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Journal of Orthopaedics and... Jun 2016While proximal humerus fractures remain common within the elderly population, the optimal treatment method remains controversial. Intramedullary nailing has been... (Review)
Review
BACKGROUND
While proximal humerus fractures remain common within the elderly population, the optimal treatment method remains controversial. Intramedullary nailing has been advocated as an effective and less invasive surgical technique. The purpose of this study is to elucidate the demographics, outcomes, and complications of intramedullary nailing for acute, displaced proximal humerus fractures.
MATERIALS AND METHODS
Multiple computerized literature databases were used to perform a systematic review of English-language literature. Studies that met our stated criteria were further assessed for the requisite data, and when possible, similar outcome data were combined to generate frequency-weighted means.
RESULTS
Fourteen studies with 448 patients met our inclusion criteria. The frequency-weighted mean age was 64.3 years, and mean follow-up was 22.6 months. Females accounted for 71 % of the included patients. Three-part fractures (51 %) were most commonly treated. The overall frequency-weighted mean Constant score was 72.8, and American Shoulder and Elbow Surgeons (ASES) score was 84.3. Frequency-weighted mean forward elevation, abduction, extension, and external rotation were 137.3°, 138.4°, 33.8°, and 43.1°, respectively. The Constant score for two- and three-part fractures was significantly higher than for four-part fractures (p = 0.007 and p = 0.0009, respectively). The reoperation rate for two-, three-, and four-part fractures was 13.6, 17.4, and 63.2 %, respectively.
CONCLUSIONS
Intramedullary nailing of acute, displaced two- and three-part proximal humerus fractures yields satisfactory clinical outcomes, although reoperation and complication rates remain high. Use of this implant for four-part fractures cannot be recommended until further clinical studies with larger patient numbers are available.
LEVEL OF EVIDENCE
Level IV, Systematic review.
Topics: Bone Nails; Fracture Fixation, Intramedullary; Humans; Outcome and Process Assessment, Health Care; Postoperative Complications; Shoulder Fractures
PubMed: 26507521
DOI: 10.1007/s10195-015-0384-5 -
The Journal of Foot and Ankle Surgery :... 2023The standard surgical treatment for unstable ankle fractures involves open reduction and internal fixation (ORIF) with plates. However, ORIF has been associated with... (Meta-Analysis)
Meta-Analysis Review
The standard surgical treatment for unstable ankle fractures involves open reduction and internal fixation (ORIF) with plates. However, ORIF has been associated with several complications, such as soft tissue irritation, wound infection, and nerve injury. Previous studies have shown that closed reduction and internal fixation with locked intramedullary nails (LIMNs) yields satisfactory efficacy in the treatment of ankle fractures and is associated with low complication rates. Therefore, a systematic review and meta-analysis of randomized controlled trials is imperative to provide evidence on whether or not LIMN fixation is comparable to or superior than traditional ORIF. We conducted a comprehensive literature search in the PubMed, Cochrane Library and EMBASE databases. A total of 4 randomized controlled trials involving 359 participants who suffered ankle fractures were included in this systematic review and meta-analysis. The results showed that the LIMN fixation group was statistically significant in terms of functional outcomes at the 3-month follow-up and wound-related complications. There was no statistical advantage for patients in the LIMN fixation group in terms of nonwound-related complications, total complications, or mid-term follow-up functional outcomes. There was no statistical difference between the LIMN and ORIF groups regarding operation time and quality of reduction. We believe LIMN fixation is a viable option for the treatment of unstable ankle fractures in both young and elderly individuals.
Topics: Humans; Aged; Ankle Fractures; Fibula; Treatment Outcome; Fracture Fixation, Internal; Fracture Fixation, Intramedullary; Bone Plates
PubMed: 36333182
DOI: 10.1053/j.jfas.2022.10.003 -
Journal of Shoulder and Elbow Surgery Oct 2016The purpose of this study was to perform a meta-analysis comparing the clinical outcomes and complications between anterior humeral minimally invasive plate... (Meta-Analysis)
Meta-Analysis Review
Minimally invasive plating versus either open reduction and plate fixation or intramedullary nailing of humeral shaft fractures: a systematic review and meta-analysis of randomized controlled trials.
