Lateral versus posterior approach for insertion of hemiarthroplasties for hip fractures: A randomised trial of 216 patients

No Differences in Major In-Hospital Outcome Metrics When Comparing the Direct Lateral Approach to the Posterior Approach for Hemiarthroplasties After Traumatic Displaced Femoral Neck Fractures

Introduction

The surgical approach of hemiarthroplasty for displaced femoral neck fractures remains debated. The study objective was to compare in-hospital outcomes for geriatric displaced femoral neck fractures treated with hemiarthroplasty based on surgical approach (direct lateral vs. posterior approach).

Materials and Methods

This retrospective cohort study included geriatric patients (≥60 y/o) admitted 7/1/2016-3/31/2020 treated with hemiarthroplasty. Outcomes included: operative time (incision to closure), length of stay (HLOS), and blood loss volume (mL). The Harding direct lateral approach was compared to the posterior approach; P < .05.

Results

There were 164 patients (59% direct lateral, 41% posterior). Patients treated with the direct lateral approach had an advanced directive (P = .03), dementia, (P = .03), or were functionally dependent (P = .03) more often than patients treated with the posterior approach. Time to surgery was comparable between groups (P = .52). The direct lateral approach was associated with a shorter operative time (2.3 vs. 2.8 h, P = .03), a longer HLOS (5.0 vs. 4.0 days, P < .01), and a lower median volume of blood loss (50 vs. 100 mL, P = .01), than the posterior approach, respectively. In a stratified analysis, for those who were not functionally dependent, did not have dementia or an advanced directive, the direct lateral approach led to a longer HLOS (P = .03) and shorter operative time (P = .04) than the posterior approach. Whereas among those who were functionally dependent, had dementia or had an advanced directive, the direct lateral approach led to less blood loss (P = .02) than the posterior approach.

Discussion

While those treated with the direct lateral approach lost significantly less blood, they had a significantly longer HLOS than those treated with the posterior approach. Comorbidities significantly modified outcomes, which may suggest their presence could assist with treatment decisions.

Conclusions

This study found neither approach, the direct lateral nor posterior, to be superior. Surgical approach could remain physician preference.

A Comparison of Surgical Approaches for Hip Hemiarthroplasty Performed for the Treatment of Femoral Neck Fracture: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

BACKGROUND

Multiple hemiarthroplasty (HA) approaches exist for femoral neck fracture (FNF) treatment. However, there is no consensus on the superiority of one approach for postoperative outcomes. This study assessed outcomes among randomized controlled trials (RCTs) comparing the posterior approach (PA), direct lateral approach (DLA), anterolateral approach (ALA), and the direct anterior approach (DAA) in HA for FNF.

METHODS

PubMed, Ovid/MEDLINE, Scopus, Cochrane Central Registry of Controlled Trials, and Cochrane Database of Systematic Reviews were queried in February 2024. A frequentist model network meta-analysis of eligible prospective RCTs compared outcomes among approaches using P-scores.

RESULTS

Of 1,481 retrieved studies, 11 RCTs totaling 1,513 FNF patients who underwent HA through a PA (n = 446; 29.5%), DLA (n = 481; 31.8%), ALA (n = 296; 19.6%), or DAA (n = 290; 19.2%) with median (interquartile range) follow-up of 6 (4.5-12.0) months were included for meta-analysis. DAA was associated with statistically increased operative duration (mean difference [MD], 1.89 minutes; 95% CI, 0.08 to 3.69 minutes; p < 0.001) compared with a PA, whereas an ALA was associated with statistically greater blood loss compared with a PA (MD, 5.81 mL; 95% CI, 4.11 to 7.50 mL; p < 0.001). There were no differences in the incidence of fracture, dislocation, infection, complications, revision, nor 1-year mortality among approaches. There were also no differences in hip nor pain score improvement at latest follow-up, although with high heterogeneity (I2 = 85.7% and 94.2%, respectively).

CONCLUSION

This study found no clinical difference in improvement in pain, function, nor in revision outcomes and operative characteristics among HA approaches for FNF, and each approach had a similar adverse event profile. Despite limited randomized evidence, these findings suggest comparable short-term efficacy and safety of all approaches.

LEVEL OF EVIDENCE

Therapeutic, Level I. See Instructions for Authors for a complete description of levels of evidence.

