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e-ISSN 1643-3750
© Med Sci Monit, 2014; 20: 1628-1633
DOI: 10.12659/MSM.890962

Received: 2014.05.04
Accepted: 2014.05.27 Proximal Femoral Nail vs. Dynamic Hip Screw
Published: 2014.09.12
in Treatment of Intertrochanteric Fractures:
A Meta-Analysis
Authors’ Contribution: AC 1 Kairui Zhang* 1 Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern
Study Design  A AC 1 Sheng Zhang* Medical University, Guangzhou, China
Data Collection  B 2 Department of Orthopaedics, 421 Hospital of PLA, Guangzhou, China
Analysis  C
Statistical B 1,2 Jun Yang 3 Department of Orthopaedics, First Affiliated Hospital to Guangzhou Medical

Data Interpretation  D B 1,3 Weiqiang Dong University, Guangzhou, China
Manuscript Preparation  E B 1 Shengnan Wang 4 Department of Orthopaedics, Subei People’s Hospital of Jiangsu Province (Clinical
Literature Search  F Medical College of Yangzhou University), Yangzhou, Jiangsu Province, China
Collection  G
Funds F 1 Yirong Cheng
D 1 Mohammed Al-Qwbani
A 4 Qiang Wang
A 1 Bin Yu

* Kairui Zhang and Sheng Zhang are co-first authors who contributed equally to this work
Corresponding Author: Bin Yu, e-mail: 280219927@qq.com and Qiang Wang, e-mail: 1780468505@qq.com
Source of support: Departmental sources

Background: The aim of this meta-analysis was to compare the outcomes of proximal femoral nail (PFN) and dynamic hip
screw (DHS) in treatment of intertrochanteric fractures.
Material/Methods: Relevant randomized or quasi-randomized controlled studies comparing the effects of PFN and DHS were
searched for following the requirements of the Cochrane Library Handbook. Six eligible studies involving 669
fractures were included. Their methodological quality was assessed and data were extracted independently for
meta-analysis.
Results: The results showed that the PFN group had significantly less operative time (WMD: –21.15, 95% CI: –34.91 –
–7.39, P=0.003), intraoperative blood loss (WMD: –139.81, 95% CI: –210.39 – –69.22, P=0.0001), and length of
incision (WMD: –6.97, 95% CI: –9.19 – –4.74, P<0.00001) than the DHS group. No significant differences were
found between the 2 groups regarding postoperative infection rate, lag screw cut-out rate, or reoperation rate.
Conclusions: The current evidence indicates that PFN may be a better choice than DHS in the treatment of intertrochanter-
ic fractures.

MeSH Keywords: Bone Screws • Hip Fractures • Meta-Analysis as Topic

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Proximal femoral nail vs. dynamic hip screw in treatment…
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Background Data were collected by 2 independent researchers who screened


