluated after fixation of geriatric trochanteric fractures using the Gamma3 ™ nail . Methods Patients aged 60 years old or older , with pertrochanteric and subtrochanteric femoral fractures , were included . Patients with polytrauma or pathological fractures were excluded . Age , sex , and fracture type were collected on admission . In addition , data were recorded concerning the surgeon ( resident vs. consultant ) , time of operation , and local or systemic perioperative complications . Complications were also collected at the 6- and 12-month follow-ups after trauma . Barthel Index , IADL , and EQ-5D measurements were evaluated retrospectively on admission , as well as at discharge and during the follow-up . Results Ninety patients were prospect ively included between April 2009 and September 2010 . The patients ’ average age was 81 years old , and their average ASA score was 3 . The incision/suture time was 53 min ( 95 % CI 46–60 min ) . Hospital mortality was 4 % , and overall mortality was 22 % at the 12-month follow-up . Eight local complications occurred ( 4 haematomas , 1 deep infection , 1 cutting out , 1 irritation of the iliotibial tract , 1 periosteosynthetic fracture ) . The incidence of relevant systemic complications was 6 % . Forty-two percent of the patients were operated on by residents in training , without significant differences in duration of surgery , complication rate , or mortality rate . The Barthel Index ( 82 to 71 , p < .001 ) , IADL ( 4.5 to 4.3 , p = .0195 ) and EQ-5-D ( 0.75 to 0.66 , p = .068 ) values did not reach pre-fracture levels during the follow-up period of 12 months . Conclusion The results showed a relatively low complication rate  using the Gamma3 ™ nail , even if the nailing was performed by residents in training .  The high mortality , declines in function , and low quality of life could probably be attributed to pre-existing conditions , such as physical status . In summary , the Gamma3 ™ nail seems to be a useful implant for the nailing of trochanteric fractures , although further studies are necessary comparing different currently available devices This study is a r and omized prospect i ve study comparing two fracture fixation implants , the extramedullary sliding hip screw ( SHS ) and the dual lag screw cephalomedullary nail , in the treatment of intertrochanteric femoral fractures in the elderly . One hundred and sixty-five patients with low-energy intertrochanteric fractures , classified as AO/OTA 31A , were prospect ively included during a 2-year period ( 2005–2006 ) . Patients were r and omized into two groups : group A included 79 hip fractures managed with sliding hip screws and group B included 86 fractures treated with cephalomedullary nails .  Delay to surgery , duration of surgery , time of fluoroscopy , total hospital stay , implant-related complications , transfusion requirements , re-operation details , functional recovery , and mortality were recorded . The mean follow-up was 36 months ( 24–56 months ) . The mean surgical time was statistically significantly shorter and fluoroscopy time longer for the group B. No intraoperative femoral shaft fractures occurred . There was no statistically significant difference in the functional recovery score , reoperation , and mortality rates between the 2 groups . A new type of complication , the so-called Z-effect phenomenon , was noticed in the cephalomedullary nail group . There are no statistically significant differences between the two techniques in terms of type and rate of complications , functional outcome , reoperation and mortality rates when comparing the SHS and the cephalomedullary nail for low-energy AO/OTA 31A intertrochanteric fractures . Our data do not support recommendations for the use of one implant over the other We analysed the time-dependent mean changes in the femoral neck length , neck-shaft angle and hip offset in a r and omised study comprising 48 patients who were treated with the dynamic hip screw ( DHS ) or the proximal femoral nail ( PFN ) for an unstable intertrochanteric femoral fracture . As a consequence of fracture compression , the mean post-operative neck length was significantly shorter in patients treated with the DHS . During the first 6 weeks after the operation , a mean decrease of 4.6 ° was observed in the neck-shaft angle , but there was not a significant difference between the treatment groups . The radiographic measures remained virtually unaffected during the interval from 6 weeks to 4 months in both groups . When the operated hip was compared to the opposite hip , patients who had received the DHS showed significantly greater medialisation of the femoral shaft at 4 months than those treated with the PFN . We thus recommend that unstable intertrochanteric fractures should be initially reduced in a slight valgus position in order to achieve an outcome after healing that is as normal as possible . As a result of differences in operative technique and implant stability , the PFN may be superior to the DHS in retaining the anatomical relations in the hip region in unstable intertrochanteric fractures . RésuméNous avons analysé les modifications , en fonction du temps , des valeurs moyennes de la longueur du col fémoral , de l’angle cervico-diaphysaire et du bras de levier de la hanche dans une étude r and omisée qui comprenait 48 malades traités avec une Vis Dynamique ( DHS )  ou un Clou Fémoral Proximal ( PFN ) aprés une fracture intertrochantérienne instable . Par suite de la compression de la fracture , la longueur du col était nettement plus courte chez les malades traités avec une DHS . Pendant les premières six semaines après l’opération , une baisse moyenne de 4.6 ° de l’angle cervico-diaphysaire a été observée mais il n’y avait pas de différence notable entre les groupes de traitement . Les mesures radiographiques sont restées pratiquement non affectées pendant l’intervalle de six semaines à quatre mois dans les deux groupes . Comparé à la hanche opposée , les malades qui avaient reçu une DHS ont montré à 4 mois une nettement plus gr and e médialisation de la diaphyse que ceux traités avec le PFN . Nous recomm and ons que ces fractures intertrochantériennes instables soient réduites en léger valgus pour avoir une situation aussi normale que possible après consolidation . Par suite de différences dans la technique opératoire et dans la stabilité de l’implant , le PFN semble supérieur au DHS pour rétablir l’anatomie de la région de la hanche dans les fractures intertrochantériennes instables The purpose of our study was to compare the proximal femoral nail antirotation ( PFNA ; Synthes , Paoli , Pennsylvania ) with a reconstruction nail ( Recon ; Zimmer , Warsaw , Indiana ) in the treatment of comminuted proximal femoral fractures . Between 2003 and 2010 , twenty-three consecutive patients with AO/Orthopaedic Trauma Association 31-A3 fractures combined with proximal 32 fractures who had a minimum 18-month follow-up were evaluated retrospectively . There were 10 patients ( age range , 18 - 74 years ) in the Recon nail group and 13 patients ( age range , 22 - 90 years ) in the PFNA nail group . Patients treated with Recon nails experienced a longer operation time ( P=.006 ) and more blood loss ( P=.012 ) than patients treated with the PFNA nail . On postoperative radiographs , the change in the neck-shaft angle was 8.8 ° in the Recon nail group and 4.7 ° in the PFNA nail group ( P=.048 ) . The fracture union time averaged 31.8 weeks in the Recon nail group and 21.5 weeks in the PFNA nail group ( P=.148 ) . More patients in the Recon nail group underwent major or minor reoperation ( P=.038 ) compared with the PFNA nail group . No implant failure occurred in either group . The functional results were similar in the 2 groups . For the treatment of comminuted proximal femoral fractures , use of either the PFNA and Recon nail is clinical ly effective . However , the PFNA nail provides a shorter operation time , less blood loss , and better realignment ability and reduces the incidence of reoperation . Therefore , the PFNA nail can be considered a better device than the Recon nail ObjectTo compare the Sliding with Non-sliding lag screw of a gamma nail in the treatment of A1 and A2 AO-OTA intertrochanteric fractures . Material s and methods 80 patients were prospect ively collected . In each group , AO/OTA 31-A were classified into group A. AO/OTA 31-A2.1 was classified as group B. We classified the A2.2 and A2.3 as group C. According to the set-screw locking formation of Gamma-III , the cases were r and omly allocated to Sliding subgroup and Non-sliding subgroup in A , B and C groups . Follow-ups were performed 1 , 3 , 6 and 12 months postoperatively . Results In the Sliding group , the bone healing rate 3 , 6 , 12 months postoperatively reached 85.00 % , 97.50 % , 100 % in group A , B and C. Meanwhile , in Non-sliding group , postoperatively , bone healing rate were 90.00 % , 95.00 % and 97.50 % in group A , B and C , respectively . Both differences were not significant . Lower limb discrepancy between  Sliding and Non-sliding pattern was significantly different in group C which represent fracture types of AO/OTA 31-A2.2 and A2.3 ( 0.573 ± 0.019 mm in Non-sliding group , 0.955 mm ± 0.024 mm in Sliding group , P < 0.001 ) . Difference of sliding distance among the three groups was significant among group A , B and C : 0.48 mm ± 0.04 mm , 0.62 mm ± 0.07 mm and 0.92 mm ± 0.04 mm ( P < 0.001 ) . Differences in average healing time and Harris scores also presented no significance in the three groups . Conclusions As a result , we can conclude that the sliding distance is minimal in Gamma nails and it is related to the comminuted extent of the intertrochanteric area in A1 and A2 AO-OTA intertrochanteric fractures . For treating these kinds of fractures , the sliding of the lag screw of an Gamma nail does not improve any clinical results and in certain cases , such as highly comminuted A1 and