Fracture fixation versus hemiarthroplasty for unstable intertrochanteric fractures in elderly patients: A systematic review and network meta-analysis of randomized controlled trials

INTRODUCTION:There are three common types of operative options for unstable intertrochanteric fracture (ITF), i.e. dynamic hip screw (DHS), proximal femoral nail (PFN), and bipolar hemiarthroplasty (BHA). Results of these operations are still inconclusive. This systematic review and network meta-analysis was therefore conducted to compare the efficacy among those operative strategies. HYPOTHESIS:These three operative techniques (i.e., DHS, PFN, and BHA) were not different in operative failure, reoperation, and Harris Hip Score (HHS) for unstable ITF. MATERIAL AND METHODS:Randomized controlled trials (RCTs) comparing outcomes among DHS, PFN, and BHA in patients with unstable ITFs were searched from Medline and Scopus databases. Primary outcomes included operative failure, reoperation, and HHS. Direct meta-analysis (DMA) and network meta-analysis (NMA) were performed to compare among three operative techniques. Qualitative and quantitative evidences of all included studies were tested for heterogeneity, transitivity, and consistency in NMA. The surface under the cumulative ranking curve (SUCRA) was used to estimate the probability of being the best in lowering poor clinical outcomes, but high HHS. RESULTS:Seven RCTs (n=528) were eligible. DMA showed that DHS and PFN were significantly higher risk of operative failure compared with BHA with risk ratio (RR) and 95% confidence interval of 7.98 (1.35, 47.06) and 3.08 (1.00, 9.51), respectively. Compared with BHA, PFN was 4.47 (1.04, 21.60) times significantly higher risk of reoperation, and lower HHS at 3-6months [mean difference (MD)=-5.41 (-15.91, 5.10)], but higher HHS at>6-12months [MD 11.67 (2.98, 20.36)], although these HHSs were not significant. NMA and SUCRA demonstrated the highest ranks for operative failure and reoperation were DHS and PFN, whereas the highest HHS was BHA. DISCUSSION:In specific group of unstable ITF, BHA might be the best operative technique in term of lower operative failure and reoperation, and highest HHS during short to intermediate period comparing with PFN and DHS. However, PFN had higher long-term HHS than BHA. LEVEL OF EVIDENCE:I, meta-analysis of RCTs.