Hemiarthroplasty vs. proximal femoral nail fixation in unstable pertrochanteric fractures: an updated systematic review and meta-analysis

Background: Pertrochanteric fractures are common and challenging for surgeons, especially in unstable conditions. Proximal femoral nails or nails anti-rotation variants are well-established surgical instruments to treat this, but some reports suggest that in unstable situations, hemiarthroplasty provides superior benefits to patients. This study aimed to compare hemiarthroplasty with proximal femoral nails, highlighting the differences to assist surgical decision-making. Methods: Online databases were searched for eligible studies in accordance with PRISMA guidelines. Results were analyzed across 18 domains, categorized into three branches: function, complication, and perioperative condition and mortality. Effect sizes were calculated, and the heterogeneities thereof were analyzed. We also tested sensitivity, publication biases, and graded certainty of evidence. Finally, comprehensive results were interpreted. Results: Twenty-seven studies, with a total of 2,517 patients, were included. The hemiarthroplasty performed better than nails in early Harris hip scores, full weight-bearing time, and complication rate related to implants. Proximal femoral nails performed better in terms of surgery duration and superficial infection. No significant differences were observed in final Harris hip scores, general and implant-unrelated complications, mortality, hospital stay, re-operation incidence, bedsores, and deep venous thrombosis. Ambulation time, blood loss, and transfusion incidence showed potential publication bias. Conclusion: Hemiarthroplasty and proximal femoral nails/nails anti-rotation are effective methods for treating unstable pertrochanteric fractures. No clinically important differences-such as re-operation rates due to implant-related complications-were identified between these two tactics. Surgeons should prioritize internal fixations, barring conditions wherein hemiarthroplasty is essential.