Surgical interventions for treating extracapsular hip fractures in older adults: a network meta‐analysis

Sharon R Lewis; Richard Macey; Joseph Lewis; Jamie Stokes; James R Gill; Jonathan A Cook; William GP Eardley; Martyn J Parker; Xavier L Griffin

doi:10.1002/14651858.CD013405.pub2

. 2022 Feb 10;2022(2):CD013405. doi: 10.1002/14651858.CD013405.pub2

Surgical interventions for treating extracapsular hip fractures in older adults: a network meta‐analysis

Sharon R Lewis ^1,^✉, Richard Macey ², Joseph Lewis ³, Jamie Stokes ⁴, James R Gill ⁵, Jonathan A Cook ⁴, William GP Eardley ⁶, Martyn J Parker ⁷, Xavier L Griffin ^1,⁸

Editor: Cochrane Bone, Joint and Muscle Trauma Group

PMCID: PMC8830342 PMID: 35142366

Abstract

Background

Hip fractures are a major healthcare problem, presenting a challenge and burden to individuals and healthcare systems. The number of hip fractures globally is rising. The majority of extracapsular hip fractures are treated surgically.

Objectives

To assess the relative effects (benefits and harms) of all surgical treatments used in the management of extracapsular hip fractures in older adults, using a network meta‐analysis of randomised trials, and to generate a hierarchy of interventions according to their outcomes.

Search methods

We searched CENTRAL, MEDLINE, Embase, Web of Science and five other databases in July 2020.

Selection criteria

We included randomised controlled trials (RCTs) and quasi‐RCTs comparing different treatments for fragility extracapsular hip fractures in older adults. We included internal and external fixation, arthroplasties and non‐operative treatment. We excluded studies of hip fractures with specific pathologies other than osteoporosis or resulting from high‐energy trauma.

Data collection and analysis

Two review authors independently assessed studies for inclusion. One review author completed data extraction which was checked by a second review author. We collected data for three outcomes at different time points: mortality and health‐related quality of life (HRQoL) ‐ both reported within 4 months, at 12 months and after 24 months of surgery, and unplanned return to theatre (at end of study follow‐up).

We performed a network meta‐analysis (NMA) with Stata software, using frequentist methods, and calculated the differences between treatments using risk ratios (RRs) and standardised mean differences (SMDs) and their corresponding 95% confidence intervals (CIs). We also performed direct comparisons using the same codes.

Main results

We included 184 studies (160 RCTs and 24 quasi‐RCTs) with 26,073 participants with 26,086 extracapsular hip fractures in the review. The mean age in most studies ranged from 60 to 93 years, and 69% were women.

After discussion with clinical experts, we selected nine nodes that represented the best balance between clinical plausibility and efficiency of the networks: fixed angle plate (dynamic and static), cephalomedullary nail (short and long), condylocephalic nail, external fixation, hemiarthroplasty, total hip arthroplasty (THA) and non‐operative treatment. Seventy‐three studies (with 11,126 participants) with data for at least two of these treatments contributed to the NMA.

We selected the dynamic fixed angle plate as a reference treatment against which other treatments were compared. This was a common treatment in the networks, providing a clinically appropriate comparison.

We downgraded the certainty of the evidence for serious and very serious risks of bias, and because some of the estimates included the possibility of transitivity owing to the proportion of stable and unstable fractures between treatment comparisons. We also downgraded if we noted evidence of inconsistency in direct or indirect estimates from which the network estimate was derived. Most estimates included the possibility of benefits and harms, and we downgraded the evidence for these treatments for imprecision.

Overall, 20.2% of participants who received the reference treatment had died by 12 months after surgery. We noted no evidence of any differences in mortality at this time point between the treatments compared. Effect estimates of all treatments included plausible benefits as well as harms. Short cephalomedullary nails had the narrowest confidence interval (CI), with 7 fewer deaths (26 fewer to 15 more) per 1000 participants, compared to the reference treatment (risk ratio (RR) 0.97, 95% CI 0.87 to 1.07). THA had the widest CI, with 62 fewer deaths (177 fewer to 610 more) per 1000 participants, compared to the reference treatment (RR 0.69, 95% CI 0.12 to 4.03). The certainty of the evidence for all treatments was low to very low. Although we ranked the treatments, this ranking should be interpreted cautiously because of the imprecision in all the network estimates for these treatments.

Overall, 4.3% of participants who received the reference treatment had unplanned return to theatre. Compared to this treatment, we found very low‐certainty evidence that 58 more participants (14 to 137 more) per 1000 participants returned to theatre if they were treated with a static fixed angle plate (RR 2.48, 95% CI 1.36 to 4.50), and 91 more participants (37 to 182 more) per 1000 participants returned to theatre if treated with a condylocephalic nail (RR 3.33, 95% CI 1.95 to 5.68). We also found that these treatments were ranked as having the highest probability of unplanned return to theatre. In the remaining treatments, we noted no evidence of any differences in unplanned return to theatre, with effect estimates including benefits as well as harms. The certainty of the evidence for these other treatments ranged from low to very low.

We did not use GRADE to assess the certainty of the evidence for early mortality, but our findings were similar to those for 12‐month mortality, with no evidence of any differences in treatments when compared to dynamic fixed angle plate. Very few studies reported HRQoL and we were unable to build networks from these studies and perform network meta‐analysis.

Authors' conclusions

Across the networks, we found that there was considerable variability in the ranking of each treatment such that there was no one outstanding, or subset of outstanding, superior treatments. However, static implants such as condylocephalic nails and static fixed angle plates did yield a higher risk of unplanned return to theatre. We had insufficient evidence to determine the effects of any treatments on HRQoL, and this review includes data for only two outcomes. More detailed pairwise comparisons of some of the included treatments are reported in other Cochrane Reviews in this series. Short cephalomedullary nails versus dynamic fixed angle plates contributed the most evidence to each network, and our findings indicate that there may be no difference between these treatments. These data included people with both stable and unstable extracapsular fractures. At this time, there are too few studies to draw any conclusions regarding the benefits or harms of arthroplasty or external fixation for extracapsular fracture in older adults.

Future research could focus on the benefits and harms of arthroplasty interventions compared with internal fixation using a dynamic implant.

Plain language summary

Which are the best treatments for hip fractures in older adults?

Key messages

‐ There is no 'best treatment' for this type of broken hip.

‐ More people needed additional surgery on their broken hip after treatment with condylocephalic nails (where a nail is inserted upwards from the knee towards the hip joint) or static fixed angle plates (where pins or screws attach a plate to the broken bone).

‐ There may be no difference between a short cephalomedullary nail (where a nail is inserted downwards from the hip joint towards the knee) and a dynamic fixed angle plate (where the pins or screws attaching a plate to the broken bone are able to slide in a sleeve).

‐ We found too few studies to know whether any of these treatments were better at improving people's quality of life after surgery.

Hip fractures in older people

A hip fractures is a break at the top of the leg bone. There are two types of hip fractures; in this review, we included people with a break just outside the hip joint. The other type of hip fracture is a break just below the ball and socket joint ‐ we reviewed these fractures in another review. Both types of broken hip are common in older adults whose bones may be fragile because of a condition called osteoporosis.

What are the treatments?

‐ Using metal implants to fix the broken parts of the bone. A nail is inserted inside the thigh bone. These long or short nails may be inserted downwards from the hip joint towards the knee (cephalomedullary nails). Some nails may be inserted upwards from the knee towards the hip joint (condylocephalic nail). Alternatively, the surgeon may use a 'fixed angle plate' which sits on the outer edge of the broken bone and is attached to the bone with screws or pins. Often the screws for these plates slide in a sleeve and the plate is called a dynamic fixed angle plate. Without this, it is a static fixed angle plate.

‐ Replacing the broken hip with an artificial one. This can be done using a hemiarthroplasty (HA), which replaces only the ball part of the joint, or with a total hip arthroplasty (THA) which replaces all of the hip joint including the socket.

‐ Using external fixation. Pins or screws are placed into the bones around the fracture and a metal frame holds these nails in place. The frame sits outside the body, around the broken hip.

‐ Treatment without an operation, usually requiring a period of rest in bed whilst the leg is held in position using traction with weights.

What did we do?

We searched for studies that compared one or more of these treatments. We wanted to find out the benefits and harms of these different treatments. We combined the findings from studies, and created a 'network' (which is used when researchers compare all available treatments in a single analysis called a 'network meta‐analysis') to see if we could find out if some treatments were better than others.

What did we find?

We found 184 studies with 26,073 people who had this type of hip fracture. Most people were aged between 60 and 93 years, and 69% were women, which is usual for people with this type of broken bone. We included 73 of these studies in our 'network'.

We found little or no difference in how many people died with each treatment. We were not sure whether any of the treatments were better than another at reducing deaths within 12 months of surgery.

For most treatments, we also found little or no difference in whether people needed to have additional surgery on their broken hip. However, for the condylocephalic nail and the static fixed angle plate, more people needed additional surgery compared to people treated with a dynamic fixed angle plate. It seemed that these treatments increased the chance of needing additional surgery.

Very few studies reported whether or not people had better health‐related quality of life after their treatment.

Are we confident in what we found?

We are not very confident in these findings because:

‐ most of the studies were not well reported. It is possible that their study methods could introduce errors in their results;

‐ we found some differences between some of the study results which we could not explain;

‐ we found some differences in the types of fractures in some studies;

‐ most treatments included the possibility of a benefit (for example, fewer deaths) as well as the possibility of a harm (for example, more deaths). This made the result very uncertain.

The true effects of these treatments might be very different to what we have found in this review.

How up to date is this review?

The evidence is up to date to July 2020.

Summary of findings

Background

This review has been written in accordance with guidance for authors on preparing a protocol for a systematic review with multiple interventions (Chaimani 2017; CMIMG 2014).

Description of the condition

Epidemiology

A hip fracture, or proximal femoral fracture, is a break in the upper region of the femur (thigh bone) between the subcapital region (the area just under the femoral head) and 5 cm below the lesser trochanter (a bony projection of the upper femur). The incidence of hip fractures rises with age; they are most common in the older adult population (Court‐Brown 2017; Kanis 2001). Those seen in younger adults are usually associated with poor bone health (Karantana 2011; Rogmark 2018). A very small proportion of fractures in younger people are caused by high‐energy trauma such as road traffic collisions, industrial injuries and sports injuries. The overwhelming majority of hip fractures are fragility fractures associated with osteoporosis; such fractures are caused by mechanical forces that would not ordinarily result in fracture. The World Health Organization (WHO) has defined fragility fractures as those sustained from injuries equivalent to a fall from a standing height or less (Kanis 2001). In the UK, the mean age of a person with hip fracture is 83 years, and approximately two‐thirds occur in women (NHFD 2017).

