Intramedullary nailing shows lower odds of nonunion and infection than sliding hip screwsIntramedullary nailing shows better outcomes for unstable hip fractures

BMC musculoskeletal disorders Published July 5, 2026 Study authors: Zhang Yunjie, Lützner Cornelia, Kaboth Pauline, Fuhrmann Anna, Neuerburg Carl, Deckert Stefanie PubMed ↗ DOI ↗ Editorial oversight: Dr. Lars van Dijk, PhD · Surgical, Procedural & Diagnostic

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Key Takeaway

Note that intramedullary nailing is associated with lower odds of nonunion and infection compared to sliding hip screws.

This meta-analysis of randomized controlled trials evaluated 3237 adult patients with unstable trochanteric femoral fractures (AO/OTA 31-A2 and 31-A3) to compare intramedullary nailing (IMN) against sliding hip screws (SHS). The analysis focused on primary outcomes like mortality and reoperation, alongside secondary outcomes including infection, nonunion, and functional scores.

Key findings indicate that while there was no significant difference in 3-month or 12-month mortality between the two groups, SHS was associated with higher odds of several complications. Specifically, SHS showed higher odds of nonunion (OR 1.93; 95% CI, 1.12-3.34), infection (OR 2.20; 95% CI, 1.29-3.74), and arthroplasty conversion (OR 1.92; 95% CI, 1.00-3.68). Additionally, IMN was associated with higher functional scores, less pain within 3 months, and a greater likelihood of regaining pre-fracture mobility compared to SHS.

Several outcomes, including reoperation, arthroplasty conversion, nonunion, and infection, were noted to have low certainty of evidence (CoE). While IMN appears associated with lower odds of specific complications like nonunion and infection, the clinical application of these findings should be interpreted with caution due to the reported low to moderate CoE for most outcomes.

When a person suffers an unstable fracture near the top of the femur, the choice of surgical hardware is critical for their recovery. This study looked at over 3,000 patients to compare two common methods: intramedullary nailing (a rod placed inside the bone) and sliding hip screws.

The results showed that patients who received the internal rod reported less pain and better mobility within three months compared to those with the screw. While both methods performed similarly regarding survival rates, the rod was linked to lower rates of serious complications like infection, nonunion (where the bone fails to heal), and the need for a follow-up surgery to replace the hardware.

It is important to note that while these trends are promising, the evidence for some specific outcomes like infection and nonunion is not yet fully certain. Because the data quality varies across different studies, patients should discuss these specific surgical options with their orthopedic team to decide the best path forward.

What this means for you:

Intramedullary nailing may offer less pain and fewer complications than sliding hip screws for unstable hip fractures.

Common questions

What are the benefits of using an internal rod for a hip fracture?

Patients who received intramedullary nailing (the rod) reported less pain within three months and had higher scores for mobility and function. The study also found these patients were less likely to experience infections or nonunion, which is when the bone fails to heal properly after surgery.

How do the two surgical methods compare regarding survival?

The study compared intramedullary nailing and sliding hip screws for 3,237 patients. It found no significant difference in mortality rates at either three months or twelve months for patients treated with either of the two surgical methods.

Are there risks associated with the sliding hip screw method?

Patients who received a sliding hip screw showed higher rates of infection and nonunion compared to those who had the internal rod. There was also a higher rate of arthroplasty conversion, which means needing to replace the hardware with an artificial joint.

Study Details

Study typeMeta analysis

Sample sizen = 3,237

EvidenceLevel 1

Follow-up12.0 mo

PublishedJun 2026

PMID42343289

View Original Abstract ↓

BACKGROUND: Trochanteric femoral fractures (TFFs) are frequent injuries in older adults, with unstable patterns (AO/OTA 31-A2 and A3) carrying a higher risk of complications. Intramedullary nailing (IMN) and sliding hip screw (SHS) are the two main surgical options. However, guideline recommendations differ, and prior meta-analyses are limited. This study aimed to systematically compare the efficacy and safety of IMN versus SHS in treating adult patients with unstable TFFs based on randomized controlled trials (RCTs). METHODS: MEDLINE, Embase, and CENTRAL (January 2008-March 2025) were searched for eligible RCTs, which included adults with 31-A2 or A3 fractures randomized to IMN or SHS. Primary outcomes were mortality and reoperation. Secondary outcomes included implant failures, nonunion, surgical parameters, and postoperative mobility, pain, and function. Risk of bias (RoB) was assessed using RoB 2, and the certainty of evidence (CoE) with GRADE. RESULTS: Eighteen RCTs (n = 3237 patients) were included. No significant differences were found between IMN and SHS in three-month (low CoE) and 12-month mortality (moderate CoE). Reoperation rates trended higher with SHS, but not significantly (pooled OR = 1.70; 95% CI, 0.97-2.97; low CoE). SHS was associated with higher rates of arthroplasty conversion (pooled OR 1.92; 95% CI 1.00-3.68; low CoE), nonunion (pooled OR 1.93; 95% CI 1.12-3.34; low CoE), and infection (pooled OR 2.20; 95% CI 1.29-3.74; low CoE), while implant failure did not differ significantly (pooled OR 1.35; 95% CI 0.91 to 2.01; low CoE). IMN was associated with higher functional scores, less pain (within three months), and a greater likelihood of regaining pre-fracture mobility (CoE low- moderate). CONCLUSIONS: IMN demonstrated comparable mortality to SHS. Although overall reoperation rates did not differ significantly, IMN was associated with lower odds of arthroplasty conversion, nonunion, and infection, as well as reduced early postoperative pain and improved early postoperative function. However, given the overall low to moderate CoE, these findings should be interpreted with caution. Implant selection should remain individualized, taking into account patient characteristics, fracture morphology, and surgeon experience.

Intramedullary nailing shows lower odds of nonunion and infection than sliding hip screwsIntramedullary nailing shows better outcomes for unstable hip fractures

Common questions

Study Details

Low-intensity pulsed ultrasound shows a 0.79 healing rate in nonunion fractures across observational studies

Trial results show mixed success for ultrasound on nonunion fractures

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Intramedullary nailing shows lower odds of nonunion and infection than sliding hip screwsIntramedullary nailing shows better outcomes for unstable hip fractures

Common questions

Study Details

Low-intensity pulsed ultrasound shows a 0.79 healing rate in nonunion fractures across observational studies

Trial results show mixed success for ultrasound on nonunion fractures

Clinical research that matters. Delivered to your inbox.

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