
==== Front
PLoS One
PLoS One
plos
PLOS ONE
1932-6203
Public Library of Science San Francisco, CA USA

10.1371/journal.pone.0310971
PONE-D-24-24072
Study Protocol
Research and Analysis Methods
Mathematical and Statistical Techniques
Statistical Methods
Metaanalysis
Physical Sciences
Mathematics
Statistics
Statistical Methods
Metaanalysis
Computer and Information Sciences
Network Analysis
Research and Analysis Methods
Research Assessment
Systematic Reviews
Research and Analysis Methods
Database and Informatics Methods
Database Searching
Science Policy
Research Integrity
Publication Ethics
Biology and Life Sciences
Anatomy
Musculoskeletal System
Skeleton
Pelvis
Hip
Medicine and Health Sciences
Anatomy
Musculoskeletal System
Skeleton
Pelvis
Hip
Medicine and Health Sciences
Surgical and Invasive Medical Procedures
Biology and Life Sciences
Biomechanics
Eleven internal fixations for young vertical femoral neck fractures: A protocol for systematic review and network meta-analysis
Internal fixations for VFNF: A protocol for NMA
https://orcid.org/0000-0002-3207-3592
Shen Weiwei Conceptualization Formal analysis Investigation Methodology Project administration Resources Software Supervision Writing – original draft Writing – review & editing 1
Xue Yun Data curation Software Validation 1 *
Shi Jie Data curation Resources Validation 1
Deng Xiaowen Investigation Resources 1
Pu Zhongshu Conceptualization Formal analysis Methodology Writing – original draft 2
Gao Qiuming Conceptualization Project administration Supervision Visualization Writing – review & editing 1
1 Orthopedics Center of PLA, The 940th Hospital of Joint Logistics Support Force Army of PLA, Lanzhou, Gansu Province, China
2 Department of Infection Control, The 940th Hospital of Joint Logistics Support Force Army of PLA, Lanzhou, Gansu Province, China
Klosowski Pawel Editor
Gdańsk University of Technology: Politechnika Gdanska, POLAND
Competing Interests: The authors have declared that no competing interests exist.

* E-mail: xueyuncloud@163.com
24 9 2024
2024
19 9 e031097127 6 2024
10 9 2024
© 2024 Shen et al
2024
Shen et al
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Background and objectives

Vertical femoral neck fractures (VFNFs) in young patients lead to significant biomechanical instability. Multitudinous internal fixation devices have been developed and utilized in clinical interventions. However, there has yet to be a consensus expert opinion regarding the optimal internal fixation configurations. This study aims to conduct a network meta-analysis to evaluate the safety and efficacy of all currently recognized internal fixation procedures for the treatment of VFNFs in young individuals.

Methods

Comprehensive literature searches will be performed in China National Knowledge Infrastructure, the Cochrane Library, PubMed, Web of Science, Embase, the Wanfang Database, and the Chinese Biomedical Literature Database, covering the entire database history up until May 21, 2024. Individual papers will be evaluated for possible bias using RoB 2.0, the most recent version of the randomized trial Cochrane risk-of-bias approach. Pairwise meta-analysis and network meta-analysis (NMA) will be conducted for data analysis using STATA 15.0 and R 4.1.3. Inconsistency tests, subgroup analyses, sensitivity analyses, and assessments of publication bias will also be performed.

Conclusion

The study will provide evidence-based recommendations for the optimal internal fixation methods in treating young patients with VFNFs.

Trial registration

INPLASY202460017.

Scientific and Technological Planning Projects of Gansu Province (No. 21JR7RA016) and Key Clinical Specialties of PLA. https://orcid.org/0000-0002-3207-3592
Shen Weiwei The work is supported by the Scientific and Technological Planning Projects of Gansu Province (No. 21JR7RA016) and Key Clinical Specialties of PLA. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Data AvailabilityNo datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.
Data Availability

No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.
==== Body
pmcIntroduction

Femoral neck fractures (FNFs) are the predominant type of fracture encountered in clinical practice, constituting 60% of all hip fractures [1]. The worldwide incidence of hip fractures, estimated at 1.3 million annually in 1990, is projected to increase to 2.6 million by 2025 and reach 4.5 million by 2050 [2]. Vertical FNFs (VFNFs) in young patients primarily occur due to high-force incidents, including automobile accidents and forceful collisions. These fractures lead to increased biomechanical instability [3]. To provide a successful clinical outcome for these fractures, effective internal fixation and anatomic reduction are commonly acknowledged [4]. Unfortunately, there is a significant prevalence of postoperative problems after performing internal fixation on vertical fractures in young patients. Approximately 45% of young patients with FNFs experience problems, including failed fixation, nonunion, malunion, and osteonecrosis. Out of these patients, 32% require significant reconstructive surgery [5].

