Intramedullary Nailing versus Dynamic Screw and Plate for Treatment of Trochanteric Fractures of the Femur
Authors: Morsy Ahmed Mohamed , Abu-Elgeat Zakaria Ibrahim Hassan , Eltawila Mohammed Mohammed Hafez 
Published: August 2023

Background
Trochanteric and intertrochanteric femur fractures are extracapsular fractures of the proximal femur at the level of the greater and lesser trochanter. Trochanteric fractures in adults mostly affect elderly subjects. Frequency is increasing with population aging despite the development of treatments for osteoporosis. The two most widely used types of internal fixation are intramedullary nailing and screw-plate fixation, often performed by trainee surgeons due to their frequency and reputed simplicity.

Aim of the Work
The aim of the study is to conduct a systematic review of literature and metaanalysis comparing between intramedullary nailing and dynamic plate and screw in treatment of trochanteric fractures of the femur according to: Length of mean operation time, time of radiation exposure (fluoroscopy time), Intraoperative blood loss, reoperation rate, fracture non-union and postoperative wound infection wither superficial or deep infection.

Patients and Methods
We followed the PRISMA statement guidelines during this study preparation and performed all steps according to the Cochrane handbook of systematic reviews of intervention. We searched PubMed, Scopus, Cochrane, and Web of Science, Embase, and Science Direct in June 2021 and updated the search in July 2021 using relevant Keywords. The eligibility inclusion criteria for studies inclusion were the following: (1) Adult patients above 18 years old (2) Double arm designs (3) Studies designs are limited to randomized control trial (RCT) (4) English studies (5) Any outcome is acceptable. The risk of bias was evaluated by the Cochrane handbook of systematic reviews of interventions 5.1.0. Regarding the data extraction, we obtained data from text, tables, figures (using graph grabber version 2.0), and supplementary data. We conducted this metaanalysis by using Review Manager software (RevMan version 5.4).

Results
Compared to the control group (Dynamic hip screw and plate technique), Intramedullary nailing (IMN) showed a significant improvement in length of operation time (MD = −9.27; 95% CI: [-18.07, -0.47]; P = 0.04) and perioperative blood loss(MD = -120; 95% CI: [-164.05, -77.89]; P &lt; 0.00001) than dynamic hip screw with plate fixation technique. However, in the term of intraoperative radiation exposure time (Fluoroscopy time), dynamic hip screw (DHS) with plate fixation showed a significant lesser fluoroscopy time than IMN(MD = 0.61; 95% CI: [0.23, 0.99]; P = 0.002). Regarding the postoperative patient satisfaction (assessed by visual analogue scale), postoperative Fracture non-union, perioperative wound infection, femur shaft fracture, and hip prosthetic instability, they showed no significant difference between IMN and dynamic hip screw with plate fixation. Reoperation rate also showed no significant difference between IMN and DHS with plate fixation.

Conclusion
DHS with plate is not the preferred implant for stable intertrochanteric femur fractures. IMN showed a better result than DHS. We believe that the IMN is biologically superior to DHS for fixation of unstable inter-trochanteric fractures as it provides stable intramedullary fixation resistant to varus collapse and fixation failure, with relatively less operation time, and blood loss.