A Systematic Review and Meta-analysis of Open Versus Closed Reduction and Intramedullary Nailing of Femoral Shaft Fractures

Abstract

INTRODUCTION: Femoral shaft fractures are significant injuries with a predominately traumatic etiology. Intramedullary nailing is the preferred surgical intervention, and reduction of the fracture can be accomplished through closed or open methods. Closed reduction is often considered the gold standard as it is theorized that an intact fracture hematoma has osteogenic properties that will result in superior healing with fewer complications. Open reduction procedures persist in cases of polytraumatic injury, when the fracture proves difficult to reduce by closed methods, or in geographical areas with limited resources. Studies comparing outcomes between the treatments have conflicting results. The purpose of this systematic review and meta-analysis was to compare the outcomes and complications of intramedullary nailing of femoral shaft fractures between open and closed reduction. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed (MEDLINE), Embase, Scopus, and CENTRAL were searched to identify comparative studies up to May 2022. Additional studies were identified through hand and citation searching. Exclusion criteria included pediatric patients younger than 17 years of age, studies not published in English, and studies that reported fractures of the proximal or distal femur. The primary outcome was the rate of union. Secondary outcomes included time to union, operative time, and complication rate. RESULTS: Closed reduction had a higher pooled union rate (93.93%, 92.02%), an increased odds ratio for union (OR =1.624 [95% CI: 1.004, 2.624]; p =.048), and a faster time to union (SMD = -0.292 [95% CI: -0.549, -.0.035]; p =.026). There were no differences in operative time (SMD = .128 [95% CI: -0.700, .956] p = .762) or overall complication rate (OR = 1.314 [95% CI: .966, 1.787] p = .082). DISCUSSION AND CONCLUSION: Closed reduction has the advantage of higher union rates, quicker time to union, and lower overall infection compared to open reduction for intramedullary nailing of femoral shaft fractures. Open reduction remains a reasonable alternative with acceptable union rates when closed reduction is not feasible.