Aims

The primary aim of this study was to compare surgical methods (sliding hip screw (SHS) vs intramedullary nailing (IMN)) for trochanteric hip fracture in relation to death within 120 days after surgery and return to independent living. The secondary aim was to assess whether the associations between surgical method and death or ability to return to independent living varied depending on fracture subtype or other patient characteristics.

Background: The treatment of trochanteric and subtrochanteric fractures is still controversial. In Norway the most commonly used implant for these fractures is the Sliding Hip Screw (SHS), with or without a trochanteric support plate. The Intertan nail (Smith & Nephew) has been launched as a nail with improved biomechanical properties for the treatment of these fractures, but so far it has not been shown that the clinical results are superior to the traditional Sliding Hip Screw. We wanted to investigate any differences in pain and function between the new Intertan nail and the Sliding Hip Screw in the early postoperative phase. Materials and Methods: 665 patients older than 60 years with a trochanteric or subtrochanteric fracture were randomized to either a SHS (CHS/DHS) or an Intertan nail in 5 hospitals. For practical reasons only 315 patients (47%) were evaluated at day 5 postoperatively (163 Intertan and 152 SHS), and these patients were used for our analysis. Pain was measured using a Visual Analog Scale (VAS), and early functional mobility by the “Timed Up and Go”- test (TUG-test). T-tests and chi-square tests were used to examine differences between the groups. Results: The average pain at rest was similar for the 2 groups (VAS 21). Pain at mobilization, however, differed, where patients operated with the Intertan nail had less pain than those operated with the SHS (VAS 47 vs. 53, p = 0.02). The difference between the implants was most pronounced for the simple two-part fractures (AO Type A1). More patients treated with the nail than with the SHS performed the TUG-test at day 5 (85/163 vs. 63/152, p = 0.06), but there was no statistically significant difference regarding the average speed the TUG-test was performed with (71 vs. 66sec, p = 0.36). The implant type did not influence the length of hospital stay. Discussion/Conclusion: Regarding early postoperative pain and function, there seems to be similar or better results for trochanteric and subtrochanteric fractures treated with the Intertan nail compared to the SHS. The difference in measured pain level was statistically significant, but may not be clinically significant (a difference of VAS 6). We could not detect any significant differences in terms of early functional mobility between the two implants. In our opinion it still remains to show good long-term results and acceptable complication rates before the new Intertan nail is widely taken into use. Due to the additional costs for the Intertan nail also economic aspects should be considered when choosing the implant and operative method for these fractures

The Sliding Hip Screw (SHS) is currently the treatment of choice for all trochanteric hip fractures. An alternative treatment is the short femoral nail. Earlier designs of these nails were associated with an increased fracture healing complication rate in comparison to the sliding hip screw. The new designs of nails (third generation nails) may however be as good as or even superior to sliding hip screw fixation. We conducted a large randomised trial to compare the Targon Proximal Femoral Nail with the Sliding Hip Screw. Patients with trochanteric hip fractures as per the AO classification (A1–A3) were randomised to either implant. All surgery was supervised by one surgeon. All patients were followed up for a minimum of one year months by a blinded observer. The mean age was 82 years, range 27 to 104 years), 20% were male. Length of surgery was slightly increased for the nail (44 versus 49 minutes, p=0.002). Fluoroscopic screening time was increased in the nail group (0.3 versus 0.6 minutes, p< 0.0001). Intra-operative complications were more common with the nailing. There was no difference in blood transfusion requirement between groups. Postoperatively there was no difference in the occurrence of medical complications or mortality. Deep wound infection requiring removal of the implant occurred in one case in the SHS group. In addition there were two cases of cut-out, three of plate detachment from the femur and one non-union in the SHS group, requiring secondary surgery. There was only one compilation in the nailed a case of cut-out which required secondary surgery. At follow-up no difference in pain scores but there was a tendency to improved mobility in the nailed group (p=0.004). These results suggest that with improved designs and surgical technique, the newer versions of short nails for proximal femoral fractures may not suffer from the complications of the earlier short intramedullary nails. Intramedullary fixation can result in a lower re-operation rate (3.5% versus 0.5%) and improved mobility in comparison to the sliding hip screw

