
==== Front
Medicine (Baltimore)
Medicine (Baltimore)
MD
Medicine
0025-7974
1536-5964
Lippincott Williams & Wilkins Hagerstown, MD

MD-D-24-00103
00007
10.1097/MD.0000000000039676
3
7100
Research Article
Systematic Review and Meta-Analysis
Different surgical interventions for unstable intertrochanteric fracture of the femur: Network meta-analysis
Zhou Yuqiao MD 690953731@qq.com
a
Zhang Xiufang MD 598668333@qq.com
b
Wei Yun MD 519637091@qq.com
a
Xu Yuhao MD 453181564@qq.com
a
Feng Min MD 5856419862@qq.com
a
Wang Chunlin MD a*
a Department of Rehabilitative, Quzhou Second People’s Hospital, Zhejiang, China
b Department of Oncology, Quzhou Second People’s Hospital, Zhejiang, China.
* Correspondence: Chunlin Wang, Quzhou Second People’s Hospital, Qujiang County, Quzhou city 324000, China (e-mail: 15070168234@163.com).
13 9 2024
13 9 2024
103 37 e3967605 1 2024
19 7 2024
23 8 2024
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

Objective:

Although a large body of evidence has reported on surgical approaches for the treatment of unstable intertrochanteric femoral fractures, studies that comprehensively evaluate treatment outcomes are limited. The purpose of this study was to compare the effectiveness of extramedullary fixation (i.e., dynamic hip screw [DHS]), intramedullary fixation (i.e., the proximal femoral nailing [PFN]), and hemiarthroplasty (HA) for the treatment of unstable intertrochanteric femoral fractures using network meta-analysis.

Methods:

This study meets the preferred reporting items for systematic reviews and meta-analyses criteria. The Patient, Intervention, Comparison and Outcome search protocol framework was used to search the Google Scholar, PubMed, Embase, and Cochrane Library databases were searched from inception until June 2023.

Results:

A total of 15 randomized controlled trials, including 1282 patients were analyzed. The Harris hip score (HHS) after DHS fixation was the lowest compared with that of PFN fixation and HA. DHS fixation had a significantly longer operation time than that of PFN fixation. Compared with HA, a lower incidence of superficial wound infection was observed with PFN and DHS fixations. PFN was significantly more likely to be implant cut out compared with HA. Compared with DHS, PFN and HA showed a lower incidence of fracture healing malunion.

Conclusion:

HA and PFN have good efficacy in improving the HHS and preventing joint deformities. However, HA showed a higher incidence of superficial infection than that observed with PFN, whereas a higher risk of screw cutout is observed with PFN than with HA.

hip fractures
network meta-analysis
randomized controlled trial
systematic reviews
Guiding project of science and technology plan of Quzhou Qjiang District, Zhejiang Province ChinaQJ2021032 Yuqiao zhouOPEN-ACCESSTRUE
==== Body
pmc1. Introduction

Hip fracture is a common fracture in the human body, accounting for approximately 7.01% of all bone fractures.[1] As the global population ages, this proportion is expected to further increase and remains a major public health concern. Hip fractures in the United States in the population aged 50 years and over is projected to rise to 512, 000 by the year 2040.[2] These fractures primarily include femoral neck and intertrochanteric fractures, with the latter accounting for 45% to 50% of all hip fractures (with 50–60% being unstable intertrochanteric femoral fractures [UIFF]),[3] UIFF has a mortality rate between 15% and 30% and is also referred to as end stage fractures caused by hemorrhage, pain, bedsores, acquired pneumonia, and other complications. Nonsurgical methods can result in complications such as unhealed fractures, healed deformities, thrombosis, and prolonged bed rest, which may affect the patient’s prognosis and lead to considerable disability and morbidity.[4] Conversely, surgical interventions for fractures may effectively reduce mortality and improve quality of life. Mainstream surgical treatment approaches for UIFF include: extramedullary fixation, intramedullary fixation, and artificial arthroplasty. Recent studies have shown that for stable fractures, dynamic hip screw (DHS) fixation provides good clinical outcomes,[5] However, the best treatment option for unstable fractures (Evans type III–V and AO/ATO31-A2/A3 types) is still controversial. While conventional meta-analysis cannot be used to compare more than 2 interventions, network meta-analysis allows for a systematic analysis of different interventions in the same setting. This study collected primary data from different surgical studies, and conducted a network meta-analysis using statistical methods from frequentist theory to deduce conclusions through statistical analysis, and hypothesis testing[6] to provide evidence-based medical evidence for the surgical treatment of UIFF.

