Long Versus Short Intramedullary Nails for Trochanteric Hip Fractures: A Secondary Analysis of the Insite Trial

We aimed to use data from a recent randomized controlled trial (RCT) comparing the sliding hip screw vs. intramedullary nailing for trochanteric fractures to examine complication rates between those managed with a short vs. long nail. This is a secondary analysis using one arm of an RCT that included ambulatory patients ³18 years with AO type 31-A1 or 31-A2 trochanteric fractures. We examined differences in fracture-related (femoral shaft fracture, implant failure, surgical site infection, nonunion, limb shortening, and pain) and medical adverse events (AE, organ failure, respiratory distress, stroke, deep vein thrombosis [DVT] gastrointestinal upset, pneumonia, myocardial infarction, sepsis, or urinary tract infection [UTI]), and readmission between those managed with a short vs. long IMN. We used logistic regression to examine the independent association between nail length and outcomes. We included 412 trochanteric fracture patients managed with an IMN. Of these, 339 (82.2%) received a short (170mm-200mm) nail, while 73 (17.7%) received a long (260mm-460 mm) nail. Patients managed with a short nail were more likely to be admitted from an institution (vs. home), while those managed with a long nail were more likely to have comorbidities, and more complex fracture types. Patients in the long nail group had higher rates of fracture-related AE (12.3%) vs. the short IMN group (3.5%). Specifically, the unadjusted rates of surgical site infection (SSI) and pain were significantly higher in the long group (SSI: 5.5%, pain: 2.7%) compared to the short group (SSI: 0.3%, pain: 0.0%). Similarly, patients in the long group were more likely to develop DVT (Long: 2.7%; Short: 0.3%), and readmitted to the hospital (Long: 28.8%; short: 20.7%). Following covariable adjustment, long nails remained independently associated with a higher odds of fracture-related AE (5.11, 1.96-13.33) compared to short nails. We found no association between the odds of readmission and nail length following covariable adjustment (1.00, 0.52-1.94). Our analyses revealed that trochanteric fracture patients managed with long IMN nails (260mm-460mm) may have a higher odds of fracture-related AE compared to short nails (170mm to 200mm). Future research is required to validate these findings with larger event rates, and further optimize IMN for trochanteric fracture patients.