Orthopedics

Feature Article 

Complication Risk After Treatment of Intertrochanteric Hip Fractures in the Medicare Population

Cameron Henzman, MD; Kevin Ong, PhD; Edmund Lau, MS; David Seligson, MD; Craig S. Roberts, MD; Arthur L. Malkani, MD

Abstract

The study evaluated the incidence of and complications associated with the use of an intramedullary nail vs open reduction and internal fixation (ORIF) with a sliding compression hip screw and plate in treating intertrochanteric fractures. The authors hypothesized that the biomechanically stronger and less invasive intramedullary nail would have superior results and fewer complications compared with ORIF. Patients followed for up to 1 year postoperatively were identified from the 5% nationwide sample of Medicare administrative claims data (1998–2007) using the corresponding International Classification of Diseases, 9th revision, Clinical Modification, codes 820.21 and 820.31. There were 9157 patients treated with intramedullary nails and 27,687 treated with compression screw and plate fixation. Intertrochanteric hip fractures treated with an intramedullary nail during this period increased from 3.3% to 63.1% compared with ORIF. Patients treated with an intramedullary nail had a higher adjusted risk of pulmonary embolism at 90 days (P=.003) and a higher risk of mortality at 1 year (P<.001) compared with those treated with ORIF. Patients who underwent intramedullary nailing during 2006 to 2007 had a lower adjusted risk of conversion to total hip replacement at 1 year (P=.037) compared with those who had ORIF. Over the decade of the study, intramedullary nail usage increased 59.8% compared with ORIF. Increased use of intramedullary nails compared with ORIF has not shown improved outcomes or decreased complications in patients with intertrochanteric hip fractures. The increased use of intramedullary nails for intertrochanteric hip fractures appears to be multifactorial, including the less invasive nature of the surgery and increased experience with the closed surgical technique. [Orthopedics. 2015; 38(9):e799–e805.]

The authors are from the Department of Orthopaedic Surgery (CH, DS, CSR, ALM), University of Louisville, and the Department of Orthopedics (ALM), KentuckyOne Health, Louisville, Kentucky; Exponent, Inc (KO), Philadelphia, Pennsylvania; and Exponent, Inc (EL), Menlo Park, California.

Dr Roberts has no relevant financial relationships to disclose. Dr Henzman is a paid consultant for Sintea Plustek. Dr Ong’s institution receives consulting fees from Stryker, Paradigm Spine, Medtronic, and Pacira. Mr Lau’s institution has received grants from Stryker and receives consulting fees from Medtronic, Boston Scientific, Paradigm Spine, Pacira, MAKO Orthopedics, and Alcon Corp. Dr Seligson is a paid consultant for Stryker. Dr Malkani is a paid consultant for, is on the speaker’s bureau of, has received patents from, receives royalties from, has received payment for development of educational presentations from, and has received travel expenses from Stryker; and his institution has received grants from Synthes and Stryker.

Correspondence should be addressed to: Arthur L. Malkani, MD, Department of Orthopedics, KentuckyOne Health, 201 Abraham Flexner Way, Ste 100, Louisville, KY 40202 ( art.malkani@louisville.edu).

Received: September 28, 2014
Accepted: January 06, 2015

Abstract

The study evaluated the incidence of and complications associated with the use of an intramedullary nail vs open reduction and internal fixation (ORIF) with a sliding compression hip screw and plate in treating intertrochanteric fractures. The authors hypothesized that the biomechanically stronger and less invasive intramedullary nail would have superior results and fewer complications compared with ORIF. Patients followed for up to 1 year postoperatively were identified from the 5% nationwide sample of Medicare administrative claims data (1998–2007) using the corresponding International Classification of Diseases, 9th revision, Clinical Modification, codes 820.21 and 820.31. There were 9157 patients treated with intramedullary nails and 27,687 treated with compression screw and plate fixation. Intertrochanteric hip fractures treated with an intramedullary nail during this period increased from 3.3% to 63.1% compared with ORIF. Patients treated with an intramedullary nail had a higher adjusted risk of pulmonary embolism at 90 days (P=.003) and a higher risk of mortality at 1 year (P<.001) compared with those treated with ORIF. Patients who underwent intramedullary nailing during 2006 to 2007 had a lower adjusted risk of conversion to total hip replacement at 1 year (P=.037) compared with those who had ORIF. Over the decade of the study, intramedullary nail usage increased 59.8% compared with ORIF. Increased use of intramedullary nails compared with ORIF has not shown improved outcomes or decreased complications in patients with intertrochanteric hip fractures. The increased use of intramedullary nails for intertrochanteric hip fractures appears to be multifactorial, including the less invasive nature of the surgery and increased experience with the closed surgical technique. [Orthopedics. 2015; 38(9):e799–e805.]

