Key messages
- There is no 'best treatment' for this type of broken hip.
- More people needed additional surgery on their broken hip after treatment with condylocephalic nails (where a nail is inserted upwards from the knee towards the hip joint) or static fixed angle plates (where pins or screws attach a plate to the broken bone).
- There may be no difference between a short cephalomedullary nail (where a nail is inserted downwards from the hip joint towards the knee) and a dynamic fixed angle plate (where the pins or screws attaching a plate to the broken bone are able to slide in a sleeve).
- We found too few studies to know whether any of these treatments were better at improving people's quality of life after surgery.
Hip fractures in older people
A hip fractures is a break at the top of the leg bone. There are two types of hip fractures; in this review, we included people with a break just outside the hip joint. The other type of hip fracture is a break just below the ball and socket joint - we reviewed these fractures in another review. Both types of broken hip are common in older adults whose bones may be fragile because of a condition called osteoporosis.
What are the treatments?
- Using metal implants to fix the broken parts of the bone. A nail is inserted inside the thigh bone. These long or short nails may be inserted downwards from the hip joint towards the knee (cephalomedullary nails). Some nails may be inserted upwards from the knee towards the hip joint (condylocephalic nail). Alternatively, the surgeon may use a 'fixed angle plate' which sits on the outer edge of the broken bone and is attached to the bone with screws or pins. Often the screws for these plates slide in a sleeve and the plate is called a dynamic fixed angle plate. Without this, it is a static fixed angle plate.
- Replacing the broken hip with an artificial one. This can be done using a hemiarthroplasty (HA), which replaces only the ball part of the joint, or with a total hip arthroplasty (THA) which replaces all of the hip joint including the socket.
- Using external fixation. Pins or screws are placed into the bones around the fracture and a metal frame holds these nails in place. The frame sits outside the body, around the broken hip.
- Treatment without an operation, usually requiring a period of rest in bed whilst the leg is held in position using traction with weights.
What did we do?
We searched for studies that compared one or more of these treatments. We wanted to find out the benefits and harms of these different treatments. We combined the findings from studies, and created a 'network' (which is used when researchers compare all available treatments in a single analysis called a 'network meta-analysis') to see if we could find out if some treatments were better than others.
What did we find?
We found 184 studies with 26,073 people who had this type of hip fracture. Most people were aged between 60 and 93 years, and 69% were women, which is usual for people with this type of broken bone. We included 73 of these studies in our 'network'.
We found little or no difference in how many people died with each treatment. We were not sure whether any of the treatments were better than another at reducing deaths within 12 months of surgery.
For most treatments, we also found little or no difference in whether people needed to have additional surgery on their broken hip. However, for the condylocephalic nail and the static fixed angle plate, more people needed additional surgery compared to people treated with a dynamic fixed angle plate. It seemed that these treatments increased the chance of needing additional surgery.
Very few studies reported whether or not people had better health-related quality of life after their treatment.
Are we confident in what we found?
We are not very confident in these findings because:
- most of the studies were not well reported. It is possible that their study methods could introduce errors in their results;
- we found some differences between some of the study results which we could not explain;
- we found some differences in the types of fractures in some studies;
- most treatments included the possibility of a benefit (for example, fewer deaths) as well as the possibility of a harm (for example, more deaths). This made the result very uncertain.
The true effects of these treatments might be very different to what we have found in this review.
How up to date is this review?
The evidence is up to date to July 2020.
Across the networks, we found that there was considerable variability in the ranking of each treatment such that there was no one outstanding, or subset of outstanding, superior treatments. However, static implants such as condylocephalic nails and static fixed angle plates did yield a higher risk of unplanned return to theatre. We had insufficient evidence to determine the effects of any treatments on HRQoL, and this review includes data for only two outcomes. More detailed pairwise comparisons of some of the included treatments are reported in other Cochrane Reviews in this series. Short cephalomedullary nails versus dynamic fixed angle plates contributed the most evidence to each network, and our findings indicate that there may be no difference between these treatments. These data included people with both stable and unstable extracapsular fractures. At this time, there are too few studies to draw any conclusions regarding the benefits or harms of arthroplasty or external fixation for extracapsular fracture in older adults.
Future research could focus on the benefits and harms of arthroplasty interventions compared with internal fixation using a dynamic implant.