2. Materials and methods

2.1. Protocol and registration

This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines,[7] is registered in the prospective register of systematic review protocols in health and social care (CRD42023438248 available at: http://www.crd.york.ac.uk/), and the protocol has been published.

2.2. Inclusion and exclusion criteria

2.2.1. Research type

Randomized controlled trials (RCTs) with or without blinding or allocation concealment.

2.2.2. Eligibility criteria

RCTs that compared at least 2 kinds of in-house fixation methods for UIFF (Evans III–V, AO/ATO31-A2/A3 or clear description of instability fractures) in elderly patients were included in our review. These studies should have compared any pair of DHS fixation, proximal femoral nailing (PFN) fixation, and hemiarthroplasty (HA) and should have reported at least one of the following outcomes: Harris hip score, operation time, superficial wound infection, deep venous thrombosis, deep wound infection, implant cutout, malunion, bedsore, and mortality. Exclusion criteria were as follows: (i) non-RCTs, literature reviews, and case reports; (ii) duplicate papers; (iii) studies without relevant outcome indicators or missing data; (iv) nonhuman studies; (v) follow-up time below 6 months; and (vi) the average age of elderly patients <60 years.

2.3. Literature search strategy

2.3.1. Search strategy

On June 30, 2023, the Patient, Intervention, Comparison and Outcome search protocol framework was adopted, and the Google Scholar, PubMed, Embase, and Cochrane Library databases were searched to retrieve RCTs on DHS fixation, PFN fixation, and HA for UIFF. The specific search strategy, using the PubMed database as a case in point, is outlined in Table 1.

Table 1 PubMed database retrieval strategy.

Search subject	Strategy	Result	
#1Population	(((unstable hip fracture [Title/Abstract]) OR (unstable intertrochanteric fracture [Title/Abstract])) OR (unstable femoral fracture [Title/Abstract])) OR (UIFF [Title/Abstract])	1974	
#2Intervention/comparison	((((((((((((((femoral nails [Title/Abstract]) OR (PFN [Title/Abstract])) OR (Proximal Femoral Nail [Title/Abstract])) OR (Proximal Femoral Nailing [Title/Abstract])) OR (InterTan [Title/Abstract])) OR (Dynamic Hip Screw [Title/Abstract])) OR (DHS [Title/Abstract])) OR (plates [Title/Abstract])) OR (Fracture fixation [Title/Abstract])) OR (Hemiarthroplasty [Title/Abstract])) OR (BHA [Title/Abstract])) OR (Arthroplasty [Title/Abstract])) OR (Replacement [Title/Abstract])) OR (Prosthesis Implantation [Title/Abstract])) OR (HA [Title/Abstract])	1,117,365	
#3Study design	(((((Clinical Trial[Filter]) OR (Randomized controlled trial[Filter])) OR (controlled clinical trial[Filter])) OR (placebo [tiab])) OR (randomized[tiab])) OR (groups[tiab]))	3,543,321	
#4Combination of all search keywords	#1AND#2AND#3	457	

2.3.2. Study selection

Two blinded reviewers (XZ and YX) independently screened all the articles retrieved using the search strategy and assessed the full texts for potential inclusion, with discrepancies resolved by discussion with the third author (YW).

2.3.3. Data extraction

A data collection form created using Excel (Microsoft, Redmond, WA) was designed and piloted. Data extracted included author name, year and month of publication, sample size, diagnostic criteria, interventions for the treatment and control groups, treatment course, and outcome indicators.

2.3.4. Evaluation of the risk of bias

The Cochrane risk-of-bias assessment tool (RevMan5.4) was used by 2 evaluators (YX and YZ) to assess bias in the studies based on the following 7 aspects: (i) randomization method; (ii) concealed protocol for randomization; (iii) blinding during the treatment (intervention) process; (iv) blinding during the outcome measurement process; (v) report of incomplete data for each of the primary outcome indicators; (vi) report of data on all outcome indicators; and (vii) other biases.

2.4. Statistical analysis

The reviewers (CW and YZ) performed the meta-analyses. Continuous variables are presented as standardized mean difference (SMD), and counting data are presented as odds ratio. When the number of included studies was small, we analyzed metadata from studies using the Hartung–Knapp–Sidik–Jonkman method.The effects of each treatment are presented using the effect size and its 95% confidence interval (CI). The I2 statistic was calculated to quantify the degree of heterogeneity between trials and assess impact on the meta-analysis. Publication bias was evaluated using Egger t test.

