Thousands of NHS patients with broken hips may face a higher risk of death if surgeons choose nails instead of screws to fix them.

A study found people whose hips are repaired with nails are 12.5 per cent more likely to die within a month than those whose are fixed with screws.

Experts say nails lead to higher pressure inside the bone, boosting the risk of clots, air bubbles and fat lumps leaking into the blood.  

Nails are becoming a more popular option among NHS surgeons and now account for around a fifth of all procedures on a certain type of break. 

But experts working in the UK warn the increasing use of nails, which can cost £1,100 each to the screws’ £300, is ‘perplexing’ and ‘unjustified’. 

Intramedullary nails, which can be used to stabilise an entire femur, may increase the pressure inside the bone to the extent it forces cells inside into the bloodstream and risks damaging the heart or lungs, according to researchers

Intramedullary nails, which can be used to stabilise an entire femur, may increase the pressure inside the bone to the extent it forces cells inside into the bloodstream and risks damaging the heart or lungs, according to researchers

A group of surgeons and researchers in Bristol studied the results of 82,990 hip operations between 2011 and 2014 on patients with an average age of 85. 

They focused on fractures of the trochanters – the rounded top of the thigh bone – which affect up to 32,000 people per year in the UK. 

Trochanteric hip breaks involve part of the tip of the femur splitting away and having to be reattached by surgeons.

And they are fixed either by a long nail being driven through the length of the femur (thigh bone) or by screws which hold a plate to reattach and fix the bone in place. 

Despite nails, which can be as long as 38cm, being the expensive option for hospitals, they are becoming more popular.

The proportion of patients receiving them rose by 12 per cent between 2011 and 2016.

WHY DO SURGEONS USE NAILS INSTEAD OF SCREWS? 

In many countries intramedullary nails have long been the preferred fixing for hip fractures.

‘In Germany they nail everything,’ said Bristol-based orthopaedic surgeon Tim Chesser. ‘It’s the same in the US, Australia, France and Italy.’

Part of the reason for this, Mr Chesser believes, is the way they’re marketed.

Although they’re more expensive – costing between £600 and £1,100 compared to £300 for screws – they may be more actively marketed by manufacturers and hospitals given better deals when they buy them.

The use of nails varies across hospitals in the UK. Nationally it rose by 12 per cent between 2011 and 2016.

At Southampton General Hospital surgeons used screws in only 7.2 per cent of trochanter (part of the hip) repair procedures last year. 

But at the same time, Queen Elizabeth Hospital in King’s Lynn used screws in 100 per cent of the same type of op.

And because there has never been any conclusive data to prove they are more dangerous, many surgeons will have worked with them for years and never had a problem, meaning personal preference plays a role.

If a surgeon is trained by someone who has a personal preference for using nails, they are likely to pick up the same habit themselves, suggested the University of Bristol’s Adrian Sayers.

And for patients with cancer or who need their entire thigh bone stabilising in the procedure, nails continue to be the right choice. 

But now researchers fear using nails increases pressure inside the bone, risking fat cells or blood being forced out into the bloodstream and potentially travelling to the heart and lungs and causing serious damage. 

A spokesperson for the British Orthopaedic Association said: ‘Sometimes the variation in practice between hospitals is for good reason but on other occasions the reasons are not so clear.

Researchers from Bristol said the rising popularity of nails is both ‘perplexing’ and ‘unjustified’. 

Around 20 per cent of patients with this type of fracture in the UK had it repaired with a nail rather than a screw in 2017.

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The nails are already the preferred option in the US, with 81 per cent of surgeons using them and experts recommending them in place of screws. 

The Bristol researchers estimate 98 people died during the course of their four-year study as a direct result of nail use – one extra death for every 112 operations using nails.

Thousands of people die every year within 30 days of having surgery to repair a broken hip – usually because they are already old, frail and seriously ill. In 2017 there were around 4,600 deaths.

But researchers now believe the nails are contributing to the death toll. 

Adrian Sayers, a University of Bristol researcher involved in the study, told MailOnline the increased risk of death could be related to how the nails affect the bone.

