Proximal femoral nails antirotation, Gamma nails, and dynamic hip screws for fixation of intertrochanteric fractures of femur: A meta-analysis.

BACKGROUND: Which surgical strategy is the best one for intertrochanteric fractures remains a controversial issue. Dynamic hip screw (DHS) and Gamma nail were commonly used but often associated with some complications, such as fixation failure and implant-related fractures. Meanwhile, proximal femoral nail anti-rotation (PFNA) fixation has recently been developed for minimally invasive surgery to reduce the complications rate. To facilitate the clinical decision-making, we conducted an updated meta-analysis to discuss the optimal treatment of intertrochanteric fractures aiming to determine which implant gives the lower rates of blood loss, complications (peri-implant fracture, fixation failure, infection, thromboembolic), reoperation, and mortality, as well as the minimal duration related to surgery (fluoroscopic exposure, surgery and hospital stay).

PATIENTS AND METHODS: Seven electronic databases were searched for randomized controlled trials (including OVID, Springer, Google Scholar, PubMed, Cochrane library, Embase, and Web of Science). Fourteen studies with 1983 patients were included. The modified Jadad Scale was used to assess the methodological quality of these studies. Risk of bias in the included studies was assessed using the Cochrane Risk of Bias tool. Comparison among the three groups was based on twelve indicators, including operative time, fluoroscopy time, operative blood loss, length of hospital stays, wound infection or hematoma, pneumonia, thromboembolic complications, fixation failure, operative fracture of femur, later fracture of femur, reoperation, and mortality.

RESULTS: (1) PFNA group versus DHS group: PFNA was associated with less blood loss (mean difference (MD) -253.86, 95% CI -270.25 to 237.47; P<0.00001) and lower rate of fixation failure (MD 0.20, 95% CI 0.07 to 0.59; P=0.004), but led to more fluoroscopy time (MD 2.11, 95% CI 1.78 to 2.43; P<0.00001). (2) PFNA group versus Gamma nail group: PFNA led to less blood loss (MD -55.30, 95% CI -60.07 to -50.53; P<0.00001), shorter fluoroscopy time (MD -0.50, 95% CI -0.55 to -0.45; P<0.00001) and length of hospital stay (MD -0.20, 95% CI -0.27 to -0.13; P<0.00001). (3) DHS group versus Gamma nail group: DHS was associated with lower rate of operative fracture of femur (MD 0.31, 95% CI 0.11 to 0.89; P=0.03), later fracture of femur (MD 0.16, 95% CI 0.06 to 0.43; P=0.0004), and reoperation (MD 0.49, 95% CI 0.27 to 0.88; P=0.02), but caused more blood loss (MD 29.49, 95% CI 8.27 to 50.70; P=0.006). In contrast, there was no difference regarding operative time, infection hematoma, pneumonia, thromboembolic events, and mortality.

DISCUSSION: PFNA should be a priority choice for treatment of intertrochanteric fractures with minimal rate of fixation failure, less blood loss and shorter length of hospital stay. DHS has distinct advantages over Gamma nail with lower rate of plant-related complications and should be preferred device for intertrochanteric fractures. However, owing to the low quality evidence currently available, more high-quality RCTs are needed to confirm these findings.

LEVEL OF EVIDENCE: Level II.