HYPOTHESIS
The purpose of this study was to perform a meta-analysis comparing the clinical outcomes and complications between anterior humeral minimally invasive plate osteosynthesis (MIPO) and the 2 standard techniques, either open reduction and plating or humeral nailing.
METHODS
We performed a systematic review of Medline, Embase, Scopus, and Google Scholar to identify relevant randomized controlled trials in the English- and German-language literature. Eligibility criteria included randomized controlled trials comparing at least 1 surgical intervention with MIPO and reporting the primary clinical outcome using a validated functional scoring system and description of complications. Publication bias was assessed by funnel plot, and the risk of bias was established using the Cochrane Collaboration's Risk of Bias Tool. Heterogeneity was assessed using χ(2) and I(2) statistics.
RESULTS
Eight prospective randomized studies (N = 376) met the eligibility criteria and were included in the analysis. The pooled estimate for clinical outcome showed that MIPO resulted in a significantly better outcome (standardized mean difference, 0.366; 95% confidence interval, 0.16 to 0.571; P = .0001; I(2) = 61%). The pooled estimate for all complications showed that the open reduction-internal fixation/nail group had a significantly higher complication rate (odds ratio, 0.507; 95% confidence interval, 0.285 to 0.905; P = .021; I(2) = 97%).
CONCLUSION
Current evidence indicates the MIPO approach has better clinical outcomes with a lower rate of complications compared with alternative surgical techniques. However, the results of this meta-analysis are limited by problems inherent in the primary studies, including poor reporting of randomization protocols, as well as possible attrition bias and reporting bias, of the primary studies. Future publications may therefore change the trend of the pooled estimate in either direction.
Topics: Bone Nails; Bone Plates; Fracture Fixation, Intramedullary; Humans; Humeral Fractures; Minimally Invasive Surgical Procedures; Open Fracture Reduction; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 27522336
DOI: 10.1016/j.jse.2016.05.014 -
Knee Surgery, Sports Traumatology,... Jun 2021Press-fit fixation is a hardware-free technique in anterior cruciate ligament reconstruction (ACLR). The purpose of this review was to quantitatively assess the risk... (Meta-Analysis)
Meta-Analysis
PURPOSE
Press-fit fixation is a hardware-free technique in anterior cruciate ligament reconstruction (ACLR). The purpose of this review was to quantitatively assess the risk profile and outcomes of press-fit fixation and provide an update on its effectiveness compared to more standard fixation techniques of ACLR.
METHODS
The electronic databases PUBMED, MEDLINE, and EMBASE were searched on March 26, 2020 for therapeutic randomized controlled trials (RCT) addressing press-fit fixation for primary ACLR. The Grading of Recommendations Assessment, Development and Evaluation tool was used to assess the quality for randomized studies. A meta-analysis with a random-effects model was used to pool applicable outcomes data.
RESULTS
A total of six eligible RCTs were included in this review. There were 292 patients (72.9% male) with a mean age of 28.8 ± 3.8 years and a mean follow-up of 81.3 ± 88.3 months that underwent press-fit ACLR on the femoral, tibial or both tunnels. Femoral fixation techniques included press-fit fixation (96.6%) and cross-pin fixation (3.4%). Tibial fixation techniques included press-fit (37.0%), staples (28.1%), interference screws (21.2%) and abarticular post-screws (13.7%). Graft options included bone-patellar tend--bone autografts (73.6%) and semitendinosus and gracilis tendon autograft (26.4%). Significant improvements (p < 0.05) from baseline to follow-up were found for clinical outcomes. Significantly less postoperative bone tunnel enlargement (p < 0.05) was found with tibial press-fit fixation when compared to biodegradable screws. The overall complication rate was 13.3%. There were no significant differences in complication rates [odds ratio = 0.84 (95%CI 0.43-1.66); p = n.s.] (I = 0%) between patients undergoing femoral press-fit fixation and femoral metal interference screw fixation.
CONCLUSION
The overall graft failure and revision rates with press-fit ACLR were low. There were no significant differences in complication rates between patients undergoing femoral press-fit and femoral metal interference screw fixation. Included studies found that patients undergoing press-fit fixation for ACLR had significant improvements in functional outcome scores postoperatively and had significantly reduced postoperative bone tunnel enlargement compared to patients undergoing bioabsorbable fixation. Thus, early evidence suggests that press-fit fixation appears to be a good option for patients undergoing ACLR.
