Comparative efficacy of cementless bipolar hemiarthroplasty and proximal femoral nail anti-rotation in unstable intertrochanteric fractures: A meta-analysis

Abstract

Background: Unstable intertrochanteric fractures in elderly patients require effective surgical management, with both cementless bipolar hemiarthroplasty (CBHA) and proximal femoral nail anti-rotation (PFNA) being valid treatment options to reduce morbidity and mortality.

Aim: To evaluate and compare the outcomes of CBHA and PFNA in treatment of unstable intertrochanteric fractures.

Methods: A comprehensive search was conducted to identify relevant studies discussing the outcomes of using both CBH and PFNA in treatment of unstable intertrochanteric fractures. Studies published up to January 1, 2025 were searched across multiple databases, including PubMed, EMBASE, Scopus, Web of Science, Cochrane Library, and Google Scholar. Full texts of the selected articles were retrieved, reviewed, and independently assessed by the investigators. Discrepancies were resolved by consensus, with any remaining disagreements being arbitrated by a third author.

Results: This meta-analysis included three studies, all of which were retrospective, involving a total of 240 patients. The follow-up period for participants was at least 12 months. CBHA was associated with significantly higher blood loss compared to PFNA [mean differences (MD): 129.14, 95%CI (52.51, 205.77), P = 0.001], though heterogeneity was high (I² = 97%). Operative time showed no significant difference initially [MD: 6.10, 95%CI (-13.34, 25.54), P = 0.54], but after excluding one study, BHA had longer operative times [MD: 21.51, 95%CI (18.60, 24.41), P < 0.00001]. Hospital stay and Harris scores showed no significant differences between groups. CBHA facilitated faster progression to weight-bearing [MD: -11.92, 95%CI (-22.46, -1.39), P = 0.03] and a lower incidence of prosthetic loosening [risk ratio: 0.21, 95%CI (0.05, 0.92), P = 0.04]. Refracture and thrombus formation rates were comparable between the two groups.

Conclusion: CBHA offers shorter weight-bearing duration and reduced prosthetic loosening but incurs greater blood loss and longer operative times compared to PFNA. Both techniques show comparable functional recovery, hospital stay, refracture, and thrombus risks. Clinical choice should prioritize early mobilization or surgical minimalism, guided by patient needs. Further prospective studies are warranted.

Keywords: Cementless bipolar hemiarthroplasty; FFNA; Meta-analysis; Proximal femoral nail anti-rotation; Unstable intertrochanteric fractures; Unstable, Functional outcomes.

Figure 1

Flowchart of study search and inclusion criteria.

Figure 2

Meta-analysis comparing bipolar hemiarthroplasty and proximal femoral nail anti-rotation outcomes. A: Blood loss between groups; B: Blood loss analysis excluding Cai et al[26], 2022; C: Operative time comparison; D: Operative time analysis excluding Song et al[27], 2022.

Figure 3

Meta-analysis comparing bipolar hemiarthroplasty and proximal femoral nail anti-rotation outcomes. A: Hospital stay duration (days); B: Weight-bearing duration (days); C: Harris score comparison.

Figure 4

Meta-analysis of complications between bipolar hemiarthroplasty and proximal femoral nail anti-rotation. A: Refracture incidence; B: Thrombus formation; C: Thrombus formation after excluding Cai et al[26], 2022; D: Prosthetic loosening incidence.