Intramedullary Fixation vs Arthroplasty Management of Trochanteric Fractures in Elderly Patients a Systematic Review and Meta-Analysis
Authors: Abdelrahman Ahmed Saber Mohamed , Fayed Mahmoud Mohamed Hassan , Haroun Haitham Kamel Omar 
Published: November 2024

Abstract

Introduction
Intertrochanteric fractures of the femur are very common in elderly people. Their incidence has increased due to the increased life expectancy and osteoporosis; fall is the main cause of injuries. Most of the classification systems for intertrochanteric fractures have poor reliability and reproducibility. Intertrochanteric fractures are considered unstable in the presence of a comminuted posteromedial cortex, reverse obliquity, and subtrochanteric extension. Early operation within 12 hours to 48 hours is mandatory in the relatively fit patients. The surgical goal is to achieve a painless and stable lower limb with early return of function, with the lowest rates of mortality and morbidity. The mainstay of treatment of intertrochanteric hip fractures is internal fixation. Compare and contrast different clinical outcomes and provide a meta-analysis study of the data retrieved. This study was conducted aiming to help clinicians and surgeons to provide the best quality of health care to their patients in management of these fractures and help improve their quality of life.

Methods
We conducted a systematic search on four different databases: PubMed, Web of Science, Cochrane Central, and SCOPUS. The search was done by two independent researchers and differences was sorted out and solved by third independent researcher according to the PRISMA statement and the guidelines mentioned by the Cochrane’s handbook of systematic reviews. Eligibility criteria was predefined with clearly stated inclusion and exclusion criteria of studies. After clear screening of studies between two independent participants and solving contradictions by a third participant, our systematic research yielded 41 eligible studies. Data extraction was done including demographic data of subjects, outcomes to be measured, and data extracted for domains of risk of bias. Quality assessment of retrieved data was performed according to GRADE guidelines. This includes ROB2 bias tool for randomized control trials and ROBIN-1 tool for non-randomized control trials. Statistical analysis of analysis of outcomes were conducted using Review Manager Software. Outcomes to be measured were Operation time, Intraoperative blood loss, duration of hospital stay, time to weight bearing, Harris hip score at (1.5,3,6,12,18,24) month post surgery, General complications, Wound complications, Local major and minor complications, and mortality within (3,6,12,18,24) Month post-surgery, Reoperation rate.

Results
Study was conducted on 41 studies: 10 Randomized control studies and 31 Non- randomized control study. Collectively retrieving a total of 4782 patients: 2398 patient were allocated to the intramedullary fixation group and 2384 to the arthroplasty group; weighted mean age was 77.49 years and 79.18 years respectively. Our study yielded that arthroplasty and replacement procedures had favorable outcome regarding Harris hip score at 1 year after surgery, earlier time to weight bearing, and lower reoperation rate when compared to intramedullary fixation. However, arthroplasty had less favorable value regarding the operation time, blood loss and need for blood transfusion; while equal value in the length of hospital stays, complication rates, and incidence of mortality in the first year post surgery.

Conclusion
This study concluded a statistically significant favorable clinical outcome and equal complications of replacement procedures when compared to intramedullary fixation procedures at one year post surgery. However, several limitations were observed in our study which may affect this conclusion and urge the need for further research.