Incidence of dislocation and associated risk factors in patients with a femoral neck fracture operated with an uncemented hemiarthroplasty

BACKGROUND

Several factors might be associated with risk of dislocating following uncemented hemiarthroplasty (HA) due to femoral neck fracture (FNF). Current evidence is limited with great variance in reported incidence of dislocation (1-15%). Aim of this study was to identify the cumulative incidence of first-time dislocation following HA and to identify the associated risk factors.

METHOD

We performed a retrospective cohort study of patients receiving an HA (BFX Biomet stem, posterior approach) at Copenhagen University Hospital, Bispebjerg, in 2010-2016. Patients were followed until death or end of study (dec 2018). Dislocation was identified by code extraction from the Danish National Patient Registry. Variables included in the multivariate model were defined pre-analysis to include: age, sex and variables with a p-value < 0.1 in univariate analysis. A regression model was fitted for 90 days dislocation as the assumption of proportional hazard rate (HR) was not met here after.

RESULTS

We identified 772 stems (some patients occurred with both right and left hip) and 58 stems suffered 90 dislocations during the observation period, resulting in a 7% (CI 5-9) incidence of dislocation 90 days after index surgery. 55 of the 58 stems (95%) experienced the first dislocation within 90 days after surgery. Only absence of dementia was identified as an independent protective factor in the cause-specific model (HR 0.46 (CI 0.23-0.89)) resulting in a 2.4-fold cumulative risk of experiencing a dislocation in case of dementia. Several other variables such as age, sex, various medical conditions, surgery delay and surgical experience were eliminated as statistical risk factors. We found a decrease in survival probability for patients who experienced a dislocation during follow-up.

CONCLUSIONS

The incidence of first-time dislocation of HA (BFX Biomet stem, posterior approach) in patients with a hip fracture is found to be 7% 90 days after surgery. Due to the non-existing attribution bias, we claim it to be the true incidence. Dementia was among several variables identified as the only risk factor for dislocation. In perspective, we may consider treating patients with dementia by other methods than HA e.g., HA with cement or with a more constrained solution. Also, a surgical approach that reduce the risk of dislocation should be considered.

The outcomes of constrained total hip arthroplasty for recurrent dislocation of hip hemiarthroplasty

INTRODUCTION

The incidence of hemiarthroplasty dislocation for fracture neck of femurs ranges between 1 and 15% and the one-year mortality is 49- 70%. Revision of hemiarthroplasty to total hip replacement using a constrained liner has shown to improve the morbidity and mortality rates. The aim of the study was to assess whether conversion of dislocated hemiarthroplasty to total hip replacement improve functional and one year mortality.

METHODS

A retrospective analysis of the number of patients who had recurrent dislocations of hemiarthroplasty for fracture neck of femurs were carried out. The data were obtained from NHFD (National Hip Fracture Database) and internal hospital computer systems (Medway, Theatre notes and PACS) between Dec 2008 and Dec 2020. Patient demographics including age, sex, Abbreviated Mental Test Score (AMTS), functional assessment, mortality at one and two years were documented. The risk factors which led to dislocations such as Parkinsons disease, Cerebrovascular accidents, Musculo-neuropathies and Alzheimer`s disease was also noted.

RESULTS

A total of 3994 patients were admitted during the study period of which 1735 (43.4%) patients had hemiarthroplasty. Fifty-six (3.23%) patients had dislocation of hemiarthroplasty. The mean age was 81.4 years (range - 61 to 95). There were 40 (71.4%) females and 16 males (28.6%). The average AMTS score was 5.3. All 56 patients had closed manipulative reduction under anaesthesia within in 12 h of admission. Thirty-one patients (55.4%) went on to have recurrent dislocations of which 18 patients (58.4%) had total hip replacement using captive cup, 6 patients (19.4%) had open reduction,3 patients (9.7%) had excision arthroplasty procedure and four patients (12.5%) had no intervention, Eighteen patients who had total hip replacement with constrained captive for followed up to a minimum of two years (range2- 12 years). There were no intraoperative complications, dislocation or periprosthetic fractures in the follow up period. There was no mortality at the end of two years of follow up in this group, two-year mortality for the patients with alternative management for dislocated hemiarthroplasty was 76.67.

CONCLUSION

Treatment of recurrent hemiarthroplasty dislocation by revising to a total hip replacement with a constrained liner gives good functional and mortality outcomes.