A2 fractures , can therefore even benefit from a locked lag screw by tightening the set-screw BACKGROUND We hypothesized that undergoing surgery as soon as possible reduces early mortality in patients with a proximal femoral fracture . Our aim was to evaluate the association between surgical delay and early mortality in these patients . METHODS We performed a retrospective analysis of prospect ively collected data from the Danish Fracture Data base and the Civil Registration System on patients who were fifty years of age or older and had undergone surgery for a proximal femoral fracture . Femoral head fracture ( classified as OTA/AO 31C per the OTA/AO classification system ) , high-energy trauma , pathological fractures , multiple fractures , and surgeries performed with implants not commonly used were excluded . End points were adjusted odds ratios for thirty-day and ninety-day mortality . RESULTS For the 3517 surgeries included in this study , the median patient age was 82.0 years ( range , fifty-one to 107 years ) , 2458 patients ( 70 % ) were female , and 1720 surgeries ( 49 % ) were performed because of a trochanteric fracture . Within twelve hours , 722 of the surgeries ( 21 % ) had been performed ; within twenty-four hours , 2482 surgeries ( 71 % ) ; within thirty-six hours , 3024 surgeries ( 86 % ) ; within forty-eight hours , 3242 surgeries ( 92 % ) ; and within seventy-two hours , 3353 surgeries ( 95 % ) . Unsupervised surgeons with an education level below that of an attending surgeon performed the surgery in 1807 ( 51 % ) of all cases . The thirty-day mortality was 380 ( 10.8 % ) and the ninety-day mortality was 612 ( 17.4 % ) . The risk of thirty-day mortality increased with a surgical delay of more than twelve hours ( odds ratio , 1.45 ; p = 0.02 ) , more than twenty-four hours ( odds ratio , 1.34 ; p = 0.02 ) , and more than forty-eight hours ( odds ratio , 1.56 ; p = 0.02 ) ; the risk of ninety-day mortality increased with a surgical delay of more than twenty-four hours ( odds ratio , 1.23 ; p = 0.04 ) . An education level of the surgeon below that of an attending surgeon increased the risk of thirty-day mortality ( odds ratio , 1.28 ; p = 0.035 ) and ninety-day mortality ( odds ratio , 1.26 ; p = 0.016 ) . Increasing American Society of Anesthesiologists score and male sex significantly increased both thirty-day and ninety-day mortality . CONCLUSIONS In this study , a surgical delay of more than twelve hours significantly increased the adjusted risk of thirty-day mortality and a surgical delay of more than twenty-four hours significantly increased the adjusted risk of ninety-day mortality . The adjusted risk of both thirty-day and ninety-day mortality increased significantly when the education level of the surgeon was below that of an attending surgeon . The study findings challenge orthopaedic departments to facilitate fast surgical treatment supported by attending orthopaedic surgeons As health care costs increase , evaluating treatment methods in femoral neck fractures to determine the most effective treatment paradigm will become increasingly important . The current study compared two methods of treatment in similar cohorts of displaced femoral neck fractures . One hundred and twenty two patients were r and omly assigned to two groups : In Group A , 62 patients were treated with a hemiarthroplasty .  In group B , 60 patients were treated with dynamic screw fixation .  Patients were evaluated at a minimum 3 year follow-up . Using the Matta functional hip score , 42 % of group A and 70 % of group B had good to excellent results . This difference was significant ( p = 0.004 ) . A significant agreement between physician assessment using the Matta score , and patient perception of outcome using the SF-36 scale was demonstrated ( r = 0.64 ) . No statistical difference between groups for revision surgery existed . Both physician based and patient based outcome scores favour retention and internal fixation of the femoral head in this cohort of patients at a short-term follow-up Background Technical advancements have produced many challenges to intramedullary implants for unstable pertrochanteric fractures .  Helical blade fixation of the femoral head has the theoretical advantages of higher rotational stability and cutout resistance and should have a lower rate of reoperation than a locked plating technique . Questions / purpose sWe asked whether ( 1 ) helical blade nailing reduces the rate of reoperation within 24 months compared with locked plating and ( 2 ) any of various preoperative , intraoperative , or postoperative factors predicted failure in these two groups . Methods We prospect ively enrolled 108 patients with unstable pertrochanteric fractures in a surgeon-allocated study between November 2005 and November 2008 : 54 with percutaneous compression plates ( PCCP ) and 54 with proximal femoral nail antirotation ( PFNA ) .  We evaluated patients regarding reoperation , mortality , and function .  Seventy-four patients had a minimum followup of 24 months ( mean , 26 months ; range , 24–30 months ) . Results We found no differences in the number of reoperations attributable to mechanical problems in the two groups : PCCP = six and PFNA = five . Despite a greater incidence of postoperative lateral wall fractures with helical blade nailing , only postoperative varisation of the neck-shaft angle and tip-apex distance ( 33 mm versus 28 mm ) predicted reoperation . Mortality and function were similar in the two groups . Conclusions Our data suggest unstable pertrochanteric fractures may be fixed either with locked extramedullary small-diameter screw systems to avoid lateral wall fractures or with the new intramedullary systems to avoid potential mechanical complications of a broken lateral wall . Tip-apex distance and preservation of the preoperative femoral neck-shaft angle are the key technical factors for prevention of reoperation . Level of Evidence Level III , therapeutic study . See the Guidelines for Authors for a complete description of levels of evidence Introduction : In this study , we initiated a prospect i ve , r and omised , clinical trial comparing the AMBI , TGN and PFN operations used for treatment of unstable fractures , for differences in intra-operative use , consolidation , complications and functional outcome . Material s and methods : We have compared the pre- , intra- and post-operating variables of AMBI , TGN and PFN operations that were used for treatment of unstable trochanteric fractures , of 120 patients all above 60 years old diagnosed with extracapsular hip fractures classified as AO Type 31-A2 or Type 31-A3 . Results : According to our results the three methods are comparable in the treatment of unstable trochanteric fractures  of patients above 60 years old . Conclusion : The AMBI remains the gold st and ard for the fractures of trochanteric region . TGN has an easier and faster procedure , facilitates early weight bearing and had minor late complications . An improper use of the PFN system was the reason for the most complications and the longer operation time of the device . PFN is also an accepted minimally invasive implant for unstable proximal femoral fractures but future modification of the implant to avoid Z-effect phenomenon , careful surgical technique and selection of the patients should reduce its high complication rate Objective . To compare two internal fixation devices clinical ly in stabilisation of intertrochanteric femur fractures . Methods . Eighty-seven patients were r and omised upon their admission to the hospital using a sealed envelope method . Forty-five were treated with proximal femur nail antirotation ( PFNA ) and 42 with reverse less invasive stabilisation system ( LISS ) . The perioperative data were recorded and compared in relation to fracture type . Results . In each type of fractures , no significant differences were found with respect to the blood loss , the quality of reduction , the time to bony healing , and the Harris hip score between the 2 groups . The mean duration of surgery was significantly longer in reverse LISS group than in PFNA group . Conclusion . Both the PFNA and the reversed LISS are effective in the treatment of different types of intertrochanteric femur fractures . PFNA is superior to reverse LISS in terms of surgical time , weight-bearing , and perhaps fluoroscopy time There is an urgent need for the introduction of new implant technology in orthopedic surgery to be conducted in a more controlled manner than in the past . Inadequate regulation and lack of effective post-market surveillance have meant that patients have not been protected from potentially harmful implants and procedures . Compounding the problem is a lack of question ing , a lack of critical appraisal , and lack of a requirement for clinical evidence by both surgeons and manufacturers before large-scale introduction of new technology to the market . There is a long and growing history of failed innovation , demonstrated by the failure or recall of individual products such as Boneloc ( bone cement ) , The Capital Hip ( total hip arthroplasty ) , and the ASR hip system ( total hip arthroplasty ) among others , as well as whole classes of devices such as large-head metal-on-metal bearings . This demonstrates simple , yet severe flaws in the mechanisms that should protect patients from increased risk associated with introduction of new technology . Insufficient or inadequate pre clinical data , a lack of clinical data from timely RSA ( radiostereometric analysis ) studies , and limited larger , multicenter cohort studies prior to general release all increase the risk to patients . The 510k process , where the majority of so-called innovative new design s have been cleared or approved by FDA - or CE-notified bodies for clinical use , is based on similarities to previously used implants . In the 510k process , there is no requirement for specific clinical evidence , so