Fixation

 

Hip cannulated screwsDHS garden 1FNS

 

Indications

 

Undisplaced subcapital fracture

Displaced in young adult

 

Options ORIF

 

Cannulated screws

Sliding hip screw (SHS/DHS) + derotation screw

Femoral neck system

 

Results

 

Fixation versus hemiarthroplasty (HA)

 

Dolatowski et al JBJS Am 2019

- RCT of screw versus HA in elderly patients with undisplaced subcapital fractures

- 229 patients

- no difference in outcome scores at 2 years

- increased mobility with HA

- increased reoperation rate with screws versus HA (20% versus 5%)

 

DHS versus cannulated screws

 

FAITH trial Lancet 2017

- RCT of 1100 patients

- 2 hole DHS versus cannulated screws

- no difference in reoperation rate: 20% versus 22%

- AVN more common with DHS: 9% versus 5%

- infection rate same at 1%

 

FNS versus cannulated screws

 

Patel et al Eur J Orthop Surg Traumatol 2023

- systematic review of 8 studies with 509 cases

- FNS versus cannulated screws

- FNS had shorter time to union / less neck shortening / better outcomes

- more blood loss with FNS

 

Cannulated screws

 

Hip cannulated screwsHip cann screws

 

Technique

 

Arthrex animated cannulated screw video

 

Hip cann screws 1Hip cann screws 2

 

Lateral on traction table

- adequate reduction / no varus

- small incision or percutaneous

- 3 screws

- ensure inferior screw entry point is above lesser trochanter to prevent fracture

- ensure threads cross fracture site entirely to obtain compression

- need correct screw length so screw head can compress against cortex

 

DHS and derotation screw

 

DHS garden 1DHS garden 1

 

Synthes technique guide PDF

 

Youtube step by step sawbone guide

 

Synthes FNS (Femoral neck system)

 

FNS 1FNS

 

Technique

 

Youtube animation FNS video

 

Synthes FNS surgical technique guide

 

Complications

 

Nonunion

 

Risk factors

- displaced fractures

- varus fixation

- instability

- vertical fracture configuration (Pauwel's type III)

 

Failed cann screws

 

Failed Subcapital ORIFSubcapital ORIF Lateral

 

Management

 

Older patient - arthroplasty

Young patient - valgus osteotomy

 

Subcapital NOF Non UnionSubcapital NOF Nonunion CTTHR post Subcapital Nonunion

 

Results

 

Mahmoud et al Bone Joint J 2016

- systematic review of salvage THA after failed fixation subcapital fractures

- compared to primary THA for subcapital fractures

- increased risk deep infection, early dislocation and peri-prosthetic fracture with salvage THA

 

AVN

 

Subcapital NOF AVN

 

Risk factors

 

Displaced fractures

High energy injuries

? delay in surgery

Non-anatomical reduction

 

Rogmark et al JBJS Am 2002

- multicenter RCT patients

- 409 patients > 70 years with displaced fracture

- ORIF 43% failure

 

Xu et al J Orthop Surg Res 2017

- systematic review of 29 studies and 5000 patients with undisplaced fractures

- union rate 93% with surgery

 

Management Options

 

Older patient

- arthroplasty

 

Younger patient

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