Fixation Options Following Greater Trochanteric Osteotomies and Fractures in Total Hip Arthroplasty: A Systematic Review.

Background: The optimal system for greater trochanteric fixation following osteotomy or fracture remains unknown. This systematic review aimsto synthesize the available English-language literature on 5 commonly reported trochanteric fixation methods to quantify and compare rates of complications and reoperation. Methods: A comprehensive search of MEDLINE and Embase databases from January 1946 to June 2017 was performed for articles in English describing fixation of trochanteric osteotomies and fractures using wires, cables, cable-plate devices, claw or locking plates, and trochanteric bolts. Pooled mean rates of complications and reoperation with 95% confidence intervals (CIs) were analyzed using a random-effects model. Results: Fifty-seven studies involving 10,956 hips were eligible for inclusion. Five studies had Level-III evidence and 52 had Level-IV evidence. The pooled meanrate of nonunion was 4.17% (95% CI, 3.21% to 5.13%; I25 79%) for wires, 5.07%(95% CI, 0.37% to 9.77%; I-2 = 74%) for cables, 16.11% (95% CI, 10.85% to 21.37%; I-2 = 89%) for cable-plate systems, 9.60% (95% CI, 2.23% to 16.97%; I-2 = 59%) for claw or locking plates, and 12.42% (95% CI, 3.41% to 21.43%; I-2 = 75%) for trochantericbolts. Substantial heterogeneity in the data precluded formal statistical comparison of outcomes and complications between implants. Conclusions: Available literature on the various trochanteric fixation implants is heterogeneous and consists primarily of retrospective case series. Based on the current literature, it is difficult to support the use of one implant over another. Despite superior mechanical properties, rates of complication and reoperation following cable-plate fixation remains suboptimal, especially in complex revision scenarios. Additional rigorous prospective randomized and cohort studies are needed to make definitive recommendations regarding the most reliable method of trochanteric fixation. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.