manufactures have not obtained clinical data . Registry post-market surveillance has proven to be a powerful method for detection of increased risk of implant failure , but this is not available in all countries . When registries do identify poor-performing devices , regulators and manufacturers are often slow to respond . The main problem with the current approach to the introduction of new technology is the inability to identify unanticipated failures before wider release ( Bauer 1992 ) . It is 20 years since the stepwise introduction of new implants was first described ( Malchau 1995 ) . The basic concept of this approach is that the smallest possible numbers of patients ( after sufficient pre clinical testing ) are exposed to the implant prior to general release . Stepwise introduction uses a combination of ( 1 ) outcome measurements with high-precision metrics in small cohorts , such as RSA , and ( 2 ) limited clinical introduction in a larger cohort , prospect ively monitoring outcomes and revisions . Adoption of this concept would certainly have reduced the large number of poor-performing new implants introduced in recent years . The concept has , however , never been implemented due to lack of support from surgeons , manufacturers , and regulatory authorities . Now trends have changed , with increasing focus on implementing an effective approach to pre-release clinical assessment . The ongoing work and discussion s in the International Society of Arthroplasty Registries ( ISAR ) , the reports from the Australian Orthopaedic Association total joint registry , and the actions taken in the UK to put a “ beyond compliance ” program into action will facilitate a more cautious market introduction . In addition , the Arthroplastywatch project ( www.arthroplastywatch.com ) is in action : data are collected on the web through a specially developed search routine . Based on examination in several steps using medical and statistical expertise , a caution could be warranted or a warning declared . These combined initiatives say one thing : that close monitoring of new implants by well-established registries during a phase of controlled introduction must be a universal requirement . We propose a structured model for clinical trials involving 4 levels : ( 1 ) a pure observational study using reoperation data from multiple registries , as shown in several papers by the Nordic Arthroplasty Register Association ( NARA ) ; ( 2 ) patient-reported outcome measures , either from national implant registries or from other registries for specific studies ; ( 3 ) radiographic data plus other parameters such as blood levels of metal ions , based on specific needs for a new technology ; and ( 4 ) options for r and omized studies with use of , for example , RSA in the evaluation . The cornerstone in this structural model should be the exp and ed use of existing and future registries with a high degree of coverage and completeness . While registries have a strong tradition in arthroplasty surgery , this is not as well developed in other areas of orthopedic surgery . It is the responsibility of orthopedic surgeons and their professional bodies to support and implement registries where they can be of benefit . The arthroplasty registry experience has shown that it is possible to use registries to effectively monitor the introduction of new technology . Without this registry-based surveillance , identification of many of the failed innovations would have been delayed or might even have gone unrecognized . It is encouraging that registries in fracture surgery are now emerging , where implants are inserted in large and increasing numbers . Finally , implant performance is potentially confounded by the technical difficulty of inserting the implant , the knowledge and abilities of the surgeon inserting them , and the complexity of the cases . Many registries monitor performance at the surgeon level . This together with continuous education and training in how to use new implants should be an integral part of the process of a more cautious market introduction . If training is linked in with the stepwise introduction , it will be possible to identify the need for and the extent of training . Our proposed regulatory change to require registry-based monitoring of new implants during the phase of limited introduction must be accompanied by a change in the way we think and act as orthopedic surgeons . In the training of future orthopedic surgeons , emphasis must be placed on developing a healthy skepticism to innovation , on recognizing the need for evidence -based introduction , and on building a culture holding the view that reporting to a registry is imperative . The registries will then be able to offer back data to enable surgeons to choose the best clinical practice . To increase innovation and to ensure that innovation is effective and beneficial , the role of registries should be exp and ed . The registries should not undertake the role of a regulatory authority , but in compliance with the industry and the orthopedic community they should ensure that a more cautious approach is used when new technology is introduced . This could lead to a better balance between the inborn conservatism that a registry represents and the continuous need for innovation . The independence , infrastructure , and expertise of the registries can be used more fully to optimize how new implants are introduced . All stakeholders need to join to ensure that first and foremost , we do no harm Background Trochanteric fractures ( TF ) have become a major source of morbidity and mortality in elderly . We conducted this study to compare the outcomes of unstable trochanteric fractures treated with the InterTan nail and Gamma3 nail . Methods Between January 2008 and May 2013 , patients aged 60 years or older with a diagnosis of unstable TF treated with InterTan nail or Gamma3 nail were included . Patients treated with InterTan nail were pair-matched to patients treated with Gamma3 nail in a 1:2 ratio . Radiographs were obtained at 1 , 3 , 6 , and 12 months follow-up , and all implant position changes , complications , fixation failures and functional scores were recorded . Results Eighty-seven patients were included in the InterTan nail group , and 174 pair-matched patients were included in the Gamma3 nail group . Preoperative scores were similar between the 2 groups . There are significant improvements postoperatively in both groups . The incidence of cut-out and femoral shaft fracture were significantly higher in the Gamma3 nail group than the InterTan nail group ( P = 0.024 and P = 0.044 , respectively ) . Patients treated with the InterTan nail experienced longer fluoroscopy and operative times . Conclusions The InterTan nail may have a tendency in better outcomes for patients with unstable TF . However , the limited period of follow-up and inherent defects of nonr and omized trials indicate that better- design ed r and omized controlled trials will be required . Virtual SlidesThe virtual slide(s ) for this article can be found here : We compared the outcome of patients treated for an intertrochanteric fracture of the femoral neck with a locked  , long intramedullary nail with those treated with a dynamic hip screw ( DHS )  in a prospect i ve r and omised study . Each patient who presented with an extra-capsular hip fracture was r and omised to operative stabilisation with either a long intramedullary Holl and nail or a DHS . We treated 92 patients with a Holl and nail and 98 with a DHS .  Pre-operative variables included the Mini Mental test score , patient mobility , fracture pattern and American Society of Anesthesiologists grading . Peri-operative variables were anaesthetic time , operating time , radiation time and blood loss . Post-operative variables were time to mobilising with a frame , wound infection , time to discharge , time to fracture union , and mortality . We found no significant difference in the pre-operative variables . The mean anaesthetic and operation times were shorter in the DHS group than in the Holl and nail group ( 29.7 vs 40.4 minutes , p < 0.001 ; and 40.3 vs 54 minutes , p < 0.001 , respectively ) . There was an increased mean blood loss within the DHS group versus the Holl and nail group ( 160 ml vs 78 ml , respectively , p < 0.001 ) . The mean time to mobilisation with a frame was shorter in the Holl and nail group ( DHS 4.3 days , Holl and nail 3.6 days , p = 0.012 ) . More patients needed a post-operative blood transfusion in the DHS group ( 23 vs seven , p = 0.003 ) and the mean radiation time was shorter in this group ( DHS 0.9 minutes vs Holl and nail 1.56 minutes , p < 0.001 ) . The screw of the DHS cut out in two patients , one of whom underwent revision to a Holl and nail . There were no revisions in the Holl and nail group . All fractures in both groups were united when followed up after one year . We conclude that the DHS can be implanted more quickly and with less exposure to radiation than the Holl and nail . However , the result ant blood loss and need for transfusion is greater . The Holl and nail allows patients to mobilise faster and to a greater extent . We have therefore adopted the Holl and nail as our preferred method of treating intertrochanteric fractures of the hip Background Intertrochanteric fractures are surgically treated by using different methods and implants . The optional type of surgical stabilization is still under debate . However , between devices with the same philosophy , different design characteristics may substantially influence fracture healing . This is a prospect i ve study comparing the complication and final functional outcome of two intramedullary devices , the intramedullary hip screw ( IMHS ) and the ENDOVIS nail . Material s and methods Two hundred fifteen patients were r and omized on admission in two treatment groups . Epidemiology features and functional status was similar between two treatment groups . Fracture stability was assessed according to the Evan 's classification . One hundred ten patients were treated with IMHS and 105 with ENDOVIS nail .  