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Do We Need Routine Postoperative Radiographs After Hip Fracture Fixation?

*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
Ysbyty Gwynedd, 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 clinical purpose.
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 unstable fractures.
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.
: Dynamic hip screw, post operative, radiograph, image intensifier.

J.Orthopaedics 2006;3(3)e10


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 [1] [2], 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 [3], 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 patient. 

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.

Discussion :

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 [2]. According to figures from Medicare in the United States, a single hip x-ray costs $ 27.79[4]. 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 [3] [5]. 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 [4], routine post-operative x-rays in knee replacements [6] and following ankle fracture fixation under image control [7]. 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.

Reference :

  1. Pattison RM, Calzada S, Koka SR, et al. Postoperative radiographs or thermal prints after internal fixation of fractures? A study of DHS fixation of hip fractures. Ann R Coll Surg Engl. 1996;78(6):509-11.
  2. Haddad FS, Williams RL, Prendergast CM. The check X-ray: an unnecessary investigation after hip fracture fixation? Injury 1996;27(5):351-2.
  3. Koval KJ, Zuckerman JD. Hip Fractures: II. Evaluation and Treatment of Intertrochanteric Fractures. J Am Acad Orthop Surg. 1994;2(3):150-156.
  4. Kaneriya PP, Schweitzer ME, Spettell C, et al. The cost-effectiveness of routine pelvic radiography in the evaluation of blunt trauma patients. Skeletal Radiol 1999;28(5):271-3.
  5. Madsen JE, Naess L, Aune AK, et al . Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral fractures: a comparative study with the Gamma nail and compression hip screw. J Orthop Trauma 1998;12(4):241-8.
  6. Glaser D, Lotke P. Cost-effectiveness of immediate postoperative radiographs after uncomplicated total knee arthroplasty: a retrospective and prospective study of 750 patients. J Arthroplasty 2000;15(4):475-8.
  7. Harish S, Vince AS, Patel AD. Routine radiography following ankle fracture fixation: a case for limiting its use. Injury 1999;30(10):699-701.


This is a peer reviewed paper 

Please cite as : H.V. Kurup: Do We Need Routine Postoperative Radiographs After Hip Fracture Fixation?

J.Orthopaedics 2006;3(3)e10





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