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

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

The choice between intramedullary (IM) nailing or plating of distal tibia fractures without articular involvement remains controversial. A meta-analysis of randomized controlled trials (RCTs) and observational studies was performed to compare IM nailing with plating for distal tibia fractures without articular involvement and to determine the dominant strategy. The PubMed, Embase, Cochrane Library databases, Chinese Wan-Fang Database, and China National Knowledge Infrastructure were searched. Twenty-eight studies, which included 1863 fractures, met the eligible criteria. The meta-analysis did not identify a statistically significant difference between the two treatments in terms of the rate of deep infection, delayed union, removal of instrumentation, or secondary procedures either in the RCT or retrospective subgroups. IM nailing was associated with significantly more malunion events and a higher incidence of knee pain in the retrospective subgroup and across all the studies, but not significantly in the RCT subgroup, and a lower rate of delayed wound healing and superficial infection both in the RCT and retrospective subgroups relative to plating. A meta-analysis of the functional scores or questionnaires was not possible because of the considerable variation among the included studies, and no significant differences were observed. Evidence suggests that both IM nailing and plating are appropriate treatments as IM nailing shows lower rate of delayed wound healing and superficial infection and plating may avoid malunion and knee pain. These findings should be interpreted with caution, however, because of the heterogeneity of the study designs. Large, rigorous RCTs are required.

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Intramedullary nailing versus plating for distal tibia fractures without articular involvement: a meta-analysis

Extraarticular distal tibial fractures are among the most challenging fractures encountered by an orthopedician for treatment because of its subcutaneous location, poor blood supply and decreased muscular cover anteriorly, complications such as delayed union, nonunion, wound infection, and wound dehiscence are often seen as a great challenge to the surgeon. Minimally invasive plate osteosynthesis (MIPO) and intramedullary interlocking nail (IMLN) are two well-accepted and effective methods, but each has been historically related to complications. This study compares clinical and radiological outcome in extraarticular distal tibia fractures treated by intramedullary interlocking nail (IMLN) and minimally invasive plate osteosynthesis (MIPO). 42 patients included in this study, 21 underwent IMLN and 21 were treated with MIPO who met the inclusion criteria and operated between June 2014 and May 2015. Patients were followed up for clinical and radiological evaluation. In IMLN group, average union time was 18.26 weeks compared to 21.70 weeks in plating group which was significant (P < 0.0001). Average time required for partial and full weight bearing in the nailing group was 4.95 weeks and 10.09 weeks respectively which was significantly less (P < 0.0001) as compared to 6.90 weeks and 13.38 weeks in the plating group. Lesser complications in terms of implant irritation, ankle stiffness, and infection, were seen in interlocking group as compared to plating group. Average functional outcome according to American Orthopedic Foot and Ankle Society score was measured which came out to be 96.67. IMLN group was associated with lesser duration of surgery, earlier weight bearing and union rate, lesser incidence of infection and implant irritation which makes it a preferable choice for fixation of extra-articular distal tibial fractures. However, larger randomized controlled trials are required for confirming the results.

A comparative study of intramedullary interlocking nailing and minimally invasive plate osteosynthesis in extra articular distal tibial fractures

Intramedullary nail versus plate treatments for distal tibial fractures: a meta-analysis.

Introduction: Dynamic Hip Screw fixation is currently considered as a standard treatment for pre-trochanteric fractures; however, due to the long-term hospitalization and some other complications, some researchers have proposed intramedullary nailing as the alternative surgical treatment. The aim of this study was to compare and examine the consequences of the using intramedullary nailing method versus Dynamic Hip Screw. Methods: In this study 114 patients with unstable Intertrochanteric fracture refer to Rasoul Akram hospital during 2011 to 2013 has been selected. After reduction, fixation surgery with PFN nail (60 patients) and Dynamic Hip Screw (54 patients) has been performed. All patients were screen during surgery and six months after surgery and some parameters like, bleeding, union, as well as complications such as collapse, varus and medialization of the distal fragment were record and patients. Results: About some parameters like cutting length, surgery duration, bleeding there were significant differences between two groups. In six months follow up period 2 patinas from nail and 8 patients from DHS group had non-union. Also from the point of radiologic and clinical parameters, like anterior thigh pain, cut out, medialization of the distal fragment, collapse of the neck, walking recovery and daily activities were significant between two groups. Conclusion: Due to the reduced hospital stay in intramedullary nailing method and the necessity of doing repeated surgery and applying intramedullary nailing when the patients are not treated with external fixation, the researchers recommend intramedullary nailing as the first option in treating such patients.