In recent times, multitudinous internal fixation devices have been developed and used in clinical practice, such as proximal femoral nail anti-rotation (PFNA), cannulated compression screw (CCS), dynamic hip screw (DHS), medial buttress plate (MBP), and femoral neck system (FNS). However, there is no consensus expert opinion on the most efficient internal fixation configurations. Many biomechanical investigations and clinical trials have been performed to find the most effective arrangements of internal fixations for VFNFs. Several researches have revealed that the inverted triangle arrangement of three cannulated screws exhibits greater strength compared to the configuration with triangle screws [6, 7]. Meanwhile, some other studies have demonstrated that DHS is more effective compared to cancellous screw constructs, as DHS could resist more shear forces in vitro biomechanical tests [8, 9]. The FAITH-2 research (Fixation Using Alternative Implants for the Treatment of Hip Fractures), which involved multiple countries and centres, conducted a randomized controlled experiment in young femoral neck fracture patients [10]. The research showed insignificant differences in the outcomes between cannulated screw constructs and fixed-angle devices up till now.

Multiple meta-analyses and systematic reviews have documented the comparative analysis of various forms of internal fixations. Xia et al. [11] reported a higher incidence rate of avascular necrosis of the femoral head with SHS, whereas CCS showed a higher rate of implant loosening. Zhou et al. [12] performed a meta-analysis comprising 21 trials and 1,347 patients. Their findings indicate that FNS is better than CCS in terms of both effectiveness and safety for the internal fixation of FNFs. However, the traditional meta-analysis has not been able to compare all treatment strategies for young VFNFs thoroughly. The emerging network meta-analysis (NMA) has gained a significant acceptance in medical research and is recognized as yielding high-quality evidence, because of the ability to simultaneously compare multiple interventions directly and indirectly [13, 14]. Zhang et al. [15] conducted the first NMA to compare and rank four surgical procedures for the elderly displaced FNFs. This NMA focused on the difference between hemiarthroplasty, internal fixation, and total hip arthroplasty. However, it didn’t detail the differences between various internal fixations. This is a significant inadequacy, as existing evidence has demonstrated that young individuals with VFNFs should have internal fixation for treatment [16]. So far, numerous internal fixation devices have been developed and utilized in the interventions of VFNFs, including CCS, DHS, PFNA, and FNS [17, 18]. Meanwhile, many modified techniques and configurations of CCS have been clinically proven effective, such as adding a fourth Pauwel screw [19], and a biplane double-supported screw fixation method [20]. Therefore, there is an urgent need to update this NMA and solve the deficiency.

This study aims to conduct the NMA of published randomized controlled trials (RCTs) in order to assess the effectiveness of eleven different internal fixations for young patients with VFNFs. The fixation techniques under evaluation include: 1) three parallel screws with inverted triangular (ITR) or 2) triangular (TRI) configurations, as well as configurations involving 3) inverted parallel screws with a Pauwel screw, arranged in an "alpha" configuration (ALP); and 4) with a buttress plate (BUT) strengthening the calcar (BUT); 5); biplane double-supported screw fixation (F-technique); 6) four parallel screws arranged in a "rhomboid" configuration (RHO); 7) dynamic hip screw fixation without anti-rotation screws (DHS); 8) dynamic hip screw fixation with anti-rotation screws (DHS+); 9) femoral neck system (FNS); 10) cephalomedullary nails (CMN); 11) proximal femoral plates (PFP). It is anticipated that this novel NMA will furnish empirical medical data for the management of juvenile VFNFs using internal fixations, hence enhancing support for orthopaedic practitioners.

Methods

Both this systematic review and the NMA protocol have followed the guidelines set forth in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocols (PRISMA-P) [21]. The checklist of PRISMA-P is available in S1 File on the website. Our protocol is now officially registered on the INPLASY database under the reference number INPLASY202460017.

Eligibility criteria

The criteria for inclusion or exclusion of studies are formulated based on the PICOS framework, which encompasses factors related to the patient population, comparator, outcomes, intervention, and study design.

Participants (P)

All young patients who have been diagnosed with VFNFs using X-plain film or CT scan will be included in our systematic review, independent of their country of origin, race, or gender. Patients with pathological VFNFs or those who are elderly and have a femoral neck fracture (age ≥ 60 years) will be excluded.

Interventions (I)

There will be more than or equal to one form of internal fixations for juvenile VFNFs that will be included as part of the experimental group. These include ITR, TRI, ALP, RHO, BUT, F-technique, DHS, DHS+, FNS, CMN, and PFP fixes. Furthermore, operations including hemiarthroplasty or complete hip arthroplasty, free vascularized fibula grafting, and valgus osteotomy will not be permitted, regardless of whether cement or noncement is used. Regarding reduction techniques (close versus open) or surgical approaches (later versus anterior versus anterolateral), there will be no limitations placed on either.

Comparator (C)

Patients who received another form of internal fixation treatment will be included in the contrast group.

