Proximal femoral nail antirotation versus bipolar hemiarthroplasty for intertrochanteric fractures: a meta-analysis

Introduction Intertrochanteric fractures account for almost half of all hip fractures, with a mortality rate of 15 to 20 % within one year following fracture, primarily in elderly patients aged 65 years old and older. The purpose of this study is to compare the operative time, intraoperative blood loss, intraoperative blood transfusion, hospitalization time, weight-bearing time, Harris Hip Score at 1, 3, 6, 12 months follow-up, and  complications after proximal femoral nail antirotation versus bipolar hemiarthroplasty for intertrochanteric fracture in elderly patients based on the published literature of their comparison.

Methods We conducted a comprehensive search in the electronic databases such as PubMed, Scopus, and  Google  Scholar. Original articles up to November 2024 were screened, focusing on retrospective or prospective cohort studies.

Results and Discussion The initial search yielded 702 studies. Six cohort studies with a total of  495  participants  were assessed. The Proximal Femoral Nail Antirotation (PFNA) showed statistically significant shorter operative time (p = 0.006), lower intraoperative blood loss (p < 0.0001) compared with  bipolar hemiarthroplasty. Bipolar Hemiarthroplastty had statistically significant better Harris Hip Score at 1 and 3 month follow-up post-operatively (p < 0.00001), (p = 0.001). It provides early weight-bearing (p = 0.003) and helps mobilize post-operative patients. Blood transfusion, hospitalization time, Harris Hip Score after 6- month follow-up, and complications had balanced results between two apporaches.

Conclusion PFNA and bipolar Hemiarthroplasty have comparable results in intertrochateric fractures in the elderly. PFNA has the advantages of shorter operative time, and lower intraoperative blood loss. Bipolar hemiarthroplasty has the advantages of better Harris Hip Score at 1 and 3 month follow-up and earlier weight-bearing.

Level of Evidence: I.

1. Zheng L, Wong DW, Chen X, et al. Risk of proximal femoral nail antirotation (PFNA) implant failure upon different lateral femoral wall thickness in intertrochanteric fracture: a finite element analysis. Comput Methods Biomech Biomed Engin. 2022;25(5):512-520. doi: 10.1080/10255842.2021.1964488.

2. Chang SM, Hou ZY, Hu SJ, Du SC. Intertrochanteric Femur Fracture Treatment in Asia: What We Know and What the World Can Learn. Orthop Clin North Am. 2020 Apr;51(2):189-205. doi: 10.1016/j.ocl.2019.11.011.

3. Ruecker AH, Rupprecht M, Gruber M, et al. The treatment of intertrochanteric fractures: results using an intramedullary nail with integrated cephalocervical screws and linear compression. J Orthop Trauma. 2009;23(1):22-30. doi: 10.1097/BOT.0b013e31819211b2.

4. Mundi S, Pindiprolu B, Simunovic N, Bhandari M. Similar mortality rates in hip fracture patients over the past 31 years. Acta Orthop. 2014;85(1):54-59. doi: 10.3109/17453674.2013.878831.

5. De Laet CE, van Hout BA, Burger H, et al. Bone density and risk of hip fracture in men and women: cross sectional analysis. BMJ. 1997;315(7102):221-225. doi: 10.1136/bmj.315.7102.221.

6. Burge R, Dawson-Hughes B, Solomon DH, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res. 2007;22(3):465-475. doi: 10.1359/jbmr.061113.

7. Søgaard AJ, Holvik K, Meyer HE, et al. Continued decline in hip fracture incidence in Norway: a NOREPOS study. Osteoporos Int. 2016;27(7):2217-2222. doi: 10.1007/s00198-016-3516-8.

8. Nieves JW, Bilezikian JP, Lane JM, et al. Fragility fractures of the hip and femur: incidence and patient characteristics. Osteoporos Int. 2010;21(3):399-408. doi: 10.1007/s00198-009-0962-6.

9. Lisk R, Yeong K. Reducing mortality from hip fractures: a systematic quality improvement programme. BMJ Qual Improv Rep. 2014;3(1):u205006.w2103. doi: 10.1136/bmjquality.u205006.w2103.

10. Amphansap T, Nitiwarangkul L. One-year mortality rate after osteoporotic hip fractures and associated risk factors in Police General Hospital. Osteoporos Sarcopenia. 2015;1(1):75-79. doi: 10.1016/j.afos.2015.07.006.

11. Klop C, Welsing PM, Cooper C, Harvey NC, Elders PJ, Bijlsma JW, Leufkens HG, de Vries F. Mortality in British hip fracture patients, 2000-2010: a population-based retrospective cohort study. Bone. 2014;66:171-177. doi: 10.1016/j.bone.2014.06.011.

12. Imai N, Endo N, Hoshino T, et al. Mortality after hip fracture with vertebral compression fracture is poor. J Bone Miner Metab. 2016;34(1):51-4. doi: 10.1007/s00774-014-0640-4.

13. Papadimitriou N, Tsilidis KK, Orfanos P, et al. Burden of hip fracture using disability-adjusted life-years: a pooled analysis of prospective cohorts in the CHANCES consortium. Lancet Public Health. 2017;2(5):e239-e246. doi: 10.1016/S2468-2667(17)30046-4.

14. Songpatanasilp T, Sritara C, Kittisomprayoonkul W, et al. Thai Osteoporosis Foundation (TOPF) position statements on management of osteoporosis. Osteoporos Sarcopenia. 2016;2(4):191-207. doi: 10.1016/j.afos.2016.10.002.

15. Ülkü TK, Tok O, Seyhan M et al. Comparison of Third Generation Proximal Femoral Nails in Treatment of Reverse Oblique Intertrochanteric Fractures. Bezmialem Sci. 2019;7(4):271-275. doi: 10.14235/bas.galenos.2018.2798.

