Intramedullary nail versus arthroplasty: a prospective study for the treatment of borderline fractures of the upper femur

Introduction The ideal treatment of borderline fractures of upper femur is matter of scientific debate. This multicenter prospective study was carried out to evaluate the outcome of intramedullary (IM) nail versus arthroplasty in patients with borderline fractures of the proximal femur. Materials and methods We assessed 4- and 12-month mortality, walking ability, and activities of daily living (ADL scale) in 166 patients (42 males and 124 females; mean age 78.8 ± 10 years) who underwent IM nailing (100 cases) or arthroplasty (66 cases) for AO-ASIF 31B2.1 hip (52 cases) or AO-ASIF 31-A1.1 and 31-A1.2 trochanteric fracture (114 cases) between January 2010 and January 2012 at our departments. Models of linear and logistic multivariate analysis were constructed to evaluate the effect of the surgical treatment (IM nail or arthroplasty) on functional outcomes and mortality, adjusting the analysis for age, gender, type of fracture, co-morbidity (CIRS scale), cognitive functioning (MMSE), and pre-fracture functional level. Results The overall mortality at 1 month, 4 months, 12 months was 2.4, 10.8 and 15.7 %, respectively. Fifty-three percent of patients treated with IM nail and 36 % of those treated with prosthesis walked independently without aids 12 months after the fracture (p = 0.007). Forty-five percent of patients in both therapeutic groups obtained the maximum score on the ADL scale12 months after the fracture. At the multivariate analysis, arthroplasty was associated with higher 4-month (O.R. = 11.9; 95 %C.I. = 2.7–52.0) and 12-month (O.R. = 5.3; 95 % C.I. = 1.7–16.5) mortality and with poorer 12-month walking ability (c = -0.5; p = 0.006)when compared to IM nail.Negative effect of the age and of a poor pre-fracture cognitive and functional status on mortality and functional outcomes was also detected. The incidence of local complications and revisions was slightly higher in the IM nail compared to the arthroplasty group. Discussion This is the first prospective comparative study evaluating IM nailing versus arthroplasty for the treatment of borderline fractures of the proximal femur with the use of an expanded set of validated explanatory and outcome variables. Conclusions IM nail was superior to arthroplasty on 12-month mortality and walking ability.