LEVEL OF EVIDENCE
I.
Topics: Adult; Anterior Cruciate Ligament; Anterior Cruciate Ligament Injuries; Anterior Cruciate Ligament Reconstruction; Arthroplasty; Bone Screws; Bone Transplantation; Female; Femur; Hamstring Muscles; Humans; Male; Patella; Randomized Controlled Trials as Topic; Reoperation; Rotation; Tendons; Tibia; Transplantation, Autologous
PubMed: 32785757
DOI: 10.1007/s00167-020-06173-4 -
Journal of Orthopaedic Trauma Apr 2022To perform a systematic review and meta-analysis of subtrochanteric femur fractures treated with an intramedullary nail, augmented with or without cerclage wiring,... (Meta-Analysis)
Meta-Analysis
Subtrochanteric Femur Fractures Treated With Femoral Nail: The Effect of Cerclage Wire Augmentation on Complications, Fracture Union, and Reduction: A Systematic Review and Meta-Analysis of Comparative Studies.
OBJECTIVE
To perform a systematic review and meta-analysis of subtrochanteric femur fractures treated with an intramedullary nail, augmented with or without cerclage wiring, comparing the risk of reoperation, nonunion, loss of fixation, and implant failure; fracture reduction and time to union.
DATA SOURCE
A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed through MEDLINE, EMBASE, PubMed, Web of Science, and Scopus databases using a combination of controlled vocabulary and keywords on September 30, 2020.
STUDY SELECTION
All comparative (prospective and retrospective) studies of subtrochanteric fractures managed with intramedullary nail, that compared the addition of cerclage wire to without in patients 16 years of age or older were included. Pathological, atypical bisphosphonate, and segmental fractures were excluded, as were non-English literature.
DATA EXTRACTION
Data from each study were independently recorded by 2 investigators.
DATA SYNTHESIS
Agreement was obtained on 18 studies (all retrospective) for final inclusion, with 378 patients receiving cerclage wire and 911 without. A random-effects meta-analysis was used to analyze the pooled aggregate data.
CONCLUSIONS
There is no statistically significant advantage in using cerclage wire with femoral intramedullary nail when treating subtrochanteric femur fractures regarding risk of reoperation, nonunion, loss of fixation, and implant failure or time to union. An advantage favoring cerclage wire was seen for accuracy of fracture reduction. Cerclage wiring was used more often in cases associated with high-energy trauma. Given the relatively small number of events available to be modelled, a clinical benefit for cerclage wiring may still exist for certain fracture types.
LEVEL OF EVIDENCE
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Topics: Bone Nails; Femoral Fractures; Femur; Fracture Fixation, Intramedullary; Hip Fractures; Humans; Prospective Studies; Retrospective Studies
PubMed: 34510127
DOI: 10.1097/BOT.0000000000002266 -
PloS One 2015The objective of this study was to systematically review the literature for a more comprehensive understanding of the complications of open elbow arthrolysis in patients... (Review)
Review
OBJECTIVE
The objective of this study was to systematically review the literature for a more comprehensive understanding of the complications of open elbow arthrolysis in patients with post-traumatic elbow stiffness and provide a reference for better prevention and treatment of them.
METHODS
The PubMed, EMBASE, Cochrane Library, and Google Scholar databases were searched for therapeutic studies with a set of inclusion and exclusion criteria. Data were extracted from selected articles, and a statistical analysis was performed to evaluate related factors and management of the complications.
RESULTS
Twenty-eight articles published between 1989 and 2013, involving 810 patients, were included. Most of the complications included in the selected articles were nerve complications, heterotopic ossification, elbow instability, infection, pin-related complications and repeat elbow contracture. The total complication rate was 24.3% ± 3.0%, and the reoperation rate was 34.0%. Furthermore, the statistical analysis revealed that preoperative range of motion (β = -0.004, P = 0.01) and proportion of female (β = 0.336, P = 0.04) were the independent factors affecting the total complication rate.