Hip fractures are a major healthcare problem at the individual and population level. They present a huge challenge and burden to individuals, healthcare systems and society. The increased proportion of older adults in the world population means that the absolute number of hip fractures is rising rapidly across the globe. For example, in 2016 there were 65,645 new presentations of hip fracture to 177 trauma units in England, Wales and Northern Ireland (NHFD 2017). Based on population estimates for these regions for mid‐2016, this equates to an incidence rate of 109 cases per 100,000 population (ONS 2016). By 2050, it is estimated that the annual worldwide incidence of hip fracture will be 6 million (Cooper 2011; Johnell 2004). Incident hip fracture rates are higher in industrialised countries than in developing countries. Northern Europe and the USA have the highest rates of hip fracture, whereas Latin America and Africa have the lowest (Dhanwal 2011). European studies show that there are more hip fractures in the north of the region than in the south, and there is also a similar north‐south gradient in the USA (Dhanwal 2011). Factors thought to be responsible for this variation are population demographics (with older populations in countries with higher incidence rates) and the influence of ethnicity, latitude and environmental factors such as socioeconomic deprivation (Bardsley 2013; Cooper 2011; Dhanwal 2011; Kanis 2012).

Burden of disease

Hip fractures are associated with a high risk of death. For example, in England, Wales and Northern Ireland, the 30‐day mortality rate in 2016 remained high at 6.7%, despite a decline from 8.5% in 2011 and 7.1% in 2015 (NHFD 2017). The mortality rate one year after a hip fracture is approximately 30%; however, fewer than half of deaths are attributable to the fracture itself, which reflects the frailty of the patients and associated high prevalence of comorbidities and complications (Parker 1991; SIGN 2009). The impact of morbidity associated with hip fractures is similar to that of stroke, and entails a substantial loss of healthy life‐years in older people (Griffin 2015). Hip fractures commonly result in reduced mobility and greater dependency, with many people failing to return to their pre‐injury residence. In addition, the public health impact of hip fractures is significant: data from large prospective cohorts show the burden of disease due to hip fracture is 27 disability‐adjusted life years (DALYs) per 1000 individuals, which equates to an average loss of 2.7% of the healthy life expectancy in the population at risk of fragility hip fracture (Papadimitriou 2017). The direct economic burden of hip fractures is also substantial. Hip fractures are amongst the most expensive conditions seen in hospitals; the aggregated cost for 316,000 inpatient episodes in the USA in 2011 was nearly USD 4.9 billion (USD 4900 million; Torio 2011). In England, Wales and Northern Ireland, people with hip fractures occupy 1.5 million hospital bed days each year, and cost the National Health Service and social care GBP 1 billion (GBP 1000 million; NHFD 2017). Combined health and social care costs incurred during the first year following a hip fracture have been estimated at USD 43,669, which is greater than the cost for non‐communicable diseases such as acute coronary syndrome (USD 32,345) and ischaemic stroke (USD 34,772) (Williamson 2017). In established market economies, hip fractures represent 1.4% of the total healthcare burden (Johnell 2004).

Extracapsular hip fracture

Hip fractures either involve the region of the bone which is enveloped by the ligamentous hip joint capsule (intracapsular), or that outside the capsule (extracapsular). Extracapsular fractures traverse the femur within the area of bone bounded by the intertrochanteric line proximally, up to a distance of 5 cm from the distal part of the lesser trochanter. Several classification methods have been proposed to define different types of extracapsular fractures (AO Foundation 2018; Evans 1949; Jensen 1980). They are generally subdivided depending on their relationship to the greater and lesser trochanters (the two bony projections present at the upper end of the femur) and the complexity of the fracture configuration. It is increasingly clear that each of these classifications is limited in its generalisability since inter‐ and intra‐observer agreement is poor. Table 3 provides a description of the most recent classification of trochanteric fractures (AO Foundation 2018). For this review, we use a pragmatic simplification of these classifications, as follows.

1. Trochanteric region fractures: type and surgical management (Revised AO/OTA classification, January 2018).

Type	Features	Stability	Description
Simple, pertrochanteric fractures (A1)	Isolated pertrochanteric fracture Two‐part fracture Lateral wall intact	Stable	The fracture line can begin anywhere on the greater trochanter and end either above or below the lesser trochanter. The medial cortex is interrupted in only one place.
Multifragmentary pertrochanteric fractures (A2)	With one or more intermediate fragments Lateral wall may be incompetent	Unstable	The fracture line can start laterally anywhere on the greater trochanter and runs towards the medial cortex, which is typically broken in two places. This can result in the detachment of a third fragment which may include the lesser trochanter.
Intertrochanteric fractures (A3)	Simple oblique fracture Simple transverse fracture Wedge or multifragmentary fracture	Unstable	The fracture line passes between the two trochanters, above the lesser trochanter medially and below the crest of the vastus lateralis laterally.

Implant category	Grouping variable	Implant subcategory (entry point/static or dynamic)	Examples^a	Description
Extracapsular fractures
External fixation
External fixator	n/a	n/a	Hoffman (Stryker) Large External Fixator (DePuy Synthes) Lower Extremity Fixator (Orthofix)	Threaded pins are passed into the bone proximal and distal to the fracture. These pins are attached to external bars which may be arranged in numerous configurations to bridge the fracture.
Internal fixation
Intramedullary nails	n/a	Cephalomedullary nails	Y‐nail (Küntscher 1967) Zickel nail (Zicker 1976) Gamma nail (first generation, Howmedica) Gamma nail (second generation, Stryker) Gamma3 nail (Stryker) Gamma3 Trochanteric Nail Gamma3 Long Nail Gamma3 RC Lag Screw Gamma3 Distal Targeting System Gamma3 sliding lag screw (Stryker) Gamma3 non‐sliding lag screw (Stryker) Proximal femoral nail (PFN) Expandable PFN (Fixion) Proximal femoral nail antirotation (PFNA) (DePuy Synthes) PFNA nail long PFNA nail standard PFNA II TFNA (Synthes) ACE Trochanteric nail System (ATN) (DePuy) Russel‐Taylor Recon nail Intramedullary hip screw clinically proven (IMHS CP) (Smith & Nephew) Targon proximal femoral nail (Aesculap) Zimmer® Natural Nail® System (Zimmer) Holland Nail™ System Endovis Cephomedullary nail (Citieffe) Trigen InterTAN nail Elos Intramedullary nail Affixus Hip Fracture Nail System	A nail is inserted antegrade into the intramedullary canal of the femur. Once the nail is in place, a pin, nail or screw is passed from the lateral cortex of the femur across the fracture and through the nail into the femoral head. The pin or screw can be fixed to the nail in various ways to allow or prevent sliding as well as provide rotational stability about the axis of the femoral neck. Küntscher Y‐nail: an early intramedullary nail based on the principles of stable fixation and closed nailing. Zickel nail: similar to the Küntscher Y‐nail. The Küntscher Y‐nail was considered to be more difficult to insert than the Zickel nail. The major complication of the Küntscher Y‐nail was distal migration of the intramedullary nail, although this may be prevented by the insertion of a bolt through the upper end of the nail. Zickel developed his device to address the difficulties with the former. Gamma nail (first generation, 1980s) or Standard Gamma Nail (SGN): a prototype intramedullary nailing system which became the most widely used for trochanteric fractures worldwide. Complications such as cut‐out, implant breakage, femoral shaft fractures, and reduction loss were reported with its use. Long Gamma Nail (LGN) (1992): used for subtrochanteric hip fractures, femoral shaft fractures and combined trochanter‐diaphyseal fractures of the femur. Trochanteric Gamma Nail (TGN) (1997): a modified SGN, replaced the SGN. Gamma3 Nailing System: third generation of intramedullary short and long Gamma fixation nails. Four locking grooves allow for quarter‐turn advancement of 0.8 mm to allow for precise lag screw positioning. PFN (Synthes, Solothurn, Switzerland) and ATN (DePuy, Warsaw, IN, USA): developed to address the mechanical complications of the standard gamma nail. These intramedullary implants provide sliding head‐neck screws. However, complications still occurred, such as lateral migration of head‐neck screw, cut‐out from head‐neck fragment and cut‐through of the antirotation screw into the joint. The expandable PFN was a development of this nail with a hydraulic expansion mechanism in the head reducing the need for reaming for the lag screw. PFNA (Synthes, Solothurn, Switzerland) was designed by the AO/ASIF group for improving the rotational stability. It used a single head‐neck fixation device called a 'helical blade'. The TFN and TFNA are the first‐ and second‐generation trochanteric entry point cephalomedullary nails made by Synthes (Switzerland) using lag screws or blades. ACE Trochanteric nail System (ATN) (DePuy): intended to treat stable and unstable proximal fractures of the femur including pertrochanteric fractures, intertrochanteric fractures, high subtrochanteric fractures and combinations of these fractures. Trochanteric Long Nail System: additionally indicated to treat pertrochanteric fractures associated with shaft fractures, pathologic fractures in osteoporotic bone of the trochanteric and diaphyseal areas, long subtrochanteric fractures, ipsilateral femoral fractures, proximal or distal non‐unions and malunions and revision procedures. Russel‐Taylor Recon nail: a second‐generation locking femoral nail. Intramedullary hip screw (IMHS): a short intramedullary nail with interlocking screws that can be used to treat subtrochanteric and intertrochanteric femur fractures. This nail, which has the biomechanical advantage of being an intramedullary appliance but can be placed percutaneously, is inserted under fluoroscopic control with the patient on a fracture table. Reaming is not usually necessary. Intramedullary Hip Screw Clinically Proven (IMHS™ CP): intramedullary hip screw device that provides a barrel through which a lag screw can slide. Introduced in 1991 with its design, the IMHS system provided a more minimally invasive technique than the traditional Compression Hip Screw. By featuring a centering sleeve to enhance lag screw sliding and medialising the implant to reduce the moment arm, this design improved implant biomechanics for the treatment of hip fractures. Targon® PFT nailing system: targeting device is suitable for all caput collum diaphyseal (CCD) angles and permits shorter and less invasive incisions thanks to an optimised geometry. Zimmer Natural Nail System: intramedullary nails, screws, instruments and other associated implants. Holland Nail™ System includes a short, universal nail in diameters of 9, 11 and 13 mm x 24 cm length and long, anatomic (L & R) nails in diameters of 9 mm and 12 mm in various lengths. A 7 mm cannulated, partially threaded screw is used for proximal reconstructive interlocking. A unique pilot thread screw is used for proximal and distal interlocking. Distal screw options offer shaft fracture compression while controlling rotation by a distal slot, or the option of static interlocking. Endovis cephalomedullary nail (Citieffe, Italy) is implanted without reaming and has two lag screws placed in the femoral head. The Trigen Intertan (Smith and Nephew) intramedullary nail was designed as a trochanteric entry nail especially shaped for fractures of the proximal femur. It offers an integrated interlocking screw option to increase stability and resistance to intraoperative and postoperative femoral head rotation, thus eliminating excessive sliding and the possibility of Z‐effect. Femoral intramedullary nail (Elos) is a trapezoidal section piriformis fossa entry point nail with cannulated cephalic lag screw. Affixus Hip Fracture Nail System (ZimmerBiomet) is a cephalomedullary nail with double cephalic lag screws.
Intramedullary nails	n/a	Condylocephallic nails	Ender nail (Pankoich and Tarabishy) Harris nail	Condylocephalic nails are intramedullary nails which are inserted retrograde through the femoral canal across the fracture and into the femoral head. Ender nails are pre‐bent flexible rods. Three to five of these of appropriate length are inserted into the femoral canal. The femoral canal is thus 'stacked' with nails, whilst their tips should radiate out to produce a secure fixation within the femoral head. Harris nail is a larger nail used as a single nail.
Fixed angle plates	Sliding	Static	Holt nail plate Jewett nail plate McLaughlin nail plate Thornton nail plate LCP (Locking Compression Plate) Dynamic Helical Hip System (DHHS) Contralateral reverse distal femoral locking compression plate (DFLCP) (Green Surgicals) AO Angle Blade Plate Baixauli (IQL) Less‐Invasive Stabilisation System (LISS) (Synthes)	Static device consisting of a nail, pin or screw which is passed across the fracture into the femoral head and connected to a plate on the lateral femur. These implants have no capacity for ‘sliding’ between the plate and pin or screw components and hence are termed static implants. Holt nail plate: a four‐flanged nail connected to a plate at the time of surgery. Jewett nail: the nail is fixed to the plate at manufacture. Thornton and McLaughlin nail plates: the nail is connected to the plate at the time of surgery with a locking bolt. RAB plate: similar to a Jewett fixed nail plate but has an additional oblique strut to connect the nail and the side plate. AO Angle Blade Plate (Synthes) is a well‐used fixed angle static implant where the cephalic placed blade is angled at various degrees from 90 to 150 with a plate attached to the lateral side of the femur. Less‐Invasive Stabilisation System (LISS) (Synthes) is a fixed angle plating system where screws fix into the plate but are statically locked.
Fixed angle plates	Sliding	Dynamic	Dynamic hip screw Precimed Hip Screw System AMBI/Classic Hip Screw System (Smith & Nephew Richards) HDS/DCS Dynamic Hip & Condylar Screw System Pugh nail Medoff plate Resistance Augmented or Rigidity Augmentation Baixauli (RAB) plate Gotfried percutaneous compression plate (PCCP) Dynamic condylar screw (DCS) X‐BOLT Hip System (XHS™) Compression hip screw (Smith & Nephew) Richards sliding hip screw	Dynamic device consisting of a nail, pin or screw which is passed across the fracture into the femoral head and connected to a plate on the lateral femur. These implants allow ‘sliding’ between the plate and pin or screw components and hence are termed dynamic implants. Weight bearing or translation during surgery causes the femoral head to become impacted on the femoral neck, leading to compression of the fracture. Precimed Hip Screw System: compression fixation system used for the treatment of femoral neck and distal femoral fractures. It consists of compression plates, lag screws, compression screws, bone screws and angled blade plates. The system functions to provide immediate stability and temporary fixation during the natural healing process following fractures of the femoral neck or distal femur. AMBI/Classic Hip Screw System: compression fixation system consisting of hip screw plates and nails. AMBI plates have a barrel design which is keyless but can be converted to keyed with the insertion of a small keying clip; Classic plates have a keyed barrel design only. AMBI/Classic Lag Screws: 18 lengths: 55 mm to 140 mm; nonself‐tapping for cancellous bone. Pugh nail: similar to SHS except instead of a lag screw being passed up the femoral neck, a nail with a trifin or three‐flanged terminus is inserted by a punching mechanism. This is then connected to the side plate in the same manner as for a SHS. Medoff plate: a modification of SHS, where a lag screw is passed up the femoral neck and attached to a plate on the side of the femur. The difference is that the plate has an inner and outer sleeve, which can slide between each other. This creates an additional capacity for sliding to occur at the level of the lesser trochanter as well as at the lag screw. An additional variant of the Medoff plate is the capability of compressing the fracture distally using the two interlocking plates and a compression screw. In addition, sliding at the lag screw can be prevented with a locking screw to create a 'one way' sliding Medoff instead of a 'two way' sliding Medoff. At a later date, the locking device on the lag screw can be removed to 'dynamise' the fracture. Gotfried PCCP has a side plate that is inserted via a small incision level to the lesser trochanter by use of a connecting jig. Using the latter, two sliding proximal screws are passed up the femoral neck and the plate is fixed to the femur shaft with three screws. DCS is an implant assembly that consists of a lag screw, angled barrel plate fixed to the bone (usually distal femur) by 4.5 cortical screws. DCS and DHS work on the same principle of the sliding nail that allows impaction of the fracture. This is due to insertion of wide diameter into the condyle (or femoral head). A side plate, which has a barrel at a fixed angle, is slid over the screw and fixed to the femoral shaft. DCS has all other components the same as DHS; only the side plate is different. The plate barrel angle is 95 degrees and the plate is shaped to accommodate the lateral aspect of lateral condyle. DCS was mainly developed for fractures of distal femoral condyles. It is also used in fixation of subtrochanteric fractures of femur. Sometimes, it can be used in revision surgeries of selected intertrochanteric fractures. Compression hip screw (Smith & Nephew) is similar to other types of sliding hip screw with an angled barrel, sliding lag screw and plate attached to the side of the femur. Richards sliding hip screw is similar to other types of sliding hip screw with an angled barrel, sliding lag screw and plate attached to the side of the femur. X‐BOLT®: an expanding bolt akin to a Chinese lantern with a central drive shaft. The opposing threads compress the expandable section from both ends to expand the wings perpendicularly to the shaft, without spinning, pushing or pulling the femoral head.
External fixation
	n/a	Pertrochanteric external fixator		Pertrochanteric external fixator: held outside the thigh by two pairs of pins. One pair is passed up the femoral neck under X‐ray control. The other pair is placed in the femur. The fixator is left in place until the fracture has healed, which usually takes about three months. It is then removed under local anaesthesia, generally as an outpatient procedure.