titles, abstracts, and keywords both electronically and by hand;
The incidence of intertrochanteric fractures has been increas- differences were resolved by discussion. Full texts of citations
ing significantly due to the rising age of modern human pop- that could possibly be included in the present meta-analysis
ulations [1,2]. Generally, intramedullary fixation and extra- were retrieved for further analysis. The assessment method from
medullary fixation are the 2 primary options for treatment the Cochrane Handbook for Systematic Reviews of Interventions
of such fractures. The dynamic hip screw (DHS), commonly was used to evaluate the studies in terms of blinding, alloca-
used in extramedullary fixation, has become a standard im- tion concealment, follow-up coverage, and quality level. The
plant in treatment of these fractures [3,4]. Proximal femo- study quality was assessed according to whether allocation
ral nail (PFN) and Gamma nail are 2 commonly used devices concealment was: adequate (A), unclear (B), inadequate (C), or
in the intramedullary fixation. Previous studies showed that not used (D). Operative time (min), intraoperative blood loss
the Gamma nail did not perform as well as DHS because it (ml), length of incision, post-operative infection, lag screw cut-
led to a relatively higher incidence of post-operative femo- out rate, and reoperation rate were the main measures in the
ral shaft fracture [5,6]. studies included, which the present meta-analysis evaluated
to compare the effects of PFN and DHS. We did not undertake
PFN, introduced by the AO/ASIF group in 1997, has become a subgroup analysis for different fracture types because not all
prevalent in treatment of intertrochanteric fractures in recent of the studies included described the fracture types.
years because it was improved by addition of an antirotation
hip screw proximal to the main lag screw. However, both ben- In each eligible study the relative risk (RR) was calculated for
efits and technical failures of PFN have been reported [7–9] dichotomous outcomes and the weighted mean difference
for continuous outcomes using the software Review Manager
Although the effects of PFN and DHS in treatment of intertro- 5.0, with a 95% confidence interval (CI) adopted in both.
chanteric fractures have been reported, the results and con- Heterogeneity was tested using both the chi-square test and
clusions are not consistent [10–15]. Therefore, we conducted the I-square test. A significance level of less than 0.10 for the
this meta-analysis to investigate whether there is a significant chi-square test was interpreted as evidence of heterogeneity.
difference between PFN and DHS fixation in treatment of in- The I-square was used to estimate total variation across stud-
tertrochanteric fractures. ies. When there was no statistical evidence of heterogeneity,
a fixed-effect model was adopted; otherwise, a random-ef-
Our aim was to evaluate clinical results comparing PFN with fect model was chosen. We did not include the possibility of
DHS, including comparison of operative time, intraoperative publishing bias due to the small number of studies included.
blood loss, length of incision, postoperative infection rate, lag
screw cut-out rate, and reoperation rate. We hypothesized that
PFN would be a superior treatment for intertrochanteric frac- Results
tures compared with DHS.
A total of 48 articles comparing PFN and DHS that had been pub-
lished from 1969 to August 2012 were retrieved: 37 were from
Material and Methods MEDLINE, 6 from the Cochrane Library, and 5 from the EMBASE
Library. Among them, 13 trials met the inclusion criteria. After ex-
We searched for randomized or quasi-randomized controlled cluding non-randomized control trials and retrospective articles, 6
studies comparing the effects of PFN and DHS according to randomized and quasi-randomized controlled trials [10–15] were
the search strategy of the Cochrane Collaboration. It includ- included (Figure 1). The number of fractures included in a single
ed searching of the Cochrane Musculoskeletal Injuries Group study ranged from 64 to 206. There were a total of 669 fractures.
Trials Register, computer searching of MEDLINE, EMBASE, and Three research papers targeted Asian patients, and the other 3
Current Contents, and hand searching of orthopedic jour- targeted Caucasians. All studies except 1 had more female than
nals. All databases were searched from the earliest records male patients; 308 fractures were managed with PFN and 361
to August 2012. The inclusion and exclusion criteria used in managed with DHS. The quality of the 6 studies included was
selecting eligible studies were: (1) target population – individ- level B because the allocation concealment was unclear accord-
uals with intertrochanteric fractures, excluding subtrochan- ing to the evaluation criteria mentioned above (Tables 1 and 2).
teric and pathological fractures; (2) intervention – DHS fixa-
tion compared with PFN fixation; (3) methodological criteria Operative time
– prospective, randomized, or quasi-randomized controlled tri-
als; (4) duplicate or multiple publications of the same study Four studies [10,12,14,15] provided data on operative time.
were not included. The random-effects model was used because of the statistical

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© Med Sci Monit, 2014; 20: 1628-1633

the statistical heterogeneity (I2=94%). The meta-analysis in-


Potentially relevant articles identified and screened for retrieval (n=48) dicated that the intraoperative blood loss for the PFN group
was significantly less than for the DHS group (WMD: –139.81,
Articles not meeting inclusion criteria (n= 35)
95% CI: –210.39 – –69.22, P=0.0001) (Figure 3).

Studies retrieved for more detailed evaluation (n=13)