The authors are from the Department of Orthopaedic Surgery (CH, DS, CSR, ALM), University of Louisville, and the Department of Orthopedics (ALM), KentuckyOne Health, Louisville, Kentucky; Exponent, Inc (KO), Philadelphia, Pennsylvania; and Exponent, Inc (EL), Menlo Park, California.

Dr Roberts has no relevant financial relationships to disclose. Dr Henzman is a paid consultant for Sintea Plustek. Dr Ong’s institution receives consulting fees from Stryker, Paradigm Spine, Medtronic, and Pacira. Mr Lau’s institution has received grants from Stryker and receives consulting fees from Medtronic, Boston Scientific, Paradigm Spine, Pacira, MAKO Orthopedics, and Alcon Corp. Dr Seligson is a paid consultant for Stryker. Dr Malkani is a paid consultant for, is on the speaker’s bureau of, has received patents from, receives royalties from, has received payment for development of educational presentations from, and has received travel expenses from Stryker; and his institution has received grants from Synthes and Stryker.

Correspondence should be addressed to: Arthur L. Malkani, MD, Department of Orthopedics, KentuckyOne Health, 201 Abraham Flexner Way, Ste 100, Louisville, KY 40202 ( art.malkani@louisville.edu).

Received: September 28, 2014
Accepted: January 06, 2015

In the United States, the annual incidence of hip fracture is approximately 296,000, with roughly half being intertrochanteric fractures.1 Recent evidence suggested that in spite of an aging population, there is an overall decline in the incidence of hip fractures in the United States. The strongest risk factor for fracture continues to be age, with the most common fracture in the elderly occurring in the trochanteric region.2–7 Several interventions contributed to this overall decrease, including the use of bone mineral density screening, calcium and vitamin D supplementation, exercise and mobility programs, and bisphosphonate therapy, particularly in women.8–11 Internal fixation is the treatment of choice for intertrochanteric femur fractures. However, nonoperative management may be appropriate in patients who are nonambulatory or who have other serious medical conditions that preclude surgical intervention.12,13

Historically, the implant of choice for intertrochanteric femur fractures was the sliding compression hip screw, an extramedullary device.14–16 In the early 1990s, the intramedullary nail was introduced as a new fixation device for intertrochanteric hip fracture. This implant offered proposed advantages, including a less invasive surgical approach for placement and improved fracture fixation biomechanics by shortening the lever arm, with improved fracture stabilization.3,4,16–21 Theoretically, the intramedullary nail technique should provide superior stabilization and allow for earlier postoperative mobility.3,14,19,20 However, the intramedullary nail technique was associated with a higher rate of perioperative fracture and an increased reoperation rate.22 The sliding screw plate reduces complications associated with early intramedullary nails, including femoral head penetration, by facilitating controlled collapse of the fracture.14,19

Recent studies reported increasing use of intramedullary nails in the treatment of intertrochanteric fractures. The intramedullary nail has surpassed the sliding compression hip screw and become the method of choice, despite the greater incidence of complications and the need for revision associated with its use.14–16,22 More recent studies showed little difference in the rate of perioperative fracture and similar clinical outcomes between these 2 surgical methods.13,23–25 These new findings make it difficult to identify the ideal implant because each device has benefits and risks.

This study evaluated patients with intertrochanteric hip fractures and compared the use of a cephalomedullary nail vs a sliding hip screw in patients from a large database to identify differences in outcomes and complications. The authors’ hypothesis was that patients treated with intramedullary nailing would have superior results and fewer complications than those undergoing open reduction and internal fixation (ORIF) with a sliding compression hip screw and plate, corresponding to the increasing use of intramedullary nails.

Materials and Methods

Patients diagnosed with intertrochanteric hip fractures were identified from the 5% nationwide sample of the Medicare administrative claims data between 1998 and 2007 using the corresponding International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM), codes 820.21 and 820.31. The Medicare database was used previously to conduct longitudinal studies of revision risk and complication risk after total joint arthroplasty.26,27 Patients who underwent internal fixation with intramedullary nail or plate fixation procedures were followed longitudinally for up to 1 year postoperatively. Current Procedural Terminology, 4th edition, codes 27244 and 27245 were used to identify plate fixation and intramedullary nail fixation, respectively.

