Sliding Hip Screw has edge over Intramedullary Nailing for Trochanteric Fractures: INSITE trial

The insite trial found that sliding hip screws (SHSs) had similar one-year outcomes in terms of health-related quality of life, function, mobility, or revision surgery at 1-year post-surgery when compared to Intramedullary nails (IMN) and was more economical than IMN for trochanteric fracture fixation. The trial results were published in the journal JAMA Network Open. 

Hip Fractures have devastating effects on function and quality of life. Trochanteric hip fractures are extracapsular, with the fracture line between the greater and lesser trochanters. These fractures are surgically treated by intramedullary nail (IMN) fixation or extramedullary fixation with a sliding hip screw (SHS). IMNs are the dominant implant choice for the treatment of trochanteric fractures of the hip but are expensive. As it is debatable on any one fixation type researchers conducted a randomized clinical trial to evaluate the 1-year outcomes of patients with trochanteric fractures treated with the IMN vs an SHS. 

The trial was carried out at 25 international sites across 12 countries. Participants included ambulatory patients aged 18 years and older with low-energy trochanteric (AO Foundation and Orthopedic Trauma Association [AO/OTA] type 31-A1 or 31-A2) fractures. Patients were recruited between January 2012 and January 2016 and were followed up for 52 weeks till January 2017. Surgical fixation with a Gamma3 IMN or an SHS was carried out on all participants. The primary outcome was health-related quality of life (HRQOL), measured by the EuroQol–5 Dimension (EQ5D) at 1-year post-surgery. Secondary outcomes included revision surgical procedures, fracture healing, adverse events, patient mobility (measured by the Parker mobility score), and hip function (measured by the Harris hip score). 

Key findings: 

• About 850 patients with a mean [range] age of 78.5 [18-102] years (549 [64.6% female) with trochanteric fractures were randomized to undergo fixation with either the IMN (n = 423) or an SHS (n = 427).
• A total of 621 patients completed follow-up at 1 year post-surgery.
• Among the total 304 were treated with the IMN [71.9%], and 317 were treated with an SHS [74.2%]).
• No significant differences were found between groups in EQ5D scores. 
• No between-group differences were observed in EQ5D scores after adjusting for relevant covariables. 
• No between-group differences for any secondary outcomes were seen.
• There were also no significant interactions for fracture stability or previous fracture and treatment group. 

INSITE trial is one of the first large trials to compare the fracture fixation between IMN and SHS. The researchers concluded that IMN offered no significant benefits in HRQOL, revision surgical procedures, fracture healing rate, or adverse events at 1-year postoperative over SHS for trochanteric fractures. 

Further reading: Schemitsch EH, Nowak LL, Schulz AP, et al. Intramedullary Nailing vs Sliding Hip Screw in Trochanteric Fracture Management: The INSITE Randomized Clinical Trial. JAMA Netw Open. 2023;6(6):e2317164. doi: 10.1001/jamanetworkopen.2023.17164