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Meta-Analysis
. 2021 Mar 9;3(3):CD013409.
doi: 10.1002/14651858.CD013409.pub2.

Internal fixation implants for intracapsular hip fractures in older adults

Sharon R Lewis  1 , Richard Macey  1 , Will Gp Eardley  2 , Ján Robert Dixon  3 , Jonathan Cook  1 , Xavier L Griffin  4
Affiliations
Meta-Analysis

Internal fixation implants for intracapsular hip fractures in older adults

Sharon R Lewis et al. Cochrane Database Syst Rev. .

Abstract

Background: Hip fractures are a major healthcare problem, presenting a huge challenge and burden to patients, healthcare systems and society. The increased proportion of older adults in the world population means that the absolute number of hip fractures is rising rapidly across the globe. The majority of hip fractures are treated surgically. This review evaluates evidence for types of internal fixation implants used in joint-preserving surgery for intracapsular hip fractures.

Objectives: To determine the relative effects (benefits and harms) of different implants for the internal fixation of intracapsular hip fractures in older adults.

Search methods: We searched CENTRAL, MEDLINE, Embase, Web of Science, Cochrane Database of Systematic Reviews, Epistemonikos, Proquest Dissertations and Theses, and National Technical Information Service in July 2020. We also searched clinical trials databases, conference proceedings, reference lists of retrieved articles and conducted backward-citation searches.

Selection criteria: We included randomised controlled trials (RCTs) and quasi-RCTs comparing implants used for internal fixation of fragility intracapsular proximal femoral fractures in older adults. Types of implants were smooth pins (these include pins with fold-out hooks), screws, or fixed angle plates. We excluded studies in which all or most fractures were caused by specific pathologies other than osteoporosis or were the result of a high energy trauma.

Data collection and analysis: Two review authors independently assessed studies for inclusion. One review author extracted data and assessed risk of bias which was checked by a second review author. We collected data for seven outcomes: activities of daily living (ADL), delirium, functional status, health-related quality of life (HRQoL), mobility, mortality (reported within four months of surgery as early mortality, and at 12 months since surgery), and unplanned return to theatre for treating a complication resulting directly or indirectly from the primary procedure (such as deep infection or non-union). We assessed the certainty of the evidence for these outcomes using GRADE.

Main results: We included 38 studies (32 RCTs, six quasi-RCTs) with 8585 participants with 8590 intracapsular fractures. The mean ages of participants in the studies ranged from 60 to 84 years; 73% were women, and 38% of fractures were undisplaced. We report here the findings of the four main comparisons, which were between different categories of implants. We downgraded the certainty of the outcomes for imprecision (when data were available from insufficient numbers of participants or the confidence interval (CI) was wide), study limitations (e.g. high or unclear risks of bias), and inconsistency (when we noted substantial levels of statistical heterogeneity). Smooth pins versus fixed angle plate (four studies, 1313 participants) We found very low-certainty evidence of little or no difference between the two implant types in independent mobility with no more than one walking stick (1 study, 112 participants), early mortality (1 study, 383 participants), mortality at 12 months (2 studies, 661 participants), and unplanned return to theatre (3 studies, 736 participants). No studies reported on ADL, delirium, functional status, or HRQoL. Screws versus fixed angle plates (11 studies, 2471 participants) We found low-certainty evidence of no clinically important differences between the two implant types in functional status using WOMAC (MD -3.18, 95% CI -6.35 to -0.01; 2 studies, 498 participants; range of scores from 0 to 96, lower values indicate better function), and HRQoL using EQ-5D (MD 0.03, 95% CI 0.00 to 0.06; 2 studies, 521 participants; range -0.654 (worst), 0 (dead), 1 (best)). We also found low-certainty evidence showing little or no difference between the two implant types in mortality at 12 months (RR 1.04, 95% CI 0.83 to 1.31; 7 studies, 1690 participants), and unplanned return to theatre (RR 1.10, 95% CI 0.95 to 1.26; 11 studies, 2321 participants). We found very low-certainty evidence of little or no difference between the two implant types in independent mobility (1 study, 70 participants), and early mortality (3 studies, 467 participants). No studies reported on ADL or delirium. Screws versus smooth pins (seven studies, 1119 participants) We found low-certainty evidence of no or little difference between the two implant types in mortality at 12 months (RR 1.07, 95% CI 0.85 to 1.35; 6 studies, 1005 participants; low-certainty evidence). We found very low-certainty evidence of little or no difference between the two implant types in early mortality (3 studies, 584 participants) and unplanned return to theatre (5 studies, 862 participants). No studies reported on ADL, delirium, functional status, HRQoL, or mobility. Screws or smooth pins versus fixed angle plates (15 studies, 3784 participants) In this comparison, we combined data from the first two comparison groups. We found low-certainty evidence of no or little difference between the two groups of implants in mortality at 12 months (RR 1.04, 95% CI.083 to 1.31; 7 studies, 1690 participants) and unplanned return to theatre (RR 1.02, 95% CI 0.88 to 1.18; 14 studies, 3057 participants). We found very low-certainty evidence of little or no difference between the two groups of implants in independent mobility (2 studies, 182 participants), and early mortality (4 studies, 850 participants). We found no additional evidence to support the findings for functional status or HRQoL as reported in 'Screws versus fixed angle plates'. No studies reported ADL or delirium.

