Internal Fixation Treatments for Intertrochanteric Fracture：A Systematic Review and Network Meta-Analysis

Abstract

Background: Choosing the best internal fixation treatment for intertrochanteric fractures is a challenge faced by orthopedic doctors. This network meta-analysis aims to search and analyze outcomes from randomized clinical trials (RCTs) of internal fixation methods for intertrochanteric fractures. Methods: we performed searches in MEDLINE, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials from inception to April 2020. Data were extracted if the sample size of RCTs was over 100 and the follow-up period was at least 1 month. A Bayesian multiple treatment network meta-analysis was performed. And a pairwise meta-analysis was conducted to generate the direct estimates for outcomes. Findings: 61 RCTs (13728 patients) included 25 internal fixation methods were eligible. In network meta-analysis of complications, proximal femoral nail (PFN) had the highest probability of re-operation and later fracture events based on the SUCRA value, while sliding hip screws (SHS) had the lowest probability of re-operation and later fracture events based on the SUCRA value. In the subgroup analysis of patients aged 60 years and older, patients with PFN were found to have a higher risk of later fracture than gamma nail (GN) (GN vs. PFN: 0.31 [0.10, 0.91]), and GN needed shorter operation time than patients who used dynamic hip screw (DHS) (GN vs. DHS: -6.30 [-11.74, -0.86]). In the subgroup analysis of unstable fractures, DHS’s operation time and intraoperative blood loss were more than GN and proximal femoral nail anti-rotation (PFNA). Patients using PFN had a higher later fracture risk than using GN (PFN vs. GN: 3.27 [1.10, 9.71]), and the mortality rate of patients using GN was higher than that using DHS (DHS vs. GN: 0.19 [0.05, 0.65]). Interpretation: PFN had the highest risk of complications, followed by GN, and SHS had the lowest risk of complications. PFNA had a short operation time, less intraoperative blood loss, and a relatively low risk of complications, which should be a priority choice for intertrochanteric fractures, especially in elderly patients. Funding Statement: This study is supported by National Natural Science Foundation of China(No. 81702133). Declaration of Interests: No conflicts to declare.