Results There were no significant statistical differences between the two groups regarding blood loss , transfusion requirements and mortality rate . In contrast , the number of total complications was significantly higher in the ENDOVIS nail group . Moreover , the overall functional and walking competence was superior in the patients treated with the IMHS nail . Conclusions These results indicate that the choice of the proper implant plays probably an important role in the final outcome of surgical treatment of intertrochanteric fractures . IMHS nail allows for accurate surgical technique , for both static and dynamic compression and high rotational stability . IMHS nail proved more reliable in our study regarding nail insertion and overall uncomplicated outcome BACKGROUND Both intramedullary nails and sliding hip screws are used with good results in the treatment of intertrochanteric and subtrochanteric fractures . The aim of our study was to assess whether use of the TRIGEN INTERTAN nail , as compared with a sliding hip screw , result ed in less postoperative pain , improved functional mobility , and reduced surgical complication rates for patients with an intertrochanteric or subtrochanteric fracture . METHODS In a prospect i ve , r and omized multicenter study , 684 elderly patients were treated with the INTERTAN nail or with a sliding hip screw with or without a trochanteric stabilizing plate . The patients were assessed during their hospital stay and at three and twelve months postoperatively . A visual analogue scale ( VAS ) pain score was recorded at all time points , and functional mobility was assessed with use of the timed Up & Go test . The Harris hip score ( HHS ) was used to assess hip function more specifically . Quality of life was measured with the EuroQol-5D ( EQ-5D ) . Radiographic findings as well as intraoperative and postoperative complications were recorded and analyzed . RESULTS Patients treated with an INTERTAN nail had slightly less pain at the time of early postoperative mobilization ( VAS score , 48 versus 52 ; p = 0.042 ) , although this did not influence the length of the hospital stay and there was no difference at three or twelve months . Regardless of the fracture and implant type , functional mobility , hip function , patient satisfaction , and quality -of-life assessment s were comparable between the groups at three and twelve months . The numbers of patients with surgical complications were similar for the two groups ( twenty-nine in the sliding-hip-screw group and thirty-two in the INTERTAN group , p = 0.67 ) . CONCLUSIONS INTERTAN nails and sliding hip screws are similar in terms of pain , function , and reoperation rates twelve months after treatment of intertrochanteric and subtrochanteric fractures Aim Our objective was to compare the results of PCCP ( Percutaneous Compression Plate ) device and Gamma 3 nail for the treatment of stable trochanteric hip fractures and to demonstrate that PCCP device is a minimally invasive system . Method Prospect i ve , r and omized trial . Eighty patients aged 60 and over with stable trochanteric fracture were selected and then r and omized using a table of r and omized numbers . Length of time of operative procedure , hemoglobin levels at 6 and 48 h after surgery , packed cells units administered , and hospital stay were recorded . In addition , the postoperative complications in the first year after the surgery was collected . Results No differences were found in hospital stay , surgical time , blood loss , functional outcome at 1-year follow-up , neck-shaft angle , fracture collapse , and mortality . Conclusions PCCP and Gamma 3 have not presented significant differences in any measured parameter for treatment of stable trochanteric fractures . Therefore , the PCCP system is shown to be as minimally invasive as the Gamma 3 Background : Intertrochanteric fractures are composed of different anatomic patterns that vary in their degree of stability following open reduction and internal fixation . A particularly unstable group is classified as AO/OTA 31-A3 , with the fracture pattern described as reverse oblique or transverse . The purpose of this study was to compare the results of intramedullary fixation with those of plate fixation for these intertrochanteric fractures in elderly patients . Methods : Thirty-nine elderly patients with AO/OTA 31-A3 intertrochanteric fractures of the femur were r and omized into two treatment groups and were followed for a minimum of one year . The nineteen patients in Group I were treated with a 95 ° fixed-angle screw-plate ( Dynamic Condylar Screw ) , and the twenty patients in Group II were treated with an intramedullary nail ( Proximal Femoral Nail ) . The treatment groups were comparable with regard to all demographic and injury variables . Results : Patients treated with an intramedullary nail  had shorter operative times , fewer blood transfusions , and shorter hospital stays compared with those treated with a 95 ° screw-plate .  Implant failure and /or nonunion was noted in seven of the nineteen patients who had been treated with the 95 ° screw-plate . Only one of the twenty fractures that had been treated with an intramedullary nail did not heal . Conclusion : The results of our study support the use of an intramedullary nail rather than a 95 ° screw-plate for the fixation of reverse oblique and transverse intertrochanteric fractures in elderly patients We report the results of a prospect i ve r and omized clinical trial comparing the Gamma 3 nail with the ACE trochanteric nail for the treatment of pertrochanteric femoral fractures . One hundred and twelve consecutive patients were enrolled in the study : 61 patients were treated with the Gamma 3 nail , 51 with the ACE trochanteric nail .  The two groups were matched for age , fracture type and preoperative Merle d'Aubigné hip score . All patients were followed up clinical ly and radiographically on a regular basis between 6 weeks and one year postoperatively . Twenty-six patients ( 23 % ) died within the first postoperative year . Six patients were lost to follow-up . In each group , two patients were revised due to mechanical failure . Nonunion did not occur . The mean postoperative hip scores in the Gamma 3 and the ACE group were 14.19 and 14.12 respectively , with no significant difference ( p = 0.92 ) . Walking ability was adequately restored in approximately 80 % of the patients . Both implants appeared as safe and effective methods of treatment for intertrochanteric hip fractures This prospect i ve r and omized study compared the outcome of elderly patients with an unstable pertrochanteric fracture , treated with a proximal femoral nail antirotation device ( PFNA ; n = 51 ) or a dynamic hip screw ( DHS ; n = 55 ) . All patients in the DHS group and nine in the PFNA group had open reductions . Incisions were significantly shorter for the PFNA than the DHS group . Blood loss and the number of patients requiring postoperative blood transfusions were significantly greater , but operation and fluoroscopy times were significantly shorter , for the DHS versus the PFNA group . Time to mobilization with a frame was significantly shorter in the PFNA group , and post-operative complications were more common in the DHS group . Poor fracture reduction led to three revisions . All fractures in both groups united during follow-up . The PFNA allowed earlier mobilization and faster recovery than the DHS . The PFNA is a highly acceptable , minimally invasive implant for unstable fractures We compared fixation with hook pins or sliding screw plate in a prospect i ve r and omized study of 222 patients with a cervical hip fracture . Radiographic evidence of early redisplacement , nonunion , or late segmental collapse was found in 43 of 122 patients operated on with two hook pins and in 40 of 100 patients operated on with the sliding screw plate . According to the actuarial method , the failure rate after 2 years was 38 % with hook pins and 46 % with screw plates , which not is a significant difference . Due to early redisplacement , reoperation with an endoprosthesis was performed within 0.5 ( 2 ) years in 11 ( 22 ) patients in the hook-pin group and in 4 ( 17 ) patients in the sliding-screw plate group We report a r and omised , prospect i ve study comparing a st and ard sliding hip screw and the intramedullary hip screw for the treatment of unstable intertrochanteric fractures in the elderly . One hundred and two patients were r and omised on admission to two treatment groups . Fifty-two patients were treated with a compression hip screw ( CHS ) , and fifty had intramedullary fixation with an intramedullary hip screw ( IMHS ) . Patients were followed for 1 year and had a clinical and radiological review at 3 , 6 and 12 months . The mean duration of operation and fluoroscopy screening time was significantly greater for insertion of the intramedullary hip screw . There was no difference between the groups with regard to transfusion requirements or time to mobilise after surgery . There were two technical complications in the CHS group and three in the IMHS group . There was no significant difference between the two groups in radiological or functional outcome at 12 months . It remains to be shown whether the theoretical advantages of intramedullary fixation of extracapsular hip fractures bring a significant improvement in eventual outcome In this prospect i ve r and omised trial we compare the mortality , morbidity and functional results of patients following each of the three principal methods of treatment for displaced subcapital fractures of the femur . Two hundred and ninety patients over the age of 65 years were included and r and omly allocated to undergo closed reduction and internal fixation with a sliding compression screw plate or uncemented Austin Moore hemiarthroplasty or cemented Howse II total hip arthroplasty ( THA ) .  