Evaluation of the comparative efficacy and safety of surgical strategies for long bone defects: a network meta-analysis

Abstract To evaluate the safety and efficacy of various surgical treatments for long bone defects. Despite numerous observational studies, randomized controlled trials (RCTs), and meta-analyses, the optimal surgical treatment for long bone defects remains undetermined. Methods: A network meta-analysis (NMA) was conducted. PubMed, Embase, and the Cochrane Library were searched for articles published between 1 January 2000, and 12 January 2023, on surgical treatments for long bone defects. RCTs and observational studies comparing five surgical treatments were selected: the Masquelet technique (MT), bone transport (BT), vascularized bone graft (VBG), non-VBG (NVBG), and bone tissue engineering (BTE). Data were extracted by two independent reviewers. The NMA aggregated direct and indirect evidence. Treatments were ranked using the surface under the cumulative ranking curve (SUCRA) scores. Data are presented as mean differences and 95% confidence intervals. The primary outcomes were the postoperative healing rate, with subgroup analysis based on defect size (4–8 cm and >8 cm). The secondary outcomes included postoperative complications. Results: This NMA included 23 studies (3 RCTs and 20 observational studies) with 930 participants (median age, 35 years). There were no significant differences in clinical outcomes among the treatments. VBG (SUCRA, 75.1%) was rated as optimal for healing, and BTE (SUCRA, 28.5%) was the least effective. BTE had the highest complication rate (SUCRA, 90.9%), whereas NVBG had the lowest complication rate (SUCRA, 27.6%). Subgroup analysis showed reduced heterogeneity: for 4–8 cm defects, VBG (SUCRA, 80.4%) was optimal, and for >8 cm defects, BT (SUCRA, 76.2%) was optimal. Conclusions: VBG and BT may offer superior clinical outcomes for long bone defects compared to MT, NVBG, and BTE. However, BTE is associated with a high risk of complications. Further high-quality, large-sample RCTs are required to confirm these findings.