Fracture fixation in the operative management of hip fractures (FAITH): an international, multicentre, randomised controlled trial

Abstract

Background: Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes.

Methods: For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813.

Findings: Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0·83, 95% CI 0·63-1·09; p=0·18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1·91, 1·06-3·44; p=0·0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0·82; appendix); these events included pulmonary embolism (two patients [<1%] vs four [1%] patients; p=0·41) and sepsis (seven [1%] vs six [1%]; p=0·79).

Interpretation: In terms of reoperation rates the sliding hip screw shows no advantage, but some groups of patients (smokers and those with displaced or base of neck fractures) might do better with a sliding hip screw than with cancellous screws.

Funding: National Institutes of Health, Canadian Institutes of Health Research, Stichting NutsOhra, Netherlands Organisation for Health Research and Development, Physicians' Services Incorporated.

Conflict of interest statement

Declaration of interests

MB reports grants from Canadian Institutes of Health Research, the National Institutes of Health, Stichting NutsOhra, The Netherlands Organisation for Health Research and Development, Physicians’ Services Incorporated and Stryker GmBH, and the Early Research Award Program during the conduct of the study; and personal fees from Sanofi, Pendopharm, Ferring, DJO, and Stryker, and grants from Pluristem and Amgen, outside the submitted work. MJH reports grants from Stichting NutsOhra and The Netherlands Organization for Health Research and Development during the conduct of the study. PJD reports grants from Abbott Diagnostics, Boehringer Ingelheim, Covidien, Octopharma, Roche Diagnostics, and Stryker, outside the submitted work. KJJ reports grants from the National Institutes of Health and Canadian Institutes of Health Research during the conduct of the study; and personal fees from Zimmer, outside the submitted work. EHS reports personal fees from Stryker, Smith & Nephew, Zimmer, Acumed, Amgen, Sanofi, and Bioventus, and other from Elsevier, outside the submitted work. PT III reports personal fees from Lippicott Williams & Wilkins, outside the submitted work, and has a patent (US8888824 B2) with royalties paid by Smith & Nephew. GJDR reports grants from the University of Minnesota during the conduct of the study; and grants from DePuy-Synthes, personal fees from Bioventus and DePuy-Synthes, other from Amedica, The Orthopaedic Implant Company, LuminCare, Mergenet Medical, and Intellectual ventures, outside the submitted work. RM reports personal fees from Sanofi and Pendopharm, outside the submitted work. AR reports grants from the Canadian Institutes of Health Research, during the conduct of the study; and grants from the National Institute for Health Research (UK), Orthopaedic Research UK, and DePuy, outside the submitted work. GPS reports personal fees from Zimmer Biomet and grants from the Canadian Institutes of Health Research, outside the submitted work. SS reports other from McMaster University and Global Research Solutions, and personal fees from the University of Maryland, outside the submitted work. JA reports grants from the National Institutes of Health during the conduct of the study. SMZ reports grants from Stichting NutsOhra (SNO-T-0602-43) and The Netherlands Organisation for Health Research and Development (80-82310-97-11032), during the conduct of the study. EMMVL reports grants from Stichting NutsOhra and The Netherlands Organization for Health Research and Development during the conduct of the study. MS reports grants from the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases, during the conduct of the study; and other from The Journal of Bone & Joint Surgery Editor, outside the submitted work. MJMS reports personal fees from DePuy Synthes and AO Trauma Europe, outside the submitted work. GG, LT, SDW, SL, REB, TMO, MR, TS, AG, QZ, DH-A, HV, HJ, and BCH declare no competing interests.

Copyright © 2017 Elsevier Ltd. All rights reserved.

Figures

Figure 1

Trial profile

Figure 2

Kaplan-Meier curves for reoperation

Figure 3. Subgroup analyses of surgical fixation primary endpoint (reoperation)

BMI=body-mass index.*Interaction p value for group comparison. †Defined at study start. ‡Defined at study close (before unblinding).