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. 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. 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). In
For 30 years, the field debated sliding hip screw vs cancellous screws for femoral neck fractures. Prior small trials and a Cochrane meta-analysis suggested cancellous screws were equivalent but that sliding hip screw might reduce AVN risk — a reason some surgeons favored it.
FAITH, with over 1,000 patients, definitively shows no reoperation advantage to either implant. It also flips the AVN finding: sliding hip screw nearly doubles AVN risk (9% vs 5%). This result has a plausible mechanism. Large implants risk disrupting retinacular vessels. But did not translate into more total reoperations or worse quality of life.
In practice: for most femoral neck fractures requiring fixation, choose based on surgeon familiarity and fracture characteristics rather than expecting one implant to universally outperform. When your patient is a current smoker, has a displaced fracture, or has a basal neck pattern, FAITH's subgroup data (low-to-moderate credibility) favor sliding hip screw. And this is the reasoning to document.
Know that the higher THA conversion rate with sliding hip screw (12% vs 7%) is clinically meaningful: revision THA after failed fixation carries higher complication risk than primary THA, which gives cancellous screws a subtle advantage in patients who are good THA candidates at baseline.
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. 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. 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). In
For 30 years, the field debated sliding hip screw vs cancellous screws for femoral neck fractures. Prior small trials and a Cochrane meta-analysis suggested cancellous screws were equivalent but that sliding hip screw might reduce AVN risk — a reason some surgeons favored it.
FAITH, with over 1,000 patients, definitively shows no reoperation advantage to either implant. It also flips the AVN finding: sliding hip screw nearly doubles AVN risk (9% vs 5%). This result has a plausible mechanism. Large implants risk disrupting retinacular vessels. But did not translate into more total reoperations or worse quality of life.
In practice: for most femoral neck fractures requiring fixation, choose based on surgeon familiarity and fracture characteristics rather than expecting one implant to universally outperform. When your patient is a current smoker, has a displaced fracture, or has a basal neck pattern, FAITH's subgroup data (low-to-moderate credibility) favor sliding hip screw. And this is the reasoning to document.
Know that the higher THA conversion rate with sliding hip screw (12% vs 7%) is clinically meaningful: revision THA after failed fixation carries higher complication risk than primary THA, which gives cancellous screws a subtle advantage in patients who are good THA candidates at baseline.