400 patients with a trochanteric hip fracture were randomised to fixation with either a 220mm long Targon PF (proximal femoral) nail or a Sliding Hip Screw. All surgery was undertaken or supervised by one surgeon. All patients were followed up for a minimum of one year by a blinded observer. The mean age was 82 years (range 27 to 104 years), 20% were male. Mean length of surgery was slightly increased for the nail (44 versus 49 minutes, p=0.002). Fluoroscopic screening time was increased in the nail group (0.3 versus 0.6 minutes, p< 0.0001). Intra-operative complications were more common with the nailing. There was no difference in blood transfusion requirement between groups. Postoperatively there was no difference in the occurrence of medical complications or mortality. Deep wound infection requiring removal of the implant occurred in one case in the SHS group. In addition there were two cases of cut-out, three of plate detachment from the femur and one non-union in the SHS group, requiring secondary surgery. There were only once compilations in the nailed a case of cut-out which required secondary surgery. At follow-up there was no difference in pain scores between groups but there was a tendency to improved mobility in the nailed group (p=0.004). These results suggest that with improved designs and surgical technique, the newer versions of short nails for proximal femoral fractures may not suffer from the complications of the earlier short intramedullary nails. Intramedullary fixation can result in a lower re-operation rate (3.5% versus 0.5%) and improved mobility in comparison to the sliding hip screw

Extracapsular Hip Fractures (EHF's) are a significant health burden on healthcare services. Optimal treatment is controversial with conflicting evidence being reported. Currently treatment is undertaken with Intramedullary Nail (IMN) or Dynamic Hip Screw (DHS) constructs with a recent increase in IMN use (1). This study aims to conduct a systematic review of Randomised Control Trials published between 2020 and 2023 with particular focus on patient demographics and holistic patient outcomes.

Using a unified search-protocol, RCT's published between 2020 and 2023 were collected from CENTRAL, PubMed, MEDLINE and EMBASE. Rayyan software screened duplicates. Using the CASP and Cochrane Risk of Bias Tool papers were critically examined twice, and Blood Loss, Infection and Mobility described the patient journey. Patient demographics were recorded and were contrasted with geographically diverse cohort studies to compare population differences. Parametric tests were used to determine significance levels between population demographics, namely Age and Sex.

Eleven papers were included, representing 908 patients (436 Male). The mean age for patients was 64.39. There was considerable risk of bias in 7/11 studies owing to the randomization process and the recording of data. Four Cohort studies were selected for comparison representing 14314 patients. Mean age was significantly different between Cohort Studies and RCT's (Independent T-Test, df 13, t=7.8, p = <0.001, mean difference = 19.251, 95% CI = 13.888, 24.613). This was also true for sex ratios included in the studies (df 13, t = -2.268, p = 0.024, Mean Difference = -0.4884, 95% CI = -0.9702, -0.0066).

To conclude, RCT's published in the post COVID-19 era are not representative of patient demographics. This has the potential to provide inaccurate information for implant selection. Additionally further research must be conducted in how to better improve RCT patient inclusion so as to be more representative of patients whilst balancing the risks of operations.

Background: Hip fractures are common among the aged population, with high mortality and morbidity rates. It ‘s annual cost in the United States is expected to double by the year 2040 to about 16 billion U.S Dollars. Of those, approximately 50% are inter-trochanteric fractures. Among them, 50 to 60% are categorized as unstable fractures. Unstable intertrochanteric fractures are defined as 1) fractures with comminution of the posteromedial buttress which exceeds a simple lesser trochanteric fragment; 2) fractures with evidence of subtrochanteric fracture lines; and 3) reverse oblique fractures of the femoral neck. Review of the literature reveals large variations in the amount of complications after surgical treatment of unstable intertrochanteric fractures, among various medial institutes. Infection rates winds from fewer than 1% and up to 15% of cases, and reports of cutout events range from % to 20%. Other complications, such as non-unioin, femoral shaft fractures, and painful hardware, are much less common.