All eligible studies were included in a network analysis using STATA 16.0 software package (Stata Corporation, Lakeway, TX). This software was used for plotting network relation schemes, inconsistency analysis, surface under the cumulative ranking analysis (SUCRA), etc. Node splitting, which is a closed-loop method in the random effects model, was performed. Consistency between the direct and indirect comparisons was determined using the inconsistency factor (IF value). If the IF 95% CI begins at 0, the direct evidence is consistent with the indirect evidence. The SUCRA was used to rank the effectiveness or safety of the internal fixation methods by estimating the likelihood that a method would provide the best fixation. The larger the SUCRA, the better the fixation. Funnel plot with comparison correction was performed to identify the possibility of a small sample effect.

3. Results

3.1. Identification of eligible studies

According to the search protocol, 761 documents were initially obtained, 450 documents were excluded due to duplicates, 275 were excluded based on the exclusion criteria, 21 were excluded after full-text reviews, and 15 articles were finally included in our network study. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram for the study selection process is shown in Figure 1.

Figure 1. PRISMA flow diagram of the study. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

3.2. Bias risk assessment

The quality of included studies is presented in Figure 2. Our findings show that a large proportion of studies had unclear and low risk. The overall quality of the 15 RCTs was acceptable.

Figure 2. Quality assessment of the risk of bias for each included study.

3.3. Characteristics of the included studies

A total of 1282 participants were included in the 15 double-arm trials. The baseline characteristics are provided in Table 2.

Table 2 Characteristics of the included study.

Author/year	Country	Age (year)	Male gender	Treatment methods	Number of patients	Follow-up (months)	Classification	Outcomes	
I	C	I	C	I	C	I	C	
Garg B 2011[8]	India	64.3	60.2	32	27	PFN	DHS	42	39	12	NM	1,5,7	
Kim SY 2005[9]	Korea	82	81	6	8	HA	IT	29	29	12	AO/ATO31-A2/A3	1,2,3,4,5,6,9	
Saraf H 2018[10]	India	82.4	80.8	10	9	PFN	HA	20	20	12	NM	1,2,3,6	
Hassankhani EG 2014[11]	Iran	71.3	78.9	13	17	DHS	HA	40	40	12	AO/ATO31-A2/A3	2,3,6,7,8	
Zehir S 2014[12]	Turkey	76.86	77.2	39	37	DHS	PFN	102	96	6	AO/ATO31-A2/A3	2,3,4,5,6	
Gashi YN 2018[13]	Sudan	76.15	79.3	23	20	HA	DHS	60	38	12	Evans III–V	3,4,5,6,7	
Singh NN 2021[14]	India	80.7	78.6	25	23	PFN	HA	50	50	12	NM	1,2,3,6,7	
Jolly A 2019[15]	India	81.2	78.7	NM	NM	IT	HA	50	50	12	NM	1,2,3,4,8	
Mansukhani SA 2017[16]	India	71.74	74	12	12	DHS	IT	19	18	12	Evans III–V	2,3,4,5,6,8,9	
Xu YZ 2010[17]	China	78.5	77.9	15	16	PFN	DHS	51	55	12	AO/ATO31-A2/A3	2,3,8,9	
Das PB 2020[18]	India	68.8	68.6	27	21	DHS	IT	75	75	6	AO/ATO31-A2/A3	1,2,3,6,7	
Vugt V 1993[19]	Netherlands	75.3	76	10	8	DHS	HA	21	22	12	Evans III–V	5,7,8,9	
Chua JH 2013[20]	Singapore	75	77	13	18	PFN	DHS	25	38	12	AO/ATO31-A2/A3	6	
Garg A 2022[21]	India	76.2	70.3	13	10	HA	PFN	35	35	12	AO/ATO31-A2/A3	1,2,3,4,5	
Wang CX 2009[22]	China	81	79	12	14	HA	DHS	28	30	19	Evans III–V	1,2,3,4,5,7,8	
1—Harris hip score; 2—operation time; 3—superficial wound infection; 4—deep venous thrombosis; 5—deep wound infection;6—implant cut out; 7—malunion; 8—bedsore; 9—mortality.

I = intervention; C = comparison; NM =not mentioned.