Length of incision

Non-randomised control studies and retrospective studies


(n=7) Two studies [12,15] provided data on length of incision. The ran-
dom-effects model was used because of the statistical heteroge-
Articles included in the meta-analysis (n=6)
neity (I2=91%). The meta-analysis indicated that the length of in-
cision in the PFN group was significantly shorter than in the DHS
Figure 1. Flowchart of study search and selection for the group (WMD: –6.97, 95% CI: –9.19 – –4.74, P<0.00001) (Figure 4).
meta-analysis.
Postoperative infection rate
heterogeneity (I2=97%). The meta-analysis indicated that the
operative time for the PFN group was significantly shorter Five studies [10–14] provided data on postoperative infection
than for the DHS group (WMD: –21.15, 95% CI: –34.91 – –7.39, rate. Postoperative infection was observed in 6 of the 254 frac-
P=0.003) (Figure 2). tures managed with PFN, and in 7 of the 273 fractures man-
aged with DHS. Heterogeneity tests indicated no statistical
Intraoperative blood loss evidence of heterogeneity (I2=0%). Data pooled by a fixed-ef-
fects model and the meta-analysis indicated an insignificant-
Four studies [11,12,14,15] provided data on intraoperative ly higher rate of postoperative infection in the DHS group (RR:
blood loss. The random-effects model was used because of 0.96, 95% CI: 0.33–2.8, P=0.94) (Figure 5).

Table 1. Description of the studies included in the meta-analysis.

Target Length of Number of fractures


Studies Age (years): PFN/DHS Men (%) Outcomes*
population follow-up PFN DHS

Saudan et al. [10] 83±9.7/83.7±10.1 22.3 Switzerland 12 months 100 100 1, 4, 5, 6

PAN et al. [12] 70±6.8/69±7.11 73 Asia 16 months 30 34 1, 2, 3, 4

Papasimos et al. [13] 79.4/81.4 38.6 Greece 12 months 40 40 4, 5, 6

Pajarinen et al. [11] 80.9±9.1/80.3±10.8 25 Finland 4 months 54 54 2, 4, 5, 6

Shen et al. [14] 72.1±6.61/71.2±7.11 40.2 Asia 16 months 51 56 1, 2, 4

ZHAO et al. [15] 76 (63–87)/74.5 (61–92) 40.4 Asia 19 months 33 71 1, 2, 3, 5

* 1 – operative time; 2 – intraoperative blood loss; 3 – length of incision; 4 – postoperative infection rate; 5 – lag screw cut-out rate;
6 – reoperation rate.

Table 2. Methodological quality of studies included.

Baseline Allocation Loss to


Studies Randomisation Blinding Level
Age Sex Fracture type concealment follow-up

Saudan et al. [10] Comparable Comparable Incomparable Inadequate Unclear Unclear Yes B

PAN et al. [12] Comparable Comparable Comparable Inadequate Unclear Unclear Not reported B

Papasimos et al. [13] Comparable Comparable Comparable Adequate Unclear Unclear None B

Pajarinen et al. [11] Comparable Comparable Comparable Inadequate Unclear Unclear Yes B

Shen et al. [14] Comparable Comparable Incomparable Inadequate Unclear Unclear None B

ZHAO et al. [15] Comparable Comparable Comparable Inadequate Unclear Unclear None B

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PFN DHS Mean difference Mean difference


Study or subgroup Mean SD Total Mean SD Total Weight IV, random, 95% CI IV, random, 95% CI
Pan et al. 2004 59.16 16.92 30 87.35 21.29 34 23.6% –28.19 [–37.56, –18.82]
Saudan et al. 2002 64.00 33.00 100 65.00 26.00 106 24.2% –1.00 [–9.14, 7.14]
Shen et al. 2007 62.06 7.89 51 99.56 12.51 56 25.9% –37.50 [–41.43, –33.57]
Zhao et al. 2009 51.50 4.40 33 68.80 5.90 71 26.3% –17.30 [–19.33, –15.27]

Total (95% CI) 214 267 100.% –21.15 [–34.91, –7.39]

Heterogeneity: Tau2=186.24; Chi2=105.92, df=3 (P<0.00001); I2=97% –100 –50 0 50 100


Test for overall effect: Z=3.01 (P=0.003) PFN DHS

Figure 2. Operative time.

PFN DHS Mean difference Mean difference


Study or subgroup Mean SD Total Mean SD Total Weight IV, random, 95% CI IV, random, 95% CI
Pajarinen et al. 2005 320.00 310.00 54 357.00 495.00 54 12.6% –37.00 [–192.78, 118.78]
Pan et al. 2004 273.33 120.80 30 480.88 177.90 34 24.0% –207.55 [–281.34, –133.76]
Shen et al. 2007 123.73 45.74 51 304.12 82.12 56 31.2% –180.39 [–205.46, –155.32]
Zhao et al. 2009 179.00 12.90 33 269.30 269.30 71 32.3% –90.30 [–100.59, –80.01]

Total (95% CI) 168 215 100.% –139.81 [–210.39, –69.22]

Heterogeneity: Tau2=3993.56; Chi2=50.71, df=3 (P<0.00001); I2=94% –500 –250 0 250 500
Test for overall effect: Z=3.88 (P=0.0001) PFN DHS

Figure 3. Intraoperative blood loss.

