title: Comparison of intramedullary and extramedullary fixation of stable intertrochanteric fractures in the elderly: a prospective randomised controlled trial exploring hidden perioperative blood loss.
abstract: Hip fracture is a severe and common injury that occurs predominantly in the elderly. Blood loss in the perioperative period is associated with a greater risk of dying in anaemic patients. The aim of the study was to explore the best way to treat stable intertrochanteric fractures, taking hidden blood loss into account.
  
  
  
  This prospective, randomised blinded study included patients aged over 65 years with stable intertrochanteric fractures (Evans grades I and II). The patients were allocated to one of two groups treated via extramedullary or intramedullary fixation. Patient data were retrieved from electronic charts. Functional recovery was evaluated using the Functional Recovery Score of Zuckerman. Postoperative complications were also recorded. The formula of Nadler and Gross was used to calculate blood loss.
  
  
  
  There were 92 patients in the extramedullary and 106 in the intramedullary group. Age, sex, the cause of injury, the type of fracture, the observed blood loss, functional recovery, time to union, complications, and American Society of Anesthesiologists classification did not differ significantly between the two groups (all p-values > 0.05). The frequencies of lung infection, electrolyte imbalance, and hypoproteinemia differed between groups (all p-values < 0.05). Total and hidden blood loss were higher in the intramedullary group (p = 0.001).
  
  
  
  Extramedullary (compared with intramedullary) fixation of stable intertrochanteric fractures significantly reduces perioperative blood loss but affords similar functional outcomes and times to union. In view of the morbidity and complications associated with acute anaemia and transfusions, extramedullary fixation may be the optimal choice for treatment of stable fractures, being associated with reduced blood loss.
  
  
  
  The study was retrospectively registered at the Chinese Clinical Trial Registry, number: ChiCTR-INQ-16009754 , trial registration date: 6th Nov. 2016.
authors.affiliation: Department of Orthopaedics Surgery, The Second Affiliated Hospital of Wenzhou Medical University, NO.109, XueYuan West Road, Luheng District, Wenzhou, Zhejiang Province, 325000, People's Republic of China.
authors.forename: Leyi
authors.initials: L
authors.lastname: Cai
authors.affiliation: Department of Orthopaedics Surgery, The Second Affiliated Hospital of Wenzhou Medical University, NO.109, XueYuan West Road, Luheng District, Wenzhou, Zhejiang Province, 325000, People's Republic of China.
authors.forename: Te
authors.initials: T
authors.lastname: Wang
authors.affiliation: Department of Orthopaedics Surgery, The Second Affiliated Hospital of Wenzhou Medical University, NO.109, XueYuan West Road, Luheng District, Wenzhou, Zhejiang Province, 325000, People's Republic of China.
authors.forename: Lu
authors.initials: L
authors.lastname: Di
authors.affiliation: Department of Orthopaedics Surgery, The Second Affiliated Hospital of Wenzhou Medical University, NO.109, XueYuan West Road, Luheng District, Wenzhou, Zhejiang Province, 325000, People's Republic of China.
authors.forename: Wei
authors.initials: W
authors.lastname: Hu
authors.affiliation: Department of Orthopaedics Surgery, The Second Affiliated Hospital of Wenzhou Medical University, NO.109, XueYuan West Road, Luheng District, Wenzhou, Zhejiang Province, 325000, People's Republic of China. wjszdl@aliyun.com.
authors.forename: Jianshun
authors.initials: J
authors.lastname: Wang
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data*; D001803:Blood Transfusion; D001858:Bone Nails; D001863:Bone Screws; D005260:Female; D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects* / Q000295:instrumentation; D006620:Hip Fractures / Q000601:surgery*; D006801:Humans; D008297:Male; D061646:Operative Time; D059035:Perioperative Period; D011183:Postoperative Complications / Q000453:epidemiology*; D011446:Prospective Studies; D020127:Recovery of Function; D012189:Retrospective Studies
keywords: Blood loss; Elderly; Extramedullary fixation; Intertrochanteric fracture; Intramedullary fixation