3.4. Publication bias

The overall quality of the 15 RCTs[8–22] was acceptable. Direct analysis of the comparisons showed that some of the results were heterogeneous. This could be due to differences in treatment philosophy, surgical technique, and details of outcome indicators. A subgroup analyses to further explore the source of heterogeneity could not be performed due to insufficient sample size. This heterogeneity was ignored, and a random effects model was used for the meta-analysis. Egger test showed no risk of publication bias (Table 3).

Table 3 Assessment of heterogeneity and publication bias.

Comparisons	Number	Q-test heterogeneity (P/I2)	Egger test (P)	
Harris hip score				
DHSvsPFN	1	NA	NA	
DHSvsHA	2	0.498/0.0%	1	
PFNvsHA	5	0.00/89.8%	0.506	
Operation time				
DHSvsPFN	4	0.00/97.3%	0.635	
DHSvsHA	2	0.00/98.5%	1	
PFNvsHA	5	0.00/89.0%	0.566	
Superficial wound infection				
DHSvsPFN	5	0.486/0.0%	0.305	
DHSvsHA	1	0.274/16.6%	0.274	
PFNvsHA	5	0.488/0.0%	0.352	
Deep venous thrombosis				
DHSvsPFN	2	0.614/0.0%	1	
DHSvsHA	2	0.919/0.0%	1	
PFNvsHA	3	0.245/26.1%	1	
Deep wound infection				
DHSvsPFN	3	0.109/61.1%	1	
DHSvsHA	2	NA	1	
PFNvsHA	3	NA	1	
Implant cutout				
DHSvsPFN	4	0.797/0.0%	0.401	
DHSvsHA	2	0.832/0.0%	1	
PFNvsHA	3	0.929/0.0%	0.098	
Varus malunion				
DHSvsPFN	2	0.271/17.5%	1	
DHSvsHA	4	0.673/0.0%	0.701	
PFNvsHA	1	NA	NA	
Bedsore				
DHSvsPFN	2	0.254/23%	1	
DHSvsHA	3	0.545/0.0%	1	
PFNvsHA	1	NA	NA	
Mortality				
DHSvsPFN	2	0.496/0.0%	1	
DHSvsHA	1	NA	NA	
PFNvsHA	1	NA	NA	
NA = not available.

The few included studies were not distributed around the vertical line (x = 0) as shown by the network meta-analysis funnel plots, indicating a small sample effect in Figure 3. The publication bias of included studies was acceptable.

Figure 3. Network meta-analysis funnel plots.

3.5. Evidence network

Figure 4 shows that each RCT directly studied a treatment group. The widths of the connecting lines show the number of comparisons included, and the sizes of the blue points represent the number of patients.

Figure 4. Network meta-analysis maps.

3.6. Harris hip score

Eight studies[8,9,12,14,15,19–21] with 687 participants reported this outcome. Figure 4A shows the overall structure. In comparing network estimates of the Harris hip score, users of PFN fixation (SMD: 1.38; 95% CI: ‐2.25 to ‐0.51) and HA (SMD: ‐1.5; 95% CI: ‐2.31 to ‐0.68) showed a statistically significant reduction in the Harris hip score, relative to that shown by users of DHS fixation (Fig. 5A). Regarding the Harris hip score, HA (SUCRA = 83.0%) was most likely to be ranked the best, followed by PFN (SUCRA = 66.9%) (Fig. 6A).

Figure 5. Results of the direct and indirect meta-analysis. Estimates in the upper triangle are direct comparisons; the estimates in the lower triangle are from the network meta-analysis. *Statistically significant differences.

Figure 6. Surface under the cumulative ranking curve.

In general, the node splitting method between direct and indirect comparisons showed an IF value of 1.190 and a 95% CI of 0.00 to 2.92, which indicated that direct and indirect comparisons had little bearing on the outcome of the analysis.

3.7. Operation time

Eleven studies[8–14,17,19–21] with 997 participants reported this outcome. Figure 4B shows the overall structure. In comparing network estimates of the operation time, PFN fixation (SMD: 2.18; 95% CI: 0.42–3.93) showed a statistically significant reduced operation time, compared with that shown by the DHS procedure (Fig. 5B). DHS (SUCRA = 93.9%) was the most likely procedure with the longest operation time, followed by HA (SUCRA = 49.8%) (Fig. 6B).