Surgical Approach and Dislocation Risk After Hemiarthroplasty in Geriatric Patients With Femoral Neck Fracture With and Without Cognitive Impairments-Does Cognitive Impairment Influence Dislocation Risk?

OBJECTIVES

To determine whether there is an association between surgical approach and dislocation risk in patients with cognitive impairment compared with those without cognitive impairment treated with hemiarthroplasty for femoral neck fracture.

DESIGN

Retrospective study.

SETTING

Large, multicenter health system.

PATIENTS/PARTICIPANTS

One thousand four hundred eighty-one patients who underwent hemiarthroplasty for femoral neck fractures. 828 hips met inclusion criteria, 290 (35.0%) were cognitively impaired, and 538 (65.0%) were cognitively intact.

INTERVENTION

Hemiarthroplasty.

MAIN OUTCOME MEASURE

Prosthetic hip dislocation.

RESULTS

The overall dislocation rate was 2.1% (17 of 828), 3.4% (10 of 290) in the cognitively impaired group, and 1.3% (7 of 538) in the cognitively intact group with a median time to dislocation of 20.5 days (range 2-326 days), 24.5 days (range 3-326 days), and 19.0 days (range 2-36 days), respectively. In the entire cohort, there were no dislocations (0 of 58) with the direct anterior approach (DA); 1.1% (6 of 553) and 5.1% (11 of 217) dislocated with the modified Hardinge (MH) and posterior approaches (PA), respectively. In the cognitively impaired group, there were no dislocations with the DA (0 of 19); 1.5% (3 of 202) and 10.1% (7 of 69) dislocated with the MH and PA, respectively. In the cognitively intact group, there were no dislocations (0 of 39) with the DA; 0.85% (3 of 351) and 2.7% (4 of 148) dislocated with the MH and PA, respectively. There were statistically significant associations between surgical approach and dislocation in the entire cohort and the cognitively impaired group when comparing the MH and PA groups. This was not observed in the cognitively intact group. Patients who dislocated had 3.2 times (95% CI 1.2, 8.7) ( P = 0.0226) the hazard of death compared with patients who did not dislocate. Dislocation effectively increased the risk of death by 221% (HR 3.2 95% CI 1.2, 8.7) ( P = 0.0226).

CONCLUSIONS

In this patient population, the PA has a higher dislocation rate than other approaches and has an especially high rate of dislocation when the patients were cognitively impaired. The authors of this study suggest careful consideration of surgical approach when treating these injuries.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does Surgical Approach Influence Complication Rate of Hip Hemiarthroplasty for Femoral Neck Fractures? A Literature Review and Meta-Analysis

Background: Femoral neck fractures are an epidemiologically significant issue with major effects on patients and health care systems, as they account for a large percentage of bone injuries in the elderly. Hip hemiarthroplasty is a common surgical procedure in the treatment of displaced femoral neck fractures. Several surgical approaches may be used to access the hip joint in case of femoral neck fractures, each with its own benefits and potential drawbacks, but none of them has consistently been found to be superior to the others. This article aims to systematically review and compare the different approaches in terms of the complication rate at the last follow-up. Methods: an in-depth search on PubMed/Scopus/Web of Science databases and a cross-referencing search was carried out concerning the articles comparing different approaches in hemiarthroplasty and reporting detailed data. Results: A total of 97,576 hips were included: 1030 treated with a direct anterior approach, 4131 with an anterolateral approach, 59,110 with a direct lateral approach, and 33,007 with a posterolateral approach. Comparing the different approaches, significant differences were found in both the overall complication rate and the rate of revision surgery performed (p < 0.05). In particular, the posterolateral approach showed a significantly higher complication rate than the lateral approach (8.4% vs. 3.2%, p < 0.001). Furthermore, the dislocation rate in the posterolateral group was significantly higher than in the other three groups considered (p < 0.026). However, the posterolateral group showed less blood loss than the anterolateral group (p < 0.001), a lower intraoperative fractures rate than the direct anterior group (p < 0.035), and shorter mean operative time than the direct lateral group (p < 0.018). Conclusions: The posterolateral approach showed a higher complication rate than direct lateral approach and a higher prosthetic dislocation rate than the other three types of surgical approaches. On the other hand, patients treated with posterolateral approach showed better outcomes in other parameters considered, such as mean operative time, mean blood loss and intraoperative fractures rate. The knowledge of the limitations of each approach and the most common associated complications can lead to choosing a surgical technique based on the patient's individual risk.