Purpose: To investigate the rate of complications after surgical treatment of unstable inter-trochanteric fractures, in our department.

Method: Retrospective review of 61 patients who were admitted in our department due to unstable intertro-chanteric fractures, after simple falls, between May 2001 to August 2006, and were treated with intramedullary sliding hip screw. Most of the hardware (90%) were A.O nails (PFN, proximal femoral nail).

Results: There were 4 cases of infections, which are 4.9% of cases. Three of them required removal of the hardware. One admission was due to superficial surgical wound infection. There were 3 cases of mechanical cutout of the femoral head screw, which are 6.5% of the cases. No cases of non-union, femoral shaft fractures, or painful hard are noted.

Conclusions: To our experience, intramedullary sliding hip screw is a safe and effective treatment for unstable intertrochanteric fractures. Complication rates to our experience are at the lower third compared to reports from medical institutes over the world.

Background

Intracapsular neck of femur fractures are one of the most common injuries seen in Orthopaedics. When the fracture is amenable to internal fixation there are 2 main treatment options, namely multiple cannulated hip screws (MCS) and 2-hole sliding hip screws (SHS). In this retrospective study we examine the outcomes associated with these two methods of internal fixation. At present there is little consensus regarding which treatment should be used

Appropriate surgical management of hip fractures has major clinical and economic consequences. Recently IMN use has increased compared to SHS constructs, despite no clear evidence demonstrating superiority of outcome. We therefore set out to provide further evidence about the clinical and economic implications of implant choice when considering hip fracture fixation strategies.

A retrospective cohort study using Scottish hip fracture audit (SHFA) data was performed for the period 2016–2022. Patients ≥50 with a hip fracture and treated with IMN or SHS constructs at Scottish Hospitals were included. Comparative analyses, including adjustment for confounders, were performed utilising Multivariable logistic regression for dichotomous outcomes and Mann-Whitney-U tests for non-parametric data. A sub-group analysis was also performed focusing on AO-A1/A2 configurations which utilised additional regional data. Cost differences in Length of Stay (LOS) were calculated using defined costs from the NHS Scotland Costs book. In all analyses p<0.05 denoted significance.

13638 records were included (72% female). 9867 received a SHS (72%).

No significant differences were identified in 30 or 60-day survival (Odds Ratio [OR] 1.05, 95%CI 0.90–1.23; p=0.532), (OR 1.10, 95%CI 0.97–1.24; p=0.138) between SHS and IMN's.

There was however a significantly lower early mobilisation rate with IMN vs SHS (OR 0.64, 95%CI 0.59–0.70; p<0.001), and lower likelihood of discharge to domicile by day-30 post-admission (OR 0.77, 95%CI 0.71–0.84; p<0.001). Acute and overall, LOS were significantly lower for SHS vs IMN (11 vs 12 days and 20 vs 24 days respectively; p<0.001). Findings were similar across a sub-group analysis of 559 AO A1/A2 fracture configurations.

Differences in LOS potentially increases costs by £1230 per-patient, irrespective of the higher costs of IMN's v SHS.

Appropriate SHS use is associated with early mobilisation, reduced LOS and likely with reduced cost of treatment. Further research exploring potential reasons for the identified differences in early mobilisation are warranted.

Purpose: The results of surgical treatment of intertrochanteric hip fractures using a sliding hip screw-plate and Norian-SRS, as an adjuvant means of stabilization, are presented.

Material – Methods: 103 patients (27 male, 76 female) with intertrochanteric hip fractures, were treated with a sliding hip screw. Their age ranged from 56 to93 years (av. 68,9y) . In group A (50 patients) we only used a sliding hip screw -plate, while in group B ( 53 patients) we also used Norian-SRS above the upper surface of the sliding hip screw.

