Fixation using alternative implants for the treatment of hip fractures (FAITH-2): design and rationale for a pilot multi-centre 2 × 2 factorial randomized controlled trial in young femoral neck fracture patients

Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH-2): The Exploratory Health-Related Quality of Life and Patient-Reported Functional Outcomes of a Multi-Centre 2 × 2 Factorial Randomized Controlled Pilot Trial in Young Femoral Neck Fracture Patients

PURPOSE

Femoral neck fractures in young patients are typically managed with internal fixation using either cancellous screws or a sliding hip screw (SHS). Although fixation preserves the hip joint, patients are still at risk of complications and poor clinical outcomes which lead to diminished function and health related quality of life (HRQL). The Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH-2) pilot randomized controlled factorial trial evaluated the effect of surgical fixation (cancellous screws vs. SHS) and vitamin D supplementation vs. placebo on patient-reported function and HRQL.

METHODS

Patients between the ages of 18-60 years with a femoral neck fracture requiring surgical fixation were eligible. Eligible patients were randomized to receive either a sliding hip screw or cancellous screws for fracture fixation AND vitamin D₃ 4,000 IU or placebo daily for 6 months. Patient-reported function (Hip Outcome Score) and HRQL (Short Form-12) were assessed at standardized time points in the 12 months following their fixation surgery. Patient-reported function and HRQL were summarized using means, SD, and 95% confidence intervals (CIs), or percentages and counts. Longitudinal data analysis with mixed models was used to explore the effect of treatment group and time on the patient-reported function and HRQL.

RESULTS

86 of the 91 patients randomized into the FAITH-2 pilot study were deemed eligible. There were no significant differences in patient-reported function or HRQL between the treatment groups at 12 months post-fracture. At the 6- and 9-month assessments, a potential benefit in hip function was seen in the cancellous screw group. In all treatment groups, participants reported lower function and HRQL at 12 months post-fracture as compared to their pre-injury assessment.

CONCLUSIONS

Few differences were found in function and HRQL among the treatment groups in the FAITH-2 pilot study. Despite modern implants and vitamin D supplementation, neither function nor HRQL returns to baseline in this population. Additional efforts to improve the outcomes of these challenging injuries are still needed.

LEVEL OF EVIDENCE

Therapeutic Level II.

Osteosynthesis of non-displaced femoral neck fractures in the elderly population using the femoral neck system (FNS): short-term clinical and radiological outcomes

Background

Femoral neck fractures (FNF) are frequent in the elderly population, and surgical management is indicated in the vast majority of cases. Osteosynthesis is an alternative to arthroplasty for non-displaced FNF. Triple screw construct (TS) and the dynamic hip screw system (DHS) are considered gold standards for osteosynthesis. The newly available femoral neck system (FNS) currently lacks evidence as to whether it is a valid alternative to TS and DHS. The purpose of this study was to evaluate the short-term clinical and radiological outcomes after non-displaced (Garden I and II) FNF osteosynthesis using TS, DHS, and FNS.

Methods

All the patients of the author’s institution aged ≥ 75 years with a non-displaced (Garden I and II) FNF eligible for osteosynthesis between November 2015 and December 2019 were included in this single-center retrospective non-randomized study. Patients were treated with either TS, DHS, or FNS depending on the surgeon’s preference. Clinical data (age, gender, ASA score, duration of surgery, need for blood transfusion and number of packed red blood cells transfused, surgical site complications, length of stay, discharge location, postoperative medical complications and readmission within 30 days, and mortality within 3 months) were extracted from the patients’ charts. The radiological analysis assessed the fracture classification, fracture impaction, and proximal femur shortening at 3 and 6 months using the institutional imaging software.

Results

Baseline characteristics in the TS (n = 32), DHS (n = 16), and FNS (n = 15) groups were similar with respect to age (mean 85 years), gender (female to male ratio 4:1), and ASA score. There were no significant differences across the groups for the need for blood transfusion, surgical site complications, length of stay, postoperative medical complications and readmission within 30 days, discharge location, and mortality within 3 months. The duration of surgery was significantly lower in the FNS group (43.3 vs 68.8 min; p < 0.001). The radiological assessment found similar impaction (5.2 mm ± 4.8) and shortening (8.6 mm ± 8.2) in all groups that did not seem to progress after 3 months.

Conclusion

The FNS appears to be a valid alternative implant for FNF osteosynthesis and is associated with a shorter operative time than TS and DHS. Short-term clinical and radiological outcomes of FNS are similar to TS and DHS implants. Further long-term multicenter randomized studies are however necessary to confirm these first results.

Medial femoral plate with cannulated screw for Pauwels type III femoral neck fracture: A meta-analysis

BACKGROUND

Femoral neck fractures often occur in the elderly, which usually results in hip pain.

OBJECTIVE

The purpose of this study was to evaluate the difference in the treatment of Pauwels type III femoral neck fractures with medial femoral support plate combined with cannulated screws and cannulated screws alone.

