title: Meta-Analysis of a Complex Network of Non-Pharmacological Interventions: The Example of Femoral Neck Fracture.
abstract: BACKGROUND
  Surgical interventions raise specific methodological issues in network meta-analysis (NMA). They are usually multi-component interventions resulting in complex networks of randomized controlled trials (RCTs), with multiple groups and sparse connections.
  
  
  OBJECTIVE
  To illustrate the applicability of the NMA in a complex network of surgical interventions and to prioritize the available interventions according to a clinically relevant outcome.
  
  
  METHODS
  We considered RCTs of treatments for femoral neck fracture in adults. We searched CENTRAL, MEDLINE, EMBASE and ClinicalTrials.gov up to November 2015. Two reviewers independently selected trials, extracted data and used the Cochrane Collaboration's tool for assessing the risk of bias. A group of orthopedic surgeons grouped similar but not identical interventions under the same node. We synthesized the network using a Bayesian network meta-analysis model. We derived posterior odds ratios (ORs) and 95% credible intervals (95% CrIs) for all possible pairwise comparisons. The primary outcome was all-cause revision surgery.
  
  
  RESULTS
  Data from 27 trials were combined, for 4,186 participants (72% women, mean age 80 years, 95% displaced fractures). The median follow-up was 2 years. With hemiarthroplasty (HA) and total hip arthroplasty (THA) as a comparison, risk of surgical revision was significantly higher with the treatments unthreaded cervical osteosynthesis (OR 8.0 [95% CrI 3.6-15.5] and 5.9 [2.4-12.0], respectively), screw (9.4 [6.0-16.5] and 6.7 [3.9-13.6]) and plate (12.5 [5.8-23.8] and 7.8 [3.8-19.4]).
  
  
  CONCLUSIONS
  In older women with displaced femoral neck fractures, arthroplasty (HA and THA) is the most effective treatment in terms of risk of revision surgery.
  
  
  BACKGROUND
  PROSPERO no. CRD42013004218.
  
  
  METHODS
  Network Meta-Analysis, Level 1.
authors.affiliation: INSERM U1153, Paris, France.|Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, Service de Chirurgie orthopédique et traumatologique, Paris, France.|Université Paris Diderot, Paris, France.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Mosseri
authors.affiliation: INSERM U1153, Paris, France.|Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Centre d'épidémiologie clinique, Paris, France.|French Cochrane Centre, Paris, France.|Université Paris Descartes-Sorbonne Paris cité, Paris, France.|Columbia University, Mailman School of Public Health, Department of Epidemiology, New York, United States of America.
authors.forename: Ludovic
authors.initials: L
authors.lastname: Trinquart
authors.affiliation: Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, Service de Chirurgie orthopédique et traumatologique, Paris, France.|Université Paris Diderot, Paris, France.
authors.forename: Rémy
authors.initials: R
authors.lastname: Nizard
authors.affiliation: INSERM U1153, Paris, France.|Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Centre d'épidémiologie clinique, Paris, France.|French Cochrane Centre, Paris, France.|Université Paris Descartes-Sorbonne Paris cité, Paris, France.|Columbia University, Mailman School of Public Health, Department of Epidemiology, New York, United States of America.
authors.forename: Philippe
authors.initials: P
authors.lastname: Ravaud
mesh_terms: D005264:Femoral Fractures / Q000601:surgery*; D017102:Fracture Healing; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D012086:Reoperation; D012306:Risk; D016896:Treatment Outcome