In general, the method of splitting nodes between direct and indirect comparisons showed an IF value of 2.254 and a 95% CI of 0.00 to 6.24, which indicated that the direct and indirect comparisons had little bearing on the outcome of the analysis.

3.8. Superficial wound infection

Twelve studies[8–14,17–21] with 1081 participants reported this outcome. Figure 4C shows the overall structure. In comparing network estimates of superficial wound infection, PFN fixation (SMD: ‐1.07; 95% CI: ‐1.93 to ‐0.21) showed a statistically significant reduction, compared with that shown after HA (Fig. 5C). Regarding superficial wound infection, HA (SUCRA = 86.5%) was the most likely to be ranked the worst, followed by DHS fixation (SUCRA = 61.3%) (Fig. 6C).

In general, the method of splitting nodes between direct and indirect comparisons showed an IF value of 2.254 and a 95% CI of 0.00 to 6.24, which indicated that the direct and indirect comparisons had little bearing on the outcome of the analysis.

3.9. Deep venous thrombosis

Seven studies[8,10–12,14,18,21] with 619 participants reported this outcome. Figure 4D shows the overall structure. Comparison of the network estimates of deep vein thrombosis showed no statistically significant differences among the 3 treatment options (Fig. 5D). Regarding the occurrence of deep venous thrombosis, PFN fixation (SUCRA = 71.2%) had the highest probability of being ranked the worst, followed by DHS fixation (SUCRA = 63.5%) (Fig. 6D).

In general, the node splitting method between direct and indirect comparisons showed an IF value of 0.006 and a 95% CI of 0.00 to 2.30, which indicated that the direct and indirect comparisons had little bearing on the outcome of the analysis.

3.10. Deep wound infection

Eight studies[8,10,11,14–16,18,21] with 685 participants reported this outcome. Figure 4E shows the overall structure. In comparing the network estimates of deep wound infection, no statistically significant differences were observed among the 3 treatment options (Fig. 5E). Figure 6E shows that DHS fixation (SUCRA = 87.7%) was the most likely to be classified as the worst, followed by HA (SUCRA = 44.3%).

In general, the method of splitting nodes between direct and indirect comparisons showed an IF value of 1.484 and a 95% CI of 0.00 to 4.60, which indicated that the direct and indirect comparisons had little bearing on the outcome of the analysis.

3.11. Implant cutout

Nine studies[8–11,17–20,22] with 824 participants reported this outcome. The overall structure is shown in Figure 4F. In comparing the network estimates of implant cutout, DHS (SMD: 2.2; 95% CI: 0.76–3.64) and PFN (SMD, 1.88; 95% CI: 0.48–3.28) fixation demonstrated a statistically significant reduction in the Harris hip score, relative to HA (Fig. 5F). DHS fixation (SUCRA = 89.1%) was the most likely to be classified as the worst performer in terms of implant cut out, followed by PFN fixation (SUCRA = 60.6%) (Fig. 6F).

In general, the method of splitting nodes between direct and indirect comparisons showed an IF value of 1.484 and a 95% CI of 0.00 to 4.60, which indicated that the direct and indirect comparisons had little bearing on the outcome of the analysis.

3.12. Malunion

Seven studies[15–21] with 610 participants reported this result. The overall structure is shown in Figure 4G. In comparing the network estimates of malunion, varus malunion incidence was statistically significantly less after PFN fixation (SMD: 1.18; 95% CI: 0.02–2.34), and HA (SMD, 2.09; 95% CI: 0.97–3.20) than after DHS fixation (Fig. 5G). DHS fixation (SUCRA = 99.0%) was the most likely to be classified as causing the worst type of malunion, followed by PFN fixation (SUCRA = 45.0%) (Fig. 6G).

In general, the node splitting method between direct and indirect comparisons showed an IF value of 0.623 and a 95% CI of 0.00 to 3.50, which indicated that the direct and indirect comparisons had little bearing on the outcome of the analysis.

3.13. Bedsore

Six studies[10–13,16,21] with 534 participants reported this outcome. The overall structure is shown in Figure 4H. Comparison of the bedsore estimates showed no statistically significant differences among the 3 treatment options (Fig. 5H). PFN fixation (SUCRA = 72.9%) was the most likely to be ranked the worst in terms of the number of bedsores, followed by DHS fixation (SUCRA = 66.9%) (Fig. 6H).

In general, the method of splitting nodes between direct and indirect comparisons showed an IF value of 1.465 and a 95% CI of 0.00 to 4.91, which indicated that the direct and indirect comparisons had little bearing on the outcome of the analysis.

