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Comparative outcome of PFNA, Gamma nails, PCCP, Medoff plate, LISS and dynamic hip screws for fixation in elderly trochanteric fractures: a systematic review and network meta-analysis of randomized controlled trials

  • Original Article • HIP - FRACTURES
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Abstract

The ideal implant for the treatment of an unstable intertrochanteric femoral fracture is still a matter of discussion. The aim of this systematic review is to conduct a network meta-analysis of randomized controlled trials (RCTs) comparing clinical outcomes between dynamic hip screws (DHS), Medoff sliding plating, percutaneous compression plating (PCCP), proximal femoral nails (PFN), Gamma nails and less invasive stabilization system fixation in femoral trochanteric fractures in the elderly. These clinical outcomes consist of total intra-operative time, intra-operative fluoroscopy time, intra-operative blood loss, blood component transfusion, length of hospital stay, postoperative general complications, wound complications, late complications and reoperation rates. This systematic review was conducted using PubMed and Scopus search engines for RCTs comparing clinical outcomes between treatments from inception to February 22, 2015. Thirty-six of 785 studies identified were eligible. Compared to the other implants, PCCP showed the lowest total operative time and units of blood transfusion with an unstandardized mean difference (UMD) of 29.27 min (95% CI 5.24, 53.50) and 0.89 units (95% CI 0.52, 1.25). The lowest incidence of general complications, wound complications and late complications of PCCP was 0.09 (95% CI 0.04, 0.18), 0.01 (95% CI 0.01, 0.04) and 0.05 (95% CI 0.02, 0.11), respectively, when compared to others. The lowest fluoroscopic time was with DHS with an UMD of 0.24 min (95% CI 0.16, 0.32), whereas the lowest blood loss and shortest hospital stay were with PFN with an UMD of 233.61 ml of blood loss (95% CI 153.17, 314.04) and 7.23 days of hospital stay (95% CI 7.15, 7.31) when compared to all other fixation methods. Reoperation rates of all implants had no statistically significant difference. The network meta-analysis suggested that fixation with PCCP significantly shortens operative time and decreases the units of blood transfusion required, while also lowering risks of general complications, wound complications and late complications when compared to fixation. Use of PFN showed the least intra-operative blood loss and shortest hospital stay. Multiple active treatment comparisons indicate that PCCP fixation in trochanteric fractures in the elderly is the treatment of choice in terms of intra-operative outcomes and postoperative complications.

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Abbreviations

RCTs:

Randomized controlled trials

DHS:

Dynamic hip screws

PCCP:

Percutaneous compression plating

PFN:

Proximal femoral nails

LISS:

Less invasive stabilization system

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Acknowledgements

All authors declare that no funding source or any sponsor involvement in the study design, collection, analysis and interpretation of the data; in writing of the manuscript; and in the submission to submit the manuscript for publication.

Authors’ contributions

AA was involved in conception and design, analysis and interpretation of the data, drafting of the article, critical revision of the article for important intellectual content, final approval of the article, collection and assembly of data. TA was involved in conception and design, drafting of the article, critical revision of the article for important intellectual content, final approval of the article, collection and assembly of data. PT was involved in conception and design, drafting of the article, critical revision of the article for important intellectual content, final approval of the article. PP was involved in conception and design, drafting of the article, critical revision of the article for important intellectual content, final approval of the article. PS was involved in conception and design, drafting of the article, critical revision of the article for important intellectual content, final approval of the article. JK was involved in conception and design, analysis and interpretation of the data, drafting of the article, critical revision of the article for important intellectual content, final approval of the article, statistical expertise, collection and assembly of data.

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Authors and Affiliations

  1. Orthopedics Department, Police General Hospital, Bangkok, Thailand

    Alisara Arirachakaran, Tanawat Amphansap & Peerapong Piyapittayanun

  2. Department of Orthopedic Surgery, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand

    Pichaya Thanindratarn & Phutsapong Srisawat

  3. Sport and Orthopedic Center, Samitivej Hospital, Bangkok, Thailand

    Jatupon Kongtharvonskul

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  1. Alisara Arirachakaran
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  2. Tanawat Amphansap
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Correspondence to Jatupon Kongtharvonskul.

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Appendix: Search term and search strategy

Appendix: Search term and search strategy

#1 Fracture intertrochanteric

#2 Elder

#3 Fracture femur

#4 Proximal femural nail

#5 Dynamic hip screws

#6 Gamma nail

#7 Proximal femural nail anti rotation

#8 Blood loss

#9 Hospital stay

#10 Failure rate

#11 Femeral shaft fracture

#12 Operative times

#13 Complications

#14 #1 or #2 or #3

#15 #4 or #5 or #6 or #7

#16 #8 or #9 or #10 or #11 or #12 or #13

#17 #14 and #15 and #16.

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Arirachakaran, A., Amphansap, T., Thanindratarn, P. et al. Comparative outcome of PFNA, Gamma nails, PCCP, Medoff plate, LISS and dynamic hip screws for fixation in elderly trochanteric fractures: a systematic review and network meta-analysis of randomized controlled trials. Eur J Orthop Surg Traumatol 27, 937–952 (2017). https://doi.org/10.1007/s00590-017-1964-2

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