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Decision to use screw type in ORIF should be made by surgeon
Sliding hip screws may be better suited for patients who smoke, have displaced fractures and base of neck fractures.
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VANCOUVER, British Columbia — In a symposium at the Orthopaedic Trauma Association Annual Meeting focused on the evidence-based medicine in fracture studies published in 2017, a presenter said the conclusion of the Fracture Fixation in the Operative Management of Hip Fractures or FAITH trial was the decision about the type of screws to use for open reduction and internal fixation for low-energy hip fractures should be left to the individual surgeon’s discretion.
Michael Blankstein, MSC, MD, FRCSC, noted, however, that avascular necrosis rates were slightly higher in hip fractures treated with a sliding hip screw (SHS) than fractures treated with a cancellous screw in the study in the Lancet by Mohit Bhandari, MD, FRCSC, and colleagues.
“Surgeons were given their own preference with respect to many parameters. So, they could choose their own anesthesia, implants, reduction technique [and] whether they would be doing capsulotomy or aspirate a hematoma. They could choose the exposure, the positioning, as well as the final hip screw position configuration, but surgeons were encouraged to follow the center-center position for compression hip screw and to use at least two screws in the cancellous group, one being inferior and one posterior,” Blankstein said.
Sliding hip, cancellous screws
Investigators performed an international, multicenter, randomized controlled trial of 1,108 patients who were older than 50 years and had sustained a low-energy femoral neck fracture treated with a SHS (557 patients) or cancellous screw (551 patients). Patients were followed up postoperatively at 1 week, 10 weeks, 6 months, 9 months, 12 months, 18 months and 24 months.
Twenty-four-month follow-up was obtained from 91% of the 923 patients in the study who were alive at 24 months postoperatively.
At final follow-up, the reoperation rate was the primary outcome evaluated. Other outcomes assessed included mortality, fracture rate, quality of life (QoL) outcome measures, SF-12, EuroQol-5D, the WOMAC score and complications, such as avascular necrosis (AVN), nonunion, implant failure and infection.
Similar reoperation rates in groups
There was no difference in the reoperation rate at 24 months, which was 22% in the SHS group and 22% in the cancellous screw group.
“With respect to reoperations, implant removal, exchange or revision was most common in the cancellous group, but conversion to total hip replacement was more frequent in the sliding hip screw [group],” Blankstein said.
Blankstein told Orthopedics Today, “It is important to know that both techniques resulted in similar reoperation rates. Each implant choice has both advantages and disadvantages.”
Health-related QoL measures and medically related adverse events were not significantly different between the two groups. An interesting finding was the AVN rate was 9% in the SHS group and was 5% in the cancellous screw group, Blankstein noted at the meeting.
“Lastly, subgroup analyses did favor the sliding hip screw in, specifically, smokers; those who have displaced fractures; or those who had fractures at the base of the neck,” he said. – by Monica Jaramillo
- References:
- Blankstein M. Hip fracture ORIF: Cannulated screws or DHS? Presented at: Orthopaedic Trauma Association Annual Meeting; Oct. 11-14, 2017; Vancouver, British Columbia.
- Nauth A, et al. Lancet. 2017;doi:10.1016/S0140-6736(17)30066-1.
- For more information:
- Michael Blankstein, MSC, MD, FRCSC, can be reached at University of Vermont College of Medicine, 192 Tilley Dr., South Burlington, VT 05403; email: michael.blankstein@uvmhealth.org.
Disclosure: Blankstein reports he has stock or stock options in 7D Surgical.