Retrograde versus antegrade intramedullary nailing for femoral fractures: a meta-analysis of randomized controlled trials

Objectives: To conduct a meta-analysis of randomized controlled trials assessing the effect on clinical outcomes of intramedullary nailing for femoral fractures via a retrograde or antegrade approach. Data sources: Randomized controlled trials using PubMed, Embase, and the Cochrane Library databases. Study selection: We used the following search terms with no language or study type restrictions: femoral shaft fractures, internal fixation, treatment outcome, intramedullary nailing, and retrograde or antegrade approach. Data extraction: Two independent authors extracted the data and we assessed the quality of the included studies based on Jadad score; allocation concealment; similarity of baseline characteristics; eligibility criteria; blinding; completeness of follow-up; and intention-to-treat analysis. Our primary outcome measure was the union rate and the secondary outcome measures were nonunion, knee pain, and heterotopic ossification. A total of 240 patients from three randomized controlled trials were included. Data synthesis: Risk ratios (RRs) and 95% confidence intervals (CIs) were computed for dichotomous variables, and weighted mean differences and 95% CIs for continuous variables. Heterogeneity among studies was assessed using the I-2 statistic, with I-2 450% considered significant. If heterogeneity was not significant, a fixed effects model was chosen to assess the overall estimate. Otherwise, a random effects model was used. We used Egger's regression asymmetry test and Begg's adjusted-rank correlation to assess publication bias. Conclusions: Both retrograde and antegrade intramedullary nailing produced high union rates. We found no significant difference in union rate between the retrograde nailing group and the antegrade nailing group for femoral fractures (RR 1.02, 95% CI: 0.94-1.11, p = 0.59, I-2 = 0%).