Fracture fixation versus hemiarthroplasty for unstable intertrochanteric fractures in elderly patients: A systematic review and network meta-analysis of randomized controlled trials - 10/02/21

Doi : 10.1016/j.otsr.2021.102838

Natthapong Hongku ^a,^b, Patarawan Woratanarat ^c,⁎ , Lertkong Nitiwarangkul ^a, Sasivimol Rattanasiri ^a, Ammarin Thakkinstian ^a
^a Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
^b Department of Orthopaedics, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
^c Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

^⁎Corresponding author. Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, 270 Rama VI Road, Ratchatewi, Bangkok 10400, Thailand.Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital270 Rama VI Road, RatchatewiBangkok 10400Thailand

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Wednesday 10 February 2021
Cet article a été publié dans un numéro de la revue, cliquez ici pour y accéder

Abstract

Introduction

There are three common types of operative options for unstable intertrochanteric fracture (ITF), i.e. dynamic hip screw (DHS), proximal femoral nail (PFN), and bipolar hemiarthroplasty (BHA). Results of these operations are still inconclusive. This systematic review and network meta-analysis was therefore conducted to compare the efficacy among those operative strategies.

Hypothesis

These three operative techniques (i.e., DHS, PFN, and BHA) were not different in operative failure, reoperation, and Harris Hip Score (HHS) for unstable ITF.

Material and methods

Randomized controlled trials (RCTs) comparing outcomes among DHS, PFN, and BHA in patients with unstable ITFs were searched from Medline and Scopus databases. Primary outcomes included operative failure, reoperation, and HHS. Direct meta-analysis (DMA) and network meta-analysis (NMA) were performed to compare among three operative techniques. Qualitative and quantitative evidences of all included studies were tested for heterogeneity, transitivity, and consistency in NMA. The surface under the cumulative ranking curve (SUCRA) was used to estimate the probability of being the best in lowering poor clinical outcomes, but high HHS.

Results

Seven RCTs (n=528) were eligible. DMA showed that DHS and PFN were significantly higher risk of operative failure compared with BHA with risk ratio (RR) and 95% confidence interval of 7.98 (1.35, 47.06) and 3.08 (1.00, 9.51), respectively. Compared with BHA, PFN was 4.47 (1.04, 21.60) times significantly higher risk of reoperation, and lower HHS at 3–6months [mean difference (MD)=–5.41 (−15.91, 5.10)], but higher HHS at>6–12months [MD 11.67 (2.98, 20.36)], although these HHSs were not significant. NMA and SUCRA demonstrated the highest ranks for operative failure and reoperation were DHS and PFN, whereas the highest HHS was BHA.

Discussion

In specific group of unstable ITF, BHA might be the best operative technique in term of lower operative failure and reoperation, and highest HHS during short to intermediate period comparing with PFN and DHS. However, PFN had higher long-term HHS than BHA.