Is Proximal Femoral Nail Antirotation Superior To Gamma Nail And Dynamic Hip Screw In Treatment Of Intertrochanteric Fractures? A Pairwise And Network Meta-Analysis

Purposes: Proximal femoral nail antirotation (PFNA) was theoretically designed to be an ideal intramedullary device for the fixation of intertrochanteric fractures by providing angular and rotational stability. We investigated when compared with Gamma nail (GN) and dynamic hip screw (DHS) whether PFNA was associated with (1) a lower incidence of reoperation, mortality and fixation failures, (2) a lower risk of major complications (wound infection and thromboembolism), (3) less operative blood loss, shorter surgical time, operative fluoroscopy time and hospital stay. Methods: We conducted a comprehensive search in MEDLINE (R), EMBASE, OVID and Cochrane Central Register of Controlled Trials and identified 753 papers. Of these, identified 13 randomized controlled trials comparing two (or more) common internal fixation devices (among PFNA, GN and DHS) in treatment of Intertrochanteric fractures. We performed both traditional direct-comparison meta-analysis and network meta-analysis. The strength of evidence was evaluated by using GRADE profiler software. Results: Direct-comparison meta-analysis demonstrated PFNA was associated with less operative blood loss when compared with GN (95% CI, -93.56 to -5.44, low confidence evidence) and DHS (95% CI, -291.90 to -151.58, low confidence evidence), and less operative fluoroscopy time when compared with GN (95% CI, -56.21 to -3.79, low confidence evidence). Network meta-analysis only found that PFNA was associated with less operative blood loss when compared with DHS (95% CI, -342.12 to -81.94) with very low confidence evidence. Conclusions: Current published evidence does not support the superiority of PFNA to other fixation strategies for intertrochanteric fractures. Although use of PFNA may be advantageous in reducing the operative blood loss and fluoroscopy time when compared with GN and DHS, the conclusion was limited and unacceptable because of the relatively low quality of evidences with either low or very low strength of confidence.