Background
Femoral fracture is one of the most common fractures. Due to the traction of soft tissue around the femur, most patients have an obvious displacement of fractures that require surgery [
1]. However, improper treatment often results in various complications, affecting patients’ quality of life [
2]. Professor Kuntscher first used intramedullary nails to treat femoral shaft fractures in 1939. Since that, intramedullary nailing has gradually become the preferred method for femoral fracture due to its many advantages like simplified operation, causing less damage and early weight-bearing [
3].
Closed reduction is the key and the difficulty to successfully placing intramedullary nails [
4]. The traction table has been widely used in the reduction of lower limb fractures because of its obvious advantages: higher traction force, easier fluoroscopy and better stability, and the ability to maintain the force line. Nevertheless, its shortcomings are also noticeable. First, the position of the hip joint is forced to be neutral or abducted after reduction. Inserting the intramedullary nail is difficult in that position, especially through the trochanteric fossa approach. Second, the traction table can only provide axial traction, which cannot reduce various angular displacements. In femoral fractures, the gluteus medius and gluteus minimus will abduct the proximal fracture block, and the adductor muscle will pull the distal fracture. The iliopsoas muscle will flex and externally rotate the fracture fragments. Gravity also affects the anterior femoral arch angle [
5,
6]. Third, the inappropriate use of the traction table may cause various complications like perineal injury [
7]. Recently, studies showed that the same or better prognosis could be acquired without a traction table. A survey of orthopedic surgeons showed that there is still no consensus on this issue [
8]. That is why we conducted this meta-analysis.
Methods
Study search and selection
We searched the PubMed, Embase, Web of Science, and Cochrane Library databases for related articles published until August 30, 2022. The search strategy was as follows: (femor* OR femur* intertrochanter* OR subtrochanter*) AND fractur* AND ([tract* AND (bed OR table OR frame)] OR lateral) AND nail* (refer to Additional file
1: Appendix Table 1). There were two reviewers independently assessing the papers. A third reviewer would make the final decision if they could not achieve the agreement through discussion. The inclusion criteria were as follows:
1.
Randomized controlled trials (RCTs);
2.
The study object was femoral fracture patients treated with the intramedullary nail and was 18 years of age or older;
3.
The study compared the difference in operative procedures or prognosis between using the traction table and manual traction;
4.
Sufficient data presented to allow further analysis;
5.
Data not duplicated in another manuscript (refer to Table
1).
Table 1
Inclusion and exclusion criteria of the current meta-analysis
Detailed inclusion and exclusion criteria based on PICOS framework |
Populations | Femoral fracture patients treated with intramedullary nail and was 18 years of age or older |
Intervention/Exposure | Using regular table during operation |
Control | Using traction table during operation |
Clinical outcomes | Operative time, blood loss volume, set-up time, fluoroscopy time, fracture healing time, Harris score, malunion rate |
Study design | Randomized controlled trials (RCTs) |
Exclusion criteria | Reviews |
Not RCTs |
Conference abstracts |
Besides, we found some cohort studies compared the differences between using traction repositor and traction tables during screening. We also selected them for further analysis, referring to the above criteria.
Data extraction and quality assessment
We used Microsoft Excel (Microsoft Corporation, USA) to compile the needed data. The GRADE (Grade of Recommendations Assessment, Development and Evaluation) guidelines were used to rate the quality of evidence, and we assessed RCTs' bias risk by the Cochrane Collaboration tool. The Newcastle–Ottawa Scale (NOS) score assessed the quality of cohort studies. Two evaluators conducted the independent evaluation.
Statistical analysis
We divided each RCT patient into two groups: “Manual traction” and “Traction table.” To improve the accuracy of the results, we further divided “Manual traction” into two subgroups: “Lateral position” and “Supine position” because we found there are two types of manual traction surgery in these studies. The Std. Mean difference (SMD) or risk ratios (RR) assessed their effects. We pooled continuous data by inverse variance and used the Mantel–Haenszel method for dichotomous data. The random-effect model for anticipated heterogeneity determined all outcomes. The statistics I2 > 50% indicated the high heterogeneity, and P < 0.05 indicated the statistical differences of included studies. The sensitivity analyses would be performed for the results with high heterogeneity by using different statistical methods or excluding the source of heterogeneity. Trial sequential analysis (TSA) was performed to verify the positive results. The analysis of the “Traction repository” group and “Traction table” group of cohort studies was also carried out as described above by Review Manager 5.4.
Discussion
The meta-analysis suggested that after a sufficient follow-up period (six months to about 2 years), the traction table showed no significant advantages in fracture healing time, Harris score, and postoperative fracture malunion rate in the femoral fractures patients. Instead, it prolonged the operative time and set-up time. Moreover, it proved that using a traction repositor could reduce fracture healing time.
Manual traction leaves out preoperative traction time, and its routine disinfection and draping are more manageable, which undoubtedly could reduce the set-up time [
9]. Manual traction also has advantages in operative time. Even though the intraoperative manual traction was counted, the manual traction group still takes less time than the traction table group, which is not affected by surgery in the supine or lateral position [
10]. For lower limb fractures, the traction table easily leads to excessive traction, making unstable fracture fragments shift or turning stable fractures into unstable ones during the insertion of the intramedullary nail. Regarding manual traction, doctors could move the affected limb to coordinate with the intramedullary nail, reducing operation difficulty [
11,
12]. It is reasonable that manual traction groups have shorter operative times.
The fracture healing time in the traction repositor group is lower, maybe because it could better reduce the fracture. On the one hand, compared with manual traction, a traction repositor can generate enough force to reduce overlapping deformities. On the other hand, compared with the traction table, the traction repositor can easily be adjusted during surgery to correct rotation deformities [
13]. Besides, it is cheaper than the traction table and could be an ideal substitute in community hospitals [
14]. Considering that there is no significant difference in prognosis, it is also one of the viable options. However, the number of related studies is insufficient, and this conclusion should be treated cautiously. Using a traction repositor will cause additional damage to the patient, which should also be considered carefully [
15].
This study has some limitations: 1. The lack of a high-quality study and the small sample size. Although TSA analysis confirmed the reliability of our results, more high-quality, multi-center, and large-sample RCTs are still needed to verify the conclusions of this study. 2. The included studies’ experimental designs were inconsistent, which would cause a particular risk of bias and eventually affect our conclusions' reliability. 3. Screened studies were limited to English and Chinese, and many took place in China. Hence, the results might be biased in language and ethnicity, requiring more multilingual, multi-regional clinical trials to promote our conclusions.
However, femoral intramedullary nail surgery without a traction table can significantly alleviate patients' discomfort and irritation, relieve their pain and provide a more cost-effective and straightforward surgical plan, which is worthy of further study [
16,
17]. The pros and cons should be carefully weighed in clinical, and the most appropriate surgical method should be selected according to every patient's situation.
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