CONCLUSIONS
Various risk factors are related to each of the complications, and we found that patients with less preoperative ROM and a higher proportion of female gender may point to a higher total complication rate. Therefore, to further improve the overall outcomes of this procedure, more and larger prospective studies should be performed to further elucidate the effects of prophylactic interventions targeting the risk factors, thus improving the methods of prevention and treatment of complications.
Topics: Elbow Joint; Humans; Joint Diseases; Orthopedic Procedures; Range of Motion, Articular; Recovery of Function; Treatment Outcome; Elbow Injuries
PubMed: 26383106
DOI: 10.1371/journal.pone.0138547 -
European Journal of Orthopaedic Surgery... Feb 2017To provide treatment guidelines for patients with long bone metastatic disease based on a systematic review of the literature and to propose an algorithm to guide... (Review)
Review
PURPOSE
To provide treatment guidelines for patients with long bone metastatic disease based on a systematic review of the literature and to propose an algorithm to guide orthopedic surgeons in decision-making for these patients.
MATERIALS AND METHODS
We performed a computerized literature search in MEDLINE, EMBASE and Scopus for studies on patients with long bone metastases. We used the key words "long bones", "metastasis" and "treatment" for published studies that evaluated any treatment for long bone metastases. The articles found were then studied to determine the accuracy of surgical treatments for long bone metastases in every anatomic location, regardless of cancer type, stage and grade of the oncologic disease. Guidelines inferred from this literature review were collected, and an algorithm was proposed.
RESULTS
There was no clear evidence to support excision of a long bone metastatic lesion at the same surgical setting with internal fixation or prosthetic reconstruction. However, en bloc resection of an isolated bone metastasis may have a beneficial effect on survival. The life expectancy of the patients should be considered for any surgical treatment. Internal fixation preferably with reconstruction nails is indicated for meta-diaphyseal lesions; their rate of mechanical failure and complications ranges from 2 to 22 %. Prosthetic reconstruction is indicated for extensive lytic lesions or pathologic fractures in a meta-epiphyseal locations; their rate of mechanical failure and complications ranges from 3.7 to 35 %. Most of the internal fixation-related complications occur more than 1 year after treatment, in contrast to prosthetic reconstruction-related complications that may occur earlier.
CONCLUSIONS
Intramedullary nail fixation or prosthetic reconstruction should be chosen on the basis of the location of the lesion, the extent of bone destruction and the stability of the construct to outlast the expected life of the patient. Implant-related complication is similar but may occur earlier with prosthetic reconstructions.
Topics: Bone Nails; Bone Neoplasms; Breast Neoplasms; Clinical Decision-Making; Female; Femoral Neoplasms; Fracture Fixation, Intramedullary; Fractures, Spontaneous; Humans; Kidney Neoplasms; Lung Neoplasms; Male; Prognosis; Prostatic Neoplasms; Thyroid Neoplasms
PubMed: 27650452
DOI: 10.1007/s00590-016-1857-9 -
International Journal of Surgery... Oct 2021Spinal cord injuries (SCI) are a devastating condition and can lead to severe functional and psychosocial problems. However, the influence of the timing of the surgical... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Spinal cord injuries (SCI) are a devastating condition and can lead to severe functional and psychosocial problems. However, the influence of the timing of the surgical intervention for acute SCI remains debated, with substantial variability in clinical practice. Thus, this study aims to compare the efficacy of early and late surgical intervention for acute SCI.
METHODS
A systematic search of PubMed, Embase, Cochrane Library and Web of Science up to January 10, 2021 was conducted for relevant studies that compared early and late acute SCI. Neurological outcomes were assessed by American Spinal Injury Association (ASIA). Early surgery was defined as the surgical intervention within 24 h after spinal injury. The primary outcome was the change of ASIA score from baseline to follow-up time after spinal injury. Second primary outcomes were clinical outcomes including neurological improvement rate, mortality, length of stay (LOS), charges ($), complications and ASIA Impairment Scale (AIS). All statistical analyses were performed using standard statistical procedures provided in Review Manager 5.2.
