There is ongoing debate regarding the preferential use of Intramedullary Nails as treatment for stable extracapsular fractures.

In this study we confirm that Intramedullary Nails are in fact associated with poorer rates of early mobilisation, longer length of stay and higher cost.

This study further supports the routine use of the Sliding Hip Screw for AO A1 and A2 extracapsular hip fractures.

Appropriate surgical management of hip fractures has major clinical and economic consequences. Recently Intramedullary nail (IMN) use has increased compared to Sliding Hip Screw (SHS) constructs, despite no clear evidence demonstrating superiority of outcome. We therefore set out to provide further evidence about the clinical and economic implications of implant choice when considering hip fracture fixation strategies.

A retrospective cohort study using Scottish hip fracture audit (SHFA) data was performed for the period 2016–2022. Patients ≥50 with a hip fracture and treated with IMN or SHS constructs at Scottish Hospitals were included. Comparative analyses, including adjustment for confounders. A sub-group analysis was also performed focusing on AO-A1/A2 fracture configurations. Cost differences in Length of Stay (LOS) were calculated using defined costs from the NHS Scotland Costs book.

There were 13,638 fractures (72 % female) identified which included 9867 (72 %) that received a SHS. No significant differences were identified in 30 or 60-day survival (Odds Ratio [OR] 1.05, 95 %CI 0.90–1.23; p = 0.532), (OR 1.10, 95 %CI 0.97–1.24; p = 0.138) between SHS and IMN, respectively. There was however a significantly lower early mobilisation rate with IMN (OR 0.64, 95 %CI 0.59–0.70; p < 0.001), and lower likelihood of discharge to domicile by day-30 post-admission (OR 0.77, 95 %CI 0.71–0.84; p < 0.001) compared to SHS. Acute and overall, LOS were significantly lower for SHS vs IMN (11 vs 12 days and 20 vs 24 days respectively; p < 0.001). Findings were similar across a sub-group analysis of 559 AO A1/A2 fracture configurations. Differences in LOS was associated with an increase cost of £1481 per-patient, irrespective of the higher implant costs of an IMN compared to a SHS.

Appropriate SHS use is associated with early mobilisation, reduced LOS and likely with reduced cost of treatment. Further research exploring potential reasons for the identified differences in early mobilisation are warranted.

Hip fracture

Nail

Sliding hip screw

Extracapsular

Elderly

Trauma

Geriatric

Proximal femur

Scottish hip fracture audit

Registry

© 2025 The Authors. Published by Elsevier Ltd.