Outcomes (O)

The primary outcome is defined as revision surgery regardless of study periods or any reason. Secondary measure outcomes that will be included are duration of surgery, intraoperative blood loss, osteosynthesis failure or loosening, Harris Hip Score (HHS), length of stay in the hospital, deep vein thrombosis, mortality, and postoperative complications, including surgical nonunion, site infections, and avascular necrosis of the femoral head (ANFH).

Study design (S)

This analysis will just use RCTs. Case-control studies, opinion papers, editorials, reviews, case reports, and cohort studies will not be considered.

Data repositories and search plan

A thorough search will be carried out in the following databases: China National Knowledge Infrastructure, PubMed, Embase, the Wanfang Database, the Chinese Biomedical Literature Database, Web of Science, and the Cochrane Library. The search will encompass all available data from the inception of each database up until May 21, 2024. The search for studies will be limited to publications in either Chinese or English. The literature search will integrate both free text words and MeSH terms to determine related trials. The details of the strategy of PubMed search can be found in S2 File. Search techniques specific to each database will be modified as necessary. A manual review of eligible studies and related systematic reviews will be conducted in order to identify any missed research or additional data.

Study selection

The Zotero 6.0 software will be used to import all of the retrieved research, and any duplicates will be eliminated thereafter. The abstracts and titles of all the identified studies will undergo independent scrutiny by two reviewers. After the preliminary exclusion of irrelevant publications, all potentially relevant studies’ full texts will be downloaded, and reviewed for further independent assessment. Any conflicts will be handled by collaborative discussion within the team or by seeking input from a third reviewer. Finally, the selected papers will be presented in a flow diagram (Fig 1) following the guidelines of PRISMA-P.

10.1371/journal.pone.0310971.g001 Fig 1 Flow chart of study selection.

Data acquisition

Two reviewers will independently use a pre-established, standardized data abstraction sheet to extract data from each of the listed studies. Information to be extracted includes:

Basic information: title, first authors, the publication year, country, and language.

Trial characteristics: study design, follow-up period, random method, blinding method and allocation concealment.

Participants: sample size of different groups, diagnostic methods, mean age, gender, Pauwels classification, fracture displace degree.

Interventions: internal fixation system, fracture reduction method (open vs close), and surgery times.

Outcomes: all specified outcomes, number of participants with complete follow-up and document reasons for loss to follow-up.

Evaluation of bias risk

The bias risk in the included studies will be independently assessed by two reviewers using the updated Cochrane risk-of-bias tool for randomized trials (RoB 2.0) [22]. This tool analyzes bias in five different domains: the randomization procedure; outcome measurement; missing outcome data; deviations from intended interventions; and the selection of reported outcomes, each of which is classified as low risk, moderate concerns, or high risk. According to this assessment, each investigation will be classified as having a moderate, high, or low bias risk. Any disagreements will be resolved by a third reviewer or through consensus.

Statistical analysis

1. Pairwise meta-analysis

Direct comparisons with R 4.1.3 will be conducted through pairwise meta-analysis employing the meta package [23]. Continuous variables will be assessed using the mean difference (MD) and 95% confidence intervals (CIs), while dichotomous variables will be analyzed with the risk ratio (RR) and corresponding 95% CI. Statistical heterogeneity among studies will be evaluated using the I2 statistic and 95% prediction intervals [24, 25]. Due to expected heterogeneity among the studies, the random-effects model will be applied as it provides a more conservative evaluation of effect sizes.

2. Network meta-analysis

We will perform the NMA with R 4.1.3 software (ggplot2 package and gemtc package) on the Bayesian framework [26]. The network meta-analysis will also use random-effects models, which are considered the most conservative method for addressing heterogeneity across studies. The Markov chain Monte Carlo simulations will be built in this Bayesian NMA, with a burn-in of 10,000 iterations, sampling of 50,000 iterations and thinning interval of 10. In order to analyze the model’s convergence, the Gelman-Rubin-Brooks diagnostic plots and the potential scale reduction factor will be used [27]. All potential pairwise comparisons, including mixed and indirect comparisons, will be used to summarize the NMA findings. The local inconsistency of NMA will be calculated for closed loops of interventions using the node-splitting approach [28]. To rank the interventions based on optimal probability, the study will generate the Surface Under the Cumulative Ranking (SUCRA) curve [29]. The SUCRA value is a measure that goes from 0 to 100%. A higher value, closer to 100%, implies that a treatment has a greater therapeutic efficacy compared to other therapies investigated for the same result.

Sensitivity and subgroup analyses

Subgroup analysis will be performed to identify sources of heterogeneity, focusing on factors such as the extent of fracture displacement and methods of reduction, among other relevant factors. An analysis of sensitivity will also be performed by systematically excluding each study to check if the findings possess stability. If there is a significant alteration in the variability or the meta-analysis result, the excluded study will be regarded as a contributing factor to the heterogeneity.

Quality of evidence

The quality of evidence for each result in the NMA will be examined using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) analysis [30]. Five factors contributing to potential downgrading will be evaluated: risk of bias, indirectness, publication bias, inconsistency, and imprecision. There will be 4 levels of evidence quality for each relevant outcome: extremely low, low, moderate, and high.