RESULTS
A total of 16 studies including 3977 SCI patients were identified finally. Our pooled results indicated that, compared with late surgery, patients who underwent early surgery experienced more ASIA score improvement, with pooled MDs of 2.32 points (95% CI 1.07-3.57; P = 0.0003) in total motor scores, 5.13 points (95% CI 3.94-6.32; P < 0.0001) in light touch scores, and 4.49 points (95% CI 2.22-6.76; P = 0.0001) in pin prick scores respectively. In addition, patients receiving early surgery experienced more total motor score after surgery (MD 3.30; 95% CI 0.82-5.79; P = 0.009). Patients who had early surgery also had higher neurological improvement rate (OR 1.66; 95% CI 1.19-2.31; P = 0.003), shorter LOS (MD -4.77; 95% CI -7.42 to -2.12), less charges ($) (MD -0.33; 95% CI -0.43 to -0.22), lower incidence of complications (OR 0.62; 95% CI 0.48-0.81), and higher AIS improvement rate (OR 1.71; 95% CI 1.20-2.44) respectively.
CONCLUSIONS
Compared with late surgery, acute SCI patients who underwent early surgery experienced greater recovery after spinal injury, with better neurological improvement, shorter LOS, less charges and lower incidence of complications.
Topics: Decompression, Surgical; Humans; Length of Stay; Spinal Cord Injuries; Time; Treatment Outcome
PubMed: 34509672
DOI: 10.1016/j.ijsu.2021.106098 -
Computational and Mathematical Methods... 2022The surgical treatment scheme of humeral shaft fracture is still controversial with no consensus reached. This meta-analysis was aimed at comparing the efficacy and... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The surgical treatment scheme of humeral shaft fracture is still controversial with no consensus reached. This meta-analysis was aimed at comparing the efficacy and safety of intramedullary nail (IMN) and locking compression plate (LCP) in the treatment of humeral shaft fractures.
METHODS
PubMed, Medline, Embase, Ovid, Cochrane Library, ISI Web of Science, Clinical Trials, and Chinese databases, including China National Knowledge Infrastructure Project, Wanfang database, and China biomedical abstracts database, were used to search the literature. Review Manager software was employed for statistical analysis and establishing forest and funnel maps. Categorical variables were measured by relative risk (RR), and standardized mean difference (SMD) was used to measure continuous variables. 95% confidence intervals were used for each variable. The modified Jadad scale, Newcastle-Ottawa scale, and Cochrane's bias risk tools were used to evaluate the bias and risk of eligible studies.
RESULTS
A total of 14 studies were included in the analysis with a total of 903 patients with humeral shaft fracture. Significant differences with regard to operation time (Std = -1.18, 95% CI: -2.14, -0.22, = 2.41, = 0.02), blood loss (Std = -2.97, 95% CI: -4.32, -1.63, = 4.34, < 0.001), and postoperative infection rate (RR = 0.32, 95% CI: -0.15, 0.68, = 2.98, = 0.003) were noted between the IMN group and LCP group. In addition, the American Shoulder and Elbow Surgeon (ASES) score (Std = -0.22, 95% CI: -0.44, 0.01, = 2.08, = 0.04) and the rate of shoulder and elbow function limitation (RR = 1.88, 95% CI: 1.06, 3.33, = 2.17, = 0.03) between the 2 groups were also statistically significant. There were no significant differences in the rate of radial nerve injury, nonunion, delayed healing, and secondary operation between the two groups.
CONCLUSION
IMN is superior than the LCP in terms of the operation time, intraoperative bleeding, and postoperative infection, suggesting its superiority in the humeral shaft fracture fixation. However, IMN is inferior to LCP in ASES score and shoulder elbow function limitation rate, indicating poor early postoperative functional recovery. More studies are required to evaluate and analyze the clinical efficacy between IMN and LCP regarding long-term function after artificial graft removal.
Topics: Humans; Bone Plates; Fracture Fixation, Intramedullary; Humeral Fractures; Humerus; Postoperative Complications; Treatment Outcome; Bone Nails
PubMed: 35799627
DOI: 10.1155/2022/5759233 -
The Cochrane Database of Systematic... Sep 2014Intramedullary nails may be used for the surgical fixation of extracapsular hip fractures in adults. This is an update of a Cochrane review first published in 2005 and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Intramedullary nails may be used for the surgical fixation of extracapsular hip fractures in adults. This is an update of a Cochrane review first published in 2005 and last updated in 2008.
OBJECTIVES
To assess the effects (benefits and harms) of different designs of intramedullary nails for treating extracapsular hip fractures in adults.
