Does the treatment of hip fractures with intramedullary nails kill patients ?

A huge UK registry study (Whitehouse 2019) suggested intramedullary nails (IMN) for trochanteric hip fractures increase 30-day mortality by ~12.5% versus sliding hip screws (SHS). That sounds alarming—until you look at the randomized data. A meta-analysis of 15 RCTs (2363 patients) shows no clear mortality difference at 30 days or longer term between IMN and SHS; CIs in both directions sit close to no effect. The discrepancy highlights classic limits of observational data: residual confounding, imperfect adjustment, and “statistically significant but clinically trivial” effects driven by massive sample sizes. RCTs, especially when pooled, still sit at the top of the treatment-effect hierarchy. Best current reading: IM nails don’t “kill patients,” and the registry signal should be treated as hypothesis-generating, not practice-changing.