Results: Postoperative follow-up ranged from 5 to17 μnνϵς. Mobilization was initiated on the 2nd day with partial weight bearing. A group progressed to full weight bearing in 3 , while B group in 2 months. 8 patients in group A and 2 in group B developed varous deformity. Screw cut out developed in 5 patient of group A and none of group B. Backsliding of the screw ranged from 0 to 16 mm. (av. 4,95 mm.) in group A and from 0 to16mm. (av. 3,25mm.) in group B.

Conclusion: Norian-SRS augmentation of intertrochanteric hip fractures treated with a sliding hip screw-plate, increases the stability of the osteosynthesis, permitting earlier rehabilitation and mobilization of the patient and leading to better functional results.

Controversy exists whether to treat unstable pertrochanteric hip fractures with either intramedullary or extramedullary devices. A prospective randomised control trial was performed to compare the outcome of unstable pertrochanteric hip fractures stabilised with either a sliding hip screw (SHS) or Long Gamma Nail (LGN). The hypothesis was that there is no difference in outcome between the two modes of treatment.

Over a four year period, 210 patients presenting with an unstable pertrochanteric hip fracture (AO/OTA 31 A2.1/A2.2/A2.3) were recruited into the study. Eligible patients were randomised on admission to either LGN or SHS. Follow-up was arranged for three, six, and twelve months. Primary outcome measures were implant failure and implant ‘cut-out’. Secondary measures included mortality, length of hospital stay, and EuroQol outcome score.

Five patients required revision surgery for implant cutout, of which three were LGNs and two were SHSs (no significant difference). There was a significant correlation between tip apex distance and the need for revision surgery. There were no incidences of implant failure or deep infection. Mortality rates between the two groups were similar when corrected for mini mental score. There was no difference between the two groups with respect to tip apex distance, hospital length of stay, blood transfusion requirement, and EuroQol outcome score.

The sliding hip screw remains the gold standard in the treatment of unstable pertrochanteric fractures of the proximal femur.

Background: The majority of extracapsular proximal femoral fractures are treated with a sliding hip screw. The barrel of the plate can slide over the shaft of the screw in two modes; keyed (locked) or unkeyed (unlocked). The purpose of the study was to determine whether there is a difference in outcome following fixation using a sliding hip screw in the locked and unlocked modes.

Methods: A prospective randomised controlled trial of patients requiring a sliding hip screw for a proximal femoral fracture. Patients were randomised to receive a sliding hip screw either in the locked or unlocked mode. 20 patients were randomised to each group. Patients were assessed clinically and radiologically post-operatively and at three months following discharge from hospital. Screw slide and fixation failure were used as primary outcomes. A Visual analogue scoring system (VAS) was used to assess pain.

Results: A total of 40 patients were recruited in this study. The mean age of patients in the locked group was 74.05 years (range 55–90) and 78.0 years (range 65–97) in the unlocked group. There was one case of fixation failure in the locked group compared to two in the unlocked group. The mean screw slide was 10.98mm (range 1.04–37.62) in the locked group and 12.94mm (range 1.91–20.82) in the unlocked group. The pain score according to the VAS improved over the three months. There was no significant difference in pain score between the two groups.

Conclusion: When comparing screw slide, fixation failure and pain, the results show there is no significant difference between using the sliding hip screw in the locked and unlocked mode.

Hip fracture is a common serious injury in the elderly. Between 1982 and 1998 the number of hip fractures reported annually in Scotland in patients over 55 years rose from 4,000 to 5,700. The optimum method of treatment for the various fracture types remains in contention.

We compare outcome measures between displaced, intracapsular fractures in patients over 70 years fixed with cannulated screws and sliding hip screw with side plate.

Between 1998 and 2005 a total of 30,482 patients were reviewed by the Scottish Hip Fracture Audit (SHFA). Of these 15,823(53.3% of the total) had sustained intracapsular fractures. 13,587 of these occurred in patients aged 70 or over. Of these 2,428 had undisplaced and 11,159 displaced fractures. Chi test statistical analysis compare outcome measures in this group of displaced intracapsular fractures with respect to aspects of early failure.

