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Journal of Peking University(Health Sciences) ›› 2019, Vol. 51 ›› Issue (3): 493-500. doi: 10.19723/j.issn.1671-167X.2019.03.017

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Proximal femoral nails antirotation and dynamic hip screws for fixation of unstable intertrochanteric fractures of femur: A meta-analysis

Yi-ran ZHANG,Feng RAO,Wei PI,Pei-xun ZHANG△(),Bao-guo JIANG△()   

  1. Department of Trauma and Orthopedics, Peking University People’s Hospital, Beijing 100044, China
  • Received:2019-03-07 Online:2019-01-01 Published:2019-06-26
  • Supported by:
    Supported by Major R&D Program of National Ministry of Science and Technology (2018YFB1105504),National Natural Science Foundation of China (31771322, 31571235, 81671215), Beijing Municipal Science and Technology Commission Science and Technology Nova Cross Project (2018019),the Ministry of Education Innovation Program of China (IRT-16R01)

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Abstract: Objective: To evaluate the efficacy and safety of proximal femoral nail antirotation (PFNA) and dynamic hip screw (DHS) for unstable intertrochanteric fractures using meta-analysis. Methods: The PubMed, Embase, Cocharane Central Register of Controlled Trials, Google Scholar, China Science and Technology Papers and Citation Database (CSTPCD) and China Journal Full-text Database (CNKI) were searched for published randomized controlled trials before January 1, 2019. Two researchers independently screened the literature in the light of the inclusion and exclusion criteria, evaluated the quality of the studies and extracted the data which were consisted of clinical efficacy indexes, such as incision length, operation time,intraoperative blood loss, weight-bearing time,fracture-healing time, Harris hip score and safety indicators like complications. Meta-analysis was performed with the Revman 5.3 software provided by Cochrane Community in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standard. Results: Nine randomized controlled trials met the requirement with a total of 779 patients, of whom 383 were fixed with PFNA and 396 with DHS. Meta-analysis demonstrated that PFNA was associated with smaller surgical incision length [MD=-7.43, 95%CI (-9.31, -5.55), P<0.05], shorter operation time [MD=-22.76, 95%CI (-29.57, -11.95), P<0.05], less intraoperative blood loss [MD=-216.34, 95%CI (-275.18, -157.49), P<0.05], earlier weight bearing after surgery [MD=-12.34, 95%CI (-17.71, -6.97), P<0.05], shorter fracture healing time [MD=-5.00, 95%CI (-7.73, -2.26), P<0.05], higher postoperative Harris hip score [MD=12.22, 95%CI (3.88, 20.55), P<0.05], higher rate of excellent Harris hip score [OR=3.56, 95%CI (1.44, 8.81), P<0.05] and lower incidence rate of postoperative complications [OR=0.48, 95%CI (0.33, 0.70), P<0.05], such as hip varus, wound infection, urinary tract infection, pulmonary infection, pressure sore, deep vein thrombosis, pulmonary embolism, heart failure and cerebral infraction when compared with DHS. No statistical difference was shown between the groups when it came to subgroup analysis by age. However, there was no significant difference (P>0.05) in the duration of hospitalization and the complications resulting in the occurrences of internal fixation loosening, such as femoral shaft fracture (during or post operation), internal fixation fracture, cut-out, displacement or retraction. Conclusion: Current published evidence supports the superiority of PFNA to DHS for unstable intertrochanteric fractures in terms of clinical efficacy. The conclusion was limited because of the relatively low quality of evidence with low strength of confidence. Large scale and high-quality randomized controlled trials are required to validate the safety of PFNA and DHS for unstable intertrochanteric fractures.

Key words: Hip fractures, Bone nails, Bone screws, Fracture fixation, intramedullary, Meta-analysis

CLC Number: 

  • R683.3

Figure 1

Flowchart of study selection"

Table 1

Characteristics and quality assessment of the included studies"

Study Sample size (PFNA/DHS) Mean age/years Fracture type Follow-up/months
Dong, 2015[14] 30/30 67.6/68.3 A1-A3 12-18
Chen, 2012[15] 30/30 72* Evans Ⅲ/Ⅳ/Ⅴ 3
Yu, 2014[16] 33/33 37.8* A1-A3 3
Bai, 2015[17] 36/36 35.9/36.3 A1-A3 3
Han, 2011[18] 50/50 65/67 A2-A3 6
Zhan, 2013[19] 27/30 71.2* Evans Ⅲ/Ⅳ 12.3
Xu, 2010[20] 51/55 78.5/77.9 A2 12
Zehir, 2015[21] 96/102 77.22/76.86 A2 6
Huang, 2017[22] 30/30 75.07/74.01 Evans Ⅲ/Ⅳ/Ⅴ 19.4/19.8

Figure 2

The risk of bias for the included studies"

Figure 3

The forest plots of meta-analysis for incision length"

Figure 4

The forest plots of meta-analysis for intraoperative blood loss"

Figure 5

The forest plots of meta-analysis for fracture-healing time"

Figure 6

The forest plots of meta-analysis for Harris hip score"

Figure 7

The forest plots of meta-analysis for complications"

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