Intramedullary nail versus extramedullary plate fixation for unstable intertrochanteric fractures: decision analysis

The best options of internal fixation for unstable intertrochanteric femoral fractures in elderly osteoporotic patients remain controversial. We determined whether intramedullary nail or extramedullary plate provides better treatment for unstable intertrochanteric fractures using a decision analysis tool that considers quality of life. A decision analysis model was constructed containing final outcome score and the probability of mortality within 1 year, infection, and mechanical complications. Final outcome was defined as health-related quality of life and was used as a utility in the decision tree. Probabilities were obtained by literature review, and health-related quality of life was evaluated by asking 30 orthopedic experts to complete a questionnaire. A roll back tool was used to determine the best surgical option, and sensitivity analysis was performed to compensate for decision model uncertainty. The decision model favored intramedullary nailing in terms of quality of life. In one-way sensitivity analysis, intramedullary nailing was more beneficial than the extramedullary plating, when probability of mechanical complication after intramedullary nailing was below 0.258. In terms of quality of life, the decision analysis model showed that intramedullary nailing was more beneficial for patients with an unstable intertrochanteric fracture.