Convergence of Outcomes for Hip Fracture Fixation by Nails and Plates

Recent popularity of intramedullary nails over sliding hip screws for treatment of intertrochanteric fractures is concerning given the absence of evidence for clinical superiority for nailing yet the presence of reimbursement differences. We describe the change in outcomes of both procedures across a 15-year span and address the role of reimbursements in the setting of shifting patterns in use. A 5% sample of Medicare enrollees from 1993 to 2007 was used. Cohorts were generated along diagnostic and procedure codes. Trends in device use by hospital type, surgical times, and rate of revision surgeries were compared. Historic reimbursements were examined. Since 2005, intramedullary nail fixation has become the more common treatment in government, nonprofit, and for-profit hospitals. Before 1999, intramedullary nailing required 36 minutes longer to perform than plate-and-screw fixation on average, and had higher revision surgery rates (hazard ratio, 2.48; CI, 1.37-4.48) and 1-year mortality (hazard ratio, 1.42; CI, 1.01-1.99). These differences were not significant since 2000. Reimbursement differences have been consistently in favor of intramedullary nails. Intramedullary nailing of intertrochanteric fractures has become as safe and efficient as the sliding hip screws, but has been more popular since 2006. Reimbursements were favorable for intramedullary nails in times of low and high use. These results argue against the reimbursement difference as the sole driving force for use of intramedullary nails. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.