Results of Hip Arthroplasty Versus Fixation in Management of Unstable Intertrochanteric Fractures in the Elderly: A Systematic Review of Literature

Abstract

Objectives: The aim of this review was to compare the outcomes of fixation of intertrochanteric fractures with the dynamic hip screw and proximal femoral nail and to compare the outcomes of fixation and arthroplasty in the treatment of these fractures. Design: A systematic review and meta-analysis of randomized control trials and quasi-random trials. Methods: Two reviewers searched the following databases and search engines: PubMed Central, the Cochrane library, Google scholar, Ovid database and Science direct for RCTs and quasi- random trials comparing the outcomes of the dynamic hip screw, proximal femoral nail, and arthroplasty in the treatment of intertrochanteric fractures. We assessed the quality of the studies meeting the eligibility criteria by using the Cochrane assessment tool. For measuring the outcomes we used the mean difference with 95% confidence interval for continuous data and risk difference with 95% confidence interval for dichotomous data.

Results: The electronic search revealed 4679 citations of which 2661 citations screened for possible inclusion in the review. 2541 citations excluded from title and abstract. 120 full-text articles assessed for eligibility. 27 studies included in the final review 19 studies comparing the results of the proximal femoral nail and dynamic hip screw and 8 studies comparing the results of arthroplasty and fixation. Meta-analysis of the studies showed lower operative time (mean Difference 12.54 [11.10, 13.98] 95% CI) , lower blood loss (Mean Difference 163.44 [145.13, 181.75] 95% CI) with no difference in post-operative complications and mortality risks between the dynamic hip screw and proximal femoral nail. Mean Harris hip score was higher in proximal femoral nail group in first three months (Mean Difference -5.00 [-7.08, -2.92] 95% CI) with no clinically important difference in further follow-up, but recovery of independent walking and recovery of walking ability to the preoperative state were better in proximal femoral nail group (Risk Difference -0.18 [-0.36, -0.01] 95% CI) and (Risk Difference-0.13 [-0.24, -0.03] 95% CI) respectively. Arthroplasty had longer operative time (Mean Difference 24.14 [17.87, 30.41] 95% CI), more blood loss (Mean Difference 343.00 [302.24, 383.76] 95% CI) and there was no difference in post-operative complications and mortality risks (Risk Difference -0.14 [-0.30, 0.01] 95% CI) . Mean Harris hip score was higher in the arthroplasty group in the first 3 months of follow-up (Mean Difference 18.14 [12.44, 23.84] 95% CI) which was reversed in further follow-up in favor of fixation (Mean Difference -8.94 [-13.74, -4.14] 95% CI). The cost of treatment was higher in arthroplasty group (Mean Difference 5898.00 [5364.00, 6432.00] 95% CI). Conclusion: We concluded that proximal femoral nail is a safe treatment option of intertrochanteric fractures with less operative time and blood loss and better walking recovery. Considering the cost and unclear benefit of arthroplasty in the treatment of intertrochanteric fractures we stressed on the need for further studies to determine the exact indications of arthroplasty in the treatment of intertrochanteric fractures. Keywords: Dynamic hip screw, proximal femoral nail, hip arthroplasty, intertrochanteric fractures.