Early versus late intramedullary nailing for traumatic femur fracture management: Meta-analysis

Introduction: There is no consensus yet on the impact of timing of femur fracture (FF) internal fixation on the patient outcomes. This meta-analysis was conducted to evaluate the contemporary data in patients with traumatic FF undergoing intramedullary nail fixation (IMN). Methods: English language literature was searched with publication limits set from 1994 to 2016 using PubMed, Scopus, MEDLINE (OVID), EMBASE (OVID), Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL). Studies included randomized controlled trials (RCTs), prospective observational or retrospective cohort studies, and case-control studies comparing early versus late femoral shaft fractures IMN fixation. Variable times were used across studies to distinguish between early and late IMN, but 24 h was the most frequently used cutoff. The quality assessment of the reviewed studies was performed with two instruments. Observational studies were assessed with the Newcastle-Ottawa Quality Assessment Scale. RCTs were assessed with the Cochrane Risk of Bias Tool. Results: We have searched 1151 references. Screening of titles and abstracts eliminated 1098 references. We retrieved 53 articles for full-text screening, 15 of which met study eligibility criteria. Conclusions: This meta-analysis addresses the utility of IMN in patients with FF based on the current evidence; however, the modality and timing to intervene remain controversial. While we find large pooled effects in favor of early IMN, for reasons discussed, we have little confidence in the effect estimate. Moreover, the available data do not fill all the gaps in this regard; therefore, a tailored algorithm for management of FF would be of value especially in polytrauma patients.