Nineteen patients were subsequently excluded . The 13 year results show that there was no statistical difference in the mortality between the three groups ( 81 , 85 and 91 % respectively ) . Internal fixation and hemiarthroplasty groups fared poorly with a revision rate of 33 and 24 % , respectively , compared with 6.75 % in the THA group . The dislocation rate was 13 % following hemiarthroplasty and 20 % following THA .  Average Harris hip scores were 62 , 55 and 80 , respectively , for the internal fixation , hemiarthroplasty and THA groups . In the long term , both internal fixation and hemiarthroplasty result ed in a poor outcome with respect to pain and mobility . Despite high early complications , THA result ed in least pain and most mobility both in the short and long-term and was encouraging with a revision rate of only 6.25 % . THA should be seriously considered in physiologically active patients with a displaced subcapital fracture of the femur The objective of this study comparing the proximal femoral nails Targon PF ( Aesculap , Tuttlingen , Germany ) and Proximal Femoral Nail Antirotation ( PFNA ; Synthes . Oberdorf , Switzerl and ) was to observe the complications and postoperative results following pertrochanteric femoral fracture fixation , with special attention devoted to the dynamic properties of both implants under physiological load in vivo . The survey was design ed as a r and omized , prospect i ve study of 80 patients who had sustained a pertrochanteric femoral fracture ( AO type 31.A2 ) . Postoperative radiological and clinical examinations were conducted over a period of 12 months on 40 respective patients treated with a PFNA or a Targon PF nail .  Average operative time was 66.2 minutes and average fluoroscopy time was 103.6 seconds in the PFNA group , which was significantly lower than in the Targon PF group ( 84.7 minutes and 164.5 seconds , respectively ) . No significant difference was found between the 2 groups in terms of range of motion ( P=.26 ) or Harris Hip Score ( P=.83 ) . The femoral neck components of the Targon PF showed a significantly higher sliding ability ( 14.5 mm ; P=.04 ) than the PFNA ( 11.1 mm).Both implants are suited to treat pertrochanteric femoral fractures and display comparable clinical results . The Targon PF demonstrates better dynamic properties than the PFNA under physiological load in vivo . A disadvantage of the Targon PF , however , is the more complicated surgical technique and the longer operative time Abstract . The aim of the present paper is to compare the results obtained using two osteo synthesis systems developed for the surgical treatment of fractures of the trochanteric region of the femur , based on the principles of closed intramedullary nailing : the Gamma nail and the proximal femoral nail ( PFN ) . A prospect i ve study is presented of 125 trochanteric fractures of the femur treated with PFN and 125 treated with the Gamma nail in our service between the years 1997 and 2000 , with the prerequisite of a minimum follow-up of 1 year . Fractures were classified according to the AO system , the most commonly recorded subtype encountered being the A2 . Clinical and radiographic controls were performed upon admission and in the post-operative follow-up at 1 , 3 , 6 , and 12 months , the corresponding assessment protocol being completed on each occasion . Of the 250 patients , 179 were women and the rest men . The average age was 78.9 years . Both systems enabled early mobilisation and walking in most of our patients . There were no significant differences in the use of either nail in terms of the recovery of previous functional capacity , nor in terms of the time required for fracture healing ( 12 weeks on average ) . With regard to the more significant technical complications recorded , shaft fractures and the cutting-out phenomenon were more common with the use of the Gamma nail , while secondary varus occurred at a greater rate when using the PFN.Résumé . Nous comparons les résultats obtenus avec deux systèmes d'ostéosynthèse des fractures de la région trochantérienne du fémur , basés sur le principe de l'enclouage médullaire à foyer fermé : le clou Gamma et le P.F.N ( Proximal Femoral Nail ) . Une étude prospect i ve est présentée de 125 fractures trochantériennes traitées avec P.F.N. et 125 avec le clou Gamma dans notre service entre les années 1997 et 2000 , avec un suivi minimum de une année . Les fractures ont été classées d'après le système AO , la plus fréquemment rencontrée étant la sous-classe A2 . Des contrôles cliniques et radiologiques ont été fait à l'admission et dans les suites opératoires à 1 , 3 , 6 , et 12 mois . 179 des 250 cas étaient des femmes et l'âge moyen était 78.9 années . Les deux systèmes ont permis une mobilisation précoce et la marche pour la plupart de nos patients . Il n'y avait pas de différences notables dans l'usage de l'un et l'autre clou quant à la récupération de la capacité fonctionnelle antérieure , ni quant au temps nécessaire pour la consolidation de la fracture ( 12 semaines sur moyenne ) . Quant aux complications techniques enregistrées , les fractures diaphysaires ont été plus fréquentes avec l'usage du clou Gamma , t and is que les varisations secondaires se sont produits à un plus gr and taux avec le The aim of this prospect i ve matched-pair ( age , sex , fracture type , residential status , and walking ability at fracture ) study was to analyse the short-term outcome after Gamma nail ( GN ) and dynamic hip screw ( DHS ) fixation , focusing especially on functional aspects ( St and ardised Audit of Hip Fractures in Europe [ SAHFE ] hip fracture follow-up forms ) , reoperations , and mortality .  Both groups consisted of 134 patients .  DHS and GN groups did not differ significantly with respect to location of residence at 4 months or returning to the prefracture dwelling ( 78 % vs. 73 % , P = 0.224 ) . The change in walking ability at 4 months compared to prefracture situation was better in the DHS group ( p = 0.042 ) , although there was no difference in the change of use of walking aids . The frequency of reoperations during the first year was somewhat lower in the DHS group ( 8.2 % vs. 12.7 % , p = 0.318 ) . Mortality was lower in the DHS group both at 4 months ( 6.0 % vs. 13.4 % , p = 0.061 ) and 12 months ( 14.9 % vs. 23.9 % , p = 0.044 ) . Although walking ability was better and mortality lower in the DHS group , both methods are useful in the treatment of trochanteric femoral fractures . RésuméLe but de cette étude prospect i ve est de comparer et d’analyser le devenir à long terme des fractures du col fémoral traitées par clou Gamma ( GN ) ou par le vis plaque ( DHS ) , notamment en ce qui concerne leurs aspects fonctionnels , les ré interventions et la mortalité .  Deux groupes de 134 patients ont été comparés . Il n’y a pas de différence significative entre ces deux groupes à 4 mois en ce qui concerne le retour aux activités pré-opératoires ( 78 % vs. 73 % , P = 0.224 ) entre DHS et GN . Néanmoins , la marche à 4 mois est bien meilleure dans le groupe DHS ( p = 0.042 ) , il n’y a pas de différence en ce qui concerne l’utilisation d’aide à la marche , moins de ré interventions dans le groupe DHS ( 8,2 % vs. 12,7 % , p = 0.318 ) , de même en ce qui concerne la mortalité ( 6,0 % vs. 13,4 % , p = 0.061 ) et à 12 mois ( 14,9 % vs 23,9 % , p = 0.044 ) . Ces deux méthodes sont utiles dans le traitement des fractures cervico trochantériennes , néanmoins , l’amélioration de la marche et la mortalité sont bien meilleures dans le groupe GHS que dans le groupe clou gamma One hundred elderly patients who had an intertrochanteric femoral fracture were r and omized to treatment with a compression hip-screw with a plate ( fifty patients ) or a  new intramedullary device , the intramedullary hip-screw ( fifty patients ) . All patients were followed prospect ively for one year or until death . A detailed assessment of the functional status and the plain radiographs of the hip was performed one , three , six , and twelve months postoperatively . The two treatment groups were strictly comparable . The operative time needed to insert the intramedullary hip-screw was significantly greater than that needed to insert the compression hip-screw with the plate ( p = 0.02 ) , but use of the intramedullary hip-screw was associated with less estimated intraoperative blood loss ( p = 0.011 ) . The prevalence of perioperative complications , such as bronchopneumonia , cardiac failure , and urinary tract infection , was comparable in the two treatment groups . There were one intraoperative fracture of the femoral shaft and two intraoperative fractures of the greater trochanter in the group managed with the intramedullary hip-screw . One patient had pulling-out of the compression hip-screw on the seventh postoperative day . Four patients had a trochanteric wound hematoma , without infection , after insertion of an intramedullary hip-screw . All but one of the fractures healed . The one non-union , which was in a patient who had a compression hip-screw , was treated with a hemiarthroplasty . The mortality rate was similar in the two treatment groups . The patients who had an intramedullary hip-screw had , on the average , significantly better mobility at one ( p < 0.0001 ) and three months ( p = 0.0013 ) postoperatively . This difference was no longer seen at six and twelve months , although the patients who had an intramedullary hip-screw still had significantly better walking ability outside the home at those time-periods ( p = 0.05 ) . The compression hip-screw was removed from two patients because of pain in the mid-portion of the thigh , which had begun after consolidation of the fracture . Fourteen patients who had an intramedullary hip-screw had cortical hypertrophy at the level of the tip of the nail at twelve