3.14. Mortality

Four studies[8,11,13,16] with 244 participants reported this outcome. The overall structure is shown in Figure 4I. In comparing network estimates of mortality, no statistically significant difference was found among the 3 treatment options (Fig. 5I). Regarding mortality, HA (SUCRA = 86.6%) was most likely to be ranked the worst, followed by PFN fixation (SUCRA = 39.8%) (Fig. 6I).

In general, the method of splitting nodes between direct and indirect comparisons showed an IF value of 0.479 and a 95% CI of 0.00 to 3.17, which indicated that the direct and indirect comparisons had little bearing on the outcome of the analysis.

4. Discussion

There are various types of fractures in the intertrochanteric region of the femur, with the majority caused by direct violence and traction from the muscles around the proximal femur. This leads to separation of the head and neck, femoral shaft, lesser trochanter, greater trochanter, or the lateral and medial walls, extending even as far as the subtrochanteric region.[23] Conservative management causes complications such as bedsore, hypostatic pneumonia, deep venous thrombosis, malunion, nonunion of fractures, and uncertainties including the subjection of the human hip to 2.3 to 2.8 times the force of gravity during gait walking, making it difficult to achieve satisfactory treatment outcomes.[24,25]

Anatomical studies by Professor Robert in 1834 have revealed that the proximal femur has an almost vertical plate of compact tissue, named the femoral calcar, which plays an essential role in trunk support.[26] UIFF surgeries often utilize the lateral femoral trochanter surgical approach for operative field view, which leaves the medial wall within a blind field of view., Continuation of anatomic repositioning of the medial wall can eventually result in enlarged trauma and injury to the vital surrounding neurovascular vessels.[27,28] In clinical practice, although the anatomic extent of the lateral wall is unclear, the thicker and more complete the sidewall, the stronger the grip on the internal fixation material and the more effective the fixation is in preventing malunion and collapse of the fracture.[29] Contemporary mechanical studies have demonstrated that the medial femoral moment is longitudinal and predominantly subject to gravity, while the lateral femoral moment is arched and subject to transverse constraints. These studies have also reported that this divergence in stress creates a thicker inner cortical bone and thinner outer cortical bone. Osteoporosis of the lateral cortex, compared with the medial cortex, is more prominent with age, such that the stability of the triangular lever is disrupted and the likelihood of an inversion-type hip fracture is significantly increased.[30]

Current evidence-based medical studies have shown no statistically significant difference between intramedullary and extramedullary fixations of stable inter-rotor fractures in terms of postoperative outcomes.[31] Considerable controversy regarding the effectiveness of UIFF exists, and not only must good postoperative outcomes be considered, but indices of effectiveness such as intraoperative blood loss, time to fracture healing, and postoperative complications should also be considered. The authors WuBin study[32] is extensive, with death, incision, late fracture, bone nonunion and superficial wound infection as a single unit of study. However, this approach lacks specificity and has more limited application. In our study, we integrated data from 15 randomized controlled trials with findings from 9 additional studies, resulting in a more comprehensive and diverse data set with a broader scope of content than that considered by Natthapong study.[33] Furthermore, the extensive scope of the Sharon study,[34] which examined extracapsular hip fractures in their entirety, inevitably introduced a greater number of types of information bias. We propose that routine intramedullary fixation, extramedullary fixation, and replacement surgical protocols should be collected for analysis, and in this study, we found that the reliability of some of the data is low. For example, in analyzing blood loss, the data were highly variable, and inconsistency existed between the direct and indirect comparisons (P < .05). It must be pointed out that hidden blood loss during the operation, such as intraoperative gauze leakage, invisible bleeding into the medullary cavity, and postoperative drainage tube bleeding, cannot be neglected. In addition, inconsistencies in the presentation of the units of time, including days, weeks, months, for indicators such as days in the hospital and time to fracture healing existed.

The purpose of our study was to compare the effects of 3 surgical procedures using a total of 15 RCTs on postoperative Harris hip scores, operation time, superficial wound infections, deep vein thrombosis, deep wound infections, implant cutouts, malunion, bedsore, and mortality in patients with UIFF syndrome. In order of preference, the postoperative Harris hip scores showed the following: HA > PFN > DHS; operation time showed the following: DHS > HA > PFN; postoperative superficial wound infections incidence showed the following: HA > DHS > PFN; deep vein thrombosis showed the following PFN > DHS > HA; deep wound infections showed the following: DHS > HA > PFN; implant cutout incidence showed the following: DHS > PFN > HA; malunion incidence showed the following: DHS > PFN > HA; pressure ulcer incidence showed the following: PFN > DHS > HA; and mortality incidence showed the following: HA > PFN > DHS.

