Meta-analyse en réseau des essais contrôlés randomisés évaluant les traitements des fractures du col fémoral

Abstract

Intracapsular femoral neck fractures are among the most common traumatic injuries, especially in older adults. The main treatment options are prosthetic joint replacement and osteosynthesis. Despite randomized trials and meta-analyses of the topic, uncertainty remains regarding the best treatment option. To assess the relative efficacy of treatments for femoral neck fractures. CENTRAL, MEDLINE, EMBASE and clinicaltrials.gov up to March 2013. Randomized trials of any treatment for intracapsular femoral neck fracture in adults. Two reviewers independently selected trials. Two reviewers independently extracted data and used the Cochrane Collaboration's tool for assessing the risk of bias in randomized trials. A network of trials was built, nodes representing the treatments. A group of orthopedic surgeons grouped similar but not identical interventions under the same node. We synthesized the network using a Bayesian network meta-analysis model. We derived posterior odds ratios (OR) and 95% credible intervals (95% CrIs) for all possible pair-wise comparisons. The primary outcome was all-cause revision surgery. Data were combined from 22 trials, for 3564 participants (75% women, mean age 80 years). Treatments were grouped into 5 classes – total hip arthroplasty (THA), hemiarthroplasty (HA), screw, plate, and unthreaded cervical osteosynthesis (UCO). The median follow-up was 2 years. With HA and THA as a comparison, risk of surgical revision was significantly higher with UCO (OR 7.5 [95% CrI 3.4–14.4] and 7.8 [2.9–16.6], respectively), screw (9.3 [5.9–16.1] and 8.8 [4.6–19.9]) and plate (12.2 [5.2–23.1] and 9.9 [6.4–27.4]). The risk of bias was high or unclear, with only 45% of trials (n = 10) showing adequate generation of sequence and 32% (n = 7) showing adequate allocation concealment. Arthroplasty (HA and THA) is the most effective treatment for femoral neck fractures in terms of risk of revision surgery. HA may have an advantage as the fastest and least expensive surgery.