Hip Replacement as Alternative to Intramedullary Nail in Elderly Patients with Unstable Intertrochanteric Fracture: A Systematic Review and Meta‐Analysis

Abstract

ObjectiveTo evaluate the efficacy and safety of hip replacement and intramedullary nails for treating unstable intertrochanteric fractures in elderly patients.MethodsRandomized clinical trials (RCTs) to compare hip replacement with intramedullary nail in the management of elderly patients with unstable intertrochanteric femur fracture were retrieved from Cochrane Library (up to January 2018), CNKI (China National Knowledge Infrastructure), Wanfang Data, PubMed, and Embase. The methodological quality of the included trials was assessed using the Cochrane risk of bias assessment tool, and relevant data was extracted. Statistical analysis was performed by Revman 5.3. Where possible, we performed the limited pooling of data.ResultsFourteen trials including a total of 1067 participants aged 65 and above were included for qualitative synthesis and meta‐analysis. The methodological quality of the included study was poor. The meta‐analysis indicated that the hip replacement group benefited more than the intramedullary nail group in terms of the bearing load time (WMD ‐14.61, 95% CI −21.51 to −7.7, P < 0.0001), mechanical complications (OR 0.34, 95% CI 0.21 to 0.57, P < 0.0001), and post‐operative complications (OR 0.46, 95% CI 0.22 to 0.93, P = 0.03). While the intramedullary nail was superior to arthroplasty regarding the intraoperative blood loss (WMD 58.36, 95% CI 30.77 to 85.94, P < 0.0001). However, there were no statistical significances in the length of surgery (WMD 5.27, 95% CI 4.23 to 14.77, P = 0.28), units of blood transfusion (WMD 0.34, 95% CI ‐0.16 to 0.85, P = 0.18), length of hospital stay (WMD ‐1.00, 95% CI ‐2.93 to 0.93, P = 0.31), Harris hip score (WMD 0.31, 95% CI ‐0.39 to 1.01, P = 0.38), and mortality (OR 1.24, 95% CI 0.12 to 13.10, P = 0.86).ConclusionsThis systematic review and meta‐analysis provided evidence for the efficacy and safety of hip replacement and intramedullary nail in treating unstable intertrochanteric fractures. However, the results should be interpreted cautiously because of methodological limitations and publication bias.

Cemented hemi-arthroplasty for unstable intertrochanteric fractures in the elderly: a retrospective study

“…Therefore, hemiarthroplasty is emerging as a viable alternative to internal fixation in recent decades. [1][2][3][4][5][6]8,[10][11][12] In this study, we retrospectively followed up 22 elderly patients of unstable intertrochanteric fractures treated by cemented bipolar hemiarthroplasty as the primary management plan. We observed that, hemiarthroplasty in the unstable fracture scenario is more challenging than the routine hemiarthroplasty surgeries for fractures of the neck of femur.…”

“…Intertrochanteric fractures are the commonest fractures in the elderly patients. 1 The incidence of these injuries is increasing every year and is expected to be doubled by the year 2040. 2,3 These fractures are often complicated by medical co-morbidities like diabetes, hypertension, osteoporosis, renal diseases and chronic lung diseases making them prone to complications of prolonged confinement to bed, i.e.…”

“…2 These fractures can be classified using the AO/OTA classification as 31A1, 31A2 and 31A3 types, and among them A2 and A3 varieties are considered unstable in nature, and as per Evans classification, types III, IV and V are known as unstable fractures. 1 Various clinical studies have revealed that early rehabilitation and early mobilization out of the bed are beneficial in preventing the complications of confinement to bed as well as mortality. 1,7 Stable fixation of the fractures and early mobilization is the primary goal of surgical intervention.…”

“…1 Various clinical studies have revealed that early rehabilitation and early mobilization out of the bed are beneficial in preventing the complications of confinement to bed as well as mortality. 1,7 Stable fixation of the fractures and early mobilization is the primary goal of surgical intervention. [7][8][9] Evidence also suggest that, surgical interventions within 72 hours of injury can minimize post-operative complications, even mortality rate.…”

“…[7][8][9] Evidence also suggest that, surgical interventions within 72 hours of injury can minimize post-operative complications, even mortality rate. 1 But, early intervention and rehabilitation is often easier said than done, considering the fracture comminution, instability, osteoporosis, poor soft tissue status and underlying medical conditions. 8 Proximal femoral nails (PFN) and dynamic hip screws (DHS) are widely recommended for internal fixation of intertrochanteric fractures all over the world.…”