A piriformis-preserving posterior approach reduces dislocation rate of the hemiarthroplasty in patients with femoral neck fracture

INTRODUCTION

The posterior approach (PA) for hemiarthroplasty (HA) in patients with femoral neck fracture (FFN) has a high risk of dislocation; however, by preserving the piriformis muscle, the dislocation rate could be lowered considerably. The aim of this study was to compare the surgical complications of the piriformis-preserving posterior approach (PPPA) and the PA in patients with FNF treated with HA.

METHODS

On 1 January 2019, the PPPA was introduced at two hospitals as the new treatment standard. The sample size was calculated based on a 5 percentage point dislocation reduction and 25% censoring; a sample of 264 patients per group was determined. An approximately 2-year inclusion period with 1-year follow-up was estimated, including a historical cohort from 2 years before the PPPA introduction. Data were retrieved from health care records and X-ray images from the hospitals' administrative databases. Relative risk (RR) and 95% confidence intervals were calculated using Cox regression and adjusted for age, sex, comorbidity, smoking, surgeon experience and implant type.

RESULTS

There were 527 patients included in the study, of which 72% were women and 43% were above 85 years old. There were no baseline differences between the PPPA and PA groups in sex, age, comorbidity, body mass index, smoking, alcohol, mobility, length of surgery, blood loss or implant positioning, but there were differences in 30-day mortality, surgeon experience and implant type. The dislocation rate reduced from 11.6% in the PA group to 4.7% in the PPPA group (p = 0.004), with an RR of 2.5 (1.2; 5.1). The reoperation rate reduced from 6.8% with the PA to 3.3% with the PPPA (p = 0.022), with an RR of 2.1 (0.9; 5.2), and total surgery-related complications reduced from 14.7% with the PA to 6.9% with the PPPA (p = 0.003), with an RR of 2.4 (1.3; 4.4).

INTERPRETATION

Changing from PA to PPPA in patients with FNF treated with HA resulted in a more than 50% reduction in dislocation and reoperation rates. This approach was easily introduced and may enable further lowering of dislocation rates through the sparing of all short external rotators.

The direct anterior approach is safe and shortens hospital length of stay following hemiarthroplasty for neck of femur fracture

OBJECTIVE

To investigate the safety of using the anterior approach (AA), compared to the lateral approach (LA), in hemiarthroplasty for the treatment of displaced neck of femur fractures.

DESIGN

Retrospective case-control match cohort study.

SETTING

Level 1 trauma center.

PATIENTS

Retrospective review of prospectively collected data for 39 consecutive intracapsular hip fractures treated with hemiarthroplasty using an AA between 2017 and 2021. Patients operated with the AA were matched in 1:2 ratio with patients that had hemiarthroplasty via a LA.

MAIN OUTCOME MEASURES

Discharge destination, 90-day emergency room (ER) visit or readmission rate, inpatient and 90-day mortality rate, inpatient medical complications, 90-day mechanical complications, 90-day reoperation, and length of hospital stay (LOS).

RESULTS

Discharge destination (p = 0.695), 90-day ER visit or readmission rate (p = 0.315), inpatient (p = 0.719) and 90-day mortality rate (p = 0.815), medical complications (p = 0.524), mechanical complications (p = 0.150) were similar between cohorts. Five patients, all in the LA-group, required re-operations within 90-days (p = 0.106). Patients in AA-group had shorter LOS (9.3 days, 95% CI [7.6-11.1] vs. 14.7 days [95% CI 12.2-17.3], p = 0.002).

CONCLUSIONS

The AA can be safely introduced for the treatment of hip fractures. Similar short-term outcomes relative to the LA were identified. The shorter LOS may reflect the improved early functional recovery offered from the muscle-sparing AA technique. Future, level-1 data should include early- and longer term functional outcome along with cost-effectiveness.

Comparison of Dislocation and Outcome Between Piriformis-Sparing and Conventional Posterior Approach After Bipolar Hemiarthroplasty for Femoral Neck Fracture in Patients Over 60 Years

BACKGROUND

Hemiarthroplasty is a treatment option for femoral neck fractures in patients aged more than 60 years and postoperative dislocation after a posterior approach is not uncommon. The piriformis tendon is one of the structures providing posterior hip stability. However, evidence of piriformis-sparing approach in hemiarthroplasty is unclear regarding a reduced dislocation rate.

