Meta-Analysis
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Nov 16, 2021; 9(32): 9878-9888
Published online Nov 16, 2021. doi: 10.12998/wjcc.v9.i32.9878
Arthroplasty vs proximal femoral nails for unstable intertrochanteric femoral fractures in elderly patients: A systematic review and meta-analysis
Wen-Huan Chen, Wen-Xuan Guo, Shi-Hua Gao, Qiu-Shi Wei, Zi-Qi Li, Wei He
Wen-Huan Chen, The Third Clinical Medical School, Guangzhou University of Chinese Medicine, Guangzhou 510405, Guangdong Province, China
Wen-Xuan Guo, The First Clinical College, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
Shi-Hua Gao, The First Clinical Medical School, Guangzhou University of Chinese Medicine, Guangzhou 510405, Guangdong Province, China
Qiu-Shi Wei, Zi-Qi Li, Wei He, Department of Joint Surgery, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510405, Guangdong Province, China
Author contributions: Chen WH contributed to study conception and design, drafting the submitted article; He W, Wei QS and Li ZQ revised the draft critically for important intellectual content; Guo WX and Gao SH contributed to acquisition, analysis, and interpretation the data; and all authors read and approved the final manuscript.
Conflict-of-interest statement: The authors declare that they have no competing interests.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Wei He, MD, Professor, Department of Joint Surgery, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, No. 261 Longxi Road, Liwan District, Guangzhou 510405, Guangdong Province, China. hw13802516062@126.com
Received: June 18, 2021
Peer-review started: June 18, 2021
First decision: August 18, 2021
Revised: August 27, 2021
Accepted: September 19, 2021
Article in press: September 19, 2021
Published online: November 16, 2021
Abstract
BACKGROUND

Proximal femoral nails (PFNs) are the most common method for the treatment of unstable intertrochanteric femoral fractures (IFFs), but postoperative bed rest is required. There is a large amount of blood loss during the operation. Osteoporosis in elderly patients may cause nonunion of fractures and other complications. Arthroplasty can give patients early weight bearing and reduce financial burden, but whether it can replace PFNs remains controversial.

AIM

To compare the clinical outcomes of arthroplasty and PFNs in the treatment of unstable IFFs in elderly patients.

METHODS

A search was conducted in the PubMed, Embase, and Cochrane Library databases and included relevant articles comparing arthroplasty and PFN. The search time was limited from January 1, 2005 to November 1, 2020. Two investigators independently screened studies, extracted data and evaluated the quality according to the inclusion and exclusion criteria. According to the research results, the fixed effect model or random effect model were selected for analysis. The following outcomes were analyzed: Harris Hip score, mortality, complications, operation time, blood loos, hospital stay, weight-bearing time, fracture classification and type of anesthesia.

RESULTS

We analyzed four randomized controlled trials that met the requirements. A total of 298 patients were included in these studies. According to the AO/OTA classification, there are 20 A1 types, 136 A2 types, 42 A3 types and 100 unrecorded types. Primary outcome: The Harris Hip Score at the final follow-up of the PFN group was higher [mean difference (MD): 9.01, 95% confidence interval (CI): 16.57 to 1.45), P = 0.02]. There was no significant difference between the two groups in the rate of overall mortality [risk ratio (RR): 1.44, P = 0.44] or the number of complications (RR: 0.77, P = 0.05). Secondary outcomes: blood loss of the arthroplasty group was higher (MD: 241.01, 95% CI: 43.06–438.96, P = 0.02); the operation time of the PFN group was shorter (MD: 23.12, 95%CI: 10.46–35.77, P = 0.0003); and the length of hospital stay of the arthroplasty group was shorter [MD: 0.97, 95% CI: 1.29 to 0.66), P < 0.00001]. There was no difference between the two groups in the type of anesthesia (RR: 0.99). There were only two studies recording the weight-bearing time, and the time of full weight bearing in the arthroplasty group was significantly earlier.

CONCLUSION

Compared with PFN, arthroplasty can achieve weight bearing earlier and shorten hospital stay, but it cannot achieve a better clinical outcome. Arthroplasty cannot replace PFNs in the treatment of unstable IFFs in elderly individuals.

Keywords: Arthroplasty, Proximal femoral nail, Intertrochanteric femoral fracture, Elderly, Meta-analysis, Systematic review

Core Tip: This review compared the clinical outcomes of arthroplasty and proximal femoral nails (PFNs) in the treatment of unstable intertrochanteric femoral fractures (IFFs) in elderly patients. Many people believe that arthroplasty can replace PFNs for unstable IFFs in elderly patients. However, there is no consensus. Some researchers have carried out reviews of the research, but the results were different. Therefore, we conducted this meta-analysis. We reviewed four randomized controlled trials about this topic and found that arthroplasty cannot achieve better results than PFNs in the clinic. Arthroplasty is not the first choice for the treatment of unstable IFFs in elderly patients.