Hip fractures are a major healthcare problem, presenting a challenge and burden to individuals and healthcare systems. The number of hip fractures globally is rising. The majority of extracapsular hip fractures are treated surgically.
To assess the relative effects (benefits and harms) of all surgical treatments used in the management of extracapsular hip fractures in older adults, using a network meta-analysis of randomised trials, and to generate a hierarchy of interventions according to their outcomes.
We searched CENTRAL, MEDLINE, Embase, Web of Science and five other databases in July 2020.
We included randomised controlled trials (RCTs) and quasi-RCTs comparing different treatments for fragility extracapsular hip fractures in older adults. We included internal and external fixation, arthroplasties and non-operative treatment. We excluded studies of hip fractures with specific pathologies other than osteoporosis or resulting from high-energy trauma.
Two review authors independently assessed studies for inclusion. One review author completed data extraction which was checked by a second review author. We collected data for three outcomes at different time points: mortality and health-related quality of life (HRQoL) - both reported within 4 months, at 12 months and after 24 months of surgery, and unplanned return to theatre (at end of study follow-up).
We performed a network meta-analysis (NMA) with Stata software, using frequentist methods, and calculated the differences between treatments using risk ratios (RRs) and standardised mean differences (SMDs) and their corresponding 95% confidence intervals (CIs). We also performed direct comparisons using the same codes.
We included 184 studies (160 RCTs and 24 quasi-RCTs) with 26,073 participants with 26,086 extracapsular hip fractures in the review. The mean age in most studies ranged from 60 to 93 years, and 69% were women.
After discussion with clinical experts, we selected nine nodes that represented the best balance between clinical plausibility and efficiency of the networks: fixed angle plate (dynamic and static), cephalomedullary nail (short and long), condylocephalic nail, external fixation, hemiarthroplasty, total hip arthroplasty (THA) and non-operative treatment. Seventy-three studies (with 11,126 participants) with data for at least two of these treatments contributed to the NMA.
We selected the dynamic fixed angle plate as a reference treatment against which other treatments were compared. This was a common treatment in the networks, providing a clinically appropriate comparison.
We downgraded the certainty of the evidence for serious and very serious risks of bias, and because some of the estimates included the possibility of transitivity owing to the proportion of stable and unstable fractures between treatment comparisons. We also downgraded if we noted evidence of inconsistency in direct or indirect estimates from which the network estimate was derived. Most estimates included the possibility of benefits and harms, and we downgraded the evidence for these treatments for imprecision.
Overall, 20.2% of participants who received the reference treatment had died by 12 months after surgery. We noted no evidence of any differences in mortality at this time point between the treatments compared. Effect estimates of all treatments included plausible benefits as well as harms. Short cephalomedullary nails had the narrowest confidence interval (CI), with 7 fewer deaths (26 fewer to 15 more) per 1000 participants, compared to the reference treatment (risk ratio (RR) 0.97, 95% CI 0.87 to 1.07). THA had the widest CI, with 62 fewer deaths (177 fewer to 610 more) per 1000 participants, compared to the reference treatment (RR 0.69, 95% CI 0.12 to 4.03). The certainty of the evidence for all treatments was low to very low. Although we ranked the treatments, this ranking should be interpreted cautiously because of the imprecision in all the network estimates for these treatments.
Overall, 4.3% of participants who received the reference treatment had unplanned return to theatre. Compared to this treatment, we found very low-certainty evidence that 58 more participants (14 to 137 more) per 1000 participants returned to theatre if they were treated with a static fixed angle plate (RR 2.48, 95% CI 1.36 to 4.50), and 91 more participants (37 to 182 more) per 1000 participants returned to theatre if treated with a condylocephalic nail (RR 3.33, 95% CI 1.95 to 5.68). We also found that these treatments were ranked as having the highest probability of unplanned return to theatre. In the remaining treatments, we noted no evidence of any differences in unplanned return to theatre, with effect estimates including benefits as well as harms. The certainty of the evidence for these other treatments ranged from low to very low.
We did not use GRADE to assess the certainty of the evidence for early mortality, but our findings were similar to those for 12-month mortality, with no evidence of any differences in treatments when compared to dynamic fixed angle plate. Very few studies reported HRQoL and we were unable to build networks from these studies and perform network meta-analysis.