PFN DHS Mean difference Mean difference


Study or subgroup Mean SD Total Mean SD Total Weight IV, random, 95% CI IV, random, 95% CI
Pan et al. 2004 14.20 2.02 30 22.38 2.98 34 46.7% –8.18 [–9.42, –6.94]
Zhao et al. 2009 9.60 0.90 33 15.50 1.50 71 53.3% –5.90 [–6.36, –5.44]

Total (95% CI) 63 105 100.% –6.97 [–9.19, –4.74]

Heterogeneity: Tau2=2.37; Chi2=11.46, df=1 (P<0.0007); I2=97% –20 –10 0 10 20


Test for overall effect: Z=6.12 (P<0.0001) PFN DHS

Figure 4. Length of incision.

PFN DHS Odds ratio Odds ratio


Study or subgroup Events Total Events Total Weight M-H, fixed, 95% CI M-H, fixed, 95% CI
Pajarinen et al. 2005 0 54 0 54 Not estimable
Pan et al. 2004 2 30 4 34 51.5% 0.54 [0.09, 3.16]
Papasimos et al. 2005 1 40 1 40 14.3% 1.00 [0.06, 16.56]
Saudan et al. 2002 3 79 1 89 13.3% 3.47 [0.35, 34.09]
Shen et al. 2007 0 51 1 56 20.9% 0.36 [0.01, 9.02]

Total (95% CI) 254 273 100.% 0.96 [0.33, 2.80]


Total events 6 7
Heterogeneity: Chi2=1.99, df=3 (P=0.057); I2=0%
Test for overall effect: Z=0.08 (P=0.94) 0.01 0.1 1 10 100
PFN DHS

Figure 5. Postoperative infection rate.

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PFN DHS Odds ratio Odds ratio


Study or subgroup Events Total Events Total Weight M-H, fixed, 95% CI M-H, fixed, 95% CI
Pajarinen et al. 2005 1 54 1 54 16.2% 1.00 [0.06, 16.41]
Papasimos et al. 2005 1 39 2 39 32.2% 0.49 [0.04, 5.60]
Saudan et al. 2002 3 79 1 89 15.0% 3.47 [0.35, 34.09]
Zhao et al. 2009 0 33 3 71 36.6% 0.29 [0.01, 5.82]

Total (95% CI) 205 253 100.% 0.95 [0.30, 2.97]


Total events 5 7
Heterogeneity: Chi2=2.12, df=3 (P=0.055); I2=0%
Test for overall effect: Z=0.10 (P=0.92) 0.01 0.1 1 10 100
PFN DHS

Figure 6. Lag screw cut-out rate.

PFN DHS Odds ratio Odds ratio


Study or subgroup Events Total Events Total Weight M-H, fixed, 95% CI M-H, fixed, 95% CI
Pajarinen et al. 2005 2 54 2 54 30.7% 1.00 [0.14, 7.37]
Papasimos et al. 2005 5 39 3 39 41.7% 1.76 [0.39, 7.96]
Saudan et al. 2002 6 79 2 89 27.7% 3.58 [0.70, 18.25]

Total (95% CI) 172 182 100.% 2.03 [0.79, 5.23]


Total events 13 7
Heterogeneity: Chi2=0.98, df=2 (P=0.61); I2=0%
Test for overall effect: Z=1.47 (P=0.14) 0.01 0.1 1 10 100
PFN DHS

Figure 7. Reoperation rate.