METHODS

PubMed, ScienceDirect, China Academic Journals Full-text Database (CNKI), Wanfang Database, Chinese Biomedical Literature Database (CBM), Embase and Cochrane Library were used to collect clinical controlled trials of the medial femoral support plate combined with hollow screw internal fixation and simple hollow screw internal fixation for Pauwels type III femoral neck fracture.

RESULTS

Seven articles (n= 409 cases) were evaluated for quality and included in this meta-analysis. Four hundred and nine patients with Pauwels type III femoral neck fractures were included: 202 in the experimental group and 207 in the control group. The results showed that, compared with simple hollow screw internal fixation, the medial femoral support plate combined with hollow screw internal fixation has a longer operation time (MD= 23.05, 95% CI= 13.86-32.24), and more intraoperative blood loss (MD= 91.55, 95% CI= 50.72-132.39), shorter healing time (MD=-1.48, 95% CI (-1.71, -1.26)), lower incidence of complications (RR= 0.34, 95% CI= 0.19-0.61), lower VAS score (MD=-1.28, 95% CI (-1.83, -0.72)), and higher Harris score (MD= 8.49, 95% CI (4.15, 12.83)).

CONCLUSION

Medial femoral plate combined with cannulated screw for Pauwels type III femoral neck fracture can shorten healing time, reduce postoperative complications, and improve the postoperative Harris score.

Fixation Using Alternative Implants for the Treatment of Hip Fractures (FAITH-2): The Clinical Outcomes of a Multicenter 2 × 2 Factorial Randomized Controlled Pilot Trial in Young Femoral Neck Fracture Patients

OBJECTIVE

To assess whether the fixation method and vitamin D supplementation affect the risk of patient-important outcomes within 12 months of injury in nongeriatric femoral neck fracture patients.

DESIGN

A pilot factorial randomized controlled trial.

SETTING

Fifteen North American clinical sites.

PARTICIPANTS

Ninety-one adults 18-60 years of age with a femoral neck fracture requiring surgical fixation.

INTERVENTION

Participants were randomized to a surgical intervention (sliding hip screw or cancellous screws) and a vitamin D intervention (vitamin D3 4000 IU daily vs. placebo for 6 months).

MAIN OUTCOME MEASUREMENTS

The primary clinical outcome was a composite of patient-important complications (reoperation, femoral head osteonecrosis, severe femoral neck malunion, and nonunion). Secondary outcomes included fracture-healing complications and radiographic fracture healing.

RESULTS

Eighty-six participants with a mean age of 41 years were included. We found no statistically significant difference in the risk of patient-important outcomes between the surgical treatment arms (hazard ratio 0.90, 95% confidence interval 0.40-2.02, P = 0.80) and vitamin D supplementation treatment arms (hazard ratio 0.96, 95% confidence interval 0.42-2.18, P = 0.92).

CONCLUSIONS

These pilot trial results continue to describe the results of current fixation implants, inform the challenges of improving outcomes in this fracture population, and may guide future vitamin D trials to improve healing outcomes in young fracture populations. Although the pilot trial was not adequately powered to detect treatment effects, publishing these results may facilitate future meta-analyses on this topic.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Fixation Using Alternative Implants for the Treatment of Hip Fractures: The feasibility of a multicenter 2 × 2 factorial randomized controlled trial evaluating surgical treatment and vitamin D supplementation in young femoral neck fracture patients

Objectives

To conduct a pilot trial for the Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH-2) protocol to assess feasibility of a definitive trial.

Design

Pilot trial.

Setting

Twenty-five clinical sites across North America and Australia were initiated, but enrolment occurred in only 15 North American sites.

Patients/Participants

Ninety-one randomized adults aged 18 to 60 years with a femoral neck fracture requiring surgical fixation.

Intervention

Eligible patients were randomized to receive surgical treatment (sliding hip screw or cancellous screws) AND nutritional supplementation (4000 IU of vitamin D or placebo) for 6 months postfracture.

Main Outcome Measurements

Feasibility outcomes included: clinical site initiation, participant enrolment rate, proportion of participants with complete 12-month follow-up, level of data quality, and rate of protocol adherence (number of randomization errors, crossovers between treatment groups, and daily supplementation adherence).

Results

Eighty-six of 91 participants randomized into the pilot trial from 15 North American hospitals were deemed eligible. Four of five primary feasibility criteria were not achieved as we were unable to initiate clinical sites outside of North America and Australia due to feasibility constraints, slow participant enrolment (60 participants recruited over 36 mo), low adherence with daily nutritional supplementation at the 6-week (72.1%), 3-month (60.5%), and 6-month (54.7%) follow-up visits, and a high loss to follow-up rate of 22.1% at 12 months.

Conclusions

Despite not meeting key feasibility criteria, we increased our knowledge on the logistics and anticipated barriers when conducting vitamin D supplementation trials in this trauma population, which can be used to inform the design and conduct of future trials on this topic.