Implant	Grouping variable	Implant subcategory	Examples^a	Description
Extracapsular fractures
Arthroplasty
Total hip arthroplasty	Articulation	Femoral head and acetabular bearing surface materials	Metal‐on‐polyethylene (MoP) Ceramic‐on‐polyethylene (CoP) Ceramic‐on‐ceramic (CoC) Metal‐on‐metal (MoM) Polyethylene material Highly cross linked (HCL) Not HCL	Bearing surfaces may be grouped into hard (ceramic and metal) and soft (polyethylene variants). Arthroplasties exist with many of the possible combinations of these bearing surfaces.
		Femoral head size	Large head ≥ 36 mm Standard small head < 36 mm	Over the development of hip arthroplasty, different sizes of femoral head have been used, from 22 mm to very large diameters approximating that of the native femoral head. The size of the head represents a compromise between stability and linear and volumetric wear at the articulation. The optimum size varies by indication and bearing materials. 36 mm is considered as a cut‐off between standard and large sizes.
		Acetabular cup mobility	Single Dual	A standard total hip arthroplasty has a single articulating surface between the femoral head and acetabulum bearing surface. Alternative designs incorporate two further articulations within the structure of the femoral head.
	Fixation technique	Cemented	Exeter Hip System CPT Hip System	Both components are cemented with poly(methyl methacrylate) bone cement that is inserted at the time of surgery. It sets hard and acts as grout between the prosthesis and the bone.
		Modern uncemented	Corail Hip System Avenir Hip System Taperloc Hip System	Neither component is cemented but rely on osseous integration forming a direct mechanical linkage between the bone and the implant. The femoral prosthesis may be coated with a substance such as hydroxyapatite which promotes bone growth into the prosthesis. Alternatively, the surface of the prosthesis may be macroscopically and microscopically roughened so that bone grows onto the surface of the implant. The acetabular component may be prepared similarly and may or may not be augmented with screws fixed into the pelvis.
		Hybrid	Combinations	The femoral stem is cemented and the acetabular cup is uncemented.
		Reverse hybrid	Combinations	The acetabular cup is cemented and the femoral stem is uncemented.
Hemiarthroplasty	Articulation	Unipolar	Thompson Austin‐Moore Exeter Trauma Stem Exeter Unitrax	A single articulation between the femoral head and the native acetabulum. The femoral component can be a single ‘monoblock’ of alloy or be modular, assembled from component parts during surgery.
	Articulation	Bipolar	CPT modular bipolar Exeter modular bipolar Bateman Monk	The object of the second joint is to reduce acetabular wear. This type of prosthesis has a spherical inner metal head with a size between 22 and 36 mm in diameter. This fits into a polyethylene shell, which in turn is enclosed by a metal cap. There are a number of different types of prostheses with different stem designs.
	Fixation technique	First generation uncemented	Thompson Austin Moore	These prostheses were designed before the development of poly(methyl methacrylate) bone cement and were therefore originally inserted as a ’press fit’. Long‐term stability through osseus integration was not part of the design concept.
		Cemented	Thompson Exeter Trauma Stem Exeter Hip System CPT Hip System	The femoral stem is cemented with poly(methyl methacrylate) bone cement that is inserted at the time of surgery. It sets hard and acts as grout between the prosthesis and the bone.
		Modern uncemented	Corail Furlong Avenir	The femoral stem relies on osseous integration forming a direct mechanical linkage between the bone and the implant. A prosthesis may be coated with a substance such as hydroxyapatite which promotes bone growth into the prosthesis. Alternatively, the surface of the prosthesis may be macroscopically and microscopically roughened so that bone grows onto the surface of the implant.

Certainty of the effects and network estimates for treating extracapsular hip fractures in older adults: mortality at 12 months
Patient or population: older adults (> 60 years of age) with extracapsular hip fractures Intervention: static fixed angle plate, long cephalomedullary nail, short cephalomedullary nail, condylocephalic nail, external fixation, hemiarthroplasty, non‐operative treatment, total hip arthroplasty Comparison: dynamic fixed angle plate Outcome: mortality at 12 months; range of follow‐up time points from 5 months up to 24 months (in most studies, data were reported at 12 months) Setting: in hospital
Total studies: 56 Total participants: 8407	Relative effect (95% CI)	*Anticipated absolute effect (95% CI)**			Certainty of the evidence
Total studies: 56 Total participants: 8407	Relative effect (95% CI)	With comparison	With intervention	Difference	Certainty of the evidence
Static fixed angle plate (5 studies; 847 participants)^a	RR 1.02 (0.77 to 1.36)	201 per 1000	205 per 1000	4 per 1000 more (46 fewer to 72 more)	Very low Downgraded for risk of bias,^b,c and imprecision^d
Long cephalomedullary nail (2 studies; 400 participants)^a	RR 1.27 (0.89 to 1.81)	201 per 1000	255 per 1000	54 per 1000 more (22 fewer to 162 more)	Very low Downgraded for risk of bias,^b,c imprecision^d and intransitivity^e
Short cephalomedullary nail (33 studies; 5380 participants)^a	RR 0.97 (0.87 to 1.07)	201 per 1000	194 per 1000	7 per 1000 fewer (26 fewer to 15 more)	Very low Downgraded for risk of bias^b,c and imprecision^d
Condylocephalic nail (6 studies; 847 participants)^a	RR 0.93 (0.74 to 1.16)	201 per 1000	186 per 1000	15 per 1000 fewer (52 fewer to 32 more)	Very low Downgraded for risk of bias^b,c and imprecision^d
External fixation (1 study; 100 participants)^a	RR 0.75 (0.36 to 1.57)	201 per 1000	150 per 1000	51 per 1000 fewer (130 fewer to 115 more)	Low Downgraded for risk of bias,^b and imprecision^d
Hemiarthroplasty (No direct evidence, indirect evidence only)	RR 1.36 (0.73 to 2.54)	201 per 1000	274 per 1000	73 per 1000 more (54 fewer to 309 more)	Very low Downgraded for risk of bias,^b,c imprecision^d andintransitivity^e
Non‐operative treatment (1 study; 106 participants)^a	RR 1.00 (0.53 to 1.87)	201 per 1000	201 per 1000	0 per 1000 fewer (94 fewer to 175 more)	Low Downgraded for risk of bias^b and imprecision^e
Total hip arthroplasty (1 study; 156 participants)^a	RR 0.69 (0.12 to 4.03)	201 per 1000	139 per 1000	62 per 1000 fewer (177 fewer to 610 more)	Low Downgraded for risk of bias^b and imprecision^e
Dynamic fixed angle plate	Reference comparator	‐	‐	‐	Reference comparator
Anticipated absolute effects compare two risks by calculating the difference between the risk with the intervention group and the risk with the comparison/control group (reference comparator). CI:* confidence interval; NMA: network meta‐analysis; RR: risk ratio
GRADE Working Group grades of evidence High certainty: we are confident that the true estimate lies close to the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of the effect.

