Key result
Distal unlocked intramedullary nailing for stable intertrochanteric fractures significantly reduced operation time (MD 7.04 minutes), intraoperative bleeding, and transfusion rates compared to distal locking, without affecting long-term complications or function.
Why the study?
Intramedullary nails are the main treatment for intertrochanteric fractures, but the necessity of the distal locking procedure during nailing has raised controversy.
Does distal unlocking compared to distal locking improve outcomes in adult patients with acute stable intertrochanteric fractures?
Meta-Analysis (n=1,978)
Does distal unlocking compared to distal locking improve outcomes in adult patients with acute stable intertrochanteric fractures?
Mean Difference: 7.04 (95% CI 4.42–9.67)
p-value: p=<0.00001
Distal unlocking in intramedullary nailing for stable intertrochanteric fractures reduces operation time, bleeding, and thigh pain without compromising safety or long-term functional outcomes.
Favors unlocked distal nailing for stable intertrochanteric fractures to cut operative time and bleeding; confirms safety of omitting distal locks without compromising outcomes.
Background: Intramedullary nails have become the main treatment for intertrochanteric fractures. However, distal locking procedure during nailing gradually raised controversy. A systematic review and meta-analysis of clinical trials was performed to summarize the existing evidence with the aim at determining the safety and efficacy of distal locking or unlocking in the nailing of stable intertrochanteric fractures. Methods: Appropriate articles were identified using the most common public databases such as PubMed, Embase, the Cochrane Library, and Google Scholar from the inception of each database to April 2019, without restriction of language, publication date, and also considering ongoing trials. Eligible studies were represented by randomized controlled trials or retrospective cohort studies comparing distal locking with unlocking for the treatment of acute stable intertrochanteric fractures in adult patients. Information regarding the methodological quality, patient demographics and all clinical outcomes were extracted independently by two reviewers. Patients were then divided into locking and unlocking group. Results: This study included 9 articles, a total of 1978 patients with a similar baseline. The results showed that the unlocking group had shorter operation time, less intraoperative bleeding, lower transfusion rate, and less thigh pain after the treatment of femoral intertrochanteric fracture compared with the distal locking group. No significant difference was found in safety-related outcomes including mortality, infection rate, cutting out, loss of reduction, backing out of lag screws, cephalic screw breakage, nail breakage, and peri-implant fractures between the two groups. Efficacy-related outcomes including nonunion, delayed healing rates, and Harris functional score were also not significantly different between the two groups. Conclusions: Our pooled analysis demonstrated that the distal unlocking of the stable intertrochanteric fractures can shorten the operation time, reduce intraoperative bleeding, and reduce the blood transfusion rate. The use of locked or unlocked intramedullary nailing does not affect long-term outcomes in terms of complications and function.
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Li et al. (2019) conducted a meta-analysis in Acute stable intertrochanteric fractures (n=1,978). Distal unlocked intramedullary nailing vs. Distal locked intramedullary nailing was evaluated on Duration of operation (MD 7.04, 95% CI 4.42-9.67, p=<0.00001). Distal unlocked intramedullary nailing for stable intertrochanteric fractures significantly reduced operation time (MD 7.04 minutes), intraoperative bleeding, and transfusion rates compared to distal locking, without affecting long-term complications or function.
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