Twenty studies (163 cases) were included in the analysis of treatment techniques and outcomes.
Conservative or closed treatment (skeletal traction and spica cast) tended to have high rates of complications due to malunions, compared to open treatment, as reflected in the classification of 10 patients as excellent or good and 5 patients as fair. Ender nails performed poorly compared to other internal fixation devices (5 patients classified as excellent or good, 2 patients as fair and 2 patients as poor), tending to fail to control fractures and malunions resulting in nonunions. Neither conservative treatment or ender nails are used widely.
The use of screw or screw plate fixation appeared effective for ipsilateral fractures, but complication rates for shaft fractures were comparatively high. Reoperations, malunions, nonunions and infections associated with shaft fractures underlie the classification of 8 patients as fair and 9 patients as poor, with 65 patients as excellent or good. Combinations of intramedullary nailing of the femoral shaft and screw or pin fixation of the femoral neck have been used where hip fractures were undiagnosed at nailing. Complications, such as reoperation, malalignments, nonunions, infections and avascular necrosis, show limited significant difference between intramedullary nailing with screw or pin fixation, and plate fixations (62 patients excellent or good, 6 patients fair and 5 patients poor).
Interlocking intramedullary nailing improves rotational stability and prevents shortening of comminuted fractures. Of the 48 patients with interlocking intramedullary nailing, 46 were classified as excellent or good and 2 as fair; the number of fair and poor patients was significantly fewer than for plate fixation (P=0.02) and marginally lower than for unlocked nails (P=0.1). Similarly, reoperations were less with locked nailing than after plate fixation (P=0.08) or unlocked nails (P=0.04). Used obliquely, the locked nail was associated with significantly higher complications (P=0.006) than regular locked nailing and separate hip screws (9 patients excellent or good, 2 patients fair and 2 patients poor). Cephalomedullary nailing, where screws slide in the hole of the nail, provide strength against bending. These second generation nails did not perform significantly differently to first generation locked nails (24 patients excellent or good and 1 patient fair). All forms of locked nails performed significantly better than plate fixation (P=0.004) or unlocked nailing (P=0.04).