Jie WANG, Haomin Lİ, Haobo JIA, Xinlong MA

Intramedullary versus extramedullary fixation in the treatment of subtrochanteric femur fractures: A comprehensive systematic review and meta-analysis

Objective: This meta-analysis aimed to compare the clinical outcomes of intramedullary fixation with the extramedullary fixation in the surgical management of subtrochanteric fractures by analyzing relevant randomized controlled trials (RCTs) and retrospective cohort studies (RCSs).Methods: The PubMed, Embase, Cochrane Library, Wanfang database, and Chinese National Knowledge Infrastructure (CNKI) were searched from their inception till June 29, 2020. Two reviewers extracted the data, including operation time, intraoperative blood loss, fluoroscopy time, length of stay, union time, nonunion rate, infection rate, implant failure rate, reoperation rate, Harris hip score, and mortality rate. The Cochrane risk-of-bias tool and the Newcastle-Ottawa quality assessment scale were used to evaluate the methodological quality of RCTs and RCSs, respectively. Statistical heterogeneity was quantitatively evaluated with the I2 statistic.Results: There were no significant differences in operation time, intraoperative blood loss, average length of stay in hospital, infection rate, implant failure rate, Harris hip scores, and mortality rate. Intramedullary nail could achieve shorter union time (MD=-1.77, 95% CI -3.40~-0.14, p=0.03), lower nonunion rate (RR=0.36, 95%CI 0.14~0.97, p=0.04), and reoperation rate (RR=0.46, 95% CI 0.24~0.89, p=0.02) than extramedullary fixations. The subgroup analysis indicated that intramedullary nail was superior than extramedullary fixations in operation time, reoperation rate, and Harris hip scores in the ≥60-year subgroup. However, the intraoperative blood loss in intramedullary nail group was significantly higher than that of extramedullary fixation group in the

___

1. Loizou CL, McNamara I, Ahmed K, Pryor GA, Parker MJ. Classification of subtrochanteric femoral fractures. Injury 2010; 41: 739-45. [Crossref]

2. Mattisson L, Bojan A, Enocson A. Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: Data from the swedish fracture register. BMC Musculoskelet Disord 2018; 19: 369. doi: 10.1186/s12891-018- 2276-3. [Crossref]

3. Kennedy MT, Mitra A, Hierlihy TG, Harty JA, Reidy D, Dolan M. Subtrochanteric hip fractures treated with cerclage cables and long cephalomedullary nails: A review of 17 consecutive cases over 2 years. Injury 2011; 42: 1317-21. [Crossref]

4. Koch JC. The laws of bone architecture. J Anat Am 1917; 21: 177-98. [Crossref]

5. Sims SH. Subtrochanteric femur fractures. Orthop Clin North Am 2002; 33: 113-26. [Crossref]

6. Fielding JW. Subtrochanteric fractures. Clin Orthop Relat Res 1973; 92: 86- 99. [Crossref]

7. Tencer AF, Johnson KD, Johnston DW, Gill K. A biomechanical comparison of various methods of stabilization of subtrochanteric fractures of the femur. J Orthop Res 1984; 2: 297-305. [Crossref]

8. Rahme DM, Harris IA. Intramedullary nailing versus fixed angle blade plating for subtrochanteric femoral fractures: A prospective randomised controlled trial. J Orthop Surg (Hong Kong) 2007; 15: 278-81. [Crossref]

9. Kuzyk PR, Bhandari M, McKee MD, Russell TA, Schemitsch EH. Intramedullary versus extramedullary fixation for subtrochanteric femur fractures. J Orthop Trauma 2009; 23: 465-70. [Crossref]

10. Li G, Li Z, Han N, Lu Q. A retrospective analysis of reversed femoral less invasive stable system (liss) for treatment of subtrochanteric femoral fracture. Int J Surg 2014; 12: 432-6. [Crossref]

11. Ouyang Y, Wang Y, Fan C, Liu Z, Liu S, Li F. Using the contralateral reverse less invasive plating system for subtrochanteric femur fractures in elderly patients. Med Princ Pract 2012; 21: 334-9. [Crossref]

12. Krettek C, Muller M, Miclau T. Evolution of minimally invasive plate osteosynthesis (mipo) in the femur. Injury 2001; 32 Suppl 3: Sc14-23. [Crossref]

13. Xie H, Xie L, Wang J, Chen C, Zhang C, Zheng W. Intramedullary versus extramedullary fixation for the treatment of subtrochanteric fracture: A systematic review and meta-analysis. Int J Surg 2019; 63: 43-57. [Crossref]

14. Liu P, Wu X, Shi H, et al. Intramedullary versus extramedullary fixation in the management of subtrochanteric femur fractures: A meta-analysis. Clin Interv Aging 2015; 10: 803-11. [Crossref]

15. Higgins JP, Green S. Cochrane hanbook for systematic review of interventions version 5.2.0. www.cochrane-handbook.org. Published 2017. Updated June 2017. Accessed.

16. Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (prisma-p) 2015 statement. Syst Rev 2015; 4: 1. doi: 10.1186/2046-4053-4-1. [Crossref]

17. Higgins JP, Altman DG, Gotzsche PC, et al. The cochrane collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928. doi: 10.1136/bmj.d5928. [Crossref]

18. Wang J, Lu Y, Cui Y, Wei X, Sun J. Is volar locking plate superior to external fixation for distal radius fractures? A comprehensive meta-analysis. Acta Orthop Traumatol Turc 2018; 52: 334-42. [Crossref]

19. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557-60. [Crossref]

20. Wang J, Ma JX, Zhu SW, Jia HB, Ma XL. Does distal clavicle resection decrease pain or improve shoulder function in patients with acromioclavicular joint arthritis and rotator cuff tears? A meta-analysis. Clin Orthop Relat Res 2018; 476: 2402-14. [Crossref]

21. Matre K, Vinje T, Havelin LI, et al. Trigen intertan intramedullary nail versus sliding hip screw: A prospective, randomized multicenter study on pain, function, and complications in 684 patients with an intertrochanteric or subtrochanteric fracture and one year of follow-up. J Bone Joint Surg Am 2013; 95: 200-8. [Crossref]

22. Ekstrom W, Karlsson-Thur C, Larsson S, Ragnarsson B, Alberts KA. Functional outcome in treatment of unstable trochanteric and subtrochanteric fractures with the proximal femoral nail and the medoff sliding plate. J Orthop Trauma 2007; 21: 18-25. [Crossref]

23. Miedel R, Ponzer S, Tornkvist H, Soderqvist A, Tidermark J. The standard gamma nail or the medoff sliding plate for unstable trochanteric and subtrochanteric fractures. A randomised, controlled trial. J Bone Joint Surg Br 2005; 87: 68-75. [Crossref]

24. Sadowski C, Lubbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: A prospective, randomized study. J Bone Joint Surg Am 2002; 84: 372-81. [Crossref]

25. Friedl W, Colombo-Benkmann M, Dockter S, Machens HG, Mieck U. Gamma nail osteosynthesis of per- and subtrochanteric femoral fractures. 4 years experiences and their consequences for further implant development. Chirurg 1994; 65: 953-63.

26. Pelet S, Arlettaz Y, Chevalley F. Osteosynthesis of per- and subtrochanteric fractures by blade plate versus gamma nail. A randomized prospective study. Swiss Surg 2001; 7: 126-33. [Crossref]

27. Lunsjö K, Ceder L, Tidermark J, et al. Extramedullary fixation of 107 subtrochanteric fractures: A randomized multicenter trial of the medoff sliding plate versus 3 other screw-plate systems. Acta Orthop Scand 1999; 70: 459-66. [Crossref]

28. Lee PC, Hsieh PH, Yu SW, Shiao CW, Kao HK, Wu CC. Biologic plating versus intramedullary nailing for comminuted subtrochanteric fractures in young adults: A prospective, randomized study of 66 cases. J Trauma 2007; 63: 1283- 91. [Crossref]

29. Goldhagen PR, O'Connor DR, Schwarze D, Schwartz E. A prospective comparative study of the compression hip screw and the gamma nail. J Orthop Trauma 1994; 8: 367-72. [Crossref]

30. Brien WW, Wiss DA, Becker V, Jr., Lehman T. Subtrochanteric femur fractures: A comparison of the zickel nail, 95 degrees blade plate, and interlocking nail. J Orthop Trauma 1991; 5: 458-64. [Crossref]

31. Burnei C, Popescu G, Barbu D, Capraru F. Intramedullary osteosynthesis versus plate osteosynthesis in subtrochanteric fractures. J Med Life 2011; 4: 324-9.