/pdf/comparing-the-intramedullary-nailing-method-versus-dynamic-1g7puq9b33.pdf

Comparing the Intramedullary Nailing Method Versus Dynamic Hip Screw in Treatment of Unstable Intertrochanteric Fractures

Objective
To compare the efficacies of minimally invasive plate osteosynthesis (MIPPO) and interlocking intramedullary nailing (IMN) in the treatment of extra-articular fractures of distal tibia.


Methods
Retrospective reviews were conducted for 126 patients with extra-articular distal tibia fractures.Treatment was either MIPPO (n=61) or IMN (n=65).The outcomes were assessed by comparing operating duration, time to union, the last follow-up American Orthopedic Foot and Ankle Society (AOFAS) score and complication rate.


Results
The average follow-up period was 23.7 (12-53) months.In the minimally invasive plate osteosynthesis group, there were deep infections (n=2), superficial infections (n=5), delayed union (n=2), malunion (n=2) and knee joint pain (n=10) were observed.In addition, the average operating duration (85.9±18.9 min), average time to union (17.3±3.8 weeks) and average AOFAS (83.2±11.9) were analyzed.In the interlocking intramedullary nailing group, there were delayed union (n=3), malunion (n=12) and knee joint pain (n=22).And the average operating duration (83.3±15.7 min), average time to union (16.5±3.1 weeks) and average AOFAS (84.9±12.0) were analyzed.No statistical significance existed in operating duration, time to union and the last follow-up AOFAS between two groups (P>0.05).However, the rates of malformation and knee joint pain were higher in the intramedullary nail group than those in the plate group.And the difference was statistically significant (P=0.015, P=0.025).


Conclusion
Both MIPPO and IMN are effective for extra-articular fractures of distal tibia.However, the former has the advantage of lowers rate of malformation and knee joint pain.Therefore a surgeon should consider the degree of injury while managing extra-articular fracture of distal tibia.


Key words: 
Surgicalprocedures,minimallyinvasive; Fracturefixation,internal; Tibialfractures; Bonenails

[Locked plating with minimally invasive percutaneous plate osteosynthesis versus intramedullary nailing of distal extra-articular tibial fracture: a retrospective study].

Objective
To assess the efficacies of proximal femoral nail antirotation (PFNA) versus dynamic hip screw (DHS) for intertrochanteric fracture in elders.


Methods
The databases of PubMed, Embase, CENTRAL, CBM, CNKI and WANFANG were searched for the relevant randomized controlled trials (RCTs) up to May 18, 2013. After quality evaluation and data extraction by two authors independently, meta-analyses were performed with the RevMan5.1 software. And the levels of evidence were evaluated by the GRADEprofile 3.6 software.


Results
A total of 17 studies (n=1 344) were included and there were 656 patients in PFNA group and 688 in DHS respectively. Meta-analyses showed that, as compared with DHS, PFNA could significantly decrease fixation failure rate (odds ratio (OR)=0.26, 95% confidence interval (CI)=[0.12,0.57], P=0.0008), reduce average fracture healing time (weighted mean difference (WMD)=-15.11, 95%CI=[-24.36,-5.85], P=0.001), improve excellent and good rate for Harris score (OR=0.29, 95%CI=[0.15,0.56], P=0.0002), yield a higher Harris score (WMD=6.88, 95%CI=[0.96,12.80], P=0.02) and reduce the rate of coxa vara (OR=0.40, 95%CI=[0.18,0.92], P=0.03). However, there was no statistical significance in 1-year mortality, postoperative nonunion and delayed union, postoperative femoral head necrosis, postoperative femoral fractures or femoral head necrosis. The importance of outcomes was "critical". And the level of evidences based on the GRADE approach was from "very low" to "low".


Conclusion
PFNA is superior to DHS. Due to the limitations of the included studies, more large-sample and high-quality RCTs are required. And subgroup analysis based on fracture types should be performed.


Key words: 
Femural fractures; Fractures fixation, internal; Bone nail; Meta-analysis

Daxin Yu

Papers

[Locked plating with minimally invasive percutaneous plate osteosynthesis versus intramedullary nailing of distal extra-articular tibial fracture: a retrospective study].

[Proximal femoral nail antirotation versus dynamic hip screw for intertrochanteric fracture in elders: a meta-analysis].