Certainty of the effects and network estimates for treating extracapsular hip fractures in older adults: unplanned return to theatre
Patient or population: older adults (> 60 years of age) with extracapsular hip fractures Intervention: static fixed angle plate, long cephalomedullary nail, short cephalomedullary nail, condylocephalic nail, external fixation, hemiarthroplasty Comparison: dynamic fixed angle plate Outcome: unplanned return to theatre: range of follow‐up time points from 6 weeks up to 5 years (in most studies, data were reported at 12 months; with only one study at 5 years) Setting: in hospital
Total studies: 55 Total participants: 9296	Relative effect (95% CI)	*Anticipated absolute effect (95% CI)**			Certainty of the evidence
Total studies: 55 Total participants: 9296	Relative effect (95% CI)	With comparison	With intervention	Difference	Certainty of the evidence
Static fixed angle plate (4 studies; 622 participants)^a	RR 2.48 (1.36 to 4.50)	39 per 1000	97 per 1000	58 per 1000 more (14 more to 137 more)	Very low Downgraded for risk of bias^b,c and inconsistency^d
Long cephalomedullary nail (2 studies; 400 participants)^a	RR 1.58 (0.55 to 4.56)	39 per 1000	62 per 1000	23 per 1000 more (18 fewer to 139 more)	Very low Downgraded for risk of bias,^b,c inconsistency^d and imprecision^e
Short cephalomedullary nail (34 studies; 6437 participants)^a	RR 1.12 (0.80 to 1.56)	39 per 1000	43 per 1000	4 per 1000 more (8 fewer to 22 more)	Very low Downgraded for risk of bias,^b,c inconsistency^d and imprecision^e
Condylocephalic nail (7 studies; 996 participants)^a	RR 3.33 (1.95 to 5.68)	39 per 1000	130 per 1000	91 per 1000 more (37 more to 182 more)	Very low Downgraded for risk of bias^b,c and inconsistency^d
External fixation (1 studies; 100 participants)^a	RR 0.09 (0.00 to 1.87)	39 per 1000	4 per 1000	35 per 1000 fewer (39 fewer to 34 more)	Low Downgraded for risk of bias^b and imprecision^e
Hemiarthroplasty (No direct evidence, indirect evidence only)	RR 0.37 (0.01 to 10.26)	39 per 1000	14 per 1000	25 per 1000 fewer (38 fewer to 361 more)	Very low Downgraded for risk of bias,^b,c inconsistency,^d imprecision^e and intransitivity^f
Dynamic fixed angle plate	Reference comparator	‐	‐	‐	Reference comparator
Anticipated absolute effects compare two risks by calculating the difference between the risk with the intervention group and the risk with the comparison/control group (reference comparator). CI:* confidence interval; NMA: network meta‐analysis; RR: risk ratio
GRADE Working Group grades of evidence High certainty: we are confident that the true estimate lies close to the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of the effect.

Dynamic fixed angle plate	D: 0.91 (0.36 to 2.32) I: 0.71 (0.28 to 1.79)	D: 1.80 (1.02 to 3.18) I: 0.53 (0.28 to 1.01)	D: 0.94 (0.75 to 1.19) I: 2.92 (1.34 to 6.39)	D: 0.93 (0.48 to 1.80) I: 1.12 (0.36 to 3.53)	D: 0.62 (0.23 to 1.68) I: too imprecise
0.81 (0.42 to 1.54)	Static fixed angle plate		D: 1.56 (0.14 to 16.97) I: 1.28 (0.62 to 2.64)	D: 1.29 (0.61 to 2.70) I: 1.06 (0.35 to 3.16)
1.09 (0.65 to 1.80)	1.35 (0.59 to 3.06)	Long cephalomedullary nails	D: 1.79 (0.98 to 3.25) I: 0.53 (0.28 to 0.97)
1.05 (0.81 to 1.36)	1.30 (0.65 to 2.60)	0.97 (0.58 to 1.61)	Short cephalomedullary nails			D: 0.87 (0.20 to 3.86) I: too imprecise
0.97 (0.55 to 1.71)	1.21 (0.66 to 2.21)	0.90 (0.42 to 1.92)	0.93 (0.50 to 1.72)	Condylocephalic nails
0.62 (0.23 to 1.68)	0.76 (0.23 to 2.52)	0.57 (0.18 to 1.75)	0.59 (0.21 to 1.66)	0.63 (0.20 to 2.00)	External fixation
0.91 (0.20 to 4.14)	1.14 (0.22 to 5.86)	0.84 (0.18 to 4.06)	0.87 (0.20 to 3.86)	0.94 (0.19 to 4.71)	1.49 (0.24 to 9.11)	Hemiarthroplasty

Rank	F	B	G	E	A	D	C
Best	47.8	17.6	26.3	4	0.7	0.8	2.9
2nd	21.6	29.9	15.7	14	6.3	4.3	8.3
3rd	9.1	20.6	7.8	20.6	16.9	12.3	12.6
4th	5.2	10.2	5.1	16.8	29.7	19.6	13.4
5th	4.4	7.9	4.7	12.7	27.6	27.3	15.4
6th	5.6	8.4	7.4	16.6	14.6	25	22.4
Worst	6.3	5.4	33	15.3	4.3	10.8	24.9
MEAN RANK	2.4	3.1	4	4.3	4.4	4.9	5
SUCRA	0.8	0.7	0.5	0.4	0.4	0.4	0.3

Dynamic fixed angle plate	D: 1.03 (0.74 to 1.42) I: 1.01 (0.57 to 1.79)	D: 1.28 (0.89 to 1.85) I: 1.05 (0.27 to 4.12)	D: 0.97 (0.87 to 1.07) I: 0.98 (0.40 to 2.38)	D: 0.92 (0.73 to 1.16) I: 0.98 (0.49 to 1.97)	D: 0.88 (0.34 to 2.23) I: 0.57 (0.17 to 1.93)		D: 0.91 (0.45 to 1.85) I: 1.40 (0.36 to 5.49)	D: 0.69 (0.12 to 4.03) I: too imprecise
1.02 (0.77 to 1.36)	Static fixed angle plate		D: 0.86 (0.28 to 2.59) I: 0.95 (0.70 to 1.30)	D: 0.95 (0.51 to 1.78) I: 0.89 (0.60 to 1.32)
1.27 (0.89 to 1.81)	1.24 (0.79 to 1.95)	Long cephalomedullary nail	D: 0.92 (0.23 to 3.58) I: 0.75 (0.51 to 1.10)
0.97 (0.87 to 1.07)	0.95 (0.70 to 1.28)	0.76 (0.53 to 1.10)	Short cephalomedullary nail			D: 1.41 (0.77 to 2.61) I: too imprecise
0.93 (0.74 to 1.16)	0.91 (0.65 to 1.26)	0.73 (0.48 to 1.11)	0.96 (0.75 to 1.23)	Condylocephalic nail
0.75 (0.36 to 1.57)	0.73 (0.33 to 1.62)	0.59 (0.26 to 1.34)	0.77 (0.37 to 1.64)	0.81 (0.37 to 1.75)	External fixation		1.60 (0.59 to 4.33) I: 1.04 (0.32 to 3.37)
1.36 (0.73 to 2.54)	1.34 (0.68 to 2.64)	1.08 (0.53 to 2.20)	1.41 (0.77 to 2.61)	1.47 (0.76 to 2.85)	1.83 (0.69 to 4.81)	Hemiarthroplasty
1.00 (0.53 to 1.87)	0.98 (0.49 to 1.95)	0.79 (0.38 to 1.62)	1.03 (0.55 to 1.95)	1.08 (0.55 to 2.10)	1.34 (0.63 to 2.86)	0.73 (0.30 to 1.77)	Non‐operative treatment
0.69 (0.12 to 4.03)	0.68 (0.11 to 4.04)	0.55 (0.09 to 3.30)	0.72 (0.12 to 4.19)	0.75 (0.13 to 4.41)	0.93 (0.14 to 6.27)	0.51 (0.08 to 3.29)	0.69 (0.11 to 4.50)	Total hip arthroplasty

Rank	F	I	E	D	H	A	B	C	G
Best	33.5	48.7	5.6	1.5	6.1	0.3	2.2	0.3	1.7
2nd	31.4	9.6	18.1	9	16.8	1.9	8.1	1.3	3.7
3rd	8.7	3.9	23.8	20	16.2	8.7	12.9	2.2	3.7
4th	4	2	20.1	26.5	7.4	20.4	12.9	2.8	3.8
5th	4.1	2.2	13.3	22.2	6.8	30.2	13.9	4.1	3.2
6th	5.3	3.2	10.4	14.2	9.6	24.7	17.6	9.5	5.6
7th	5.9	4.8	6.2	5.2	14	11.6	19	21.1	12.2
8th	4.4	6.8	2.2	1.3	13.4	2	10.8	35.1	23.9
Worst	2.6	18.8	0.3	0.1	9.7	0.2	2.6	23.5	42.3
MEAN RANK	2.9	3.7	3.9	4.3	5	5.1	5.3	7.4	7.4
SUCRA	0.8	0.7	0.6	0.6	0.5	0.5	0.5	0.2	0.2

Dynamic fixed angle plate	D: 2.19 (0.97 to 4.92) I: 2.91 (1.17 to 7.22)	D: 1.09 (0.19 to 6.15) I: 1.98 (0.51 to 7.70)	D: 1.13 (0.81 to 1.59) I: 0.74 (0.14 to 3.95)	D: 3.57 (1.91 to 6.66) I: 2.74 (0.93 to 8.05)	D: 0.09 (0.00 to 1.87) I: too imprecise
2.48 (1.36 to 4.50)	Static fixed angle plate		D: 0.39 (0.03 to 4.93) I: 0.45 (0.22 to 0.92)	D: 1.22 (0.58 to 2.59) I: 1.59 (0.59 to 4.30)
1.58 (0.55 to 4.56)	0.64 (0.19 to 2.15)	Long cephalomedullary nail	D: 0.57 (0.15 to 2.14) I: 1.03 (0.18 to 6.01)
1.12 (0.80 to 1.56)	0.45 (0.23 to 0.88)	0.71 (0.25 to 2.01)	Short cephalomedullary nail			D: 0.33 (0.01 to 9.05) I: too imprecise
3.33 (1.95 to 5.68)	1.34 (0.75 to 2.42)	2.11 (0.64 to 6.93)	2.98 (1.59 to 5.60)	Condylocephalic nail
0.09 (0.00 to 1.87)	0.04 (0.00 to 0.80)	0.06 (0.00 to 1.42)	0.08 (0.00 to 1.71)	0.03 (0.00 to 0.59)	External fixation
0.37 (0.01 to 10.26)	0.15 (0.01 to 4.36)	0.24 (0.01 to 7.53)	0.33 (0.01 to 9.05)	0.11 (0.00 to 3.22)	3.98 (0.05 to 350.47)	Hemiarthroplasty

