Abstract
Objectiveto conduct a systematic review with consequent meta-analysis evaluating the best treatment for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 31A1-A3 trochanteric fractures when comparing the sliding hip screw (SHS) to the intramedullary nail (IMN). The outcomes used for comparison are major complications (in total, as well as nonunion and infection specifically), mortality rates, functional outcomes and patient-reported outcome measures (PROM). Materials and methodsSearch strings for the Cochrane Library, CINAHL, Medline and Embase databases were developed with the help of a scientific librarian. Two authors screened the studies from the search string independently using Covidence.org and data extraction was performed similarly. Quality assessment was performed using the Cochrane Risk of Bias tool for randomised trials (ROB2) for RCT studies, and Cochrane Risk of Bias in Non-Randomised Studies – of Interventions (ROBINS-I) for non-RCT studies. Meta-analyses were performed using Log Risk Ratio as the primary effect estimate. ResultsOf the 2,051 studies screened by the two authors, six RCTs and six non-RCTs were included in this meta-analysis, with a total of 10,402 patients. The results indicated no significant differences in total major complications, nonunion, infection or mortality between SHS and IMN treatments for AO/OTA 31A1, 31A2 and 31A3 trochanteric fractures. Due to a lack of compatible data, we were unable to perform a meta-analysis on function scores and PROM. However, there are trends that favour IMN for 31A1 and 31A2 fractures. ConclusionNo significant difference between SHS and IMN was found in the meta-analysis in any of the examined AO/OTA fracture subtypes in terms of primary and secondary outcomes. When assessing function scores and PROM, we found trends favouring IMN for 31A1 and 31A2 fractures that should be explored further.
Highlights
Trochanteric fractures are usually treated surgically and the two predominant choices for internal fixation are the sliding hip screw (SHS) and the intramedullary nail (IMN) [1,2]
The inclusion criteria were initially met by 50 studies; upon further assessment, 38 studies were excluded as they did not classify study results in accordance with the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA)-classification
Regarding functional outcomes of 31A1 fractures in our study, Weiguang et al [71] and Zeng et al [74] found IMN to be superior to SHS when using the Harris Hip score; Matre et al [68] and Parker et al [41] found no differences in functional outcomes using Parker Mobility Score and EQ-5D. The latter two studies must be assumed to have a larger impact, as Matre et al includes a total of 7,634 hip fractures, while Parker et al performed an RCT with 1,000 patients in comparison to 225 patients with Weiguang et al and Zeng et al we found no difference in the likelihood of major complications between SHS and IMN for 31A1 fractures
Summary
Trochanteric fractures are usually treated surgically and the two predominant choices for internal fixation are the sliding hip screw (SHS) and the intramedullary nail (IMN) [1,2]. Numerous studies have demonstrated no difference in outcome between SHS and IMN, but this finding may be due to the pooling of results from all types of trochanteric fractures. The NICE guidelines [1] recommend SHS as the surgical treatment for A1 and A2 and IMN for A3 fractures. The AAOS guidelines [8] recommend either SHS or IMN for stable fractures and IMN for unstable fractures. The difference in the guidelines is not evidence-based, as most meta-analyses have demonstrated no notable advantage to choosing one treatment over the other [2,912 ]
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