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Dynamic hip screw vs. cannulated screws in treating undisplaced subcapital hip fractures
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January 2014
Dynamic hip screw vs. cannulated screws in treating undisplaced subcapital hip fractures
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
Prospective randomized controlled trial comparing dynamic hip screw and screw fixation for undisplaced subcapital hip fractures
ANZ J Surg. 2013 Sep;83(9):679-83Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
Sixty patients, over the age of 50, with acute, minimally displaced subcapital neck of femur fractures were randomly assigned into one of two groups to receive treatment with two-hole dynamic hip screws or cannulated screws. Results indicated that while both methods are effective in treating femoral neck fractures, neither one was superior. Functionality at 1 year favoured patients in the cannulated screw group, but became similar to patients who received treatment with two-hole dynamic hip screws at final follow up (24 months).
Publication Funding Details
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Funding:
Industry funded
Sponsor:
Synthes, Victorian Orthopaedic Research Trust
Conflicts:
None disclosed
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
4/4
Randomization
3/4
Outcome Measurements
3/4
Inclusion / Exclusion
4/4
Therapy Description
4/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Neck of femur fractures (NOFFs) are a major contributor to morbidity and mortality worldwide. While incidence rates are decreasing due to improved osteoporosis treatment, a substantial number of individuals still experience this issue. Minimally displaced NOFFs are often managed using internal fixation, but there is debate over which technique provides superior outcomes. The majority of orthopaedic surgeons treat these fractures using two-hole dynamic hip screws (DHS) or three partially threaded cancellous screws, but no study has been completed regarding which is the optimal treatment. The purpose of this study was to compare the outcomes of DHS to cannulated screws, and to identify, if possible, which treatment method offers the best results.
What was the principal research question?
How does the treatment of minimally displaced neck of femur fractures with two-hole dynamic hip screws compare to treatment with cannulated screws, 2 years after surgery?
Study Characteristics
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Population:
60 patients, over the age of 50, with acute, minimally displaced subcapital neck of femur fractures were included in this study.
Intervention:
DHS Group: A standard surgical technique for neck of femur fractures was performed on each patient and a two-hole dynamic hip screw (with or without an anti-rotation screw) used (Mean age: 77.9 (53-89), n= 31, 12 completed follow up, M=6/F=25).
Comparison:
Cannulated Screws Group: A standard surgical technique for neck of femur fractures was performed on each patient and three partially threaded cannulated (6.5 mm titanium) cancellous screws in an inverted V configuration were inserted (Mean age: 76.7 (53-93), n=29, 16 completed follow up, M=5/F=24).
Outcomes:
Outcomes assessed were: Mortality, revision, avascular necrosis, loss of fixation, surgical complications, Hip function (using WOMAC and Harris Hip Score), and Quality of life (using SF-12 and a patient satisfaction questionnaire).
Methods:
RCT: Prospective; Single-Center
Time:
Time: 2 years (Follow ups were performed at 6 weeks and 3, 6, 12, and 24 months).
What were the important findings?
- Each group had 6 mortalities over the study period (p=0.272). One out of 31 DHS inserted, failed due to the cutting out of the femoral head. This was the only DHS case requiring re-operation with THA. Three out of 29 cannulated screw patients required a reoperation (1 due to screw prominence and 2 due to non-union). No significant difference was found between groups regarding perioperative complications (p>0.05 for all cases of pneumonia, stroke, pressure, and pulmonary embolism).
- A significant loss to follow up at 12 and 24 months was noted in both groups (p<0.05).
- Trends towards a significantly higher average Harris Hip Score were found in favour of the cannulated screw group at 12 months (72 in the DHS group vs. 88 in the cannulated screw group) (p=0.0578), but these findings became much more similar at the final 24 month follow up (75 in the DHS group vs. 82.5 in the cannulated screw group) (p=0.5112).
- A significantly improved average WOMAC score was found in favour of the cannulated screw group, at 12 months (54.5 in the DHS group vs. 20 in the cannulated group)(p=0.0061), but this difference was not found at final follow up (41 in the DHS group vs. 29 in the cannulated group) (p=0.2466).
- No difference was found between the groups when analyzing quality of life assessments (measured by SF-12 and questionnaire) (p>0.05, at all follow up times).
- There was no significant difference between groups, at any time point, regarding radiological outcomes (p>0.05, at all follow up times).
What should I remember most?
Re-operations were required in 1/31 patients in the DHS and 3/29 patients in the cannulated screw group. No significant difference was found in terms of quality of life or radiological outcomes in either group. A trend was found regarding functionality that favoured the cancellous screw group, especially at 1 year follow up. It should be noted that the study observed a high level of physical decline in the previously fit, independently ambulating patients regardless of treatment.
How will this affect the care of my patients?
The results of this study cannot definitively state that two-hole dynamic hip screws are better than cannulated screws in treating neck of femur fractures (NOFFs) or vice-versa. However, it should be noted that both methods are effective in treating NOFFs. Further research must be completed on a larger scale (multi-center, larger sample size) to verify these results and identify possible methods to improve outcomes.
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