Rank	F	G	A	D	C	B	E
Best	71.1	26.4	1.5	0.4	0.7	0	0
2nd	22.1	43.9	20.3	6.8	6.8	0.1	0
3rd	1.7	3.7	49.3	30.8	13.9	0.6	0
4th	2	5.9	23.7	47.2	16	4.6	0.6
5th	1.5	6.5	5.3	14.6	41	26	5.2
6th	0.7	3.6	0	0.2	13	56.1	26.5
Worst	0.9	9.9	0	0	8.6	12.7	67.8
MEAN RANK	1.5	2.7	3.1	3.7	4.6	5.8	6.6
SUCRA	0.9	0.7	0.6	0.6	0.4	0.2	0.1

Methods	RCT or quasi‐randomised; parallel design Review comparison group:
Participants	Total number of randomised participants: Inclusion criteria: Exclusion criteria: Setting:type of setting, how many sites & country Baseline characteristics Intervention group 1 (specify by name) Age, mean (SD): (± ) years Gender, M/F: Smoking history, n: Medication, type, n: BMI, mean (SD): (± ) kg/m² Comorbidities, type, n: Mobility assessment/use of walking aides: Place of residence: Cognitive status/dementia: ASA status, I/II/III/IV: Preoperative waiting time, mean (SD): (± ) hours Fracture classification, stable/unstable, n: Additional information: Intervention group 2 (specify by name) Age, mean (SD): (± ) years Gender, M/F: Smoking history, n: Medication, type, n: BMI, mean (SD): (± ) kg/m² Comorbidities, type, n: Mobility assessment/use of walking aides: Place of residence: Cognitive status/dementia: ASA status, I/II/III/IV: Preoperative waiting time, mean (SD): (± ) hours Fracture classification, stable/unstable, n: Additional information: Overall Age, mean (SD): (± ) years Gender, M/F: Smoking history, n: Medication, type, n: BMI, mean (SD): (± ) kg/m² Comorbidities, type, n: Mobility assessment/use of walking aides: Place of residence: Cognitive status/dementia: ASA status, I/II/III/IV: Preoperative waiting time, mean (SD): (± ) hours Fracture classification, stable/unstable, n: Additional information: Note: specify outcomes for which baseline data are not specified are prognostic variables comparable between groups?
Interventions	General details: to include number of clinicians (and their skills and experience), type of anaesthesia, pre‐ and postoperative care (e.g. use of prophylactic antibiotics or antithromboembolics), rehabilitation (e.g. time to mobilisation or weight bearing) Intervention group 1: type of implant (with manufacturer details), description of use; number randomised to group, number of losses (for relevant outcomes, and with reasons for losses), number analysed by review authors for each review outcome Intervention group 2: type of implant (with manufacturer details), description of use; number randomised to group, number of losses (for relevant outcomes, and with reasons for losses), number analysed by review authors for each review outcome Note: specify general details for which information is not reported by study authors
Outcomes	Outcomes measured/reported by study authors: include all outcomes reported by study authors. For outcomes relevant to the review, specify all time points measured by study authors Outcomes relevant to the review: include measurement tools and time point of measure used in review analysis Note: specify outcome data which are not included in the review and reasons for not including these data
Notes	Funding/sponsor/declarations of interest: Study dates:

*Study characteristics*
Methods	RCT; parallel design Review comparison group: fixed angle plate versus fixed angle plate: keyed (locked) or unkeyed (unlocked)
Participants	Total number of randomised participants: 40 Inclusion criteria: people who have a proximal femoral fracture Exclusion criteria: not reported Setting: not reported Baseline characteristics Intervention group 1 (locked) Age, mean (range): 74.05 (55 to 90) years Intervention group 2 (unlocked) Age, mean (range): 78.0 (65 to 97) years Note: study authors did not report baseline characteristics for gender, smoking history, medication, BMI, place of residence, preoperative waiting time, fracture classification
Interventions	General details: participants assessed clinically and radiologically postoperatively at 3 months following discharge from hospital Intervention group 1 Sliding hip screw in locked (keyed allows sliding but not rotation) mode Number randomised = 20 Intervention group 2 Sliding hip screw in unlocked (unkeyed allows sliding and rotation) mode Number randomised = 20 Notes: study authors do not report the number of clinicians or their skills and experience, the type of anaesthesia used or the participants pre‐/postoperative care abstract does not report the manufactured of the implants
Outcomes	Outcomes measured/reported by study authors: screw slide; fixation failure; VAS Outcomes relevant to the review: none
Notes	Funding/sponsor/declarations of interest: not reported Study dates: not reported Notes: study is published only as an abstract we did not conduct risk of bias assessment because this study reported no review‐relevant outcomes.

*Study characteristics*
Methods	RCT; parallel design Review comparison group: Gamma nail versus SHS
Participants	Total number of randomised participants: 400 Inclusion criteria: diagnosis of intertrochanteric fractured femur Exclusion criteria: inability to give informed consent, too frail for any operative intervention, and residence outside the region of the hospital because of the difficulty of follow‐up Setting: single centre; orthopaedic hospital, UK Intervention group 1 (Gamma nail) Age, mean (range): 81.2 (48 to 99) years Gender, M/F: 39/164 Mobility assessment, independent/1 stick/2 sticks/walking frame/wheelchair and transfer, n: 88/53/2/32/28 Place of residence, own home/part IV or relative or home for elderly/acute hospital/nursing home or long stay, n: 104/27/5/67 Preoperative waiting time, mean (range): 1.7 (1.5 to 1.9) days Fracture classification, AO/OTA A1.1/A1.2/A1.3/A2.1/A2.2/A2.3/A3.1/A3.2/A3.3/B2.1, n: 41/38/0/27/40/33/2/2/2/18 Intervention group 2 (DHS) Age, mean (range): 80.7 (32 to 102) years Gender, M/F: 49/148 Mobility assessment, independent/1 stick/2 sticks/walking frame/ wheelchair and transfer, n: 88/48/6/29/26 Place of residence, own home/part IV or relative or home for elderly/acute hospital/nursing home or long stay, n: 115/27/12/43 Preoperative waiting time, mean (range): 1.8 (1.6 to 2.1) days Fracture classification, AO/OTA A1.1/A1.2/A1.3/A2.1/A2.2/A2.3/A3.1/A3.2/A3.3/B2.1, n: 43/29/1/22/50/27/1/4/5/15 Note: study authors do not report baseline characteristics for: smoking history, medications, BMI, comorbidities, cognitive status/dementia or ASA status
Interventions	General details: study authors report that surgeons were experienced with both implants; both groups received standard 3‐dose IV cefuroxime and routine antithrombotic prophylaxis; clinical follow‐up for 1 year or until death (3 months, 6 months, 12 months) Intervention group 1 Gamma intramedullary nail (Stryker‐Howmedica Ltd, London, UK); short type. Study authors did not report if the lag screw was static or locked; most common implant was the 130‐degree by 11 mm nail; distal locking screws were used at the preference of the surgeon Number randomised = 203; losses = unknown (study authors report one loss but do not report from which study group so we have used all participants in analysis for both groups); analysed = 203 Intervention group 2 CHS (Smith & Nephew, UK). The most common implant was the 135‐degree, 3‐hole plate Number randomised = 197; losses = unknown (study authors report one loss but do not report from which study group so we have used all participants in analysis for both groups), analysed = 197
Outcomes	Outcomes measured/reported by study authors: length of surgery; operative blood loss; postoperative haemoglobin; tip‐apex distance; number of participants transfused; operative fracture of the femur; later fracture of the femur; cut‐out of implant; detachment of the plate from the femur; re‐operation; deep wound infection; superficial wound infection; DVT; mortality; use of walking aids; place of residence at follow‐up; HHS (available at 3, 6, 12 months) Outcomes relevant to the review: mortality (12 months); unplanned return to theatre (12 months)
Notes	Funding/sponsor/declarations of interest: quote: "Although none of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received but are directed solely to a research fund, the Scottish Orthopaedic Research Trust into Trauma, a non‐profit organisation with which one or more of the authors is associated." Study dates: February 1994 to June 1995
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	No details
Allocation concealment (selection bias)	Low risk	Quotes: "At admission, patients were randomized by a closed, opaque envelope method and were assigned to receive either..." Confirmed by Adams in 2001 that "the opaque envelopes were sequentially numbered" ‐ and that there was concealment of allocation.
Blinding of participants and personnel (performance bias) All outcomes	Low risk	It is not possible to blind surgeons to the type of intervention. We did not, however, expect that this would influence surgeon performance.
Other performance bias: surgeon experience of both implants	Low risk	Quote (from draft report): "The surgeons were experienced in the insertion of both implants".
Blinding of outcome assessment: mortality (detection bias)	Low risk	We did not expect that lack of blinding of outcome assessors would influence objective outcome data.
Blinding of outcome assessment: unplanned return to theatre (detection bias)	High risk	It is not possible to blind surgeons to treatment groups. We judged that knowledge of the type of implant could influence judgments made by surgeons when assessing subjective outcomes.
Blinding of outcome assessment: HRQoL (detection bias)	Low risk	Quote: "Observed‐blinded functional assessments were carried out by the unit research physiotherapist, by use of the Harris hip score."
Incomplete outcome data (attrition bias) All outcomes	Low risk	Most losses were explained by death, which is expected in this population, and losses were reasonably balanced between groups.
Selective reporting (reporting bias)	Unclear risk	Study authors do not report details of pre‐published protocol or clinical trial registration. It is not feasible to effectively assess risk of reporting bias without these documents.
Other bias	Low risk	We identified no other sources of bias.