Publication bias

If there are more than ten studies, publication bias will be accessed by examining comparison-adjusted funnel plots using STATA 15.0 software [31]. These funnel plots serve as a representative tool for identifying potential publication bias in systematic reviews. The publication bias will also be evaluated by employing Egger’s test [32]. Asymmetry in the funnel plots suggests the existence of such bias.

Discussion

FNFs in young patients mostly result in VFNFs, leading to greater biomechanical instability [18]. Reduction and internal fixation are widely employed as therapies in clinical practice [33]. Unfortunately, the poor outcomes and high complication rates following the internal fixation for VFNFs in young patients are substantial. The most appropriate internal fixation configurations remain controversial.

Multiple conventional pairwise meta-analyses have examined the relative effectiveness of internal fixation for VFNFs [11, 12]. However, all these only compared the therapeutic effectiveness difference between the two or three internal fixation methods. The relative effectiveness of various methods of internal fixation in young patients with VFNFs has not yet been determined. To our knowledge, this review is the first Bayesian meta-analysis aimed at assessing and ranking the most effective internal fixation methods for young VFNFs. The results of this study will enhance understanding of the benefits associated with each specific internal fixation method and offer evidence-based medical guidance for selecting appropriate procedures to treat young patients with VFNFs.

Significantly, this study also has limitations. Complete elimination of heterogeneity is challenging due to variations in fracture displacement, reduction techniques, surgical approaches, and follow-up duration. Internal fixation has demonstrated promise for treating VFNFs in young patients; however, robust multicenter RCTs are necessary to validate these findings.

Supporting information

S1 File PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) 2015 checklist: Recommended items to address in a systematic review protocol.

(DOC)

S2 File Search strategy for PubMed.

(DOCX)

10.1371/journal.pone.0310971.r001
Decision Letter 0
Klosowski Pawel Academic Editor
© 2024 Pawel Klosowski
2024
Pawel Klosowski
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version0
27 Aug 2024

PONE-D-24-24072Eleven Internal Fixations for young vertical femoral neck fractures: a protocol for systematic review and network meta-analysisPLOS ONE

Dear Dr. Shen,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

ACADEMIC EDITOR: According to the reviewer suggestions the paper requires some changes. Please read (at the end of the message) them carefully and include into the final version of the paper

==============================

Please submit your revised manuscript by Oct 11 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Pawel Klosowski, D.Sc.

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at 

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and 

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed:

- Eleven Internal Fixations for young vertical femoral neck fractures: a protocol for systematic review and network meta-analysis (doi:10.37766/inplasy2024.6.0017)

In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

3. Thank you for stating the following financial disclosure: 

"The work is supported by the Scientific and Technological Planning Projects of Gansu Province (No. 21JR7RA016) and Key Clinical Specialties of PLA."

Please state what role the funders took in the study.  If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." 

If this statement is not correct you must amend it as needed. 

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

4. When completing the data availability statement of the submission form, you indicated that you will make your data available on acceptance. We strongly recommend all authors decide on a data sharing plan before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption. Please be assured that, once you have provided your new statement, the assessment of your exemption will not hold up the peer review process.

5. Please respond by return e-mail with an updated version of your manuscript to amend either the abstract on the online submission form or the abstract in the manuscript so that they are identical. We can make any changes on your behalf.

6. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: No

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I would first like to thank the Editor for inviting me to review this interesting manuscript for this prestigious journal.

My views on the requested manuscript (PONE-D-24-24072) are as follows.

# Overall opinion

- The purpose of the study is well described and convinces the reader of the need for it, and I believe this is a protocol that should be positively considered for publication.

- Once the following questions have been addressed, I would have no difficulty agreeing to publication.

# Questions or requests for clarification

1. It is recommended that risk ratios be used for calculating effect sizes in binary data, as they can be misleading to the majority of readers. Furthermore, it is appropriate to convert and report results calculated with odds ratios to risk ratios. Should authors have a specific reason for using ORs, they are asked to provide a detailed explanation in the manuscript. Otherwise, the use of RRs is to be preferred.

2. The choice between a random effects model and a fixed effects model, based on the I squared statistic, may introduce statistical bias. In the event that heterogeneity is suspected, it is recommended that the random-effects model be utilized as a default, with the fixed-effects model presented as supplementary material. This approach provides a more conservative view of the study.

3. The I squared statistic is not an absolute measure of heterogeneity. It would be prudent to include the measurement and reporting of prediction intervals in the protocol. The following recently published references may prove useful for researchers in this regard.

Suggested ref. Borenstein M. Avoiding common mistakes in meta-analysis: Understanding the distinct roles of Q, I-squared, tau-squared, and the prediction interval in reporting heterogeneity. Res Synth Methods. 2024 Mar;15(2):354-368. doi: 10.1002/jrsm.1678

4. It would be beneficial to provide an explanation, even in schematic form, of the planned categorization of primary and secondary outcomes at the protocol stage. It is essential that researchers have a clear pre-definition of the data that will be primarily reflected in the conclusions.

