Dynamic Hip Screw - DHS: Difference between revisions

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<div class="editorbox"> '''Original Editor '''- [[User:Rhiannon Clement|Rhiannon Clement]]<br>
<div class="editorbox"> '''Original Editor '''- [[User:Rhiannon Clement|Rhiannon Clement]]<br>
  '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
  '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
== Purpose  ==
== Introduction ==
[[File:DHS.jpg|thumb|Dynamic hip screw x-ray [image from wikimedia]]]
[[File:DHS.jpg|thumb|Xray DHS]]
The dynamic [[Hip Anatomy|hip]] screw (DHS), a [[Femur|femoral]] head-sparing orthopaedic device, is used to treat [[Femoral Neck Fractures|femoral neck fractures]]. Alternately referred to as a pin and plate. 


The Dynamic Hip Screw (DHS) or Sliding Hip Screw can be used as a fixation for [https://physio-pedia.com/Hip_Fracture?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal neck of femur fractures]. This would usually be considered for fractures that occur outside the hip capsule (extracapsular), often stable intertrochaneric fractures<ref>Dodds ''et al.'' ''The Sliding Hip Screw'' Current Opinion in Orthopaedics (2004) Volume 15, Issue 1 pp12-17</ref>. This is because there is a reduced chance of interruption to the blood supply to the head of the femur, and so it may be possible to preserve the joint. However, it may also be appropriate for younger patients with fractures within the hip capsule (intracapsular) if there is a good chance that the blood supply is preserved, reducing the risk of avasular necrosis.  
# Femoral neck fractures that are undisplaced ([[Femoral Neck Fractures, Garden Classification|Garden]] I and II fractures) can be treated with head-preserving surgery and internal fixation.
== Technique  ==
# In fractures with a high risk of [[Avascular necrosis of the femoral head|femoral head avascular necrosis]] ([[Femoral Neck Fractures, Garden Classification|Garden]] III and VI fractures), femoral head resection and [[Partial Hip Replacement|hip hemiarthroplasty]] is favoured.
{{#ev:youtube|A3x0GmAHcKY|}} 


== History of the DHS ==
Note: DHS is a trade name for the Synthes company, being one type of sliding hip screw. There are various types of sliding hip screws produced by various implant companies. <ref name=":2">Radiopedia DHS Available:https://radiopaedia.org/articles/dynamic-hip-screw (accessed 14.12.2022)</ref>  
Prior to the use of DHS sliding screws, angled blade plates were used<ref name=":0">Singh A.P. ''Dynamic Hip Screw Or Sliding Hip Screw''. [online] Available at: <<nowiki>http://www.boneandspine.com/dynamic-hip-screw/</nowiki>> [Accessed 19 September 2020].</ref>. These fixed plates matched the angle of the femural head. These plates had a number of complications, including failure to purchase, requiring frequent osteotomies. They also did not allow any compression across the fracture site, leading to stress failures and frequent non-union<ref name=":0" />. Therefore, the DHS, with sliding barrel, was created to allow controlled compression across the fracture site. This is important for [https://physio-pedia.com/Bone_Healing#sts=Stages%20of%20Indirect%20Healing?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal bone healing].    <blockquote>NICE Guidelines recommends: Use extramedullary implants such as a sliding hip screw in preference to an intramedullary nail in patients with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2)<ref name=":1">NICE ''Hip Fracture: Management''  <available from: https://www.nice.org.uk/guidance/cg124/chapter/Recommendations#analgesia> [accessed 19/9/20]</ref>. </blockquote>
== Technique ==
== Physiotherapy Interventions ==
After reduction, the fracture is internally fixed by application a large lag screw through the neck, this is held laterally by a lateral femoral plate. The DHS can slide in the plate along the longitudinal axis of the femoral neck, permitting compression of the fracture hence aiding healing. If sliding takes place, the lateral end of the lag screw may project laterally from the plate.
Considerations post surgery:
* Post op instructions and '''[https://physio-pedia.com/Weight_bearing?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal weight bearing status]'''
* Infections
* Neurovascular complications
* Pain
* Self-efficacy and motivation
* [[Falls|Fear of falling]]
<blockquote>Any transfer or mobility aids will be determined by the weight bearing status (usually highlighted in the op note). If the surgeon feels the hip needs protecting post surgery, they may advise partial or non-weight bearing for the patient.</blockquote>Physiotherapy interventions:
* Transfers (bed, chair, toiletting).
* Mobility (+/- appropriate aid).
* [https://physio-pedia.com/Goal_Setting_in_Rehabilitation?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Goal setting]
* Advising patient and team on [https://physio-pedia.com/Pharmacology_in_Pain_Management?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal pain management] and expectations post-surgery
* Advice on [https://physio-pedia.com/RICE?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal swelling managemen]t
* Exercises
* Balance retraining and confidence building
* [https://physio-pedia.com/Gait?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Gait retraining]
* Considering home environment.
* Interactions with family and carer
<blockquote>It is important that the patient is transferred out of bed, within these limitations, as early as possible to avoid complications of bed rest (e.g. chest infections, DVT, muscle atrophy). NICE guidelines advise, unless contraindicated, for patient's to mobilise the day after surgery. <ref name=":1" /></blockquote>Physiotherapy exercises post hip surgery:
{| class="wikitable sortable"
|+Illustrations by: https://myhealth.alberta.ca/Alberta/Pages/hip-fracture-hip-exercises.aspx
!
!After surgery
!
!After 6 weeks
|-
|Supine
|Hip ABD and heel slides
(slide sheet can reduce friction)[[File:Hip abd.png|thumb]][[File:Heel slide.png|thumb]]
|Inner Range Quads[[File:Inner range quads.png|thumb]]
|Bridges (unless NWB) [[File:Bridge ex.png|thumb]]
|-
|Sitting
|Knee extension[[File:Knee ext in sitting.png|thumb]]
|Knee flexion[[File:Knee flexion.png|thumb]]
|Sit to stand (one balance optimised)[[File:Sit to stand.png|thumb]]
|-
|Standing
|Once able to maintain independent standing balance.  