*Study characteristics*
Methods	RCT; parallel design Review comparison group: PFN versus DHS
Participants	Total number of randomised participants: 68 Inclusion criteria: 40 to 75 years of age; presenting with AO type A2 and A3 pertrochanteric fracture of femur diagnosed on history, clinical examination and radiograph Exclusion criteria: people with anaesthesia risk; pathological fracture; previous surgical intervention on the affected hip; metabolic bone disease diagnosed on history, clinical examination, baseline investigations, ECG, and radiograph Setting: single centre; hospital; Pakistan Baseline characteristics Intervention group 1 (PFN) Age, mean (SD): 59.32 (± 2.39) years Gender, M/F: 25/9 Fracture classification, A2/A3, n: 17/19 (we noted a discrepancy ‐ reported numbers do not add up to 34) Intervention group 2 (DHS) Age, mean (SD): 60.88 (± 12.49) years Gender, M/F: 22/12 Fracture classification, A2/A3, n: 15/17 (we noted a discrepancy ‐ reported numbers do not add up to 34) Note: study authors do not report baseline characteristics for: smoking history, medication, BMI, comorbidities, mobility assessment, place of residence, cognitive status, ASA status, or preoperative waiting times
Interventions	General details: single surgical team; ceftriaxone 1 g given half an hour before surgery, and continued 2 g per day for 3 postoperative days; general or spinal anaesthesia; encouraged to take up ankle and calf exercises from POD1, mobilised non‐weight bearing from POD2 depending on physical condition of participant Intervention group 1: PFN; study authors did not report the nail manufacturer, type of lag screw, whether the lag screw was locked or dynamic or the length of the nails number randomised to group = 34 Intervention group 2: CHS; study authors did not report the manufacturer of the extramedullary device number randomised to group = 34 Note: study authors do not report the skills or experience of surgical team
Outcomes	Outcomes measured/reported by study authors: union, operation time, volume of blood loss, complications (infection, non‐union, mal‐union, and implant failure); functional outcome (using HHS with grades of excellent, good, fair, and poor; and mean scores) Outcomes relevant to the review: none
Notes	Funding/sponsor/declarations of interest: no funding; study authors declare no conflicts of interest Study dates: September 2015 to September 2017 Note: we did not conduct risk of bias assessment because this study reported no review‐relevant outcomes.

*Study characteristics*
Methods	Quasi‐randomised; parallel design Review comparison group: fixed angle plate versus PFLCP
Participants	Total number of randomised participants: 52 Inclusion criteria: people who gave consent for inclusion into the study; > 18 years of age; and closed intertrochanteric fractures Exclusion criteria: people refusing to give consent; AO type 31A3 fractures; neurovascular injury; open fractures; associated ipsilateral or contralateral major limb injury (including fractures) affecting the treatment or rehabilitation protocol; associated upper limb fractures requiring surgery; major systemic illness (malignancy, chronic kidney, liver disease, etc.) Setting: single centre; hospital; India Baseline characteristics Intervention group 1 (DHS) Age, mean (range): 55.23 (24 to 76) years Gender, M/F: 17/9 Fracture classification, AO classification, 31A1.1/31A1.2/31A1.3 (stable)/31A2.1 (unstable)/31A2.2 (unstable)/31A2.3 (unstable), n: 3/6/4/7/2/4 Intervention group 2 (PFLCP) Age, mean (range): 56.46 (23 to 78) years Gender, M/F: 15/11 Fracture classification, AO classification, 31A1.1/31A1.2/31A1.3 (stable)/31A2.1 (unstable)/31A2.2 (unstable)/31A2.3 (unstable), n: 4/5/3/7/4/3 Note: study authors reported no baseline characteristics for: smoking history, medication, BMI, comorbidities, mobility assessment, place of residence, cognitive status/dementia, ASA status, preoperative waiting time
Interventions	General details: all surgeries performed on traction table; all surgeries performed by single surgeon; prophylactic antibiotics given preoperatively; mobilisation from POD1, toe‐touch weight bearing in DHS group at 7 days and in PFLCP group at least 6 weeks; follow‐up at 6, 12, 16, and 24 weeks, and at 3‐monthly intervals until radiological union Intervention group 1: Dynamic hip screw (manufacturer details not reported) Number randomised = 26; no losses; analysed = 26 Intervention group 2: Proximal femur locking compression plate (PFLCP) (manufacturer details not reported but it is highly likely that it is made by Synthes) fixed angle locking plate that allows up to three screws to be inserted into the femoral neck, Number randomised = 26; no losses; analysed = 26 Note: study authors did not report type of anaesthesia or skills and experience of surgeons
Outcomes	Outcomes measured/reported by study authors: duration of surgery; blood loss; need for postoperative blood transfusion; duration of hospital stay; time to radiological union; functional status; significant limb shortening; medialisation of shaft; mortality; complications (septicaemia, DVT, pulmonary embolism, stroke, MI); non‐specific hip pain; varus deformity; superficial wound infection; non‐union Outcomes relevant to the review: mortality Note: time point for mortality is not clearly reported. Study authors report a minimum follow‐up of 12 months and we have included this data at 12 months.
Notes	Funding/sponsor/declarations of interest: study authors declare no external financial aid was provided with no conflict of interest Study dates: June 2011 to June 2013
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	Participants selected on odd/even numbers
Allocation concealment (selection bias)	High risk	It is not possible to conceal allocation because of the quasi‐randomised methods.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	It is not possible to blind surgeons to treatment groups. All surgeries were performed by a single surgeon with no experience reported. We could not be certain whether the surgeon was equally experienced in using both implants.
Other performance bias: surgeon experience of both implants	Unclear risk	Skills and experience of surgeon is not reported and we could not be certain whether experience comparable for both implants
Blinding of outcome assessment: mortality (detection bias)	Low risk	We did not expect blinding to influence detection bias for this outcome.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Study authors reported that no participants were lost to follow‐up.
Selective reporting (reporting bias)	Unclear risk	Study authors did not report pre‐published protocol or clinical trial registration. It was not feasible to effectively assess risk of selective bias without these documents.
Other bias	Unclear risk	We noted differences in the time to weight bearing between the two groups. This could influence outcomes.

*Study characteristics*
Methods	Quasi‐randomised trial; parallel design Review comparison group: screw PFN versus helical PFN
Participants	Total number of randomised participants: 77 Inclusion criteria: skeletally‐mature participants > 50 years of age; new mobility score of 9 (Palmer and Parker 1993); closed unstable trochanteric fracture classified as AO 31A2 and A3 Exclusion criteria: immature skeleton; pathological fracture of any cause other than osteoporosis, open fractures, inability to walk independently prior to injury event Setting: single centre; hospital; India Baseline characteristics Intervention group 1 (screw PFN) Age, mean: 69.1 years Gender, M/F ratio: 1:2 Preoperative waiting time, mean: 6.12 days Fracture classification, 31A2/31A3, n: 28/12 Intervention group 2 (helical PFN) Age, mean: 71.2 years Gender, M/F: 9/28 Preoperative waiting time, mean: 5.90 days Fracture classification, 31A2/31A3, n: 27/10 Note: study authors report no data for: smoking history; medication; BMI; comorbidities; mobility assessment; place of residence; cognitive status/dementia; ASA status
Interventions	General details: all operations were performed on fracture table in supine position under general anaesthesia; crutch walking with partial weight bearing was allowed after 48‐hour drain removal; suture was removed on 12th day Intervention group 1 Proximal femoral nail (PFN) screw (manufacturer not reported), fixed with two dynamic cephalic screws and distal locking Number randomised = 40 Intervention group 2 Proximal femoral nail (PFN) helical blade (manufacturer not reported), fixed with dynamic cephalic helical blade and distal locking Number randomised = 37 Note: study authors did not report the number of clinicians (or their skills and experience), and use of prophylactic antibiotics or antithromboembolics
Outcomes	Outcomes measured/reported by study authors: operation time; blood loss; duration of hospitalisation; time before operation; HHS; time to union Outcomes relevant to the review: none Note: study authors did not include date on mortality, HRQoL or unplanned return to theatre
Notes	Funding/sponsor/declarations of interest: not reported Study dates: June 2008 to August 2011 Note: we did not conduct risk of bias assessment because this study reported no review‐relevant outcomes

*Study characteristics*
Methods	Quasi‐RCT; parallel design Review comparison group: Gamma nail versus DHS
Participants	Total number of randomised participants: 95 Inclusion criteria: trochanteric and subtrochanteric proximal femoral fractures Exclusion criteria: not reported Setting: single centre; orthopaedic hospital, UK Baseline characteristics Intervention group 1 (Gamma nail) Age, mean (range): 79 (55 to 92) years Gender, M/F: 16/31 Cognitive status, mental test score, mean: 6.8 Fracture classification, stable/unstable, n: intertrochanteric, 18/16 subtrochanteric, 5/8 Intervention group 2 (DHS) Age, mean (range): 78 (47 to 101) years Gender, M/F: 13/35 Cognitive status, mental test score, mean: 6.9 Fracture classification, stable/unstable, n: intertrochanteric, 12/14 subtrochanteric, 3/4 Note: study authors did not report: smoking history; medication; BMI; preoperative waiting time; comorbidities; mobility; place of residence
Interventions	General details: standard surgical procedures; surgical experience is unknown; same surgeons did both operations Intervention group 1 Gamma nail (Howmedica); predominantly short nails; 3 cases that suffered further fractures were treated with long nails; Randomised = 47; no reported losses; analysed for all outcomes = 47 Intervention group 2 DHS (Stratec); no further details reported Randomised = 48; no reported losses; analysed for all outcomes = 48 Notes: details regarding distal locking of nails were not reported in the manuscript study authors did not report details for: surgeon experience, type of anaesthesia, prophylactic use of antibiotics or antithromboembolics, postoperative mobilisation and weight bearing
Outcomes	Outcomes measured/reported by study authors: length of surgery; blood loss; later fracture of the femur; cut‐out of implant (incomplete data); non‐union (time to union); re‐operation (total inferred); wound infection; pneumonia; pressure sore; DVT; any medical complication; LOS; mortality; length of follow‐up: 'to fracture union' (generally < 6 months) Outcomes relevant to the review: mortality (5 months); unplanned return to theatre Notes: participants were followed up until satisfactory union occurred, time to union stated as (mean) 150 days for Gamma nails and 142 days for DHS
Notes	Funding/sponsor/declarations of interest: quote: "No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article" Study dates: not reported Note: we noted that the Gamma nail technique was modified without apparent advantage after 37 participants were treated with a Gamma nail
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	Quote: "Patients admitted on even‐numbered weeks were treated with a DHS and patients admitted on odd‐numbered weeks were treated with a gamma nail."
Allocation concealment (selection bias)	High risk	It is not possible to conceal allocation because of methods used to randomise participants.
Blinding of participants and personnel (performance bias) All outcomes	Low risk	It is not possible to blind surgeons to the type of intervention. We did not, however, expect that this would influence surgeon performance.
Other performance bias: surgeon experience of both implants	Unclear risk	Same surgeons did both operations, but no mention of experience and interim modification of surgical technique by the manufacturers
Blinding of outcome assessment: mortality (detection bias)	Low risk	We did not expect that lack of blinding of outcome assessors would influence objective outcome data.
Blinding of outcome assessment: unplanned return to theatre (detection bias)	High risk	It is not possible to blind surgeons to treatment groups. We judged that knowledge of the type of implant could influence judgments made by surgeons when assessing subjective outcomes.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Losses were balanced and explained by death, which is expected in this population.
Selective reporting (reporting bias)	Unclear risk	Study authors do not report registration with a clinical trials register or pre‐published protocol. It is not feasible to effectively assess risk of selective reporting bias without these documents.
Other bias	Low risk	We identified no other sources of bias.

