Raj Siddarth, Grover Sarika, Bola Harroop, Pradhan Akhilesh, Fazal Muhammad Ali, Patel Akash
GKT School of Medical Education, King's College London, London, UK.
University Hospital Coventry and Warwickshire, NHS Trust, Coventry, UK.
J Orthop. 2023 Jan 8;36:88-98. doi: 10.1016/j.jor.2022.12.015. eCollection 2023 Feb.
Extracapsular hip fractures comprise approximately half of all hip fractures and the incidence of hip fractures is exponentially increasing. Extramedullary fixation using a dynamic hip screw (DHS) has been the gold standard method of operative treatment for unstable extracapsular fractures, however, in recent years, intramedullary nails (IMN) have become a popular alternative. IMN versus DHS is continuously discussed and debated in literature. Therefore, the purpose of this systematic review and meta-analysis is to directly compare the peri- and post-operative outcomes of these two techniques to provide an up-to-date analysis of which method of fixation is superior.
The MEDLINE/PubMed, Embase and Web of Science Database were searched for eligible studies from 2008 to April 2022 that compared peri- and post-operational outcomes for patients undergoing IMN or DHS operations for fixation of unstable extracapsular hip fractures (PROSPERO registration ID:CRD42021228335). Primary outcomes included mortality rate and re-operation rate. Secondary outcomes included operation time, blood loss, transfusion requirement, complication, and failure of fixation rate. The risk of bias and quality of evidence were assessed using the Cochrane RoB 2.0 tool and GRADE analysis tool, respectively.
Of the 6776 records identified, 22 studies involving 3151 patients were included in the final review. Our meta-analysis showed no significant differences between mortality rates (10 studies, OR 0.98; 95% CI 0.80 to 1.22, p = 0.88) or re-operation rates (10 studies, OR 1.03; 95% CI 0.64 to 1.64, p = 0.91) between the two procedures. There were also no significant differences found between complication rates (17 studies, OR 1.29; 95% CI 0.79 to 2.12, p = 0.31) and failure of fixation rates (14 studies, OR 1.32; 95% CI 0.74 to 2.38, p = 0.35). However, DHS operations had a significantly longer operation time (p < 0.0001) and blood loss (p < 0.00001) than IMN operations.
Overall, based on the outcomes assessed, this review has demonstrated that there is no significant difference in the post-operative outcomes for DHS vs IMN, however a significant difference exists in two of the intraoperative outcomes assessed in this review.
髋关节囊外骨折约占所有髋部骨折的一半，且髋部骨折的发病率呈指数级增长。使用动力髋螺钉（DHS）进行髓外固定一直是不稳定髋关节囊外骨折手术治疗的金标准方法，然而近年来，髓内钉（IMN）已成为一种流行的替代方法。IMN与DHS在文献中一直被不断讨论和辩论。因此，本系统评价和荟萃分析的目的是直接比较这两种技术的围手术期和术后结果，以提供关于哪种固定方法更优的最新分析。
检索MEDLINE/PubMed、Embase和Web of Science数据库，查找2008年至2022年4月期间比较接受IMN或DHS手术固定不稳定髋关节囊外骨折患者围手术期和术后结果的合格研究（PROSPERO注册编号：CRD42021228335）。主要结局包括死亡率和再次手术率。次要结局包括手术时间、失血量、输血需求、并发症和固定失败率。分别使用Cochrane RoB 2.0工具和GRADE分析工具评估偏倚风险和证据质量。
在识别出的6776条记录中，最终纳入了22项涉及3151例患者的研究。我们的荟萃分析表明，两种手术方法在死亡率（10项研究，OR 0.98；95%CI 0.80至1.22，p = 0.88）或再次手术率（10项研究，OR 1.03；95%CI 0.64至1.64，p = 0.91）方面没有显著差异。在并发症发生率（17项研究，OR 1.29；95%CI 0.79至2.12，p = 0.31）和固定失败率（14项研究，OR 1.32；95%CI 0.74至2.38，p = 0.35）方面也没有发现显著差异。然而，DHS手术的手术时间（p < 0.0001）和失血量（p < 0.00001）明显长于IMN手术。
总体而言，基于评估的结果，本综述表明DHS与IMN的术后结果没有显著差异，然而在本综述评估的两项术中结果方面存在显著差异。