months postoperatively . Cortical hypertrophy was significantly related to the use of two interlocking screws ( p = 0.02 ) . Six of these patients also had pain in the mid-portion of the thigh , and the nail had been locked with two screws in five of them . Three of the six patients had the hardware removed because of the pain , and the symptoms resolved . A seventh patient had pain without cortical hypertrophy . The intramedullary hip-screw device was associated with significantly less sliding of the lag-screw and subsequent shortening of the limb in the region of the thigh ( p = 0.012 and 0.019 , respectively ) ; these differences were more pronounced when the unstable fractures in the two treatment groups were compared ( p < 0.001 ) Objective : To compare outcome between the proximal femoral nail ( PFN ) and the Medoff sliding plate ( MSP ) in patients with unstable trochanteric or subtrochanteric fractures . Methods : This was a consecutive prospect i ve r and omized clinical study . In all , 203 patients admitted to two university hospitals with an unstable trochanteric or a subtrochanteric fracture type were included . Surgery was performed with a short intramedullary nail or a dual-sliding plate device . Follow up visits occurred at 6 weeks , 4 months , and 12 months . Functional outcome was measured by walking ability , rising from a chair , curb test , and additional assessment s of abductor strength , pain , living conditions , and complications . Results : The ability to walk 15 m at 6 weeks was significantly better in the PFN group compared to the MSP group with an odds ratio 2.2 ( P = 0.04 , 95 % confidence limits 1.03 - 4.67 ) . No statistical difference in walking ability could be found between trochanteric and subtrochanteric fractures . The major complication rate ( 8 % in the PFN group and 4 % in the MSP group ) did not differ statistically ( P = 0.50 ) but reoperations were more frequent in the PFN group ( 9 % ) compared to the MSP group ( 1 % ; P < 0.02 ) . Conclusions : There were no major differences in functional outcome or major complications between the treatment groups . Reasons other than the operated fracture seem to be equally important in determining the long-term functional ability of the patients in our study . An advantage with the MSP was the lower reoperation rate We review ed 155 consecutive patients who were treated with a proximal femoral nail from 1997 to 2001 to determine the rate of implant specific complications . Results were stratified according to fracture type and surgeon experience to determine which problems occurred in these groups . One year postoperative followup was available for 129 of 132 surviving patients ( 98 % ) . Failure of fixation occurred in three patients ( 2 % ) , and a femoral shaft fracture occurred in one patient ( 0.7 % ) . Fixation failures included one cutout , one delayed fracture healing , and one lateral displacement of the antirotation screw . The total reoperation rate was high ( 12 % ) mainly because of hardware removals , which occurred in 13 patients ( 8.6 % ) . Stratification of results showed that hematomas and iliotibial tract irritation occurred more commonly with lesser surgical experience . General complications and intraoperative problems were seen more often with subtrochanteric fractures . Because the high reoperation rate with the proximal femoral nail is a concern , extramedullary devices continue to be the preferred implants for treatment of stable trochanteric fractures . The low rates of femoral shaft fractures and failure of fixation suggest the proximal femoral nail is useful for treatment of unstable trochanteric and subtrochanteric fractures . Level of Evidence : Therapeutic study , Level IV ( case series ) . See the Guidelines for Authors for a complete description of levels of evidence The aim of this study was design ed to assess the risk factors of lag-screw cutout in the treatment of intertrochanteric fracture with a dynamic hip screw ( DHS ) . From 2003 to 2007 , 1,150 patients who had acute unilateral intertrochanteric fractures of the femur were enrolled to the study . All fractures were managed by closed reduction and internal fixation with 135 ° DHS devices . Patient demographics , fracture patterns , reduction and fixation and perioperative course parameters were all recorded . The follow-up period was 38 months on average ( range 16–60 months ) . Finally , 937 patients were available for evaluation of final results in which we focused on lag-screw cutout . Excluding complications not related to screw position , 64 patients ( 6.8 % ) with screw cutout were encountered , and the remaining 873 patients had uneventful union , with the average union time of 17.5 weeks ( range15–24 weeks ) . Upon analysis with logistic regression , the tip−apex distance ( TAD ) was shown to be the most important predictive factor for cutout , followed by screw position , fracture pattern , reduction and patient age . In order to decrease the risk of lag-screw cutout , it is important to ensure good fracture reduction and to place the lag screw in either the middle/middle or inferior/middle position with appropriate TAD Objectives To compare the results between a sliding compression hip screw and an intramedullary nail in the treatment of pertrochanteric fractures . Design Prospect i ve computer-generated r and omization of 206 patients into two study groups : those treated by sliding compression hip screw ( Group 1;n = 106 ) and those treated by intramedullary nailing ( Group 2;n = 100 ) . Setting University Level I trauma center . Patients All patients over the age of fifty-five years presenting with fractures of the trochanteric region caused by a low-energy injury , classified as AO/OTA Type 31-A1 and A2 . Intervention Treatment with a sliding compression hip screw ( Dynamic Hip Screw ; Synthes-Stratec , Oberdorf , Switzerl and ) or an intramedullary nail ( Proximal Femoral Nail ; Synthes-Stratec , Oberdorf , Switzerl and ) . Main Outcome Measurements Intraoperative : operative and fluoroscopy times , the difficulty of the operation , intraoperative complications , and blood loss . Radiologic : fracture healing and failure of fixation . Clinical : pain , social functioning score , and mobility score . Results The minimum follow-up was one year . We did not find any statistically significant difference , intraoperatively , radiologically , or clinical ly , between the two groups of patients . Conclusions There is no advantage to an intramedullary nail versus a sliding compression hip screw for low-energy pertrochanteric fractures AO/OTA 31-A1 and A2 , specifically with its increased cost and lack of evidence to show decreased complications or improved patient outcome Objective : To evaluate the outcome and efficacy of LISS ( Less Invasive Stabilization System ; Synthes USA , Paoli , PA ) for the treatment of proximal femoral fractures to find another appropriate minimally invasive surgery for these fractures in which intramedullary nailing may be difficult . Design : A consecutive prospect i ve r and omized clinical study . Setting : University teaching hospital . Patients : Between May 2006 and March 2008 , 64 consecutive patients who had a proximal femoral fracture were r and omized to be treated with fixation with either LISS or PFNA ( Proximal Femoral Nail Anti-rotation ; Synthes USA ) . Intervention : LISS or PFNA fixation of proximal femoral fractures . Main Outcome Measurements : Intraoperative time , intraoperative blood loss , length of hospitalization , hip function ( Harris score ) , general complications , fracture complications . Results : Fifty-nine patients were evaluated with a mean follow-up time of 26.8 months ( range , 21–36 months ) . No statistical differences in general complications , intraoperative blood loss , length of hospitalization , or hip function could be found between the two groups . The average operative time was longer in the LISS group ( 98.25 minutes ) compared with the PFNA group ( 65.36 minutes ) ( P < 0.05 ) . One PFNA case had intrapelvic penetration of the helical blade ; two LISS cases had breakage of the screws . Conclusion : There were no major differences in outcome or complications between the treatment groups . LISS can be used effectively in treating proximal femoral fractures , especially for complex fractures patterns in which intramedullary nailing may be difficult . Level of Evidence : Therapeutic Level II . See page 128 for a complete description of levels of evidence The purpose of this study was to compare the clinical results and the complication rates of a new generation of two intramedullary fixation devices : Proximal Femoral Nail Antirotation ® ( PFNA ) and Gamma3 ® . We conducted a prospect i ve r and omised multicentre trial of 61 patients who underwent a PFNA fixation treatment ( 31 patients ) or a Gamma3 nail ( 30 patients ) . We documented the fixation failure complications as well as data of the surgical procedure , the clinical and functional outcomes ( the EuroQoL5 question naire , the Katz index score , the Short Form 36 ( SF-36 ) , and the Harris Hip Score ) and the plain radiographic parameters at 3,6 and 12 months follow up . The PFNA and Gamma3 fixation devices were similar in terms of complication rates . The risk for experiencing a postoperative complication after Gamma3 nailing was 40 % versus 45 % after PFNA fixation . At the 6-month and 1-year follow-up evaluations , there were no significant differences in terms of range of motion , clinical scores and radiological outcomes Objectives To compare the surgical complications and functional outcome of the Gamma nail intramedullary fixation device versus the Richards sliding hip screw and plate device in intertrochanteric femoral fractures . Design A prospect i ve , r and omised controlled clinical trial with observer blinding . Setting A regional teaching hospital in the United Kingdom . Patients All patients admitted