Are cephalomedullary interlocking screws superior to standard interlocking screws in subtrochanteric femoral fractures with an intact lesser trochanter?

Background: Subtrochanteric femoral fractures often are treated with cephalomedullary nails, but standard intramedullary nails may be sufficient to treat many subtrochanteric femoral fractures. We hypothesized that standard intramedullary nailing of subtrochanteric femoral fractures with an intact lesser trochanter is not inferior to cephalomedullary nailing. Methods: We performed a retrospective analysis of patients treated with an intramedullary device for a proximal femoral fracture within 5 cm of the lesser trochanter between January 1, 2011 and December 31, 2013. We compared standard and cephalomedullary nails with regards to fracture union, nonunion, and alignment. Exclusion criteria included comminution involving the lesser trochanter, intertrochanteric fractures, use of a plate, or pathologic fractures. Results: Fifty patients with 52 subtrochanteric femoral fractures met the inclusion criteria, with 39 men and 11 women. Thirteen fractures were treated with a standard, locked intramedullary nail, of which nine had adequate follow-up (69%). All nine fractures healed uneventfully. Thirty-nine fractures were treated with a cephalomedullary nail in 38 patients, of which 30 had adequate follow-up (77%). There were two nonunions that required revision surgery (5%) in the cephalomedullary group. There was no statistically significant difference between the two groups with respect to fracture union, nonunion, or revision surgery (P=0.59 Fisher Exact Test). Conclusions: Subtrochanteric femoral fractures with an intact lesser trochanter can be successfully treated with standard locking nails. This study is underpowered to determine if standard locking or cephalomedullary locking is superior to the other, but all failures occurred in the cephalomedullary group.