5. As the study employs a Bayesian statistical approach to NMA, it would be beneficial to provide a priori information regarding the number of iterations, burn-in period, and data extraction intervals for the MCMC model.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

10.1371/journal.pone.0310971.r002
Author response to Decision Letter 0
Submission Version1
7 Sep 2024

Response to reviews

Title: Eleven Internal Fixations for young vertical femoral neck fractures: a protocol for systematic review and network meta-analysis

Dear editor and reviewers:

Thank you for your letter and the reviewers’ comments concerning our manuscript entitled “Eleven Internal Fixations for young vertical femoral neck fractures: a protocol for systematic review and network meta-analysis” (PONE-D-24-24072). All these comments are valuable and very helpful. We have read through comments carefully and have made corrections. Based on the instructions provided in your letter, we uploaded the file of the revised manuscript. We hope the revised manuscript has now met the publication standard of your journal.

We highlighted all the revision in red. Our point-to-point responses to the reviewer's comments are presented following.

Academic editor (original comments are in blue color)

Comment 1: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response: We appreciate for your warm work earnestly. On the basis of PLOS ONE's style requirements, our manuscript had been carefully checked and corrected accordingly. Revised portion are underlined in red.

Comment 2: We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed:

- Eleven Internal Fixations for young vertical femoral neck fractures: a protocol for systematic review and network meta-analysis (doi:10.37766/inplasy2024.6.0017)

In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

Response: We fully agree with this requirement. The above-mentioned previous publication is our meta-analysis register document. This meta-analysis was registered on INPLASY, so there was some overlapping text between them to a certain extent. In fact, all the authors are well aware that copying extracts from previous publications, especially outside the methods section, word-for-word is unacceptable. The manuscript had been cross-checked by iThenticate for reviewing the text similarity. Any duplicated text had been quoted or rephrased correspondingly.

Comment 3: Thank you for stating the following financial disclosure:

"The work is supported by the Scientific and Technological Planning Projects of Gansu Province (No. 21JR7RA016) and Key Clinical Specialties of PLA."

Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

Response: The funders had no role in the study. “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.” has been stated in the revised manuscript.

Comment 4: When completing the data availability statement of the submission form, you indicated that you will make your data available on acceptance. We strongly recommend all authors decide on a data sharing plan before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption. Please be assured that, once you have provided your new statement, the assessment of your exemption will not hold up the peer review process.

Response: We are all deeply appreciative of your recommendation. Taking the publication timelines problem into consideration, we have revised our data sharing plan. All relevant data from this study will be made available upon study completion. We apologize for the confusion generated by our previous data availability statement.

Comment 5: Please respond by return e-mail with an updated version of your manuscript to amend either the abstract on the online submission form or the abstract in the manuscript so that they are identical. We can make any changes on your behalf.

Response: We all appreciate for your kindness and selfless assistance. We have updated our manuscript by e-mail so that the abstract is the same on the online and the manuscript.

Comment 6: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: According to the PLOS ONE's style requirements, all reference list in our manuscript has been checked carefully and revised accordingly to ensure that it is complete and correct. No retracted papers were cited. No changes to the reference list has been made.

Reviewer's Responses to Questions (Questions are in blue color)

Question 1: Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

Reviewer: Yes

Response: Thank you for your good comment. Our manuscript provide a valid rationale for the proposed study. Vertical femoral neck fractures (VFNFs) lead to significant biomechanical instability. However, there has yet to be a consensus expert opinion regarding the optimal internal fixation configurations. This study conducted a network meta-analysis to evaluate the safety and efficacy of all available internal fixation procedures for VFNFs.

Question 2: Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

Reviewer: Yes

Response: This protocol has been reported following the PRISRM-P guideline. The criteria for inclusion studies are formulated based on the PICOS framework. Meanwhile, both conventional pairwise meta-analyses and network meta-analysis will be conducted in this meta-analysis for the treatment of VFNFs.

Question 3: Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Reviewer: No

Response: Thank you for this valuable feedback. Despite we tried our best to describe methods in sufficient detail, there would be some shortcomings, even mistakes inevitably in this protocol. We have carefully addressed all the reviewer’s concerns. All added information and correction highlighted in red have been supplied accordingly in the revised manuscript.

Question 4: Have the authors described where all data underlying the findings will be made available when the study is complete?

Reviewer: No

Response: According the PLOS Data policy, all relevant data from this study will be made available upon study completion.

Question 5: Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer: No

Response：Thank you for pointing this out! With the help of TopEdit (www.topeditsci.com) for linguistic assistance, we carefully read the full text and corrected some language and writing problems, and marked the major changes in red. We really hope that the language level have been substantially improved.