‘Longer nails penetrate more into the femur, increasing pressure in the bone and displacing other stuff which leaks into the blood and circulates around the body,’ he said.

The team suggest nail procedures may cause fat cells to leak into the blood or the blood to clot, which could trigger problems with circulation to the heart or brain. 

The fixings, medically known as intramedullary nails, come in either short or long lengths but the short are rarely used in Britain, according to Bristol-based surgeon Tim Chesser.

Mr Chesser said the long nails tend to range from around 30 to 38cm (12-15″), while the screws, designed only to hold plates to the bone, are around 10cm (4″) long.

‘Nails are used for pathological treatments like when a patient has cancer and we need to support the whole bone,’ Mr Chesser said.  

But the long nails proved more deadly in the research.

Some 7.6 per cent of patients given a screw to repair a trochanteric fracture died within 30 days of their operation.

This rose to 8.2 per cent for a short nail, and to 8.3 per cent for a long nail.

In fully adjusted results taking patients’ circumstances into account, the rise in death risk was found to be 12.5 per cent. 

‘The growing global trend towards increased use of intramedullary nails for the treatment of this common fracture type is not currently justified,’ the team wrote.

NHS hospitals around the country make their own decisions on whether to use nails or screws.

In some places more than 90 per cent of patients have nails used to fix their hips, while in others they aren’t given to any at all. 

Sliding hip screws, which fix fractures by attaching a metal plate to the bone, have been found by researchers to be safer and cheaper than nails but are becoming less popular in the UK

Sliding hip screws, which fix fractures by attaching a metal plate to the bone, have been found by researchers to be safer and cheaper than nails but are becoming less popular in the UK

Southampton General used nails for 92.8 per cent of its patients in 2018, according to the National Hip Fracture Database.

Whereas Queen Elizabeth Hospital in King’s Lynn, Norfolk, didn’t use them at all for this type of break. 

‘Sometimes the variation in practice between hospitals is for good reason but on other occasions the reasons are not so clear,’ a spokesperson for the British Orthopaedic Association told MailOnline.

In 2017, 78.8 per cent of patients had their breaks repaired with plates and screws.

This was a drop from 80.9 per cent in 2016 suggesting that, for the first time, more than a fifth of patients had fractures fixed with nails.  

HOW OFTEN DO PEOPLE HAVE TROCHANTERIC HIP FRACTURES? 

Trochanteric hip fractures make up between a third and half of the 65,000 broken hips patients suffer each year in the UK. 

This equates to between 21,000 and 32,500 breaks each year in the UK alone. Globally, this is estimated to be in the hundreds of thousands.

Breaking the trochanter – the protruding club-shaped part at the top of the thigh bone – is most common among older people who are already frail. 

The fracture usually involves the top of the bone being nailed back on with a nail driven directly into the femur (thigh bone) or by a metal plate being screwed on to hold it in place.  

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The National Institute for Health and Care Excellence, the watchdog for NHS care, officially recommends screws instead of nails for trochanter fractures. 

The Bristol researchers said decisions between the two are ‘controversial’ because screws have been proven to have fewer complications.

Screws are also cheaper – almost a quarter of the price in some cases. 

The British Orthopaedic Association (BOA) added:  ‘NICE guidance published in 2011 advised that for the majority of these patients, a [screw] is appropriate. 

‘However, for some patients the IM nail is the better choice, for example if the fracture extends further down the thigh bone, where the fracture is through bone already damaged by disease, or some cases where the patient is on treatment for osteoporosis.’

It added a new programme called Get It Right First Time is starting this year to investigate and monitor ‘unwarranted variation’ in surgery.

In the National Hip Fracture Database annual report in 2018, the authors, who include the BOA and the Royal College of Physicians, criticised the rising use of nails.

They wrote the increasing use of nails was a ‘perplexing trend’ because there is no good evidence they are better than screws and they’re more expensive.

And the report added: ‘Failure to follow NICE guidance for these and other aspects of operative approach meant that… in 2016 only 64.2 per cent of all patients appeared to have received an operation that NICE would have recommended – with figures ranging from as low as 15.7 per cent up to 86.0 per cent in different units.’   

