FAITH Trial
Fracture Fixation in the Operative Management of Hip Fractures
FAITH Investigators · Lancet · 2017
The FAITH trial was a large international randomised controlled trial demonstrating that a sliding hip screw did not significantly reduce the 24-month revision surgery rate compared to multiple cancellous screws for intracapsular femoral neck fractures in patients aged 50 and older, though distinct complication profiles emerged between implants.
Citation & links
Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) Investigators. Fracture fixation in the operative management of hip fractures (FAITH): an international, multicentre, randomised controlled trial. Lancet. 2017 Apr 15;389(10078):1519-1527.
Key findings
- 1.No significant difference was observed in the primary outcome of unplanned revision surgery within 24 months between the sliding hip screw group (20%) and the cancellous screw group (22%) (hazard ratio 0.83, 95% CI 0.63–1.09; p=0.18).
- 2.Avascular necrosis rates were significantly lower in patients treated with a sliding hip screw compared to cancellous screws (9% vs 5%; hazard ratio 1.88, 95% CI 1.06–3.32; p=0.03 favouring SHS).
- 3.Nonunion occurred in 8% of patients receiving a sliding hip screw compared to 9% in the cancellous screw cohort, demonstrating no significant difference between treatments.
- 4.A sub-analysis revealed that in patients with displaced fractures, base-of-neck fractures, or smoker status, sliding hip screws conferred a reduced hazard of construct failure and nonunion.
- 5.The implant removal rate due to local irritation or implant prominence was higher in the cancellous screw group compared to the sliding hip screw group.
- 6.Mortality, serious medical adverse events, health-related quality of life (SF-12 and EQ-5D), and functional status showed no statistically significant differences between both fixation strategies at 24 months.
Background
Operative fixation of femoral neck fractures carries substantial risks of reoperation due to nonunion, avascular necrosis, and implant failure. Multiple parallel cancellous screws represent a minimally invasive approach preserving local vascularity, whereas sliding hip screws (SHS) offer greater biomechanical rigidity and resistance to shear forces. Previous clinical trials and meta-analyses were underpowered and inconclusive regarding whether construct stiffness or biological preservation led to superior patient outcomes. The FAITH trial was conducted to definitively establish whether using a sliding hip screw compared with multiple cancellous screws reduces the hazard of revision surgery and improves clinical outcomes.
Methods
This was an international, multicentre, allocation-concealed, randomized controlled trial conducted across 81 clinical sites in 8 countries (USA, Canada, Australia, the Netherlands, Norway, Germany, the UK, and India). A total of 1,079 skeletally mature patients aged 50 years or older with low-energy undisplaced or displaced femoral neck fractures amenable to internal fixation were enrolled. Participants were randomized via central minimization to receive either a sliding hip screw (with or without an anti-rotation screw) or multiple cancellous screws (typically three parallel screws). Follow-up occurred at 1 week, 10 weeks, and 6, 9, 12, 18, and 24 months post-surgery. The primary outcome was the rate of unplanned reoperation within 24 months to promote fracture healing, relieve pain, manage infection, or improve hip function.
Clinical implications
The FAITH trial established that routine fixation with a sliding hip screw provides no global advantage in overall revision surgery rates over multiple cancellous screws for all intracapsular neck of femur fractures. However, its detailed sub-analyses changed clinical algorithms by promoting sliding hip screws for biomechanically challenging subsets—specifically vertical shear orientations (Pauwels III), basicervical fracture patterns, and fractures in active smokers—while retaining cancellous screws as an acceptable, less invasive option for stable, undisplaced fracture patterns.
Critical appraisal
Strengths include the rigorous multicentre design, large sample size (>1,000 patients), central computerised randomization with allocation concealment, independent blinding of event adjudicators, and robust follow-up out to 24 months. Limitations include the pragmatic allowance of surgeon discretion regarding reduction technique and the inclusion of both undisplaced and displaced fracture variants within a single cohort, where arthroplasty is frequently preferred over fixation in elderly displaced patterns.
Teaching note
In viva and exit examinations, candidates must state that the overall 24-month reoperation rate does not differ between sliding hip screws and cannulated screws (~20–22%), but sliding hip screws significantly reduce avascular necrosis and perform superiorly in high-shear, basicervical, displaced patterns, and smokers.
Exam-tested points
- ›Overall 24-month unplanned revision reoperation rates showed no statistically significant difference between SHS and cancellous screws (20% vs 22%).
- ›Sliding hip screw fixation significantly reduced the risk of radiographic avascular necrosis compared to cancellous screw fixation.
- ›Patients managed with cancellous screws experienced higher rates of implant prominence and secondary implant removal.
- ›Subgroup analyses showed clear biomechanical benefit for SHS constructs in Pauwels type III/vertical fractures, basicervical patterns, and cigarette smokers.
- ›Both techniques demonstrated roughly a 20% failure/reoperation rate within 2 years, highlighting the continued clinical rationale for arthroplasty in displaced elderly femoral neck fractures.
- ›Neither implant demonstrated superiority regarding 2-year functional recovery, quality of life, or all-cause mortality.
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