Question 6: PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer: No

Respond: We sincerely appreciate the valuable suggestion. After carefully reading and thoroughly understanding the PLOS Privacy Policy, we decide to publish the peer review history when an article is published.

Review Comments to the Author (original comments are in blue color)

Comment 1: It is recommended that risk ratios be used for calculating effect sizes in binary data, as they can be misleading to the majority of readers. Furthermore, it is appropriate to convert and report results calculated with odds ratios to risk ratios. Should authors have a specific reason for using ORs, they are asked to provide a detailed explanation in the manuscript. Otherwise, the use of RRs is to be preferred.

Response: We sincerely thank the reviewer for careful reading. As is well known, it is preferable to avoid reporting odds ratios in RCTs to avoid misinterpretations. So we have replaced the “ORs” with “RRs” in the reversed manuscript.

Comment 2: The choice between a random effects model and a fixed effects model, based on the I squared statistic, may introduce statistical bias. In the event that heterogeneity is suspected, it is recommended that the random-effects model be utilized as a default, with the fixed-effects model presented as supplementary material. This approach provides a more conservative view of the study.

Response: We thank the reviewer for pointing out this issue. Due to expected heterogeneity among the studies, the random effects model provides a more conservative evaluation of effect sizes. We have re-written this part according to the reviewer’s suggestion in the revised manuscript.

Comment 3: The I squared statistic is not an absolute measure of heterogeneity. It would be prudent to include the measurement and reporting of prediction intervals in the protocol. The following recently published references may prove useful for researchers in this regard.

Suggested ref. Borenstein M. Avoiding common mistakes in meta-analysis: Understanding the distinct roles of Q, I-squared, tau-squared, and the prediction interval in reporting heterogeneity. Res Synth Methods. 2024 Mar;15(2):354-368. doi: 10.1002/jrsm.1678

Respond: We sincerely appreciate the valuable comment. We read the articles recommended by the reviewer and found a lot to learn from them. Although the vast majority of meta-analyses in medicine use I squared statistic as the primary index of heterogeneity, it is a serious mistake. The I squared index is a proportion, not an absolute amount. The prediction interval may be particularly imprecise in a meta-analysis with few studies, resulting from an imprecise estimation of the summary effect size and heterogeneity parameter. We have included prediction intervals approach in the revised manuscript, and added the suggested reference in the Reference list.

Comment 4: It would be beneficial to provide an explanation, even in schematic form, of the planned categorization of primary and secondary outcomes at the protocol stage. It is essential that researchers have a clear pre-definition of the data that will be primarily reflected in the conclusions.

Respond: We agree with this suggestion. An explanation of the primary outcome (revision surgery) has been provided in the revised manuscript. We appreciate for your warm work earnestly.

Comment 5: As the study employs a Bayesian statistical approach to NMA, it would be beneficial to provide a priori information regarding the number of iterations, burn-in period, and data extraction intervals for the MCMC model.

Respond: We thank the reviewer for point out this issue. We indeed should have provided a priori information of MCMC model when Bayesian statistical approach is applied to NMA. The number of iterations, burn-in period, and data extraction intervals for the MCMC model is provided in the reversed manuscript.

Thank you very much for the invaluable comments and suggestions you provided on my manuscript. We have carefully considered each of your points and have responded accordingly. Should you have any further questions or suggestions regarding my paper, please feel free to contact us.

Once again, I truly appreciate your valuable time and constructive feedback.

Yours sincerely,

Yun Xue, M.D.

Professor in Orthopedics

Orthopedics Center of PLA

The 940th Hospital of Joint Logistics Support Force Army of PLA,

333 Bin He South Road, Lanzhou, China

Attachment Submitted filename: Response letter.docx

10.1371/journal.pone.0310971.r003
Decision Letter 1
Klosowski Pawel Academic Editor
© 2024 Pawel Klosowski
2024
Pawel Klosowski
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version1
11 Sep 2024

Eleven Internal Fixations for young vertical femoral neck fractures: a protocol for systematic review and network meta-analysis

PONE-D-24-24072R1

Dear Dr. Shen,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Pawel Klosowski, D.Sc.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The author graciously responded to my views.

I believe that all of my comments have been addressed, so I am able to agree to the publication of the manuscript at this point.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

**********

10.1371/journal.pone.0310971.r004
Acceptance letter
Klosowski Pawel Academic Editor
© 2024 Pawel Klosowski
2024
Pawel Klosowski
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
15 Sep 2024

PONE-D-24-24072R1

PLOS ONE

Dear Dr. Shen,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

* There are no issues that prevent the paper from being properly typeset

If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps.

Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

If we can help with anything else, please email us at customercare@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Prof. Pawel Klosowski

Academic Editor

PLOS ONE
==== Refs
References

1 Kenmegne GR , Zou C , Fang Y , He X , Lin Y , Yin Y . Femoral neck fractures in non-geriatric patients: femoral neck system versus cannulated cancellous screw. BMC Musculoskelet Disord. 2023;24 (1 ):70. Epub 20230126. doi: 10.1186/s12891-023-06140-3 .36703126
2 Parker MJ . The management of intracapsular fractures of the proximal femur. J Bone Joint Surg Br. 2000;82 (7 ):937–41. doi: 10.1302/0301-620x.82b7.11595 .11041577
3 Medda S , Snoap T , Carroll EA . Treatment of Young Femoral Neck Fractures. J Orthop Trauma. 2019;33 (Suppl 1 ):S1–s6. doi: 10.1097/BOT.0000000000001369 .30540665
4 Cai L , Zheng W , Chen C , Hu W , Chen H , Wang T . Comparison of young femoral neck fractures treated by femoral neck system, multiple cancellous screws and dynamic hip screws: a retrospectively comparison study. BMC Musculoskelet Disord. 2024;25 (1 ):188. Epub 20240302. doi: 10.1186/s12891-024-07319-y .38431562
5 Collinge CA , Finlay A , Rodriguez-Buitrago A , Beltran MJ , Mitchell PM , Mir HR , et al . Treatment Failure in Femoral Neck Fractures in Adults Less Than 50 Years of Age: Analysis of 492 Patients Repaired at 26 North American Trauma Centers. J Orthop Trauma. 2022;36 (6 ):271–9. doi: 10.1097/BOT.0000000000002355 .35703846
6 Zdero R , Keast-Butler O , Schemitsch EH . A biomechanical comparison of two triple-screw methods for femoral neck fracture fixation in a synthetic bone model. J Trauma. 2010;69 (6 ):1537–44. doi: 10.1097/TA.0b013e3181efb1d1 .21045747
7 Zhang RY , Zhang WP , Yang GM , Wang DF , Su P , Zhang Y , et al . Biomechanical Research of Three Parallel Cannulated Compression Screws in Oblique Triangle Configuration for Fixation of Femoral Neck Unstable Fractures. Orthop Surg. 2024;16 (4 ):953–64. Epub 20240222. doi: 10.1111/os.14004 .38389204
8 Johnson JP , Borenstein TR , Waryasz GR , Klinge SA , McClure PK , Chambers AB , et al . Vertically Oriented Femoral Neck Fractures: A Biomechanical Comparison of 3 Fixation Constructs. J Orthop Trauma. 2017;31 (7 ):363–8. doi: 10.1097/BOT.0000000000000836 .28471920
9 Samsami S , Saberi S , Sadighi S , Rouhi G . Comparison of Three Fixation Methods for Femoral Neck Fracture in Young Adults: Experimental and Numerical Investigations. J Med Biol Eng. 2015;35 (5 ):566–79. Epub 20151001. doi: 10.1007/s40846-015-0085-9 .26500470
10 Slobogean GP , Sprague S , Bzovsky S , Scott T , Thabane L , Heels-Ansdell D , et al . Fixation Using Alternative Implants for the Treatment of Hip Fractures (FAITH-2): The Clinical Outcomes of a Multicenter 2 × 2 Factorial Randomized Controlled Pilot Trial in Young Femoral Neck Fracture Patients. J Orthop Trauma. 2020;34 (10 ):524–32. doi: 10.1097/bot.0000000000001773 .32732587
11 Xia Y , Zhang W , Zhang Z , Wang J , Yan L . Treatment of femoral neck fractures: sliding hip screw or cannulated screws? A meta-analysis. J Orthop Surg Res. 2021;16 (1 ):54. Epub 20210114. doi: 10.1186/s13018-020-02189-1 .33446230
12 Zhou Y , Li Z , Lao K , Wang Z , Zhang L , Dai S , et al . Femoral neck system vs. cannulated screws on treating femoral neck fracture: a meta-analysis and system review. Front Surg. 2023;10 :1224559. Epub 20230718. doi: 10.3389/fsurg.2023.1224559 .37533744
13 Liu Y , Béliveau A , Wei Y , Chen MY , Record-Lemon R , Kuo PL , et al . A Gentle Introduction to Bayesian Network Meta-Analysis Using an Automated R Package. Multivariate Behav Res. 2023;58 (4 ):706–22. Epub 20221018. doi: 10.1080/00273171.2022.2115965 .36254763
14 Rouse B , Chaimani A , Li T . Network meta-analysis: an introduction for clinicians. Intern Emerg Med. 2017;12 (1 ):103–11. Epub 20161202. doi: 10.1007/s11739-016-1583-7 .27913917
15 Zhang BF , Wang PF , Huang H , Cong YX , Wang H , Zhuang Y . Interventions for treating displaced intracapsular femoral neck fractures in the elderly: a Bayesian network meta-analysis of randomized controlled trials. Sci Rep. 2017;7 (1 ):13103. Epub 20171012. doi: 10.1038/s41598-017-13377-1 .29026135