*Study characteristics*
Methods	RCT, parallel groups Review comparison group: CHS versus PCCP
Participants	Total number of randomised participants: 111 Inclusion criteria: extracapsular fractures Exclusion criteria: pathological fractures; subtrochanteric fractures Setting: hospital, single centre, UK Baseline characteristics Intervention group 1 (CHS) Age, mean (SD; range): 82.8 (± 9; 57 to 97) years Gender, M/F: 12/44 Cognitive status/dementia, mini‐mental state score, mean (SD): 7.8 (± 2.7) Fracture classification, stable/unstable, n: 25/31 Intervention group 2 (PCCP) Age, mean (SD; range): 82.7 (± 8.5; 53 to 93) years Gender, M/F: 8/44 Cognitive status/dementia, mini‐mental state score, mean (SD): 8.6 (± 2.1) Fracture classification, stable/unstable, n: 24/28 Note: study authors did not report: smoking history, medication, BMI, comorbidities, mobility assessment/use of walking aides, place of residence, ASA status, preoperative waiting time
Interventions	General details: perioperative antibiotics were given and antithromboembolic stockings were worn; "three experienced surgeons who had been instructed in the use of the PCCP by its inventor before embarking on this project"; postoperative rehabilitative regime was identical for the two groups; weight bearing on first or second postoperative day; follow‐up at 6 weeks and 3 and 6 months after surgery Intervention group 1 Compression Hip Screw (Smith & Nephew) Number randomised = 56 Intervention group 2: Gotfried percutaneous compression plate (PCCP) (Efratgo Ltd); femoral head fixation with two dynamic neck screws; plate fixation with three cortical shaft screws Number randomised = 52 Note: 3 participants switched from PCCP to CHS due to technical difficulties; these were reported separately, but included in analysis as PCCP due to intention‐to‐treat
Outcomes	Outcomes measured/reported by study authors: length of surgery; blood loss; blood transfusion; LOS; DVT; PE; chest infection; cardiac complication; CA; gastrointestinal bleeding; superficial and deep infection; pressure sore; cut‐out; heel raise required; mortality (available within 48 hours, 2 to 30 days, and 30 days to 6 months) Outcomes relevant to the review: mortality (with 30 days, 6 months) Note: 1 death from the PCCP to CHS group reported on intention‐to‐treat basis with the PCCP group
Notes	Funding/sponsor/declarations of interest: study authors state no external funding was received Study dates: not reported Note: we did not conduct risk of bias assessment for this study because we were unable to include any data in the networks.

*Study characteristics*
Methods	RCT; parallel design; 3 study arms Review comparison group: PFN versus TGN versus DHS
Participants	Total number of randomised participants: 141 Inclusion criteria: unstable trochanteric proximal femoral fracture (see Notes); AO 31‐A2 and A3; > 60 years of age Exclusion criteria: unable to walk before injury; pathologic fractures; previous ipsilateral hip or femur surgery; any fracture with extension 5 cm distal to the inferior border of the lesser trochanter; stable trochanteric fractures classified as AO Type 31‐A1 Setting: single centre; orthopaedic hospital; Greece Baseline characteristics Intervention group 1 (PFN) Age, mean (SD): 79.4 years Gender, M/F: 17/23 ASA status, I/II/III/IV: 15/11/14/0 Fracture classification, A2/A3, n: 24/16 Additional information: Functional status (Salvati 1973, from 0 to 40 with higher scores indicating greater function), n: > 30 = 31; 20 ‐ 29 = 5; < 20 = 4 Intervention group 2 (TGN) Age, mean (SD): 82.8 years Gender, M/F: 16/24 ASA status, I/II/III/IV: 14/11/15/0 Fracture classification, A2/A3, n: 26/14 Additional information: Functional status (Salvati 1973, from 0 to 40 with higher scores indicating greater function), n: > 30 = 30; 20 ‐ 29 = 6; < 20 = 4 Intervention group 3 (DHS) Age, mean (SD): 81.4 years Gender, M/F: 14/26 ASA status, I/II/III/IV: 13/10/17/0 Fracture classification, A2/A3, n: 27/13 Additional information: Functional status (Salvati 1973, from 0 to 40 with higher scores indicating greater function), n: > 30 = 29; 20 ‐ 29 = 6; < 20 = 5 Note: study authors did not report: smoking history, medication, BMI, comorbidities, cognitive status/dementia, mobility, preoperative waiting time
Interventions	General details: 4 surgeons (extensive experience of TGN and DHS but limited with PFN); prophylactic antibiotics intraoperatively and 2 doses postoperatively; subcutaneous low‐molecular‐weight heparin for 6 weeks; rehabilitation was identical in all groups; mobilisation on the second postoperative day and subsequent ambulation with weight bearing as tolerated Intervention group 1 PFN (Synthes); 11 mm or 12 mm diameter PFN; all nails were locked proximally with 2 screws and distally; the standard 240 mm nail was used Randomised = unknown Intervention group 2 TGN (Stryker‐Howmedica); 180 mm long; 135 degrees with 17 mm proximal diameter and 11 mm distal diameter and distal locking in all participants Randomised = unknown Intervention group 3 SHS Ambi (Smith and Nephew); Ambi means the barrel is not keyed and so the lag screw can rotate Randomised = unknown Note: "Non‐survivors prior to first postoperative year (ten patients) and those who lost last follow‐up evaluation (11 patients) were excluded leaving a total of 120 patients for the outcome analysis"
Outcomes	Outcomes measured/reported by study authors: length of surgery; operative blood loss; radiographic screening time; operative fracture (some of greater trochanter); cut‐out of implant; later fracture of the femur; non‐union; re‐operation; superficial wound infection; haematoma; medical complications; chest infection; pneumonia; mental disturbances; DVT; PE; urinary infection; LOS; time to fracture consolidation; function: scores using Salvati 1973; length of follow‐up: mean 12 months Outcomes relevant to the review: mortality (during hospital stay); unplanned return to theatre (at 12 months)
Notes	Funding/sponsor/declarations of interest: not reported Study dates: January 2000 to December 2003 Note: we did not conduct risk of bias assessment for this study because we were unable to include any data in the networks.

Study	Reason for exclusion
ACTRN12608000162314	Study comparing Gamma nail versus DHS. We received communication from the study contact (Rob Molnar; on 3 August 2015) to explain that the study was abandoned early because of poor recruitment. We excluded this study because no outcome data are available.
Ahmad 2011	RCT comparing intramedullary hip screw versus compression hip screw. Published only as abstracts which contain insufficient information to justify inclusion in the review.
Alobaid 2004	Quasi‐RCT comparing minimally‐invasive surgical technique with a conventional surgical technique using a DHS in both groups. We excluded this study because it did not compare interventions from our review criteria.
Bong 1981	RCT comparing skeletal traction with tibial pin versus medial displacement osteotomy versus valgus osteotomy. We excluded this study because the comparisons were not consistent with our review criteria.
El‐Desouky 2016	RCT comparing proximal femoral locking plate versus anatomical reduction. We excluded this study because it included mostly younger participants with high‐energy trauma.
Emami 2013	Quasi‐RCT comparing DHS with bipolar HA. We excluded this study because the participants were aged between 45 and 65 years of age, and therefore did not meet our review criterion of older participants.
Gupta 2012	RCT comparing condylocephalic nail versus compression hip screw. We excluded this study because it was reported as an abstract with insufficient information.
Kumar 1996	RCT comparing anatomical reduction with medialisation osteotomy using a DHS in both groups. We excluded this study because it did not compare interventions from our review criteria.
Kumar 2006	RCT comparing DHS versus DHS with modular TSP fixation in unstable intertrochanteric fractures. We excluded this study because it was reported as an abstract with insufficient information.
Lee 2007a	RCT comparing minimally‐invasive surgical technique with a conventional surgical technique using a DHS in both groups. We excluded this study because it did not compare interventions from our review criteria.
Lee 2007b	Quasi‐RCT comparing Russell‐Taylor reconstruction intramedullary nail versus dynamic condylar screw. We excluded this study which evaluates hip fractures in younger adults < 55 years of age.
Li 2015a	RCT comparing traditional Chinese medicine with conventional treatment using a DHS in both groups. We excluded this study because it did not compare interventions from our review criteria.
NCT00323232	RCT comparing DHS as either a 2‐hole or 4‐hole device. Study is registered as completed in the clinical trials register in 2011. We have not sourced a full‐text report for this study and we do not expect the results of this study will be published.
NCT00686023	RCT comparing inflatable PFN versus DHS. Clinical trials register states that expected study completion was in 2012. The trial register has not been updated. We excluded this study because we presume that this study has not been, or is unlikely to be, completed.
NCT00736684	RCT comparing Gamma nail versus PFNA. Clinical trials register states that study completion was in 2009. The trial register has not been updated. We excluded this study because we presume that this study has not been, or is unlikely to be, completed.
NCT01173744	RCT comparing Gamma nails with DHS. Clinical trials register states that expected study completion was in 2012. The trial register has not been updated. We excluded this study because we presume that this study has not been, or is unlikely to be, completed.
NCT01238068	RCT comparing Gamma nail with DHS. Clinical trials register states that expected study completion was in 2011. The trial register has not been updated. We excluded this study because we presume that this study has not been, or is unlikely to be, completed.
NCT03065101	RCT comparing Trigen Intertan nail with SHS. Clinical trials register states that the study was terminated because of low recruitment. We excluded this study because we did not have contact details for the principal investigator to confirm study status/recruitment, and we presume that the results of this study are unavailable.
Savadhkoohi 2016	RCT comparing intramedullary nail with dynamic compression screw in subtrochanteric fractures. We excluded this study because it was reported as an abstract with insufficient information.
Sher 1985	Oral presentation of RCT comparing SHS with Küntscher Y nail. We excluded this study because the short report/abstract contained insufficient information.
Wong 2009	RCT comparing minimally‐invasive surgical technique with a conventional surgical technique using a DHS in both groups. We excluded this study because it did not compare interventions from our review criteria.

Methods	RCT; parallel design
Participants	Estimated participant enrolment: unknown Inclusion criteria: people with extracapsular fractures
Interventions	Compression hip screw versus intramedullary hip screw
Outcomes	Stroke volume, cardiac output, mean arterial pressure; oxygen saturation; length of hospital stay; pulmonary embolism; mortality
Notes	At the time of adding this study to the Review Manager file, the WHO search trial portal was unavailable. We have used limited information available in the Cochrane Central Register of Controlled Trials. The year of publication is reported as 2005, and we therefore expect that this study is completed. We do not have contact details and have not been able to determine if this study is already published.

Methods	RCT, parallel design
Participants	Expected number of participants: 60 Inclusion criteria 55 to 95 years fresh unstable (AO/OTA type A2) pertrochanteric fracture if medically fit, participant will undergo surgical fixation within 48 hours of admission. Otherwise, all participants must undergo surgery within 7 days of admission. informed consent/assent to participate in the study in the opinion of investigating team, participant able to complete the study assessment and visit schedule
Interventions	Endovis BA2 nail versus DHS
Outcomes	Mobility (TUG); length of hospital stay
Notes	We contacted trialists (Peter Giannoudis) in April 2021. Trialists confirmed that publication is in process but were unable to share data at this point.