Authors' conclusions: There is low-certainty evidence that there may be little or no difference between screws and fixed angle plates in functional status, HRQoL, mortality at 12 months, or unplanned return to theatre; and between screws and pins in mortality at 12 months. The limited and very low-certainty evidence for the outcomes for which data were available for the smooth pins versus fixed angle plates comparison, as well as the other outcomes for which data were available for the screws and fixed angle plates, and screws and pins comparisons means we have very little confidence in the estimates of effect for these outcomes. Additional RCTs would increase the certainty of the evidence. We encourage such studies to report outcomes consistent with the core outcome set for hip fracture, including long-term quality of life indicators such as ADL and mobility.

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Conflict of interest statement

SL: has no known conflicts of interest. RM: has no known conflicts of interest JD: has no known conflicts of interest WE: has an advisory role on infection control with Orthofix and Bone Support, but this is unrelated to this review. He has no known conflicts of interest. JC: has no known conflicts of interest. XG is funded by a National Institute for Health Research Clinician Scientist Grant. Further funding from industry and charitable grants are and have been made available to his institution. All decisions relating to the design, conduct, analysis, write‐up and publication of research are independent of these funders. He has ongoing expert consultancy with several companies; none involve the development of any implant for use in hip fracture care. He will remain independent of study selection decisions, 'Risk of bias' assessment and any data extraction of any of the studies on which he is an author, co‐applicant or has had an advisory role.

