Intramedullary and extramedullary fixations for the treatment of unstable femoral intertrochanteric fractures: a meta-analysis of prospective randomized controlled trials

Purpose Intramedullary and extramedullary fixation methods are widely used to treat unstable femoral intertrochanteric fractures, but the optimal surgical method remains controversial. The aim of this study was to estimate the outcomes of intramedullary fixation versus extramedullary fixation in treating unstable femoral intertrochanteric fractures. Methods Electronic literature databases were used for searching including MEDLINE (Ovid interface), EMBASE (Ovid interface) and the Cochrane Central Register of Controlled Trials (CENTRAL) (Wiley Online Library) (up to March 30, 2016). Only human studies, which were designed as randomized controlled clinical trials, were included. Two authors independently evaluated the quality of original literature and extracted data from eligible literature. Results Eleven randomized controlled trials involving 1,543 patients were included. Intramedullary fixation was significantly better in functional scores (SMD 0.43, 95 % CI 0.14-0.73, P = 0.004) and had less blood loss (SMD -0.96, 95 % CI -1.77 to -0.11, P = 0.03) in contrast with extramedullary fixation. No obvious discrepancies were found in adverse events, operative time, blood transfusion, and hospital stay between intramedullary and extramedullary fixations. Conclusion Our meta-analysis of 11 prospective randomized controlled trials suggested: no obvious discrepancies were found in adverse events, operative time, blood transfusion, and hospital stay between intramedullary and extramedullary fixations. Given the better results of intramedullary fixation in terms of functional scores and blood loss, we recommend the intramedullary fixation technique in treating unstable femoral intertrochanteric fractures. Large multi-center RCTs, which focused on unstable femoral intertrochanteric fractures, are needed to evaluate the efficiency of alternative internal fixation strategies in the future.