Study name	Locking plate for treatment of intertrochanteric hip fractures
Methods	RCT, parallel design
Participants	Estimated participant enrolment: 100 Inclusion criteria: primary intertrochanteric hip fracture; BMI < 30 kg/m²; no other diseases likely to affect outcome of fracture healing; no other previous surgical treatments Exclusion criteria: BMI > 30 kg/m²; other surgical treatment; health condition is not stable; other diseases affecting bone healing (such as cancer, kidney disease, needing corticosteroids)
Interventions	Locking plate versus Gamma nail
Outcomes	Incision length; transfusion volume; healing of fracture; functional scores (HHS); range of movement
Starting date	November 2010; register describes study as still recruiting
Contact information	Zhao Xiang; dr.zhaoxiang@gmail.com
Notes

Study name	Evaluating the treatment methods of proximal femur fractures in elderly trauma patients
Methods	RCT, parallel design
Participants	Estimated participant enrolment: 900 Inclusion criteria: traumatic extracapsular hip fracture; closed injury; aged over 60 years; ability to be followed for up to 6 months; presentation to hospital within 14 days of injury Exclusion criteria: concomitant injuries affecting treatment and rehabilitation of the affected limb; associated neurovascular injuries requiring immediate surgery; consent is refused; limited English proficiency including family members
Interventions	InterTAN (locked and unlocked) versus Gamma nail (unlocked)
Outcomes	Device failure; injury‐specific complications (perioperative technical complications, surgical site infection, unplanned surgery, mortality); functional independence measure (FIM); TUG; re‐operation; general medical complications; return to mobility circumstances; gross motor activity; duration of operation; fluoroscopy time; TAD; range of motion; hip join contact forces and moments; hip muscle function; hip muscle asymmetry; nail and screw sizes used by operating team; HHS; pain (VAS)
Starting date	August 2018
Contact information	A/Prof Mark Rickman; mark.rickman@sa.gov.au
Notes

PERMALINK

Surgical interventions for treating extracapsular hip fractures in older adults: a network meta‐analysis

Sharon R Lewis

Richard Macey

Joseph Lewis

Jamie Stokes

James R Gill

Jonathan A Cook

William GP Eardley

Martyn J Parker

Xavier L Griffin

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Background

Description of the condition

Epidemiology

Burden of disease

Extracapsular hip fracture

1. Trochanteric region fractures: type and surgical management (Revised AO/OTA classification, January 2018).

Description of the intervention

Osteosynthesis

2. Categorisation of internal and external fixation interventions for extracapsular hip fractures.

3. Categorisation of arthroplasty interventions for extracapsular hip fractures.

Arthroplasty

Hemiarthroplasty

Total hip arthroplasty

Component fixation

Cemented systems

Uncemented systems

Non‐operative management

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Population

Types of interventions

Grouping interventions

Types of outcome measures

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Summary measures

Relative treatment effects

Relative treatment ranking

Unit of analysis issues

Alternative trial designs

Reports of outcomes at different time points

Studies with multiple treatment groups

Dealing with missing data

Assessment of heterogeneity

Assessment of clinical and methodological heterogeneity within treatment comparisons

Assumptions when estimating the heterogeneity

Measures and tests for heterogeneity

Pairwise comparisons

Entire network

Assessment of statistical incoherence

Global approaches for evaluating incoherence

Local approaches for evaluating incoherence

Investigation of heterogeneity

Assessment of transitivity across treatment comparisons

Geometry of the network

Presentation of results

Assessment of reporting biases

Data synthesis

Methods for direct treatment comparisons

Study name	A randomized control trial for combined proximal femur intramedullary nail and lateral wall plate for the treatment of pantrochanteric fracture
Methods	Unknown
Participants	Estimated participant enrolment: unknown Inclusion criteria: at least 60 years of age; male and female; diagnosis of internal and external unstable femoral intertrochanteric fractures (Babhulkar modified type B and C fractures); undergoing surgery in the hospital; informed consent
Interventions	Intramedullary nail versus intramedullary nail with lateral plate
Outcomes	Failure rate; fracture‐associated complications; operative time; blood loss during surgery; length of hospital stay; medical complications; VAS; HHS
Starting date	Unknown
Contact information	Unknown
Notes	At the time of adding this study to the Review Manager file, the WHO search trial portal was not available. We have used limited information available in the Cochrane Central Register of Controlled Trials.

Study name	Intertrochanteric fracture in the elderly: a randomized comparison of reduction and fixation and total hip arthroplasty
Methods	Unknown
Participants	Estimated participant enrolment: unknown Inclusion criteria: > 65 years of age; intertrochanteric fracture; informed consent
Interventions	Femoral head replacement or THA
Outcomes	Radiological evaluation; routine blood text; HHS; blood transfusion rate; DVT
Starting date	Unknown
Contact information	Unknown
Notes	At the time of adding this study to the Review Manager file, the WHO search trial portal was not available. We have used limited information available in the Cochrane Central Register of Controlled Trials.

Study name	Minimally invasive percutaneous compression plating versus dynamic hip screw for intertrochanteric fractures
Methods	Unknown
Participants	Estimated participant enrolment: unknown Inclusion criteria: > 60 years of age; intertrochanteric fracture amenable to satisfactory reduction (type AO/OTA 31.A1‐A2, Evans type1); ability to ambulate independently prior to the fracture with or without assistive devices
Interventions	PCCP versus DHS
Outcomes	Blood loss; postoperative complications; VAS; HHS
Starting date	Unknown
Contact information	Unknown
Notes	At the time of adding this study to the Review Manager file, the WHO search trial portal was not available. We have used limited information available in the Cochrane Central Register of Controlled Trials.

Study name	A clinical study to evaluate the outcomes of singe lag screw and helical blade nailing in treatment of intertrochanteric femur fractures
Methods	Unknown
Participants	Estimated participant enrolment: unknown Inclusion criteria: people with intertrochanteric fracture presenting to the institution during this period; low‐energy trauma; fracture < 3 weeks old
Interventions	Single lag screw nailing versus helical blade nailing
Outcomes	Functional outcomes (modified HHS); comorbidities; pullout rate; neck shaft angle; implant position and cut‐out rate; union rate; neck length
Starting date	Unknown
Contact information	Unknown
Notes	At the time of adding this study to the Review Manager file, the WHO search trial portal was not available. We have used limited information available in the Cochrane Central Register of Controlled Trials.

Study name	A study to compare the results using dynamic hip screw and modified proximal femoral locking compression plate in fractures around the hip
Methods	Unknown
Participants	Estimated participant enrolment: unknown Inclusion criteria: people with post‐traumatic intertrochanteric fractures; adults > 18 years of either sex; intertrochanteric fractures with subtrochanteric extension; fractures included in 31A1 and 31A2 AO classification
Interventions	Modified proximal femoral locking compression plate versus DHS
Outcomes	Functional and radiological outcomes; complications
Starting date	Unknown
Contact information	Unknown
Notes	At the time of adding this study to the Review Manager file, the WHO search trial portal was not available. We have used limited information available in the Cochrane Central Register of Controlled Trials.

Study name	Comparison proximal femoral nailing (PFN) versus dynamic hip screw (DHS) in ‎intertrochanteric fracture
Methods	RCT, parallel design
Participants	Estimated participant enrolment: 36 Inclusion criteria: intertrochanteric fracture, ≥ 18 years of age, either gender, fracture < 2 weeks old, lack of multiple fractures, absence of pathologic fracture, lack of background bone disease
Interventions	PFN versus DHS
Outcomes	Wound healing; clinical improvement of fracture by radiological examination
Starting date	March 2018
Contact information	Fariba Farokhi; f.farokhi@arakmu.ac.ir; Arak University of Medical Sciences; Iran
Notes

Study name	Results of intertrochanteric fractures treated with dynamic hip screw (DHS) with or without use of static screw
Methods	Unknown
Participants	Estimated participant enrolment: unknown Inclusion criteria: intertrochanteric fractures
Interventions	DHS (conventional use) versus DHS with an additional static screw superior to the DHS
Outcomes	Failure of treatment; HHS; VAS; fracture union
Starting date	Unknown
Contact information	Unknown
Notes	At the time of adding this study to the Review Manager file, the WHO search trial portal was not available. We have used limited information available in the Cochrane Central Register of Controlled Trials.

Study name	Comparison of dynamic hip screw and dynamic external fixator in intertochanteric fractures
Methods	RCT
Participants	Estimated participant enrolment: unknown Inclusion criteria: intertrochanteric fracture of type A1 or A2; > 65 years of age; bone density less than 2.5 in T score; able to walk without help before the fracture; participant should be at high anaesthetic risk
Interventions	DHS versus dynamic external fixator
Outcomes	Pain; length of hospital stay; haematocrit
Starting date	Unknown
Contact information	Unknown
Notes	At the time of adding this study to the Review Manager file, the WHO search trial portal was unavailable. We have used limited information available in the Cochrane Central Register of Controlled Trial.

Study name	Prospective study for treatment of femoral intertrochanteric fracture ‐ ORIF vs bipolar prosthesis
Methods	RCT, parallel design
Participants	Estimated participant enrolment: 40 Inclusion criteria: < 80 years of age; with femoral intertrochanteric fracture Exclusion criteria: bilateral cases; severe dementia; neurological impairment
Interventions	Open reduction and internal fixation (ORIF) versus bipolar hip prosthesis
Outcomes	Muscle strength; functional evaluation using Barthel Index for walking or stair climbing
Starting date	August 2015
Contact information	Mitsuaki Noda; m‐noda@muf.biglobe.ne.jp
Notes

Study name	Treatment of intertrochanteric fracture with new type of intramedullary nail
Methods	RCT, parallel design
Participants	Estimated participant enrolment: 36 Inclusion criteria adult men or women aged 18 years and older (with no upper age limit) intertrochanteric fracture confirmed with either anteroposterior and lateral hip radiographs, computed tomography or MRI operative treatment of fractures within 14 days of presenting to the emergency room ambulatory prior to fracture, though they may have used an aid such as a cane or a walker anticipated medical optimisation for operative fixation of the hip provision of informed consent by participant or legal guardian no other major trauma Exclusion criteria not suitable for internal fixation (i.e. severe osteoarthritis, rheumatoid arthritis or pathologic fracture) associated major injuries of the lower extremity (i.e. ipsilateral or contralateral fractures of the foot, ankle, tibia, fibula, knee or femur; dislocations of the ankle, knee or hip; or femoral head defects or fracture) retained hardware around the affected hip infection around the hip (i.e. soft tissue or bone) disorders of bone metabolism except osteoporosis (i.e. Paget's disease, renal osteodystrophy, osteomalacia) moderate or severe cognitively impaired patients (i.e. Six Item Screener with 3 or more errors) Parkinson's disease (or dementia) severe enough to increase the likelihood of falling or severe enough to compromise rehabilitation likely problems, in the judgment of the investigators, with maintaining follow‐up. We will, for example, exclude people with no fixed address, those who report a plan to move out of town in the next year, or intellectually challenged individuals without adequate family support
Interventions	PFNA versus new type of intramedullary nail (Weigao Orthopaedic Device Co. Ltd)
Outcomes	Bone healing; rates of revision surgery; quality of life (SF‐36, ADL, FIM); complications (mortality, non‐union, implant breakage/failure, infection, DVT)
Starting date	September 2011; clinical trials register states that study is still recruiting
Contact information	Tang Peifu; Chinese PLA General Hospital
Notes