534(3.9%) of patients were treated conservatively. 509 (4.7%) fractures were fixed using cannulated screws and 499 (4.6%) using a sliding hip screw. Readmission within 120 days for any cause occurred in 62 patients(14.1%) treated with cannulated screw fixation and in 63 patients(15.7%) for those treated with a sliding hip screw(P=0.509). Of these 36 patients(8.2%) in the former and 23 patients(5.7%) in the latter group were readmitted for complications related to hip fracture(P=0.033). Mortality within this period included 69 patients(13.5%) in the CS and 98(19.6%) in the SHS group. In terms of re-operation within 120 days of the original admission, 53 patients(10.6%) receiving cannulated screws compared to 24 patients(4.8%) treated with a sliding hip screw requiring further surgery(P=0.0006). The fracture was seen to displace in 12(22.6%) patients originally treated with cannulated screws compared to 6 patients(25%) treated with sliding hip screw(P=0.156). More significantly the fixation device was seen to have migrated in 24(45.3%) of the cannulated screw as compared to 7(29.2%) patients in the sliding hip screw group(P=0.002). Periprosthetic fractures were recorded in 4(7.5%) of the former and 3(12.5%) in the latter group(P=0.708). Wound infection was higher in the SHS group(2 patients) as compared to the screw fixation group(1 patient)(P=0.565).

Statistical analysis demonstrates a dramatic difference exists between these 2 fixation types in terms of re-operation within 120 days of the original admission for which published literature has previously only recorded biomechanical, in vitro comparisons.

Data regarding specific implant factors such as number of screws, position, configuration, starting point, thread length and use of washers in cannulated screws, and position, tapping, supplementary screw and compression screw in sliding hip screws was not recorded and may be considered to bias our results.

Background: The majority of extracapsular proximal femoral fractures are treated with a sliding hip screw. The barrel of the plate can slide over the shaft of the screw in two modes; keyed (locked) or unkeyed (unlocked). The purpose of the study was to determine whether there is a difference in outcome following þxation using a sliding hip screw in the locked and unlocked modes.

Methods: A prospective randomised controlled trial of patients requiring a sliding hip screw for a proximal femoral fracture. Patients were randomised to receive a sliding hip screw either in the locked or unlocked mode. 20 patients were randomised to each group. Patients were assessed clinically and radiologically post-operatively and at three months following discharge from hospital. Screw slide and þxation failure were used as primary outcomes. A Visual analogue scoring system (VAS) was used to assess pain.

Results: 40 patients were recruited in this study. Mean age of patients in the locked group was 74.05 years (range 55–90) and 78.0 years (range 65–97) in the unlocked group. There was one case of þxation failure in the locked group compared to two in the unlocked group. The mean screw slide was 10.98mm (range 1.04–37.62) in the locked group and 12.94mm (range 1.91–20.82) in the unlocked group. The pain score according to the VAS improved over the three months. There was no signiþcant difference in pain score between the two groups.

Conclusion:When comparing screw slide, þxation failure and pain, the results show there is no signiþcant difference between using the sliding hip screw in the locked and unlocked mode.

Background: The most commonly used implant for the internal fixation of an extracapsular proximal femoral fracture is a sliding hip screw (SHS). More recently short intramedullary nails (IMN) have been advocated as an alternative, particularly for unstable fractures due to possible biomechanical advantages. The purpose of this meta-analysis was to compare, on the basis of evidence from randomised controlled trials, the fixation outcome with these two types of implant in stable and unstable fractures

Method: All randomised controlled studies comparing intramedullary nails with a SHS were considered for inclusion. Studies were identified using the search strategy of the Cochrane Collaboration, with no restriction on languages or source. Two authors independently extracted the data, and assessed trial methodology.