Hip Abduction[[File:Standing hip abd.png|thumb]]
Watch this 10 minute video on the technique.{{#ev:youtube|A3x0GmAHcKY|}} 


Hip Extension[[File:Standing hip et.png|thumb]]
== History ==
|Hamstring Curl and[[File:Hamstring curls.png|thumb]]
[[File:Dynamic-hip-screw-sliding.png|thumb|Previous lag screw, has slid, indicating # compression. ]]
Prior to the use of DHS sliding screws, angled blade plates were used<ref name=":0">Singh A.P. ''Dynamic Hip Screw Or Sliding Hip Screw''. [online] Available at: <<nowiki>http://www.boneandspine.com/dynamic-hip-screw/</nowiki>> [Accessed 19 September 2020].</ref>. These fixed plates matched the angle of the femural head. These plates had a number of complications, including failure to purchase, requiring frequent [[Osteotomy|osteotomies]]. They also did not allow any compression across the fracture site, leading to stress failures and frequent non-union<ref name=":0" />. Therefore, the DHS, with sliding barrel, was created to allow controlled compression across the fracture site. This is important for [https://physio-pedia.com/Bone_Healing#sts=Stages%20of%20Indirect%20Healing?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal bone healing].   


Marching on the Spot[[File:MOS.png|thumb]]
NICE Guidelines recommends: Use extramedullary implants such as a sliding hip screw in preference to an intramedullary nail in patients with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2)<ref name=":1">NICE ''Hip Fracture: Management'' <available from: https://www.nice.org.uk/guidance/cg124/chapter/Recommendations#analgesia> [accessed 19/9/20]</ref>.  
|Heel Raises and[[File:Heel raise.png|thumb]]
== Complications ==
 
See also [[Fracture Complications|fracture complications]]
Mini squats[[File:Mini sqauts.png|thumb]]
* Infection
|}
* Haematoma
 
* Non-union or malunion
== Evidence  ==
* Implant complication, e.g. screw or plate fracture (2% 2)
 
* [[Avascular Necrosis|Avascular necrosis]]<ref name=":2" />
DHS Vs Hemiarthroplasty: 
 
Compared to hemiarthroplasty, the DHS has been found to have a superior hip functional outcome. However, the DHS has a higher chance of blood loss requiring blood transfusion and complications requiring revisions. Both were comparable for duration of surgery, length of stay in hospital and early mobilisation<ref>Mue D.D ''Outcome of Treatment of Fracture Neck of Femur using Hemiarthroplasty Vs Dynamic Hip Screw'' Journal of West African College of Surgeons (2013)3(2)</ref>. Therefore, may have benefits for return to function for a selected patient group.   
 