Figures

1
1
Flow diagram
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study. Blank spaces in the figure indicate that 'Risk of bias' judgements were not made because study authors did not report data for these outcomes.
3
3
Funnel plot of comparison 3: Screws versus fixed angle plate. Unplanned return to theatre
4
4
Forest plot of comparison 4: Screws or pins versus fixed angle plate. Unplanned return to theatre
1.1
1.1. Analysis
Comparison 1: Smooth pins versus fixed angle plate, Outcome 1: Mobility (use of no mobility aids or one stick)
1.2
1.2. Analysis
Comparison 1: Smooth pins versus fixed angle plate, Outcome 2: Early mortality (≤ 4 months)
1.3
1.3. Analysis
Comparison 1: Smooth pins versus fixed angle plate, Outcome 3: Mortality (12 months)
1.4
1.4. Analysis
Comparison 1: Smooth pins versus fixed angle plate, Outcome 4: Unplanned return to theatre (at end of follow‐up)
1.5
1.5. Analysis
Comparison 1: Smooth pins versus fixed angle plate, Outcome 5: Adverse events related to the implant, fracture, or both
1.6
1.6. Analysis
Comparison 1: Smooth pins versus fixed angle plate, Outcome 6: Adverse events unrelated to the implant, fracture, or both
2.1
2.1. Analysis
Comparison 2: Screws versus fixed angle plate, Outcome 1: Functional status at 12 months (WOMAC, range from 0 to 96, lower scores indicate better function)
2.2
2.2. Analysis
Comparison 2: Screws versus fixed angle plate, Outcome 2: Functional status (Harris Hip Score; excellent or good)
2.3
2.3. Analysis
Comparison 2: Screws versus fixed angle plate, Outcome 3: HRQoL at 12 months (EQ‐5D: range from 0 (dead) to 1 (best quality of life))
2.4
2.4. Analysis
Comparison 2: Screws versus fixed angle plate, Outcome 4: Mobility (walking ability as before fracture, or one stick now and none before)
2.5
2.5. Analysis
Comparison 2: Screws versus fixed angle plate, Outcome 5: Early mortality (≤ 4 months)
2.6
2.6. Analysis
Comparison 2: Screws versus fixed angle plate, Outcome 6: Mortality (12 months)
2.7
2.7. Analysis
Comparison 2: Screws versus fixed angle plate, Outcome 7: Late mortality (> 24 months)
2.8
2.8. Analysis
Comparison 2: Screws versus fixed angle plate, Outcome 8: Unplanned return to theatre (at end of follow‐up)
2.9
2.9. Analysis
Comparison 2: Screws versus fixed angle plate, Outcome 9: Pain (none, or unaltered from before fracture)
2.10
2.10. Analysis
Comparison 2: Screws versus fixed angle plate, Outcome 10: Adverse events related to the implant, fracture, or both
2.11
2.11. Analysis
Comparison 2: Screws versus fixed angle plate, Outcome 11: Adverse events unrelated to implant, fracture, or both
3.1
3.1. Analysis
Comparison 3: Screws versus smooth pins, Outcome 1: Early mortality (≤ 4 months)
3.2
3.2. Analysis
Comparison 3: Screws versus smooth pins, Outcome 2: Mortality (12 months)
3.3
3.3. Analysis
Comparison 3: Screws versus smooth pins, Outcome 3: Unplanned return to theatre (at end of follow‐up)
3.4
3.4. Analysis
Comparison 3: Screws versus smooth pins, Outcome 4: Pain (experiencing no pain)
3.5
3.5. Analysis
Comparison 3: Screws versus smooth pins, Outcome 5: Discharge destination (to own home)
3.6
3.6. Analysis
Comparison 3: Screws versus smooth pins, Outcome 6: Adverse events related to the implant, fracture, or both(data from at least one study)
3.7
3.7. Analysis
Comparison 3: Screws versus smooth pins, Outcome 7: Adverse events unrelated to the implant, fracture, or both
4.1
4.1. Analysis
Comparison 4: Screws or pins versus fixed angle plate, Outcome 1: Mobility (one walking stick or none)
4.2
4.2. Analysis
Comparison 4: Screws or pins versus fixed angle plate, Outcome 2: Early mortality (≤ 4 months)
4.3
4.3. Analysis
Comparison 4: Screws or pins versus fixed angle plate, Outcome 3: Mortality (12 months)
4.4
4.4. Analysis
Comparison 4: Screws or pins versus fixed angle plate, Outcome 4: Unplanned return to theatre (at end of follow‐up)
4.5
4.5. Analysis
Comparison 4: Screws or pins versus fixed angle plate, Outcome 5: Adverse events related to implant, fracture, or both
4.6
4.6. Analysis
Comparison 4: Screws or pins versus fixed angle plate, Outcome 6: Adverse events unrelated to implant, fracture, or both
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References to studies excluded from this review

Bisaccia 2018 {published data only}
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Qiu 2016 {published data only}
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Siavashi 2015 {published data only}
    1. Siavashi B, Aalirezaei A, Moosavi M, Golbakhsh MR, Savadkoohi D, Zehtab MJ. A comparative study between multiple cannulated screws and dynamic hip screw for fixation of femoral neck fracture in adults. International Orthopaedics 2015;39(10):2069-71. [PMID: ] - PubMed
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Yin 2016 {published data only}
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References to ongoing studies

ChiCTR1800015159 {published data only}
    1. ChiCTR1800015159. Four cannulated screw internal fixation in treatment of young and middle-aged displaced femoral neck fractures: a prospective randomized study. who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR1800015159 (first received 11 March 2018).
ChiCTR1800015618 {published data only}
    1. ChiCTR1800015618. A prospective randomized controlled trial of novel anatomical femoral neck plates for treating femoral neck fractures. who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR1800015618 (first received 12 April 2018).
ChiCTR1900022697 {published data only}
    1. ChiCTR1900022697. Treatment of femoral neck fracture by axial compressing and lateral supporting screws: a randomized controlled trial. who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR1900022697 (first received 23 April 2019).
Kalsbeek 2020 {published data only}
    1. Kalsbeek JH, Roerdink WH, Krijnen P, den Akker-van Marle ME, Schipper IB. Study protocol for the DEFENDD trial: an RCT on the Dynamic Locking Blade Plate (DLBP) versus the Dynamic Hip Screw (DHS) for displaced femoral neck fractures in patients 65 years and younger. BMC Musculoskeletal Disorders 2020;21(1):139. [PMID: ] - PMC - PubMed
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NCT02699619 {published data only}
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NCT04462172 {published data only}
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References to other published versions of this review

Parker 2001
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