*H.V. Kurup, A.L.R.
Michael, A.R. Beaumont
*Salisbury District Hospital, Salisbury,
Wiltshire SP2 8BJ, United Kingdom.
Address for Correspondence
Mr. Harish V. Kurup
Specialist Registrar in Orthopaedics,
Bangor LL57 2PW, United Kingdom
Phone: +44 7984706456
Introduction: This study was designed
to establish whether obtaining routine postoperative radiographs
following Dynamic Hip Screw (DHS) fixation served any useful
Materials and methods: Fifty NHS hospitals with trauma
units were randomly selected, eighteen of which routinely
obtained check radiographs following DHS fixation. In our own
unit, routine postoperative films were being performed despite
adequate image intensifier images being obtained and printed in
theatre. In this study, 174 DHS fixations were reviewed and
assessed for adequacy of image intensifier images by comparing
them with formal postoperative radiographs.
Results: 115 of the 174 original fractures were deemed
stable and showed no change of position of fracture or metal
work on the post-operative films. 59 fractures were unstable,
and of these, 14 were shown to have medialization of the femoral
shaft on the postoperative radiographs as compared with the
image intensifier images. The case notes of 132 of the total
number of cases were reviewed and none of these patients
underwent a change in postoperative mobilization status based on
postoperative radiographic findings. These included the 14
Conclusion: We conclude that obtaining routine check
postoperative radiographs after DHS fixation is unnecessary
provided adequate image intensifier images are obtained at the
time of surgery.
Keywords: Dynamic hip
screw, post operative, radiograph, image intensifier.
The fixation of most
fractures in modern practice is performed with the assistance of
an image intensifier. Final post fixation images are usually
saved and either printed as hard copies or stored on a
radiological computer system. In spite of this, many units
routinely obtain a formal post-operative radiograph to confirm
the adequacy of the fixation. This has been shown to be
unnecessary in the past  , but contrary to the evidence in
the literature, this practice continues. Proximal femoral
fracture fixation is one of the most commonly performed
orthopaedic surgical procedures and as such, there are
implications of cost and unnecessary exposure of radiation on a
large scale to be considered. A telephonic survey was therefore
undertaken of 50 randomly selected National Health Service (NHS)
trauma units in the United Kingdom, which revealed that in 18, a
formal postoperative check radiograph following DHS fixation was
requested. Fifteen did not perform this except under exceptional
circumstances and the remaining 17 had a variable practice
depending on individual consultant preference. As it was also
the practice of our own unit to routinely obtain these
radiographs, an audit was performed in an attempt to establish
whether this practice was actually clinically indicated.
Method and materials
All DHS fixations
carried out at Salisbury district hospital, Wiltshire, United
Kingdom over a period of two years from May 2001 to April 2003
were retrospectively reviewed. Medical records and radiographs
of these patients were reviewed to check the adequacy of thermal
prints from the image intensifier for fracture reduction and
implant placement and a comparison was then made with the first
postoperative films which had been obtained. Entries made in the
medical and physiotherapy case notes were scrutinized to
establish whether the formal radiograph prompted any change in
management of the patient, particularly weight-bearing status.
Fractures were classified broadly as stable and unstable, based
on the Evans classification , to see whether there were any
differences between the two groups.
No attempt was made to investigate the
accuracy of reduction or screw placement in these films.
Necessary approval was obtained from the clinical audit
department of our hospital for this study.
From a cohort of 195
patients who underwent DHS fixation during the selected time
period, 184 sets of radiographs were available for review. Six
patients did not have a post operative radiograph because they
developed complications and died in the first week after
surgery. From the remaining 178, only four did not have both the
image intensifier prints and first post-operative radiographs
available for review and they were excluded from the study. 174
cases were therefore included in the study. 115 fractures were
classified as stable and 59 as unstable. Of these, 132 case
notes were available for review.
In the stable fractures
group, all bar two had satisfactory image pictures i.e. the
position of the screws, plate and fracture was satisfactorily
demonstrated in two planes. Comparing the image intensifier
films to formal radiographs showed that there had been no change
in position of either fracture or implant. Review of the 95 case
notes that were available from this group revealed that the
postoperative radiograph that had been obtained did not prompt
any change in weight bearing status or further management of the
In the unstable fracture
group, all image intensifier prints were satisfactory, with the
exception of one, with regards to the information they provided.
On this occasion, when comparing these prints with the formal
post-operative radiographs, it was found that 14 of the
post-operative films showed medialization of femoral shaft with
sliding of the plate over the lag screw. However, on review of
case notes (37 from the unstable group, and 11 in the subgroup
which showed medialization), weight bearing status again did not
change based on the findings on the postoperative radiograph.
Most of these patients were already partial weight bearing on
the instructions of the operating surgeon on account of the
unstable fracture pattern.
Based on these findings, the practice of
obtaining routine postoperative radiographs following DHS
fixation was stopped in our unit. Five months following this
change of practice a re-audit was performed to assess what
effect this may have had. 31 patients underwent DHS fixation
during this re-audit period and all had only image intensifier
prints from theatre following fixation. There were no adverse
events reported with the new protocol.
This study shows that
formal radiographs obtained after DHS fixation do not contribute
to patient management. This was true in both stable and unstable
fracture configurations. This has important implications with
regard to manpower and cost, patient discomfort and exposure to
radiation . According to figures from Medicare in the United
States, a single hip x-ray costs $ 27.79. Our hospital
performed close to 100 DHS fixations per year and figures are
likely to be similar in most district hospitals with a higher
number in University hospitals.
Medialization of femoral
shaft in the post operative period is known to happen in most
unstable inter-trochanteric fractures. Usually this is self
limiting and patients are mobilised partial weight bearing for
6-8 weeks  . Although it has been shown that it is
unnecessary to obtain a formal radiograph in these patients
before the start of mobilisation, a radiograph may be obtained
after they have started to mobilise if there are any concerns
about the stability of fixation.
Many authors have criticized the use of
routine radiographs in many clinical settings, not just post DHS
fixation. Examples of this include routine pelvis x-ray in blunt
trauma , routine post-operative x-rays in knee replacements
 and following ankle fracture fixation under image control
. This study adds further weight to this school of thought
and shows that this practice unnecessarily exposes patients to
radiation and, on a large scale, could prove costly.
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