32. Imerci A, Canbek U, Karatosun V, Karapinar L, Yesil M. Nailing or plating for subtrochanteric femoral fractures: A non-randomized comparative study. Eur J Orthop Surg Traumatol 2015; 25: 889-94. [Crossref]

33. Mirbolook A, Siavashi B, Jafarinezhad AE, et al. Subtrochanteric fractures: Comparison of proximal femur locking plate and intramedullary locking nail fixation outcome. Indian J Surg 2015; 77: 795-8. [Crossref]

34. Saarenpaa I, Heikkinen T, Jalovaara P. Treatment of subtrochanteric fractures. A comparison of the gamma nail and the dynamic hip screw: Short-term outcome in 58 patients. Int Orthop 2007; 31: 65-70. [Crossref]

35. Shin WC, Moon NH, Jang JH, Lee HJ, Suh KT. Comparative study between biologic plating and intramedullary nailing for the treatment of subtrochanteric fractures: Is biologic plating using lcp-df superior to intramedullary nailing? Injury 2017; 48: 2207-213. [Crossref]

36. Yadav S, Sinha S, Luther E, Arora NC, Prasad M, Varma R. Comparison of extramedullary and intramedullary devices for treatment of subtrochanteric femoral fractures at tertiary level center. Chin J Traumatol 2014; 17: 141-5.

37. Han L, Hu YG, Wang CF, Fang WL, Jin B, Xu SC. Comparison of long gamma 3 nail and proximal femur locking plate for the treatment of femoral subtrochanteric fractures. Zhongguo Gu Shang 2019; 32: 105-10.

38. Dou B, Dou L, zhu W, wang Q, Qin T, Ma W. A comparison between optional internal fixations of subtrochanteric fractures. Chin J Bone Joint 2015; 4: 460-5. 39. Li G, Shao M, He S, et al. Comparison of intramedullary nail and extramedulary fixation for unstable subtrochanteric fractures. Chin J Traumatol 2013; 15: 407-10.

40. Xie C, Chen A. Clinical analysis of pflp and intertan internal fixation in treatment of femur subtrochanteric fractures. Chin J Bone Joint Injury 2017; 32: 255-8.

41. Kregor PJ, Obremskey WT, Kreder HJ, Swiontkowski MF. Unstable pertrochanteric femoral fractures. J Orthop Trauma 2014;28 Suppl 8: S25-8. [Crossref]

42. Tornetta P, 3rd. Subtrochanteric femur fracture. J Orthop Trauma 2002; 16: 280-3. [Crossref]

43. Terjesen T, Apalset K. The influence of different degrees of stiffness of fixation plates on experimental bone healing. J Orthop Res 1988; 6: 293-9. [Crossref]

44. Pilliar RM, Cameron HU, Binnington AG, Szivek J, Macnab I. Bone ingrowth and stress shielding with a porous surface coated fracture fixation plate. J Biomed Mater Res 1979; 13: 799-810. [Crossref]

45. Woo SL, Akeson WH, Coutts RD, et al. A comparison of cortical bone atrophy secondary to fixation with plates with large differences in bending stiffness. J Bone Joint Surg Am 1976; 58: 190-5. [Crossref]

46. Wu CC, Tai CL. A biomechanical comparison of unlocked or locked reamed intramedullary nails in the treatment of mid-third simple transverse femoral shaft fractures. Chang Gung Med J 2006; 29: 275-82.

47. Eveleigh RJ. A review of biomechanical studies of intramedullary nails. Med Eng Phys 1995; 17: 323-31. [Crossref]

48. Buxbaum EJ, Ponzio DY, Griffiths S, et al. Impact of resident training level on radiation exposure during fixation of proximal femur fractures. J Orthop Trauma 2020; 34: 170-5. [Crossref]

49. Chan DS, Burris RB, Erdogan M, Sagi HC. The insertion of intramedullary nail locking screws without fluoroscopy: A faster and safer technique. J Orthop Trauma 2013; 27: 363-6. [Crossref]

50. Kalem M, Başarır K, Kocaoğlu H, Şahin E, Kınık H. The effect of c-arm mobility and field of vision on radiation exposure in the treatment of proximal femoral fractures: A randomized clinical trial. Biomed Res Int 2018; 2018: 6768272. doi: 10.1155/2018/6768272. eCollection 2018. [Crossref]

51. Wirtz C, Abbassi F, Evangelopoulos DS, Kohl S, Siebenrock KA, Kruger A. High failure rate of trochanteric fracture osteosynthesis with proximal femoral locking compression plate. Injury 2013; 44: 751-6. [Crossref]

52. Schneider K, Oh JK, Zderic I, et al. What is the underlying mechanism for the failure mode observed in the proximal femoral locking compression plate? A biomechanical study. Injury 2015; 46: 1483-90. [Crossref]

53. Krettek C, Schandelmaier P, Miclau T, Tscherne H. Minimally invasive percutaneous plate osteosynthesis (mippo) using the dcs in proximal and distal femoral fractures. Injury 1997; 28 Suppl 1:A20-30. [Crossref]

54. Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P, Tscherne H. Minimally invasive plate osteosynthesis: Does percutaneous plating disrupt femoral blood supply less than the traditional technique? J Orthop Trauma 1999; 13: 401-6. [Crossref]