Patients who had complications and those who died were identified with relevant diagnosis and procedure codes (Table 1). Complications included deep venous thrombosis, infection, mechanical complications, malunion/nonunion, neurologic complications, pulmonary embolism, cardiac complications, conversion to hip replacement, and reoperation with subsequent internal fixation. Each beneficiary’s enrollment status and date of death were identified in the annual Medicare denominator files and were used to determine mortality. The cumulative incidence of these complications was evaluated for up to 90 days postoperatively, except for malunion/nonunion, conversion to hip replacement, and reoperation with subsequent internal fixation, which were assessed for up to 1 year postoperatively.

Diagnosis and Procedure Codes for Complications

Table 1:

Diagnosis and Procedure Codes for Complications

Multivariate adjusted Cox regression analysis was used to evaluate risk factors for complications after intramedullary nail or plate fixation. Risk factors included age, sex, race, comorbidity, year of procedure, socioeconomic status, and site of service (inpatient vs outpatient). The health status of each patient was determined with the Charlson comorbidity index and categorized according to the overall degree of comorbidity as follows: 0 (none), 1 to 2 (low), 3 to 4 (moderate), and 5 or greater (high). Patient Medicare buy-in status was used as a proxy for socioeconomic status because it identified patients whose Medicare premiums and deductibles were subsidized by the state because of low income. Complication rates between the various treatment modalities were also compared after adjustment for the various risk factors with multivariate Cox regression. Subgroup analysis was also performed to compare the relative complication risk for intramedullary nail and plate fixation using the most recent 2 years (2006–2007) of Medicare data.

Results

The authors identified 9157 intramedullary nail procedures and 27,687 plate fixation procedures from the 5% Medicare database between 1998 and 2007. The 5% database also showed a decline in intertrochanteric hip fractures treated with intramedullary nail or plate fixation, from 4050 in 1998 to 3453 in 2007 (Figure). During this period, the proportion of intertrochanteric hip fractures treated with intramedullary nail fixation increased from 3.3% to 63.1% vs plate fixation.

Proportion of intertrochanteric hip fractures treated with intramedullary (IM) nails compared with plates.

Figure:

Proportion of intertrochanteric hip fractures treated with intramedullary (IM) nails compared with plates.

Based on data from 1998 to 2007, patients treated with an intramedullary nail had a higher adjusted risk of pulmonary embolism at up to 90 days (39%; P=.003) and mortality at up to 1 year (9%; P<.001) compared with those treated with plate fixation (Table 2). However, patients treated with an intramedullary nail had a 22% lower adjusted risk of conversion to hip replacement at up to 1 year (P=.054). Based on subgroup analysis of 4074 patients treated with an intramedullary nail and 2869 patients treated with plate fixation from 2006 to 2007, the lower adjusted risk of conversion to hip replacement at up to 1 year was still observed with intramedullary nails (−36%; P=.037). The previously mentioned higher risk of pulmonary embolism and mortality associated with treatment with an intramedullary nail in the larger study group was not found in subgroup analysis (Table 3). No other significant differences were found in the overall and subgroup analyses. Of the selected complications, deep venous thrombosis and mortality were the most frequently reported complications at 90 days and 1 year (4% for deep venous thrombosis and 25% for mortality in 2006–2007) (Table 3).

Complication Rate and Relative Complication Risk Associated With Intramedullary Nail and Plate Fixation (1998–2007)

Table 2:

Complication Rate and Relative Complication Risk Associated With Intramedullary Nail and Plate Fixation (1998–2007)

Complication Rate and Relative Complication Risk Associated With Intramedullary Nail and Plate Fixation (2006–2007)

Table 3:

Complication Rate and Relative Complication Risk Associated With Intramedullary Nail and Plate Fixation (2006–2007)

Risk factors for complications and mortality varied depending on the outcome and the type of procedure. Generally, age, comorbidities, and sex were risk factors for a number of complications in both patients treated with an intramedullary nail and those treated with plate fixation (Tables 45). For example, in both the intramedullary nail group and the plate fixation group, elderly patients, those with comorbidities, and men were at higher risk for mortality at 1 year (P<.001 for each of these 3 factors).