Results: 24 randomised trials involving 3202 patients with 3279 fractures were included in the analysis. Pooled results gave no statistically significant difference in the cut-out rate between the IMN or SHS 41/1556 and 37/1626 (Relative risk 1.19; 95% confidence interval 0.78 to 1.82). There was an increased total failure rate (103/1495 and 58/1565, Relative risk 1.83; 95% confidence interval 1.35 to 2.50) and re-operation rate (57/1357 and 35/1415, Relative risk 1.63; 95% confidence interval 1.11 to 2.40) with the IMN compared the SHS when all fractures were considered. Fracture healing complications were much less frequent for stable fractures. No evidence for a reduced failure rate for IMN’s in unstable fractures patterns could be found.

Conclusions: The results from studies to date indicate an increased fixation failure rate for trochanteric fractures fixed with an intramedullary nail, and show no benefit to the use of a nail in unstable fractures. Therefore the use of intramedullary nails for trochanteric fractures cannot be recommended.

Controversy exists whether to treat unstable pertrochanteric hip fractures with either intra-medullary or extra-medullary devices. A prospective randomised control trial was performed to compare the outcome of unstable pertrochanteric hip fractures stabilised with either a sliding hip screw or long Gamma Nail. The hypothesis was that there is no difference in outcome between the two modes of treatment.

Over a four year period, 210 patients presenting with an unstable pertrochanteric hip fracture (AO/OTA 31 A2) were recruited into the study. Eligible patients were randomised on admission to either long Gamma Nail or sliding hip screw. Follow-up was arranged for three, six, and twelve months. Primary outcome measures were implant failure or ‘cut-out’. Secondary measures included mortality, length of hospital stay, transfusion rate, change in mobility and residence, and EuroQol outcome score.

Five patients required revision surgery for implant cut-out (2.5%), of which three were long Gamma Nails and two were sliding hip screws (no significant difference). There were no incidences of implant failure or deep infection. Tip apex distance was found to correlate with implant cut-out. There was no statistically significant difference in either the EuroQol outcome scores or mortality rates between the two groups when corrected for mini mental score. There was no difference in transfusion rates, length of hospital stay, and change in mobility or residence. There was a clear cost difference between the implants.

The sliding hip screw remains the gold standard in the treatment of unstable pertrochanteric fractures of the proximal femur.

Purpose: To compare failure rates, and patient functional outcomes, using the Dynamic Hip Screw (DHS) and Medoff Sliding Plate (MSP) for unstable intertrochanteric hip fractures.

Method: One hundred and sixty three consecutive patients with unstable intertrochanteric hip fractures, from three hospitals, were prospectively randomized to DHS or MSP. Inclusion and exclusion criteria were designed to focus on isolated unstable intertrochanteric hip fractures in ambulatory patients over age 60, without previous hip fractures or significant subtrochanteric extension. Patients were stratified by mental status and treating hospital. Randomization was performed intra operatively, after placement of a 135 degree guide wire. Follow up assessments were performed at regular intervals for a minimum of six months. The primary outcome was re-operation rate. The secondary outcome was patient function, using a validated outcome measure, the Hip Fracture Functional Recovery Score. Tertiary outcomes included: mortality, hospital stay, quality of reduction and mal union rate.

Results: 86 patients were randomized to DHS and 76 to MSP. The groups had similar patient demographics and pre fracture status (medical and functional). The patients had similar hospital course except there were more transfusions in the MSP group (2 vs. 1 unit). The quality of reduction was the same for each group but the operative time was longer in the MSP group (61 vs. 50 min). The rate of re-operation was low (3/86 in DHS and 2/76 in MSP) with no statistically significant difference. The indication for re-operation differed for the two groups as all three failures in the DHS group were related to screw cut out and both failures in the MSP arm were because of non union. The functional outcomes were the same for both groups with functional recovery scores at six months of 51% in the DHS arm and 49% in the MSP arm.

Conclusion: The two techniques produced similar results for the clinically important outcomes of the need for further surgery and functional status of the patients. For this challenging sub group of hip fractures, based on the equivalent results in this study either implant is a reasonable choice.

Introduction

The treatment of trochanteric and subtrochanteric fractures remains controversial, and new implants are constantly being developed trying to improve outcome and minimize the number of complications in these fractures.

