Clinical outcomes in the surgical management of ankle fractures: A systematic review and meta-analysis of fibular intramedullary nail fixation vs. open reduction and internal fixation in randomized controlled trials.

BACKGROUND: What level I evidence exists to support the use of FNF for surgical management of ankle fractures in high risk patients? The purpose of this study was to compare clinical outcomes following fibular intramedullary nail fixation (FNF) and open reduction and internal fixation (ORIF) of ankle fractures. METHODS: A systematic review of the current literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Certainty of evidence reported according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Our primary hypothesis was that patients undergoing FNF procedures to manage an ankle fracture would have significantly higher patient reported outcome scores (PROs) than patients undergoing ORIF. Primary study outcome measures were validated PROs. Secondary outcome measures included complication rate, secondary surgery rate, and bony union. RESULTS: The primary outcome analysis revealed no evidence of a significant effect difference on Olerud and Molander Ankle Score (OMAS) PRO and no evidence of statistical heterogeneity. Secondary outcome analysis revealed a significant 0.30 (0.12-0.74 95CI) relative risk reduction for complications in FNF (P = 0.008). No evidence of an effect difference for bony union. The GRADE certainty of the evidence was rated as low for bone union. No evidence of reporting bias was appreciated. Sensitivity analyses did not significantly alter effect estimates. CONCLUSION: This systematic review and meta-analysis restricted to evidence derived from RCTs revealed that the quality of evidence is reasonably strong and likely sufficient to conclude: (1) there is likely no clinically important difference between FNF and ORIF up to 12 months post-operatively, as defined by OMS (moderate certainty); (2) surgeons may reasonably expect reduced complications in 14 out of every 100 patients treated with FNF (moderate certainty); (3) there is likely no difference in bony union (low certainty). Future studies should investigate more patient-centered outcomes and if short-term findings are durable over time if these findings apply to lower risk populations. LEVEL OF EVIDENCE: Systematic review and meta-analysis of level I evidence.

Clinical and functional comparison of dynamic hip screws and intramedullary nails for treating proximal femur metastases in older individuals.

OBJECTIVE: To compare the outcomes of dynamic hip screws (DHS) and intramedullary nailing (IMN) in the treatment of extra-capsular metastatic carcinoma of the proximal femur. METHODS: A retrospective case analysis method was used to examine data of patients with proximal metastatic cancer of the femur who were treated with internal fixation in Department of Orthopaedics, Beijing Friendship Hospital, from January 2007 to December 2018. Blood loss, postoperative pain, functional score, length of stay, and survival rates were compared, and postoperative complications were assessed. RESULTS: Complete follow-up data were available for 33 patients. The mean follow-up period was 12.2±3.6 (range: 9-32) months and the average age was 72.3±4.7 (range: 59-83) years old. There were 20 females and 13 males. Twenty-three patients had undergone IMN and 10 DHS, according to bone defects and the patient's overall condition. The median survival time was 10 months in the IMN group and 11 months in the DHS group. Duration of surgery (t=-7.366, P<0.001) and length of hospital stay (t=-3.509, P<0.001) differed significantly between the two groups. There was one case of breakage of internal fixation in the IMN group. CONCLUSIONS: There was no significant difference between DHS and IMN in terms of surgical efficacy. IMN and DHS were different in terms of surgical time and hospital stay. However, due to the limited number of cases in this study, multi-factor analysis has not been performed and needs to be further verified in future analysis. When developing a surgical plan, it is recommended to consider the patient's condition and the surgeon's experience.

Dynamic hip screws versus cephalocondylic intramedullary nails for unstable extracapsular hip fractures in 2021: A systematic review and meta-analysis of randomised trials.

Background: 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. Methods: 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. Results: 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. Conclusion: 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.

Intramedullary nailing versus a locking compression plate for humeral shaft fracture (AO/OTA 12-A and B): A retrospective study.

INTRODUCTION: There has been great progress in surgical techniques for treating humeral shaft fractures over the past few decades. The purpose of this study was to compare the therapeutic effects of intramedullary nailing (IMN) and locking compression plate (LCP) for humeral shaft fractures (AO/OTA 12-A and B). HYPOTHESIS: Compared with LCP, better therapeutic effects could be obtained with less invasive IMN. MATERIALS AND METHODS: Patients with a humeral shaft fracture who received anterograde IMN or LCP fixation in our institution from December 2011 to June 2016 were reviewed in this study. They were divided into two groups according to the different fixation methods: Group A (IMN) and Group B (LCP). The surgical time, intraoperative blood loss, and complications of the patients were reviewed. Fracture healing was evaluated by radiographs performed at each follow-up. The functional outcome was assessed by the DASH (Disabilities of the Arm, Shoulder and Hand) scoring system at the final follow-up. RESULTS: Thirty-four patients in Group A and forty-six patients in Group B were included in this study. Mean incision length and blood loss in Group B were greater than those in Group A (p<0.001). The average surgical times were 118.53minutes in Group A and 128.91minutes in Group B (p=0.114). The mean DASH scores were 23.76±16.78 in Group A and 22.37±15.18 in Group B (p=0.609). The complication rates were 8/34 in Group A and 7/46 in Group B, respectively (p=0.887). DISCUSSION: The study hypothesis was partially confirmed. Although IMN was a less invasive technique, similar therapeutic results were obtained for humeral shaft fractures (AO/OTA 12-A and B) fixed with two surgical methods. LEVELS OF EVIDENCE: III, retrospective comparative study.