METHODS

Between January 2017 and December 2019, 321 patients underwent a posterior approach in consecutive cohorts for a hemiarthroplasty for femoral neck fractures with the minimum 24 months follow-up time (24-60 months). There were two cohorts: (1) 129 underwent the conventional posterior (CP) approach and (2) 192 underwent the piriformis-sparing (PS) approach. The differences in dislocation rate, postoperative Harris Hip Society at 1 and 2 years and other surgical complications were compared in both groups.

RESULTS

There were 6 dislocations of 129 (4.7%) underwent the CP approach and 0 dislocation from 192 underwent the PS approach that had posterior hip dislocations (P = .004). In addition, the CP group had a significantly higher mortality rate (14.7% versus 7.3%, P = .031) and lower functional outcomes as assessed by mean Harris Hip Scores at 1 year (73 versus 78, P = .005) and 2 years postoperatively (73 versus 80, P < .001) relative to the PS group.

CONCLUSION

PS hemiarthroplasty was associated with a lower dislocation and mortality rate. Moreover, this approach gained a superior early to the mid-term functional outcome than the conventional posterior approach in elderly femoral neck fractures.

LEVEL OF EVIDENCE

II, prospective cohort study.

A comparison of different surgical approaches to hemiarthroplasty for the femoral neck fractures: A meta-analysis

There are three traditional surgical approaches to hemiarthroplasty (HA) for femoral neck fractures, respectively, the anterior approach (AA), the lateral approach (LA) and the posterior approach (PA). However, the optimum approach is still controversial, the purpose of this meta-analysis is to identify the merits and demerits of all three approaches. All clinical published studies in PubMed, Web of Science, Embase, and the Cochrane Library from January 2000 to April 2022 were searched which compared different surgical approaches and covered surgery-related outcomes and frequent complications. Five randomized controlled trials and 26 cohort studies for a total of 31 clinical trials were included in the meta-analysis. The dislocation of PA was significantly higher than LA (OR: 3.00 95% CI: 2.25-4.01 I ² = 27% P < 0.00001) and AA (OR: 6.61 95% CI: 2.28-19.13 I ² = 0% P = 0.0005); PA was substantially more than LA in terms of risk of postoperative reoperation (P < 0.05); meanwhile, AA has markedly shorter hospital length of stays than LA. The remaining items showed no significant differences in the results.The results of this meta-analysis demonstrated that the risk of PA dislocation and reoperation is higher with hemiarthroplasty, and AA has markedly shorter hospital length of stays than LA.

Dual mobility cups do not reduce the revision risk for patients with acute femoral neck fracture: A matched cohort study from the Swedish Arthroplasty Register

INTRODUCTION

Dual mobility cups (DMC) are gaining in popularity, as a method to reduce the risk of dislocation after fracture-related hip arthroplasty. Our aim was to compare revision rate in general, as well as due to dislocation and infection, after DMC and conventional THA due to femoral neck fracture, for each of the two groups of lateral and posterior approach.

MATERIALS AND METHODS

This observational cohort study based on the Swedish Arthroplasty Register (SAR) compared 2242 patients with dual mobility cups (DMC) and 6726 with conventional total hip arthroplasty (cTHA), all due to acute fracture 2005-2019. This was after propensity score matching of 1:3 (age, gender, ASA). Kaplan-Meier survival analysis was used to investigate the 5-year revision rate after DMC and cTHA in the posterior and lateral approach groups.

RESULTS

The rates of revision in general, and due to dislocation or infection, were similar for DMC and cTHA in the different approach groups during the follow-up. The cumulative revision rate after posterior approach was 4.7% (95% CI 3.1-6.2) for DMC and 4.8% (3.8-5.7) for cTHA at 5 years. For lateral approach, the result was 2.3% (CI 1.3-3.3) for DMC and 3.7% (CI 3.0-4.4) for cTHA. The 5-year results for cumulative revision rate due to dislocation after posterior approach were 1.3% (0.4-2.2) for DMC and 2.2% (1.5-2.8) for cTHA. Corresponding results for lateral approach was 0.4% (0-0.8) for DMC and 0.7% (0.4-1) for cTHA.

DISCUSSION

With implant revision surgery as outcome, we could not detect any differences between DMC and cTHA. Further studies with high external validity are needed regarding total dislocation rate, patient-reported outcome, cost-effectiveness and learning curve, to make a definitive recommendation on the use of DMC for fracture cases.