In Norway the Sliding Hip Screw(SHS), with or without a Trochanteric Stabilizing Plate (TSP), is still the most commonly used implant, but worldwide nailing of these fractures is increasing. This trend, however, has not been supported by documentation of better clinical results compared to the SHS in well designed studies. Therefore, in the present study we compared the recently launched Trigen Intertan nail (Smith and Nephew) with the SHS in the treatment of trochanteric and subtrochanteric fractures.

Aims

Patients with A1 and A2 trochanteric hip fractures represent a substantial proportion of trauma caseload, and national guidelines recommend that sliding hip screws (SHS) should be used for these injuries. Despite this, intramedullary nails (IMNs) are routinely implanted in many hospitals, at extra cost and with unproven patient outcome benefit. We have used data from the National Hip Fracture Database (NHFD) to examine the use of SHS and IMN for A1 and A2 hip fractures at a national level, and to define the cost implications of management decisions that run counter to national guidelines.

Objectives. The Sliding Hip Screw (SHS) is commonly used to treat trochanteric hip fractures. Fixation failure is a devastating complication requiring complex revision surgery. One mode of fixation failure is lag screw cut-out which is greatest in unstable fracture patterns and when the tip-apex distance of the lag screw is > 25 mm. The X-Bolt Dynamic Hip Plating System (X-Bolt Orthopaedics, Dublin, Ireland) is a new device which aims to reduce this risk of cut-out. However, some surgeons have reported difficulty minimising the tip-apex distance with subsequent concerns that this may lead to an increased risk of cut-out. Patients and Methods. We measured the tip-apex distance from the intra-operative radiographs of 93 unstable trochanteric hip fractures enrolled in a randomised controlled trial (Warwick Hip Trauma Evaluation, WHiTE One trial). Participants were treated with either the sliding hip screw or the X-Bolt dynamic hip plating system. We also recorded the incidence of cut-out in both groups, at a median follow-up time of 17 months. Results. There was a significantly increased tip-apex distance with the use of the X-Bolt (mean difference 3.7mm (95% confidence interval 1.58 to 5.73); SHS mean 17.1 mm, X-Bolt mean 20.8; p = 0.001. However, this was not associated with an increased incidence of cut-out at a median follow-up time of 17 months, with three cut-outs (6%) in the SHS group and 0 (0%) in the X-Bolt group. Conclusion. The X-Bolt is a safe implant with no increased risk for cut-out. Concerns about minimising the tip-apex distance may be justified but do not appear to be clinically important. Cite this article: M. A. Fernandez, A. Aquilina, J. Achten, N. Parsons, M. L. Costa, X. L. Griffin. The tip-apex distance in the X-Bolt dynamic plating system. Bone Joint Res 2017;6:–207. DOI: 10.1302/2046-3758.64.BJR-2015-0016.R2

Fractures of the proximal femur at the level of the lesser trochanter (reversed and transverse fracture lines, Evans classification type II, AO classification 31. A3 fractures) are known to have an increased risk of fixation failure. 53 patients with such a fracture were randomised to have the fracture fixed with either an intramedullary nail (220 mm Targon Proximal Femoral nail) or a Sliding Hip Screw (SHS). The mean age of the patients was 82 and 11% were male. All patients were followed up for one year by a research nurse blinded to the treatment groups. Mean length of surgery was 51 minutes for the nail versus 53 minutes for the SHS. There were no differences between groups in the need for blood transfusion. Operative complications tended to be less for the nail group (1/27 versus 5/26). Mean hospital stay was 17 days for the nail group versus 29 days for those treated with the SHS (p< 0.0001). The only fracture healing complications were one case of cut-out in each group requiring revision surgery. During follow-up those patient treated with the nail reported significantly lower pain scores than those treated with the SHS (p=0.08). This difference persisted even at one year from injury. In addition there was a tendency to a better regain of mobility in the first nine months from injury for those treated with the nail. These results indicate that for these difficult fractures types an intramedullary nails produces superior results to the Sliding Hip Screw