from the local population with intertrochanteric fractured femurs were included . There were 400 patients entered into the study and 399 followed-up to one year or death . Intervention The devices were assigned by r and omization to either a short-type Gamma nail ( 203 patients ) or a Richard's-type sliding hip screw and plate ( 197 patients ) . Main Outcome Measurements The main surgical outcome measurements were fixation failure and reoperation . A functional outcome of pain , mobility status , and range of movement were assessed until one year . Results The requirement for revision in the Gamma nail group was twelve ( 6 % ) ; for Richard 's group , eight ( 4 % ) . This was not statistically different ( p = 0.29 ; odds ratio , 1.48 [ 0.59–3.7 ] ) . A subcapital femoral fracture occurred in the Richard 's group . Femoral shaft fractures occurred with four in the Gamma nail group ( 2 % ) and none in the Richard 's group ( p = 0.13 ) . Three required revision to another implant . Lag-screw cut-out occurred in eight patients in the gamma nail group ( 4 % ) and four in the Richard 's group ( 2 % ) . This was not statistically significant ( p = 0.37 ; odds ratio , 2.29 [ 0.6–9.0 ] ) . The development of other postoperative complications was the same in both groups . There was no difference between the two groups in terms of early or long-term functional status at one year . Conclusions The use of an intramedullary device in the treatment of intertrochanteric femoral fractures is still associated with a higher but nonsignificant risk of postoperative complications . Routine use of the Gamma nail in this type of fracture can not be recommended over the current st and ard treatment of dynamic hip screw and plate Objectives : Reoperations are common after surgical treatment of hip fractures but may be reduced by optimal choice of implant based on fracture classification . We hypothesized that implementing a surgical treatment algorithm was possible in our hospital and would result in a reduced reoperation rate . Design : Retrospective comparative study . Setting : Provincial level III trauma center . Patients : The evidence -based “ Hvidovre Algorithm ” for treatment of hip fractures was adopted and implemented at our provincial institution in September 2008 . Three hundred eighty-six consecutive patients older than 50 years admitted with a hip fracture in the first year after implementation were prospect ively included and compared with 417 retrospectively included similar patients admitted within the last year before implementation . Intervention : Implementation of an evidence -based treatment algorithm for hip fracture surgery . Results : Eighty-five percent ( 330 of 386 ) patients were operated according to the algorithm after implementation , compared with 67 % ( 280 of 417 ) of procedures before implementation ( P < 0.001 ) . After implementation , the overall reoperation rate showed a tendency toward a reduction to 8 % ( 32 of 386 ) from 12 % ( 48 of 417 ) ( P = 0.1 ) . Among all the 803 included patients , the reoperation rate was lower if procedures had been performed according to the algorithm recommendations : 9 % ( 53 of 610 ) versus 14 % ( 27 of 193 ) ( P = 0.009 ) . Conclusions : The algorithm for hip fracture surgery was easily implemented , and our results support that using it facilitates a low reoperation rate . The reoperation rate may be further reduced with higher adherence to algorithm recommendation . Level of Evidence : Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence OBJECTIVE To evaluate whether the implantation of the modular trochanter stabilizing plate ( TSP ) in addition to the dynamic hip screw ( DHS ) prevents excessive telescoping and limb shortening in four-part and selected three-part trochanteric fractures . DESIGN Prospect i ve clinical study . SETTING The study was conducted at the trauma unit of the Surgical Department of the University of Basel , Switzerl and . PATIENTS Forty-six consecutive patients with unstable intertrochanteric fractures were treated with an additional TSP super-imposed on the regular DHS  at our institution between July 1991 and July 1993 . Five patients died before the first follow-up , one patient was lost to follow-up , and another patient refused follow-up . Thus , thirty-nine patients were followed for at least twelve months ( mean 14 months , range 12 to 20 months ) . INTERVENTION The fractures treated were classified according to the OTA classification , which is based on the AO classification . Seventeen were 31-A2.2 , seven were 31-A2.3 , and fourteen were 31-A3.3 fractures . RESULTS Lateralization of the greater trochanter was successfully prevented in all fractures . Limited fracture impaction was found in 90 percent ( n = 35 ) of the patients with telescoping of 9.5 millimeters ( range 0 to 30 millimeters ) , result ing in mean limb shortening of 5.37 millimeters ( range 0 to 14.9 millimeters ) . Four patients suffered limb shortening exceeding fifteen millimeters ( range 15.6 to 21.3 millimeters ) . Functional results were excellent and good in 87 percent of patients and fair in 13 percent according to the Salvati-Wilson score . All fractures had healed six months after the operation . Three complications required a secondary procedure : one from not inserting a second screw parallel to the gliding hip screw to prevent rotation of the head-neck fragment ( " antirotation screw " ) , one because of deep infection , and one because of a refracture after premature implant removal . CONCLUSION In unstable pertrochanteric fractures with small or missing lateral cortical buttress , the addition of a TSP to the DHS effectively supports the unstable greater trochanter fragment and can prevent rotation of the head-neck fragment . Excessive fracture impaction and consecutive limb shortening was prevented by this additional implant in 90 percent of these patients This prospect i ve , r and omized study compared the functional outcome and complications associated with a proximal femoral nail antirotation ( PFNA ) device with those of a traditional extramedullary device , the dynamic hip screw ( DHS ) , in patients with trochanteric fracture . A total of 121 patients were r and omized to the PFNA group ( n = 58 ) or the DHS group ( n = 63 ) .  Perioperative information and complications were recorded , and assessment s of functional outcome were made . The DHS group required a longer operative time and was associated with greater blood loss than the PFNA group . The re-operation rate was lower in the PFNA group compared with the DHS group , especially in patients with unstable fractures , although there was no statistically significant difference in the overall complication rate between the two groups . There were no significant differences in functional outcome between the PFNA and the DHS groups . In conclusion , the PFNA device is useful in the treatment of trochanteric fractures Objective : The aim of this study was to report the long-term outcome for patients with stable trochanteric fractures , especially regarding the health-related quality of life ( HRQoL ) . Design : A prospect i ve cohort study with a 2-year follow-up . Setting : Four university hospitals . Patients : One hundred forty-eight consecutive patients with stable trochanteric fractures , that is , a 2-part fracture ( J-M 1 and 2 ) according to the Jensen-Michaelsen classification , treated with a sliding hip screw .  Main Outcome Measurements : Mortality rate , reoperation rate , pain at the hip , walking ability , activities of daily living ( ADL ) function , and HRQoL assessed with the EuroQol-5D ( EQ-5Dindex score ) . Results : The 2-year mortality rate was 29 % . The reoperation rate was 3 % . At the final follow-up , 81 % of the patients reported no or only limited pain at the hip , 55 % had regained their prefracture walking ability , and 66 % their prefracture level of ADL function . The EQ-5Dindex score decreased from 0.69 before the fracture to 0.57 at 4 months , 0.59 at 12 months , and 0.66 at 24 months . Conclusions : Besides the expected mortality rate , the results of the study confirm a low reoperation rate and a good outcome regarding pain at the hip and only limited deterioration in HRQoL after a stable trochanteric fracture . However , a considerable number of the patients experienced deterioration in their walking ability and ADL function . The data on HRQoL obtained in this study can be used in future healthcare evaluations and to calculate quality -adjusted life years A consecutive clinical series of 33 patients with either an undisplaced ( Garden I ) or minimally displaced ( Garden II ) femoral neck fracture was r and omly divided into two operative protocol s. Half of the fractures were treated with three cannulated cancellous bone screws , while the other half were treated with a st and ard screw-angle plate device . After a mean follow-up of 2 years , 4 patients had died , while 20 of the remaining 29 hips showed excellent or good , 3 fair and 6 poor functional results . The three-screw fixation seemed to yield more technical complications as compared to the screw-angle plate fixation . However , the differences in functional end- results were of no clear statistical significance . We conclude that the screw-angle plate device gives acceptable results in this group of fractures . The use of cannulated hip screws may be more advantageous in the treatment of dislocated femoral neck fractures , where the torsional strength of fracture fixation and femoral head viability are more critical In this issue of Spine , a novel method for managing chronic discogenic low back pain with a thermal intradiscal catheter is reported . This study raises some general questions regarding the introduction of new treatment techniques and devices . Decisions about medical treatment should be based on a careful appraisal of the best evidence available . A step-wise introduction is necessary to increase