Mr Sayers said of his research: ‘It’s not perfect but this is the best evidence we’re going to get on this subject – controlled studies pale in comparison.

‘Surgeons should look at their patients and think “why am I using nails?”‘  

The research by the University of Bristol and Southmead Hospital in the city was published in the Bone and Joint Journal.

HOSPITALS IN ENGLAND RANKED BY THE PROPORTION OF PATIENTS THEY TREAT WITH SCREWS (Source: National Hip Fracture Database, 2018)
Hospital name Number of cases submitted, 2018 Trochanteric hip fractures
treated with sliding hip screws (%)
Southampton General Hospital 622 7.2
St Peter’s Hospital 370 18.3
Peterborough City Hospital 480 30.5
Royal Surrey County Hospital 281 31.2
Watford General Hospital 437 34.3
Pinderfields General Hospital 500 36.4
Royal Sussex County Hospital 561 37.5
Royal Oldham Hospital 383 40.6
Morriston Hospital 531 46.2
Poole General Hospital 937 49.8
King’s College Hospital 140 50
Frimley Park Hospital 428 52.8
Gloucestershire Royal Hospital 786 53.6
Chelsea & Westminster Hospital 204 54.4
Bristol Royal Infirmary 278 56.8
Scunthorpe General Hospital 240 58.3
Royal Lancaster Infirmary 309 60.4
Royal Victoria Hospital 904 60.8
North Hampshire Hospital 254 61.9
Birmingham Heartlands Hospital 406 62.2
Queen Elizabeth Hospital, Edgbaston 465 62.5
Bedford Hospital 288 62.6
Royal Devon & Exeter Hospital 638 62.6
Homerton Hospital 84 62.8
University Hospital Lewisham 185 64.8
St George’s Hospital 215 64.9
University Hospital of North Tees 385 65.2
Colchester General Hospital 541 66
Hull Royal Infirmary 589 66.2
Craigavon Area Hospital 330 67
Sandwell District Hospital 341 67.8
Arrowe Park Hospital 479 67.9
York District Hospital 424 67.9
Ealing Hospital 180 68.3
Leighton Hospital 361 68.4
Barnsley District General Hospital 289 69.6
Queens Hospital Romford 540 70.2
Prince Charles Hospital 247 70.6
Ysbyty Gwynedd Hospital 304 70.7
Macclesfield District General Hospital 243 71
West Wales General 349 71.7
Broomfield Chelmsford 484 72.3
Royal Hampshire County Hospital 248 72.9
Royal London Hospital 140 73.2
Warrington District General Hospital 171 73.2
Ulster Hospital 369 73.3
Milton Keynes General Hospital 249 73.5
Royal Cornwall Hospital 590 73.5
Tameside General Hospital 263 73.5
Royal Victoria Infirmary 378 73.8
St Helier Hospital 404 73.9
Lincoln County Hospital 386 74.1
Newham General Hospital 100 75
Royal Liverpool University Hospital 385 75.2
Barnet General Hospital 394 76.4
County Hospital Hereford 327 76.6
Torbay Hospital 445 76.7
James Paget Hospital 376 77
St Marys Hospital, Paddington 241 77.2
Noble’s Hospital 101 77.3
Leeds General Infirmary 654 77.5
Yeovil District Hospital 292 78
Leicester Royal Infirmary 817 78.6
Countess of Chester Hospital 324 79
Dorset County Hospital 330 79.2
Norfolk and Norwich Hospital 816 79.4
Hillingdon Hospital 222 79.5
Scarborough General Hospital 272 79.7
Queen Elizabeth Hospital, Gateshead 282 79.8
Good Hope General Hospital 305 79.9
Queen Elizabeth Hospital, Woolwich 310 80
University Hospital Aintree 404 80.2
Salford Royal 301 80.5
Northampton General Hospital 373 80.6
Warwick Hospital 349 80.7
Harrogate District Hospital 257 81.5
Whiston Hospital 423 81.7
Royal Derby Hospital 607 82
Salisbury District Hospital 317 82.2
Mayday University Hospital 247 82.3
Queen Alexandra Hospital 716 82.5
