Multiple Comparisons of the Efficacy and Safety for Seven Treatments in Tibia Shaft Fracture Patients

Background: A tibia shaft fracture is one of the most common long bone fractures, with two general types, open fracture and close fracture. However, there is no universally accepted guideline suggesting which treatment to use under certain circumstances. Therefore, a comprehensive network meta-analysis (NMA) is needed to summarize existing studies and to provide more credible data-based medical guidelines. Methods: Available literature was identified by searching medical databases with relevant key terms. Studies that met the inclusion and exclusion criteria, baseline, intervention, and the outcome of treatments, were extracted. A comparative connection of these studies was demonstrated through net plots. Continuous variables and binary variables were reported as mean difference (MD) and odds ratio (OR) with a 95% credible interval (CrI), respectively. The comparison of direct and indirect outcome and their P-value were listed in the node-splitting table. Treatments for each endpoint were ranked by their surface under the cumulative ranking curve (SUCRA) value. A heat plot was created to illustrate the contribution of raw data and the inconsistency between direct and indirect comparisons. Results: According to the search strategy, 697 publications were identified, and 25 records were included, involving 3,032 patients with tibia shaft fractures. Seven common surgical or non-surgical treatments, including reamed intramedullary nailing (RIN), un-reamed intramedullary nailing (UIN), minimally reamed intramedullary nailing (MIN), ender nailing (EN), external fixation (EF), plate, and cast, were compared, in terms of time to union, reoperation, non-union, malunion, infection and implant failure. Plate performed relatively better for time to union, while cast might be the best choice in close cases to reduce the risks of reoperation, non-union, malunion, and infection. To prevent implant failure, EN seemed to be better. Conclusion: Cast might have the highest probability of the most optimal choice for tibia shaft fracture in close cases, while reamed intramedullary nailing ranked second.