16. Liu JJ, Shan LC, Deng BY, et al. Reason and treatment of failure of proximal femoral nail antirotation internal fixation for femoral intertrochanteric fractures of senile patients. Genet Mol Res. 2014;13(3):5949-5956. doi: 10.4238/2014.August.7.10.

17. Xie Y, Dong Q, Xie Z. Proximal femoral nail anti-rotation (PFNA) and hemi-arthroplasty in the treatment of elderly intertrochanteric fractures. Acta Orthop Belg. 2019;85(2):199-204.

18. She Z, Yang F, Zhang S, et al. A novel intramedullary nail design of intertrochanteric fracture fixation improved by proximal femoral nail antirotation. Comput Methods Biomech Biomed Engin. 2023:1-11. doi: 10.1080/10255842.2023.2286917.

19. Nie SB, Zhao YP, Li JT, et al. Medial support nail and proximal femoral nail antirotation in the treatment of reverse obliquity intertrochanteric fractures (Arbeitsgemeinschaft fur Osteosynthesfrogen/Orthopedic Trauma Association 31-A3.1): a finite-element analysis. Chin Med J (Engl). 2020;133(22):2682-2687. doi: 10.1097/CM9.0000000000001031.

20. Liang Y, Liu S, Li L, Zhong F. Proximal femoral nail antirotation versus external fixation for unstable intertrochanteric fractures in elderly patients: A randomized controlled trial. Medicine (Baltimore). 2022;101(28):e29384. doi: 10.1097/MD.0000000000029384.

21. Lee YK, Kim JT, Park CH, et al. Analysis of risk factor for nail breakage in patients with mechanical failures after proximal femoral nail antirotation in intertrochanteric fractures. Medicine (Baltimore). 2022;101(25):e29436. doi: 10.1097/MD.0000000000029436.

22. Singh M, Nagrath AR, Maini PS. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg Am. 1970;52(3):457-467.

23. Hao Z, Wang X, Zhang X. Comparing surgical interventions for intertrochanteric hip fracture by blood loss and operation time: a network meta-analysis. J Orthop Surg Res. 2018;13(1):157. doi: 10.1186/s13018-018-0852-8.

24. Aguado-Maestro I, Escudero-Marcos R, García-García JM, et al. Results and complications of pertrochanteric hip fractures using an intramedullary nail with a helical blade (proximal femoral nail antirotation) in 200 patients. Rev Esp Cir Ortop Traumatol. 2013;57(3):201-207. (In Span.) doi: 10.1016/j.recot.2013.03.001.

25. Green S, Moore T, Proano F. Bipolar prosthetic replacement for the management of unstable intertrochanteric hip fractures in the elderly. Clin Orthop Relat Res. 1987;(224):169-177.

26. Tang P, Hu F, Shen J, et al. Proximal femoral nail antirotation versus hemiarthroplasty: a study for the treatment of intertrochanteric fractures. Injury. 2012;43(6):876-881. doi: 10.1016/j.injury.2011.11.008.

27. Fahad S, Nawaz Khan MZ, Khattak MJ, et al. Primary Proximal femur replacement for unstable osteoporotic intertrochanteric and subtrochanteric fractures in the elderly: A retrospective case series. Ann Med Surg (Lond). 2019;44:94-97. doi: 10.1016/j.amsu.2019.07.014.

28. Haentjens P, Lamraski G. Endoprosthetic replacement of unstable, comminuted intertrochanteric fracture of the femur in the elderly, osteoporotic patient: a review. Disabil Rehabil. 2005;27(18-19):1167-1180. doi: 10.1080/09638280500055966.

29. Cai C, Tian L, Chen Z, et al. Cementless bipolar hemiarthroplasty compared with proximal femoral nail anti-rotation of unstable intertrochanteric fractures in senile patients with osteoporosis: a retrospective study. BMC Musculoskelet Disord. 2022;23(1):461. doi: 10.1186/s12891-022-05426-2.

30. Lu X, Gou W, Wu S, et al. Complication Rates and Survival of Nonagenarians after Hip Hemiarthroplasty versus Proximal Femoral Nail Antirotation for Intertrochanteric Fractures: A 15-Year Retrospective Cohort Study of 113 Cases. Orthop Surg. 2023;15(12):3231-3242. doi: 10.1111/os.13913.

31. Saraf H, Munot S. Comparative study of PFN antirotation vs bipolar hemiarthroplasty in unstable senile intertrochanteric fractures. Indian J Orthop Surg. 2018;4(4):380-385. doi: 10.18231/2395-1362.2018.0073.

32. Song QC, Dang SJ, Zhao Y, et al. Comparison of clinical outcomes with proximal femoral nail anti-rotation versus bipolar hemiarthroplasty for the treatment of elderly unstable comminuted intertrochanteric fractures. BMC Musculoskelet Disord. 2022;23(1):628. doi: 10.1186/s12891-022-05583-4.

33. Zhou S, Liu J, Zhen P, et al. Proximal femoral nail anti-rotation versus cementless bipolar hemiarthroplasty for unstable femoral intertrochanteric fracture in the elderly: a retrospective study. BMC Musculoskelet Disord. 2019;20(1):500. doi: 10.1186/s12891-019-2793-8.

34. Zhou X, Chen T, Jiang YL, et ak. Comparison of the clinical outcomes between proximal femoral nail anti-rotation with cement enhancement and hemiarthroplasty among elderly osteoporotic patients with intertrochanteric fracture. BMC Musculoskelet Disord. 2024;25(1):290. doi: 10.1186/s12891-024-07414-0.