Internal fixation of NOF:  
 
The FAITH study (2014) suggests that most studies into internal fixation of fractured NOF compare against hemiarthroplasty. This means there is a lack of evidence for different methods of internal fixation<ref>FAITH investigators ''Fixation using alternative implants for the treatment of hip fractures (FAITH): design and rationale for a multi-centre randomized trial comparing sliding hip screws and cancellous screws on revision surgery rates and quality of life in the treatment of femoral neck fractures'' BMC Musculoskeletal Discorders (2014) 15(219) doi: 10.1186/1471-2474-15-219</ref>. RCTs with direct comparison are too small and lack sufficient power. Therefore, the FAITH study looked at the effects on patients after cancellous screws and sliding screws.  
 
The FAITH study (2017) suggests that both are comparable for revision / reoperation rates at 24 months, but the sliding hip screw group had a greater instance of avasular necrosis. However, this was not a significant difference and the DHS was found to be more beneficial for displaced fractures and reduced rates of reoperation. It was also thought to be beneficial for those with poor bone density, such as smokers<ref>Bandhari M. ''Fracture Fixation in the Operation Management of Hip Fractures'' ''(FAITH): An international, Multicentre, Randomised Control Trial''. Lancet (2017) 15:389 1519-1527</ref>. The authors noted that this finding of benefits for displaced fractures was inconsistent with other study findings.   
 
== Precautions post surgery  ==
* [[Surgery and General Anaesthetic|Post surgical complications]]
* Intra-capsular surgery may require a period of partial or protected weight bearing to ensure no displacement of the humeral head
* Avasular necrosis of the femural head 
* Operation site infections
* Foot drop post-op
* Risk of fracture to bone below metal plate


== Physiotherapy Interventions ==
See [[Femoral Neck Hip Fracture]]
== References  ==
== References  ==


Latest revision as of 02:18, 16 December 2022

Original Editor - Rhiannon Clement
Top Contributors - Rhiannon Clement, Lucinda hampton and Kim Jackson

Introduction[edit | edit source]

Xray DHS

The dynamic hip screw (DHS), a femoral head-sparing orthopaedic device, is used to treat femoral neck fractures. Alternately referred to as a pin and plate.

  1. Femoral neck fractures that are undisplaced (Garden I and II fractures) can be treated with head-preserving surgery and internal fixation.
  2. In fractures with a high risk of femoral head avascular necrosis (Garden III and VI fractures), femoral head resection and hip hemiarthroplasty is favoured.

Note: DHS is a trade name for the Synthes company, being one type of sliding hip screw. There are various types of sliding hip screws produced by various implant companies. [1]

Technique[edit | edit source]

After reduction, the fracture is internally fixed by application a large lag screw through the neck, this is held laterally by a lateral femoral plate. The DHS can slide in the plate along the longitudinal axis of the femoral neck, permitting compression of the fracture hence aiding healing. If sliding takes place, the lateral end of the lag screw may project laterally from the plate.

Watch this 10 minute video on the technique.

History[edit | edit source]

Previous lag screw, has slid, indicating # compression.

Prior to the use of DHS sliding screws, angled blade plates were used[2]. These fixed plates matched the angle of the femural head. These plates had a number of complications, including failure to purchase, requiring frequent osteotomies. They also did not allow any compression across the fracture site, leading to stress failures and frequent non-union[2]. Therefore, the DHS, with sliding barrel, was created to allow controlled compression across the fracture site. This is important for bone healing.

NICE Guidelines recommends: Use extramedullary implants such as a sliding hip screw in preference to an intramedullary nail in patients with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2)[3].

Complications[edit | edit source]

See also fracture complications

  • Infection
  • Haematoma
  • Non-union or malunion
  • Implant complication, e.g. screw or plate fracture (2% 2)
  • Avascular necrosis[1]

Physiotherapy Interventions[edit | edit source]

See Femoral Neck Hip Fracture

References[edit | edit source]

  1. ↑ 1.0 1.1 Radiopedia DHS Available:https://radiopaedia.org/articles/dynamic-hip-screw (accessed 14.12.2022)
  2. ↑ 2.0 2.1 Singh A.P. Dynamic Hip Screw Or Sliding Hip Screw. [online] Available at: <http://www.boneandspine.com/dynamic-hip-screw/> [Accessed 19 September 2020].
  3. ↑ NICE Hip Fracture: Management <available from: https://www.nice.org.uk/guidance/cg124/chapter/Recommendations#analgesia> [accessed 19/9/20]
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