Summary 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.

Background: Tension band wiring (TBW) is the standard method for treating transverse olecranon fractures, but high rates of complications and reoperations have been reported. Plate fixation (PF) with locking screws has been introduced as an alternative method that may retain the fracture reduction better with a higher load to failure. Methods: Twenty paired cadaveric elbows were used. All soft tissues except for the triceps tendon were removed. A standardized transverse fracture was created, and each pair was allocated randomly to TBW or PF with locking screws. The triceps tendon was mounted to the materials testing machine with the elbow in 90 of flexion. Construct stiffness was compared 3 times. Then, the elbows underwent a chair lift-off test by loading the triceps tendon to 300 N for 500 cycles. Finally, a load-to-failure test was performed, and failure mechanism was recorded. Results: The construct stiffness of PF was higher in the first of 3 measurements. No difference was observed in the cyclic test or in load to failure. Hardware failure was the failure mechanism in 8 of 10 TBW constructs, and all failures occurred directly under the twists of the metal wire. Hardware failure was the cause of failure in only 1 elbow in the PF group (P < .01). Conclusion:There was no difference in fracture displacement following fixation with TBW and PF with locking screws in transverse olecranon fractures. However, assessment of the mode of hardware failure identified the metal cerclage twist as the weakest link in the TBW construct.

The novel plate design with its pin configuration enhanced torsional stability. To reveal clinical relevance a clinical study is planned.