Risk Factors Associated With Intramedullary Nail Fixation (1998–2007)

Table 4:

Risk Factors Associated With Intramedullary Nail Fixation (1998–2007)

Risk Factors Associated With Plate Fixation (1998–2007)

Table 5:

Risk Factors Associated With Plate Fixation (1998–2007)

Discussion

In 2008, the use of an intramedullary nail surpassed plate fixation as the most common procedure for fixation of intertrochanteric fractures.14 This information was surprising. There was insufficient evidence to support such a shift because complication rates and the risk of reoperation were higher with intramedullary nails.14,16 Many studies compared the use of an intramedullary nail with a sliding compression hip screw and plate for the treatment of intertrochanteric fractures. Factors that were compared included biomechanics, design, relative use, complication rates, and functional outcomes.3,14,19,24,28–34 In spite of the resources devoted to this investigation, the conflicting results from these reports prevented a consensus on the superior surgical technique. This study compared the use of a cephalomedullary nail vs compression plate fixation in patients with intertrochanteric hip fracture to determine whether the biomechanically stronger and less invasive intramedullary nail would yield superior results and lead to decreased morbidity and mortality compared with the use of a sliding hip screw and plate, based on the large Medicare database.

Based on the 1-year follow-up of Medicare patients in this study, the authors did not accept the hypothesis that intramedullary nailing would yield superior outcomes compared with plate fixation. The intramedullary nail technique was associated with an increased incidence of pulmonary embolism (P=.003) and death (P<.001) at 1 month and 1 year, respectively, according to the data from 1998 to 2007. However, the adjusted risk of conversion to hip replacement was 22% lower overall in the intramedullary nail group (P=.054).

Subgroup analysis for 2006 to 2007 yielded different results compared with overall outcomes. The incidence of pulmonary embolism and death at 1 month and 1 year, respectively, were similar (P=.30 and P=.43, respectively), and intramedullary nailing was associated with a lower adjusted risk of conversion to hip replacement (P=.037). The differences between the data for 1998 to 2007 and the subgroup data for 2006 to 2007 could be the result of selection bias. The more difficult peritrochanteric fractures, including those with trochanteric comminution, may be reserved for treatment with a sliding hip screw and therefore may be associated with higher rates of failure. Another explanation is that surgeons’ experience with intramedullary nails has significantly improved, leading to improved results compared with their initial application.14

Recent studies evaluated the cost-effectiveness of various treatment options for intertrochanteric hip fractures. Depending on the type of fracture, the use of intramedullary nails may still be cost-effective. For example, Swart et al25 constructed a decision analysis model and found that intramedullary nail fixation was more cost-effective for reverse oblique fractures (AO type A3). However, sliding hip screw fixation was likely more cost-effective for stable intertrochanteric fractures (AO type A1) or those with questionable stability (AO type A2). Other authors proposed that specific implants are used for particular patterns of fracture to help to reduce costs associated with intertrochanteric fractures while maintaining the quality of care with fewer complications and readmissions.35

Limitations

This study had several limitations. The patients were treated at multiple centers throughout the United States, allowing for confounding factors, such as regional bias toward a particular method and differences in postoperative management.8 In addition, this study did not control for the heterogeneous population of surgeons, including their individual experience with different techniques. The criteria used to select a particular surgical technique were not identified or considered in the data analysis. In addition, no radiographic or clinical data were available, including patients’ mental status, ambulatory ability, and family support system.

Even with these limitations, the results showed that, despite an overall decrease in the incidence of intertrochanteric hip fracture fixation, the intramedullary nail is being used significantly more than compression hip screw and plate fixation, without a significant clinical benefit. In addition, the initial differences in complications between the use of an intramedullary nail and plate fixation have become more equal. A multicenter randomized prospective trial comparing these 2 surgical interventions is needed to further distinguish between the true benefits and cost-effectiveness of these 2 techniques. The significant increase in the use of intramedullary nails for intertrochanteric hip fractures appears to be multifactorial. Less invasive or closed surgical techniques are sometimes equated with improved outcomes and fewer complications, although these were not found in this study. Given the limited health care resources available, a more cost-effective approach may be needed to treat intertrochanteric hip fractures with a specific implant based on the fracture pattern.

Conclusion

Hip fractures have long been associated with significant morbidity and mortality, regardless of the surgical mode of treatment, with 1-year mortality rates of 13% to 32.5% reported.15,20–22,34,36 Mortality rates in patients treated with an intramedullary nail and ORIF with plate fixation were more than 27%. The increased age and the extent of comorbidities in patients with hip fractures contributed to the overall complications, but clinical efforts must be improved to decrease the incidence of pulmonary embolism and the overall mortality rate in this population.