CONCLUSIONS

As treatment of acute femoral neck fractures, total hip arthroplasty with a dual mobility cup have similar outcome in terms of revisions in general, and due to dislocation or infections specifically, as one with conventional bearing. The similar outcome is regardless of surgical approach.

Dislocation of hemiarthroplasty after hip fracture is common and the risk is increased with posterior approach: result from a national cohort of 25,678 individuals in the Swedish Hip Arthroplasty Register

Background and purpose - Reported revision rates due to dislocation after hemiarthroplasty span a wide range. Dislocations treated with closed reduction are rarely reported despite the fact that they can be expected to constitute most of the dislocations that occur. We aimed to describe the total dislocation rate on the national level, and to identify risk factors for dislocation.Patients and methods - We co-processed a national cohort of 25,678 patients in the Swedish Hip Arthroplasty Register, with the National Patient Register (NPR) and Statistics Sweden. Dislocation was defined as the occurrence of any ICD-10 or procedural code related to hip dislocation recorded in the NPR, with a minimum of 1-year-follow-up. In theory, all early dislocations should thereby be traced, including those treated with closed reduction only.Results - 366/13,769 (2.7%) patients operated on with direct lateral approach dislocated, compared with 850/11,834 (7.2%) of those with posterior approach. Posterior approach was the strongest risk factor for dislocation (OR = 2.7; 95% CI 2.3-3.1), followed by dementia (OR = 1.3; CI 1.1-1.5). The older the patients, the lower the risk of dislocation (OR = 0.98 per year of age; CI 0.98-1.0). Neither bipolar design nor cementless stems influenced the risk.Interpretation - The choice of posterior approach and dementia was associated with an increased dislocation risk. When hips treated with closed reduction were identified, the frequency of dislocation with use of direct lateral and posterior approach more than doubled and tripled, respectively, compared with when only revisions due to dislocation are measured.

Sex differences in incidence rate, and temporal changes in surgical management and adverse events after hip fracture surgery in Denmark 1997-2017: a register-based study of 153,058 hip fracture patients

Background and purpose - Extensive research and national multidisciplinary programs have striven to introduce uniform standards of treatment and mitigate mortality and adverse events after hip fracture surgery over the past decades. A large-scale overview of temporal developments in hip fracture surgery and care is warranted.Patients and methods - We studied Danish patients aged ≥ 60 years, sustaining their first ever hip fracture between 1997 and 2017. Patients were identified from the Danish National Patient Registry (DNPR). Incidence rates of first hip fracture were calculated per 1,000 patient-years and stratified by age group and sex. Information on pre-injury living settings, comorbidities, and medications were obtained from national administrative registers. Type of fracture and treatment choice were recorded, and patients were followed for 1 year to observe mortality, readmission, and surgical complications.Results - Data from 153,058 patients was analyzed. Incidence rate decreased in both sexes, but only led to a reduction in the annual number of hip fractures in the female population. Choice of surgery shifted away from sliding hip screws and parallel implants (SHS-PI), towards intramedullary nailing and hemi-/arthroplasties for trochanteric and femoral neck fractures, respectively. Pre-injury diagnosed morbidity and 1-year readmissions increased contrary to mortality. Median age remained stable around 83 (IQR 77-88) for women and 80 (IQR 73-86) for men.Interpretation - Over the past 2 decades important aspects of hip fracture management have improved. However, sex differences were observed, and men remain more vulnerable than women in terms of morbidity, mortality, and incidence rate.

Effects of a modified muscle sparing posterior technique in hip hemiarthroplasty for displaced intracapsular fractures on postoperative function compared to a standard lateral approach (HemiSPAIRE): protocol for a randomised controlled trial

INTRODUCTION

Currently National Institute for Health and Care Excellence clinical guidelines in the UK suggest that surgeons performing partial hip replacements (hemiarthroplasty) should consider using the lateral approach. Alternatively, a newer, modified posterior approach using a muscle sparing technique named 'Save Piriformis and Internus, Repairing Externus' (SPAIRE) can be used leaving the major muscles intact. This randomised controlled trial (RCT) aims to compare the SPAIRE approach to the standard lateral approach, to determine if it allows patients to mobilise better and experience improved function after surgery.

