**1. Introduction**

Hip fractures (HF) are a frequent problem in elderly patients, and are related to osteopenia and osteoporosis. Around 1.6 million patients suffer from HF per year [1], and by 2050, the global incidence is believed to become 4.5 million [2]. Reduced bone density, female sex (female/male ratio greater than 2/1 in those over 50 years of age), low weight and reduced physical activity are main risk factors for HF [1,2]. The mortality rate among patients who suffer a hip fracture is 5–10% one month after the fracture and 20–30% in the first year [1,2].

Hip fractures can be classified as intracapsular or extracapsular, and the latter are subdivided into basicervical, intertrochanteric/pertrochanteric and subtrochanteric. Up to half of such fractures are intertrochanteric, usually occurring in elderly patients as a result of low-energy trauma [3]. The main treatment of these trochanteric fractures is surgery, which can be extramedullary or intramedullary. Previously, extramedullary treatment with sliding hip screw (SHS) was the most indicated, but some studies showed that nailing gave better fracture fixation results for uncommon trochanteric fractures, especially subtrochanteric

**Citation:** Méndez-Ojeda, M.M.; Herrera-Rodríguez, A.; Álvarez-Benito, N.; González-Pacheco, H.; García-Bello, M.A.; Álvarez-de la Cruz, J.; Pais-Brito, J.L. Treatment of Trochanteric Hip Fractures with Cephalomedullary Nails: Single Head Screw vs. Dual Integrated Compression Screw Systems. *J. Clin. Med.* **2023**, *12*, 3411. https://doi.org/ 10.3390/jcm12103411

Academic Editor: Moshe Salai

Received: 18 March 2023 Revised: 29 April 2023 Accepted: 1 May 2023 Published: 11 May 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

fractures, so the use of nailing has dramatically increased even though there is no evidence that it is superior to the SHS in a simple intertrochanteric pattern [3].

Some of the most-used intramedullary nailing alternatives in our region are the Gamma3 nail, PFNA (Proximal Femoral Nail Antirotation) and TRIGEN InterTAN. The latter differs from the others in that it offers the possibility of two cephalo-cervical screws that provide linear compression and additional resistance to the rotation of the femoral head, while the others use a single screw [4,5]. Several studies and meta-analyses have compared the use of these methods of treatment without reaching a definitive conclusion on which fixation method is most appropriate to reduce complications and improve prognosis [6–17]. Independent risk factors for early mortality already reported in the literature are: male sex, dependence on others for the basic activities of daily living, American Society of Anesthesiologists (ASA) score > 2, older age and medical complications occurring while an inpatient [18]. Fracture stability also plays a key role in the prognosis for these patients, not only influencing early device failure requiring reoperation within 12 months, but also increasing the rate of mortality after trochanteric hip fractures by up to 1.6 times [19]. Studies such as Chehade et al. also describe an increase in early osteosynthesis failure associated with the use of double lag screw systems [19]. Attending to only unstable hip fractures, such as subtrochanteric fractures, Panteli et al. identified six risk factors associated with reoperation: age < 75 years old, pre-injury femoral neck shaft angle, choice of nail, varus reduction angle, fracture-related infection and non-union. The addition of a proximal anti-rotation screw did not confer any benefit [20] in terms of reoperation or survival rates. Figures 1 and 2 show typical cases of pertrochanteric hip fracture treated with an endomedullary nail.

**Figure 1.** Pertrocantheric hip fracture treated with a short Gamma3 nail.

**Figure 2.** Pertrocantheric hip fracture treated with a short InterTAN nail (letter D for right lower limb).

For a time, in our service, we had the impression that systems with two cephalocervical screws had a higher rate of reoperations. As such, the aim of this study is to retrospectively review major post-surgical complications as they relate to the type of nail used, comparing single head screw nails to dual integrated compression screw nails, with nails being implanted at a third-level hospital. The hypothesis of our study is that cephalomedullary nailing with double head screw systems present a greater number of post-surgical complications compared to single screw systems.