Lag screw cut-out rate post-operative complications that lead to surgical failure in
treatment of intertrochanteric fractures. The cut-out (includ-
Four studies [10,11,13,15] provided data on lag screw cut- ing ‘Z’ effect) rates were about 3–10% in PFN and DHS [16,17].
out rate. Lag screw cut-out was observed in 5 of the 205 frac-
tures managed with PFN and in 7 of the 253 fractures man- Most studies reported that lag screw position might be asso-
aged with DHS. Heterogeneity tests indicated no statistical ciated with the rate of cut-out in DHS fixation. Cut-out was
evidence of heterogeneity (I2=0%). Data pooled by a fixed-ef- thought to be caused either by improper lag screw placement
fects model and the meta-analysis indicated an insignificant- in the anterior superior quadrant of the head or by not plac-
ly higher rate of lag screw cut-out in the DHS group (RR: 0.95, ing the screw close enough to the subchondral region of the
95% CI: 0.30–2.97, P=0.92) (Figure 6). head [18]. Baumgaertner et al. showed that a small tip apex
distance (TAD) – less than 25 mm – was associated with a low-
Reoperation rate er probability for cutout. Their conclusion was widely accept-
ed by most surgeons [18–20]. Another explanation for cut-out
Three studies [10,11,13] provided data on reoperation rate. is that because the screw is rotationally unstable within the
Reoperation was needed in 13 of the 172 fractures managed bone when a single lag screw is used, flexion-extension of the
with PFN and in 7 of the 182 fractures managed with DHS. limb results in loosening of the bone screw interface, leading
Heterogeneity tests indicated no statistical evidence of heteroge- to the secondary cut-out of the screw.
neity (I2=0%). Data pooled by a fixed-effects model and the me-
ta-analysis indicated an insignificantly higher rate of reoperation In 1997, PFN was introduced for treatment of intertrochanteric
in the PFN group (RR: 2.03, 95% CI: 0.79–5.23, P=0.14) (Figure 7). fractures. It was designed to overcome implant-related compli-
cations and facilitate the surgical treatment of unstable inter-
trochanteric fractures [21]. PFN uses 2 implant screws for fix-
Discussion ation into the femoral head and neck. The larger femoral neck
screw is intended to carry most of the load. The smaller hip pin
The varus collapse of the head and neck caused by lag is inserted to provide rotational stability. Biomechanical anal-
screw cut-out or lateral protrusion is one of most common ysis of PFN showed a significant reduction of distal stress and

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Proximal femoral nail vs. dynamic hip screw in treatment…
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SPECIAL REPORTS

an increase in overall stability compared with the Gamma nail than DHS in the treatment of elderly patients with intertro-
[22]. Despite the mechanical advantages of PFN, lag screw cut- chanteric fracture.
out remains a significant problem, especially in the more un-
stable fractures. This meta-analysis also found a higher rate There are several limitations in our meta-analysis. Firstly, the
of lag screw cut-out in the DHS group, though it was not sta- number of studies included and the sample size of patients
tistically significant. This indicates that the anti-rotation screw were quite limited. In addition, the 6 studies were of relative-
of the PFN may not be beneficial enough. However, Herman ly poor quality (Level B), which might weaken the strength of
et al. showed that the mechanical failure rate increased from the findings. Secondly, we did not undertake a subgroup anal-
4.8% to 34.4% when the centre of the lag screw was not in the ysis of different fracture types because not all the studies in-
second quarter of the head-neck interface line (the so-called cluded described the fracture types. Furthermore, not all the
‘‘safe zone’’) (p=0.001) and that the lag screw insertions low- studies included had long enough follow-up periods, which
er or higher than the head apex line by 11 mm were associat- also reduces the power of our research.
ed with failure rates of 5.5% and 18.6%, respectively (p=0.004)
[23]. They suggested that placing the lag screw within the ‘‘safe
zone’’ could significantly reduce the mechanical failure rate Conclusions
when PFN was used to treat intertrochanteric fractures [23].
In summary, the current available data indicate that PFN may
PFN, inserted by means of a minimally invasive procedure, al- be a better choice than DHS in the treatment of intertrochan-
lows surgeons to minimize soft tissue dissection, thereby re- teric fractures.
ducing surgical trauma and blood loss. The results of this meta-
analysis also demonstrates that operative time, intraoperative Acknowledgments
blood loss, and length of incision in the PFN group are signif-
icantly less than in the DHS group. Therefore, because of its We gratefully acknowledge the advice and assistance of Prof.
minimal invasiveness, we recommend PFN as a better choice Ping Liang.

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