16 Rajfer RA , Carlson BA , Johnson JP . High-energy Femoral Neck Fractures in Young Patients. J Am Acad Orthop Surg. 2024;32 (7 ):e302–e12. Epub 20240118. doi: 10.5435/JAAOS-D-23-00720 .38252702
17 Zheng S , Lin D , Chen P , Lin C , Chen B , Zheng K , et al . Comparison of femoral neck shortening after femoral neck system and cannulated cancellous screw fixation for displaced femoral neck fractures in young adults. Injury. 2024;55 (6 ):111564. Epub 20240412. doi: 10.1016/j.injury.2024.111564 .38640596
18 Augat P , Bliven E , Hackl S . Biomechanics of Femoral Neck Fractures and Implications for Fixation. J Orthop Trauma. 2019;33 (Suppl 1 ):S27–S32. doi: 10.1097/BOT.0000000000001365 .30540669
19 Hoshino CM , Christian MW , O’Toole RV , Manson TT . Fixation of displaced femoral neck fractures in young adults: Fixed-angle devices or Pauwel screws? Injury. 2016;47 (8 ):1676–84. Epub 20160317. doi: 10.1016/j.injury.2016.03.014 .27269418
20 Filipov O , Gueorguiev B . Unique stability of femoral neck fractures treated with the novel biplane double-supported screw fixation method: a biomechanical cadaver study. Injury. 2015;46 (2 ):218–26. Epub 20141127. doi: 10.1016/j.injury.2014.11.013 .25527457
21 Moher D , Shamseer L , Clarke M , Ghersi D , Liberati A , Petticrew M , et al . Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4 (1 ):1. Epub 20150101. doi: 10.1186/2046-4053-4-1 .25554246
22 Sterne JAC , Savović J , Page MJ , Elbers RG , Blencowe NS , Boutron I , et al . RoB 2: a revised tool for assessing risk of bias in randomised trials. Bmj. 2019;366 :l4898. Epub 20190828. doi: 10.1136/bmj.l4898 .31462531
23 Lortie CJ , Filazzola A . A contrast of meta and metafor packages for meta-analyses in R. Ecol Evol. 2020;10 (20 ):10916–21. Epub 20200914. doi: 10.1002/ece3.6747 .33144936
24 Lin L. Comparison of four heterogeneity measures for meta-analysis. J Eval Clin Pract. 2020;26 (1 ):376–84. Epub 20190624. doi: 10.1111/jep.13159 .31234230
25 Borenstein M. Avoiding common mistakes in meta-analysis: Understanding the distinct roles of Q, I-squared, tau-squared, and the prediction interval in reporting heterogeneity. Res Synth Methods. 2024;15 (2 ):354–68. Epub 20231108. doi: 10.1002/jrsm.1678 .37940120
26 Neupane B , Richer D , Bonner AJ , Kibret T , Beyene J . Network meta-analysis using R: a review of currently available automated packages. PLoS One. 2014;9 (12 ):e115065. Epub 20141226. doi: 10.1371/journal.pone.0115065 .25541687
27 van Valkenhoef G , Lu G , de Brock B , Hillege H , Ades AE , Welton NJ . Automating network meta-analysis. Res Synth Methods. 2012;3 (4 ):285–99. Epub 20120823. doi: 10.1002/jrsm.1054 .26053422
28 van Valkenhoef G , Dias S , Ades AE , Welton NJ . Automated generation of node-splitting models for assessment of inconsistency in network meta-analysis. Res Synth Methods. 2016;7 (1 ):80–93. Epub 20151013. doi: 10.1002/jrsm.1167 .26461181
29 Cope S , Jansen JP . Quantitative summaries of treatment effect estimates obtained with network meta-analysis of survival curves to inform decision-making. BMC Med Res Methodol. 2013;13 :147. Epub 20131201. doi: 10.1186/1471-2288-13-147 .24289277
30 Puhan MA , Schünemann HJ , Murad MH , Li T , Brignardello-Petersen R , Singh JA , et al . A GRADE Working Group approach for rating the quality of treatment effect estimates from network meta-analysis. Bmj. 2014;349 :g5630. Epub 20140924. doi: 10.1136/bmj.g5630 .25252733
31 Chaimani A , Higgins JP , Mavridis D , Spyridonos P , Salanti G . Graphical tools for network meta-analysis in STATA. PLoS One. 2013;8 (10 ):e76654. Epub 20131003. doi: 10.1371/journal.pone.0076654 .24098547
32 Egger M , Davey Smith G , Schneider M , Minder C . Bias in meta-analysis detected by a simple, graphical test. Bmj. 1997;315 (7109 ):629–34. doi: 10.1136/bmj.315.7109.629 .9310563
33 Yildirim C , Demirel M , Karahan G , Cetinkaya E , Misir A , Yamak F , et al . Biomechanical comparison of four different fixation methods in the management of Pauwels type III femoral neck fractures: Is there a clear winner? Injury. 2022;53 (10 ):3124–9. Epub 20220625. doi: 10.1016/j.injury.2022.06.029 .35803747