James Cook University Hospital 457 82.9
Princess Alexandra Hospital 357 82.9
Glan Clwyd Hospital 312 83
Worthing Hospital 443 83
Royal Berkshire Hospital 432 83.2
Furness General 143 83.3
North Middlesex Hospital 232 83.3
Musgrove Park Hospital 458 83.7
Doncaster Royal Infirmary 417 84.7
Northwick Park Hospital 317 84.7
St Richards Hospital 387 84.7
Bradford Royal Infirmary 335 85
Darlington Memorial Hospital 351 85
Princess Royal Hospital, Telford 248 85.2
University Hospital Queens Medical Centre 836 85.2
Withybush General Hospital 220 85.2
Southport and Formby District General 323 85.4
North Manchester General Hospital 320 85.7
East Surrey Hospital 497 86.1
Whittington Hospital 120 86.1
St Thomas Hospital 141 86.2
John Radcliffe Hospital 448 86.8
South Tyneside District Hospital 188 86.8
Rotherham General Hospital 291 87.1
Royal Bolton Hospital 385 87.1
Kettering General Hospital 388 87.2
University Hospital Coventry 492 87.5
Derriford Hospital 579 87.9
Manor Hospital 335 88.4
Queens Hospital 328 88.4
Royal Preston Hospital 390 88.5
Sunderland Royal Hospital 390 88.5
Altnagelvin Hospital 407 88.9
Royal Shrewsbury Hospital 368 89.1
University Hospital of North Durham 382 89.1
Kings Mill Hospital 432 89.3
Princess Royal University Hospital (Bromley) 398 89.3
Conquest Hospital 641 89.5
University College Hospital 178 89.7
University Hospital of Wales 483 89.7
Royal Gwent Hospital 458 89.8
Whipps Cross Hospital 332 90.1
Addenbrooke’s Hospital 394 90.7
Southmead Hospital 510 90.7
Grantham And District General Hospital 46 90.9
North Devon District Hospital 285 91.2
Luton & Dunstable Hospital 297 91.3
Royal United Hospital Bath 591 91.6
Bronglais General Hospital 120 91.8
Pilgrim Hospital 381 91.9
William Harvey Hospital 435 92.1
Queen Elizabeth the Queen Mother Hospital 460 92.2
Chesterfield Royal 423 92.3
Kingston Hospital 311 92.4
Royal Albert Edward Infirmary 335 92.4
The Alexandra Hospital 344 92.4
Victoria Hospital 368 92.4
Stepping Hill Hospital 341 92.6
Worcestershire Royal Hospital 358 92.9
University Hospital of North Staffordshire 730 93.4
Diana, Princess of Wales Hospital 309 93.5
Manchester Royal Infirmary 203 93.5
Cumberland Infirmary 488 93.7
Basildon Hospital 433 93.8
Southend Hospital 463 93.8
Nevill Hall Hospital 288 93.9
Royal Glamorgan 218 94
Royal Blackburn Hospital 492 94.2
Weston General Hospital 265 94.2
New Cross Hospital 458 94.4
Wythenshawe Hospital 364 94.4
Russells Hall Hospital 508 94.9
Princess Of Wales Hospital 247 95
Medway Maritime Hospital 409 95.1
Airedale General Hospital 264 95.8
East and North Herts Hospital 495 95.9
Northumbria Specialist Emergency Care Hospital 709 96
The Ipswich Hospital 497 96.1
West Middlesex University Hospital 226 96.7
The Great Western Hospital 436 96.9
Stoke Mandeville Hospital 355 97.3
Tunbridge Wells Hospital 541 97.3
Maelor Hospital 214 97.4
St Mary’s Hospital, Newport 246 97.4
West Suffolk Hospital 382 97.5
Bassetlaw District General Hospital 137 97.6
Darent Valley Hospital 321 97.7
Northern General Hospital 619 97.8
Huddersfield Royal Infirmary 471 98.3
Royal Free Hospital 185 98.5
Wexham Park Hospital 403 98.6
George Eliot Hospital 285 98.8
Hinchingbrooke Hospital 201 100
Horton General Hospital 204 100
Queen Elizabeth Hospital (King’s Lynn) 412 100
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