the use of evidence -based decision making in the implementation of new surgical techniques and implants while exposing as few patients as possible to the potential risk of failure . The development of the total hip arthroplasty procedure , for example , could have been different if the introduction of new devices and techniques had been done more carefully and performed in a step-wise manner . Inferior properties could have been revealed earlier , thus reducing the number of failures and allowing for necessary improvements . It is also desirable , therefore , that members of this profession agree on a st and ardized way to introduce new surgical techniques and implants in the field of spinal disorders . Based on the results of Swedish reports and practice , the following schedule for step-wise clinical introduction of new implants is suggested ( Figure 1 ) : The initial step is a pre clinical testing and is beyond the scope of this discussion . The first clinical step is the open prospect i ve and preferably r and omized trial that includes a minimum of patients but yields a relevant evaluation . The strict rules of prospect i ve , r and omized trials should be adhered to . In this first clinical phase , methods associated with high accuracy , such as radiostereometric analysis ( RSA ) , are required . Within 6 to 24 months , this method has the potential to identify implants/ methods that provide inferior fixation and increased polyethylene wear . Results from this first step determine whether further clinical evaluation is worthwhile . It should be noted and stressed that all types of complications can not be predicted and that further follow-up study is necessary . If favorable results are obtained in the first step , the second step , a multicenter trial exposing the new procedure to a broader aspect in the orthopedic community , can be initiated . In the first step , there is a risk for susceptibility and performance bias because the inventors themselves often perform this introductory investigation . The protocol in the multicenter trial must be prepared carefully and agreed on by all participating inventors . A sufficient number of patients should be included to allow adequate statistical analysis . The ultimate goal for step two is to make even the multicenter trial r and omized by using well-documented methods /implants as the gold st and ard . The final step in the evaluation , step three , is to include a continuous control group by using register studies based on large cohorts to reveal early or unusual and potential clinical catastrophic complications . In a rather small and closed community such as Sweden , the register should be nationwide and include all units in a specific field . When applying the principles for step-wise introduction to the investigation of chronic discogenic low back pain with a  thermal intradiscalcatheterbySaal  and Saal , oneobserves that the current study falls between the pre clinical step and step one . The lack of r and omization toward either conservative or surgical intervention is a definite limitation of the study , and before this method is introduced to a larger study group , a r and omized trial must be considered . A multicenter trial exposing the new procedure to a broader aspect of the orthopedic community is recommended before using it in general orthopedic practice . The length of the follow-up period was very short in this study , and no long-term clinical conclusions can be drawn based on the results Limited access surgery is thought to reduce post-operative morbidity and provide faster recovery of function . The percutaneous compression plate ( PCCP ) is a recently introduced device for the fixation of intertrochanteric fractures with minimal exposure . It has several potential mechanical advantages over the conventional compression hip screw ( CHS ) . Our aim in this prospect i ve , r and omised , controlled study was to compare the outcome of patients operated on using these two devices . We r and omised 104 patients with intertrochanteric fractures ( AO/OTA 31.A1-A2 ) to surgical treatment with either the PCCP or CHS  and followed them for one year postoperatively . The mean operating blood loss was 161.0 ml ( 8 to 450 ) in the PCCP group and 374.0 ml ( 11 to 980 ) in the CHS group ( Student 's t-test , p < 0.0001 ) . The pain score and ability to bear weight were significantly better in the PCCP group at six weeks post-operatively . Analysis of the radiographs in a proportion of the patients revealed a reduced amount of medial displacement in the PCCP group ( two patients , 4 % ) compared with the CHS group ( 10 patients , 18.9 % ) ; Fisher 's exact test , p < 0.02 . The PCCP device was associated with reduced intra-operative blood loss , less postoperative pain and a reduced incidence of collapse of the fracture A prospect i ve , r and omized study comparing the Dynamic Hip screws and the Gouffon screws in the treatment of femoral neck fractures was terminated before the planned number of patients had been admitted , owing to a preponderance of early failure of the Gouffon screws ( P 0.014 ) ; thus only 73 patients entered the study . After three years ' follow-up , 25/38 Gouffon screws and 12/35 Dynamic Hip screws had failed . Six patients treated with Gouffon screws and 14 treated with Dynamic Hip screws had died . The outcome still favoured the use of  Dynamic Hip screws ( P 0.02 ) In a prospect i ve study we assessed the causes of mechanical failure in a series of 230 intertrochanteric femoral fractures which had been internally fixed with either a sliding hip screw or a Küntscher Y-nail .  The overall rate of mechanical failure was 16.5 % ; cutting-out of the implant from the femoral head was the cause in three-quarters of the instances . Implants placed posteriorly in the femoral head cut out more often ( 27 % ) than those placed central ly ( 7 % ) . The cut-out rate was also determined by the quality of the fracture reduction , but age , walking ability and bone density ( assessed by the Singh grade and metacarpal indices ) had no significant influence . We conclude that these fractures should be reduced as accurately as possible and it is imperative that the implant is placed central ly within the femoral head Objective : A new device for the treatment of intertrochanteric fractures that uses 2 cephalocervical screws in an integrated mechanism allowing linear intraoperative compression and rotational stability of the head/neck fragment has been developed . The aim of this study was to describe the results using this device for the treatment of stable and unstable intertrochanteric fractures . Design : Prospect i ve , consecutive . Setting : Academic Trauma Center . Methods : Between March 1 , 2005 , and July 31 , 2006 , 100 consecutive patients with an intertrochanteric fracture were treated with a new trochanteric ante grade nail ( InterTan ; Smith-Nephew , Memphis , TN ) . All living patients were followed up for a minimum of 1 year postoperatively ( range 12 - 27 months ) . Clinical and radiographic examinations were performed until healing and at the 1-year anniversary of the index procedure . Healing , pain with ambulation , return to activities of daily living , the modified Harris hip score , and Barthel Index were used to evaluate outcomes . Results : The mean age of the patients was 81.2 ( ±11.3 ) years . Thirty-seven patients died , 12 were too infirmed for follow-up , and 3 could not be located , leaving 48 patients available for final evaluation . The average surgical time was 41 minutes ( 13 - 95 minutes ) . This rose significantly with the complexity of the fracture ( OTA/AO classification : A1 versus A3 , P = 0.016 ) . All fractures healed within 16 weeks ( range 10 - 16 weeks ) . Radiographic analysis at healing revealed no loss of reduction , no uncontrolled collapse of the neck , no nonunions , no femoral shaft fractures , and no implant failures . Two cases in the series were poorly reduced and settled into varus malalignment . There was no varus malposition seen in the remaining 46 fractures . The mean prefracture Harris hip score ( 75.1 ± 13.4 ) was significantly reduced at the time of follow-up ( 70.3 ± 14.5 , P = 0.003 ) ; 58 % of the patients recovered their prefracture status . No significant difference was seen for the Barthel Index . Conclusions : The InterTan device appears to be a reliable implant for the treatment of intertrochanteric femoral fractures . Its design provides for stability against rotation and minimizes neck malunions ( shortening ) through linear intraoperative compression of the head/neck segment to the shaft . As a result of the negligible complication rate and improved clinical outcomes , this implant is now the st and ard treatment for all intertrochanteric fractures at our institution 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 / purpose sWe compared st and ard 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 prospect i ve r and omized controlled trial comparing st and ard 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 st and ard 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 st and ard- 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 st and ard or long intramedullary nails . Level of Evidence Level II , therapeutic study . See Instructions for Authors for a complete description of levels of evidence
target: The clinical evidence behind the current implants used for proximal femoral fractures is weak considering the number of implants used worldwide .
  Sporadic evaluation is not sufficient to identify long term problems .
background: INTRODUCTION Evaluation of the long-term performance of  implants used in trauma surgery relies on post-marked clinical studies since no registry based implant assessment exists .
  The purpose of this study was to evaluate the evidence of performance of implants  currently used for treating proximal femoral fractures ( PFF ) in Denmark .