Increased Pulmonary Complications Associated With Intramedullary Fixation of Intertrochanteric Fractures

An Analysis of 13,276 Hips

Nathanael Heckmann, MD; J. Ryan Hill, MD; Venus Vakhshori, MD; Braden McKnight, MD; Amir Mostofi, MD; Jason Davis, MD; George "Rick" Hatch III, MD; Geoffrey Marecek, MD


J Am Acad Orthop Surg. 2019;27(18):690-695. 

In This Article

Abstract and Introduction


Introduction: Intramedullary devices are being used more frequently to treat intertrochanteric (IT) femur fractures but without clear benefit in several clinical trials. This study determines differences in complication rates in patients with IT fractures treated with intramedullary versus extramedullary devices.

Methods: Using the National Surgical Quality Improvement Program database, patients aged ≥55 years with an isolated IT fracture and an American Society of Anesthesiologists score of <5 were identified. Thirty-day mortality and perioperative complications were assessed.

Results: Extramedullary fixation was performed in 4,392 patients, whereas 8,884 underwent intramedullary fixation. Intramedullary fixation was associated with increased 30-day mortality (odds ratio [OR], 1.18; P = 0.038), ventilator use (OR, 1.57; P = 0.004), transfusion (OR, 1.12; P < 0.001), and deep vein thrombosis (DVT) (OR, 1.45; P = 0.032). Mean postoperative hospital stay was 1 day shorter for the intramedullary group (P < 0.001). After multivariate analysis, ventilator use (OR, 1.59), DVT (OR, 1.44), and transfusion (OR, 1.15) were more common with intramedullary fixation group.

Discussion: Intramedullary fixation for IT fractures was associated with an increased risk of pulmonary complications, DVT, and transfusion. Further randomized controlled studies are required to determine the relative safety of intramedullary versus extramedullary implants.

Level of Evidence: Level III, therapeutic, retrospective comparative study


Intertrochanteric (IT) fractures are common in the elderly, with more than 250,000 hip fractures in patients older than 65 years occurring annually in the United States alone.[1,2] As the United States population continues to age, the number of IT fractures is expected to increase in the coming decade.[3] Recently, an increase was observed in the use of intramedullary devices for the treatment of these injuries.[4] Although biomechanical and radiographic data suggest superiority of intramedullary implants, several prospective randomized studies have shown equivalence between intramedullary devices and sliding hip screws in the treatment of stable IT fractures in terms of clinical outcomes.[5–7] Intramedullary devices are more expensive than standard sliding hip screws;[8] however, intramedullary devices can be used in a wider variety of fracture patterns than sliding hip screws, such as reverse obliquity IT fractures.[9] With similar clinical outcomes and higher costs associated with intramedullary devices, many question the use of these implants when treating stable IT fractures.

Recently, Bohl et al[10] used the National Surgical Quality Improvement Program (NSQIP) database to compare 30-day outcomes between patients treated with intramedullary implants versus extramedullary implants. Their study evaluated more than 4,400 patients, yet they were unable to demonstrate a difference in short-term complications rates. However, the authors of this study excluded all patients younger than 70 years and only included 4 years of data. As the NSQIP database continues to grow, larger numbers of patients may help reveal previously unidentified differences between these two types of implants.

This study compares short-term outcomes between patients who received an extramedullary implant versus an intramedullary implant for an IT fracture in a large cohort of patients.