The difference between DHS fixation compared with PFN fixation and HA for Harris hip score and hip deformity was statistically significant (P < .05). DHS fixation is the conventional extramedullary treatment for UIFF surgery, and it is an eccentric fixation according to the AO principle, which has poor anchorage strength, lacks medial wall support, and is subject to hip deformity and screw clipping. A fracture must also withstand most longitudinal and transverse stresses before healing, leading to a longer postoperative recovery time and periprosthetic pain affecting the mobility of the joint.[35] PFN fixation compared with DHS fixation has the following clear biomechanical benefits. It is consistent with the principle of BO, is minimally invasive, and is effective in reducing the length of surgery and healing period of hip deformities. In contrast, artificial femoral head arthroplasty avoids the process of fracture healing through the reconstruction of the hip joint, and no danger of screw cutting is observed. However, multiple positional changes are needed intraoperatively, and issues with prolonged exposure of the operation area exist, resulting in a higher surgical area infection rate than PFN fixation (P < .05).

There are some limitations to this study as follows: (i) the sample size of the included studies was low, which could limit the accuracy of the results., and most of the literature regarding allocation concealment and blinding was of low quality, leading to potential bias; (ii) operators’ proficiency in the surgical procedure, characteristics of the study participants, and device manufacturers were varied among the included studies, which affected the reliability of the conclusions; and (iii) at the time of surgery, an informed consent form requiring physician and patient participation was signed, which made it impossible to fully achieve concealment and blinding. Moreover, the general quality of the included studies was average, with publication bias observed in the methodology of the studies.

Overall, this study used a network meta-analysis to assess the effectiveness of the 3 different UIFF surgeries. DHS is not preferred for UIFF surgery because of its long operative time and associated poor fracture healing. HA effectively prevented the risk of screw clipping and PFN fixation performed well in the incidences of superior superficial wound infection. Due to the small sample size of this study and the high- quality bias of the included studies, RCTs with large sample sizes are needed for further analysis to provide the best evidence for clinical decision making in the treatment of UIFF.

Author contributions

Conceptualization: Yuqiao Zhou, Yun Wei, Min Feng.

Data curation: Yuqiao Zhou, Chunlin Wang, Yun Wei, Min Feng.

Formal analysis: Yuqiao Zhou, Chunlin Wang, Yun Wei.

Funding acquisition: Yuqiao Zhou.

Investigation: Yuqiao Zhou.

Methodology: Yuqiao Zhou, Chunlin Wang, Xiufang Zhang.

Project administration: Yuqiao Zhou, Chunlin Wang, Yuhao Xu.

Resources: Yuqiao Zhou, Xiufang Zhang, Yuhao Xu.

Software: Yuqiao Zhou, Xiufang Zhang, Yuhao Xu.

Supervision: Yuqiao Zhou, Xiufang Zhang, Yuhao Xu.

Validation: Yuqiao Zhou, Chunlin Wang, Min Feng, Yuhao Xu.

Visualization: Yuqiao Zhou, Chunlin Wang, Min Feng, Yuhao Xu.

Writing – original draft: Yuqiao Zhou, Yuhao Xu.

Writing – review & editing: Yuqiao Zhou, Min Feng.

Abbreviations:

CI confidence interval

DHS dynamic hip screw

HA hemiarthroplasty

IF inconsistency factor

PFN proximal femoral nailing

PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses

RCTs randomized controlled trials

SMD standardized mean difference

SUCRA surface under the cumulative ranking analysis

UIFF unstable intertrochanteric femoral fractures

This work was supported by the Science and Technology Planning Project of Quzhou Qujiang District, Zhejiang Province China (No. QJ2021032).

The authors have no conflicts of interest to disclose.

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

How to cite this article: Zhou Y, Zhang X, Wei Y, Xu Y, Feng M, Wang C. Different surgical interventions for unstable intertrochanteric fracture of the femur: Network meta-analysis. Medicine 2024;103:37(e39676).

This manuscript was previously published in Research Square: doi: https://doi.org/10.21203/rs.3.rs-3258227/v1.
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