References

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  35. Egol KA, Marcano AI, Lewis L, Tejwani NC, McLaurin TM, Davidovitch RI. Can the use of an evidence-based algorithm for the treatment of intertrochanteric fractures of the hip maintain quality at a reduced cost?Bone Joint J. 2014; 96(9):1192–1197. doi:10.1302/0301-620X.96B9.34153 [CrossRef]
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Diagnosis and Procedure Codes for Complications

ComplicationInternational Classification of Diseases, 9th revision, Clinical Modification, Codes
Deep venous thrombosis451–453
Infection or inflammation996.60, 996.66, 996.67, 998.5
Mechanical complication of internal orthopedic device, implant, and graft996.40–996.49
Malunion/nonunion733.8
Postoperative neurologic complications997.00–997.02, 997.09
Pulmonary embolism415
Cardiac complications410, 997.1
Subsequent internal fixationa78.55, 79.15, 79.35, CPT 27244, CPT 27245
Conversion to hip replacementa81.51, CPT 27125, CPT 27130, CPT 27132

Complication Rate and Relative Complication Risk Associated With Intramedullary Nail and Plate Fixation (1998–2007)

Complication RiskIntramedullary Nail FixationPlate FixationAdjusted Risk Ratio (95% Confidence Interval)aP
<90 d
  Cardiac2.84%3.62%0.96 (0.83–1.12).63
  Deep venous thrombosis5.66%6.39%1.09 (0.97–1.21).14
  Infection0.80%0.83%1.11 (0.82–1.49).49
  Mechanical1.18%1.33%1.08 (0.84–1.37).56
  Neurologic0.04%0.10%0.38 (0.12–1.15).086
  Pulmonary embolism1.58%1.44%1.39 (1.12–1.73).003b
<1 y
  Death27.85%27.69%1.09 (1.04–1.15)<.001b
  Malunion/nonunion1.19%1.48%0.96 (0.76–1.21).72
  Conversion to hip replacement0.99%1.24%0.78 (0.61–1.00).054
  Reoperation with internal fixation3.36%3.52%1.04 (0.90–1.20).58

Complication Rate and Relative Complication Risk Associated With Intramedullary Nail and Plate Fixation (2006–2007)

Complication RiskIntramedullary Nail FixationPlate FixationAdjusted Risk Ratio (95% Confidence Interval)aP
<90 d
  Cardiac1.84%1.81%1.00 (0.70–1.43).98
  Deep venous thrombosis3.85%4.32%0.87 (0.69–1.11).26
  Infection0.54%0.45%1.19 (0.59–2.37).63
  Mechanical0.64%0.84%0.80 (0.46–1.39).42
  Neurologic0.07%0.07%0.85 (0.14–5.10).86
  Pulmonary embolism1.08%0.84%1.30 (0.79–2.15).30
<1 y
  Death25.36%25.20%1.04 (0.94–1.14).43
  Malunion/nonunion0.64%0.91%0.70 (0.40–1.21).20
  Conversion to hip replacement0.96%1.64%0.64 (0.41–0.97).037b
  Reoperation with internal fixation2.68%2.75%1.02 (0.76–1.36).91

Risk Factors Associated With Intramedullary Nail Fixation (1998–2007)

Demographic<90 Days<1 Year


CardiacDVTInfectionMechanicalNeurologicPEDeathMalunion/NonunionConversion to Hip ReplacementReoperation With Internal Fixation
Age.068.23.096.751.00.46<.001a.075.080.071
Medicare buy-in.17.18.46.781.00.32.34.97.036a.65
Comorbidities<.001a<.001a.003a.002a.99<.001a<.001a.002a.54.015a
Site of service.95.23.084.401.00.58.79.070.12.94
Race.46.26.47.681.00.28.054.28.95.49
Sex.44.002a.55.121.00.003a<.001a.056.37.28
Year.003a.004a.078<.001a.12.15.38.052.93.11

Risk Factors Associated With Plate Fixation (1998–2007)

Demographic<90 Days<1 Year


CardiacDVTInfectionMechanicalNeurologicPEDeathMalunion/NonunionConversion to Hip ReplacementReoperation With Internal Fixation
Age<.001a.30.078.026a.82.068<.001a<.001a<.001a<.001a
Medicare buy-in.21.67.57.20.99.72<.001a.084.067.56
Comorbidities<.001a<.001a.073.099.61.003a<.001a.12.85<.001a
Site of service.052.54.96.941.00.26.11.46.40.96
Race.18.58.27.261.00.14<.001a.029a.92.034a
Sex.90.008a.058<.001a.10.64<.001a.007a.35.002a
Year.13.003a.86.91.78.022a.22.62.014a.012a

10.3928/01477447-20150902-58

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