SEARCH METHODS
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (6 January 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 12, 2013), MEDLINE (1966 to November Week 3, 2013), MEDLINE In-Process & Other Non-Indexed Citations (3 January 2014), EMBASE (1988 to 2014, Week 1) and the World Health Organization (WHO) International Clinical Trials Registry Platform (accessed January 2014).
SELECTION CRITERIA
All randomised or quasi-randomised trials comparing different types, or design modifications, of intramedullary nails in the treatment of extracapsular hip fractures in adults.
DATA COLLECTION AND ANALYSIS
At least two review authors independently selected studies, assessed risk of bias and extracted data. We performed limited meta-analysis using the fixed-effect model.
MAIN RESULTS
We included eight new trials, testing seven new comparisons in this update. Overall, we included 17 trials, testing 12 comparisons of different cephalocondylic nail designs. The trials involved a total of 2130 adults (predominantly female and older people) with mainly unstable trochanteric fractures.All trials were at unclear risk of bias for most domains, with the majority at high risk of detection bias for subjective outcomes. The three quasi-randomised trials were at high risk for selection bias.Four trials (910 participants) compared the proximal femoral nail (PFN) with the Gamma nail. There was no significant difference between the two implants in functional outcome (the very low quality evidence being limited to results from single trials), mortality (low quality evidence: 86/415 versus 80/415; risk ratio (RR) 1.08, 95% confidence interval (CI) 0.82 to 1.41), serious fixation complications (operative fracture of the femur, cut-out, non-union and later fracture of the femur) nor re-operations (low quality evidence: 45/455 versus 36/455; RR 1.25, 95% CI 0.83 to 1.90).Two trials (185 participants) provided very low quality evidence of a lack of clinically significant difference in outcome (functional score, mortality, fracture fixation complications and re-operation) between the ACE trochanteric nail and the Gamma nail.Two trials (200 participants) provided very low quality evidence of a lack of significant difference in outcome (mobility score, pain, fracture fixation complications or re-operations) between the proximal femoral nail antirotation (PFNA) nail and the Gamma 3 nail.Seven of the nine trials evaluating different comparisons provided very low quality evidence of a lack of significant between-group differences in all of the reported main outcomes for the following comparisons: ACE trochanteric nail versus Gamma 3 nail (112 participants); gliding nail versus Gamma nail (80 participants); Russell-Taylor Recon nail versus long Gamma nail (34 participants, all under 50 years); proximal femoral nail antirotation (PFNA) nail versus Targon PF nail (80 participants); dynamically versus statically locked intramedullary hip screw (IMHS) nail (81 participants); sliding versus non-sliding Gamma 3 nail (80 participants, all under 60 years); and long versus standard PFNA nails (40 participants with reverse oblique fractures).The other two single comparison trials also provided very low quality evidence of a lack of significant between-group differences in all of the main outcomes with single exceptions. The trial (215 participants) comparing the ENDOVIS nail versus the IMHS nail found low quality evidence of poorer mobility in the ENDOVIS nail group, where more participants in this group were bedridden after their operation (29/105 versus 18/110; RR 1.69, 95% CI 1.00 to 2.85; P = 0.05). The trial (113 participants) comparing the InterTan nail versus the PFNA II nail found very low quality evidence that more PFNA II group participants experienced thigh pain (3/47 versus 12/46; RR: 0.24, 95% CI 0.07 to 0.81).
AUTHORS' CONCLUSIONS
The limited evidence from the randomised trials undertaken to date is insufficient to determine whether there are important differences in outcome between different designs of intramedullary nails used in treating extracapsular hip fractures. Given the evidence of superiority of the sliding hip screw compared with intramedullary nails for extracapsular hip fractures, further studies comparing different designs of intramedullary nails are not a priority. Any new design should be evaluated in a randomised comparison with the sliding hip screw.
Topics: Aged; Aged, 80 and over; Bone Nails; Female; Fracture Fixation, Intramedullary; Hip Fractures; Humans; Male; Middle Aged; Outcome Assessment, Health Care; Prosthesis Design; Randomized Controlled Trials as Topic
PubMed: 25212485
DOI: 10.1002/14651858.CD004961.pub4