METHODS AND ANALYSIS

HemiSPAIRE is a two-arm, assessor-blinded, definitive pragmatic RCT with nested pilot and qualitative studies. Two hundred and twenty-eight participants with displaced intracapsular fractures requiring hip hemiarthroplasty will be individually randomised 1:1 to either the SPAIRE, or control (standard lateral approach) surgical procedure. Outcomes will be assessed at postoperative day 3 (POD3) and 120 (POD120). The primary outcome measure will be level of function and mobility using the Oxford Hip Score at POD120. Secondary outcomes include: De Morton Mobility Index (DEMMI), Cumulated Ambulatory Score and Numeric Pain Rating Scale (NPRS) at POD3; DEMMI, NPRS and EQ-5D-5L at POD120, complications, acute and total length of hospital stay, and mortality. Primary analysis will be on an intention-to-treat basis. Participant experiences of the impact of surgery and recovery period will be examined via up to 20 semi-structured telephone interviews.

ETHICS AND DISSEMINATION

The protocol has been approved by Yorkshire and the Humber-Bradford Leeds Research Ethics Committee. Recruitment commenced in November 2019. Findings will be disseminated via research articles in peer-reviewed journals, presentations at conferences, public involvement events, patient groups and media releases. A summary of the trial findings will be shared with participants at the end of the study.

TRIAL REGISTRATION NUMBER

NCT04095611.

Evaluation of spin in the abstracts of orthopedic trauma literature: A cross-sectional review

OBJECTIVES

A cross-sectional analysis of orthopedic trauma randomized controlled trial (RCT) abstracts to assess the frequency and manifestations of spin, the misrepresentation or distortion of research findings, in orthopedic trauma clinical trials.

METHODS

The top 5 orthopedic trauma journals were searched from January 1, 2012, to December 31, 2017. RCTs with nonsignificant endpoints (p > .05) were analyzed for spin in the abstract. The primary endpoint of our investigation was the frequency and type of spin. The secondary endpoint was to assess whether funding source was associated with the presence of spin. Due to the low reporting of funding sources no statistics were able to be computed for this outcome.

RESULTS

Our PubMed search yielded 517 articles. Primary screening excluded 303 articles, and full text evaluation excluded an additional 161. Overall, 53 articles were included. Spin was identified in 35 of the 53 (66.0%) abstracts analyzed. Evidence of spin was found in 21 (39.6%) abstract results sections and 22 (41.5%) abstract conclusion sections. Of the 21 RCTs reporting a clinical trial registry, 3 (14.3%) had evidence of selective reporting bias.

CONCLUSIONS

Orthopedic trauma RCTs from highly ranked journals with nonsignificant endpoints published from 2012 to 2017 frequently have spin in their abstracts. Abstracts with evidence of spin may influence a reader's perception of new drugs or procedures. In orthopedic trauma, the implications of spin may affect the treatment of patients with orthopedic trauma, so efforts to mitigate spin in RCT abstracts must be prioritized.

Posterolateral or direct lateral approach for hemiarthroplasty after femoral neck fractures: a systematic review

BACKGROUND

The posterolateral approach (PLA) and direct lateral approach (DLA) are the most commonly used approaches for inserting a hemiarthroplasty in the treatment of femoral neck fractures. A recent review concluded that the routine use of PLA should be questioned, but this conclusion itself can be questioned. The aim of this study is to provide an updated overview and critical appraisal of the available evidence, focussing on outcomes most relevant for patients.

METHODS

We conducted a comprehensive search of literature in the MEDLINE and EMBASE databases and Cochrane Library. Studies (till June 2018) to identify hip fracture clinical trials/comparative studies comparing alternative surgical approaches (PLA and DLA). We explored sources of heterogeneity and conducted pooled analyses when appropriate.

RESULTS

264 potentially eligible studies were identified of which 1 RCT, 3 prospective, 3 registry data and 5 retrospective studies were included. The RCT consisted performance and attrition bias. The mean MINORS score of the prospective/register studies was 17.3 (SD 3.5) and 13.8 (SD 1.9) of the 5 retrospective studies. The GRADE score for all the outcomes was very low. Due to the high and various types of biases across the included studies, we did not pool the data. None of studies assessed the activities of daily living functionality. 6 studies reported significantly more dislocations or reoperations due to dislocation in the PLA group, 6 other studies found no differences. DLA patients were more likely to develop abductor insufficiency leading to limping and more need for walking aids. The PLA patients tended to have better quality of life, less pain and more satisfaction compared to the DLA patients.

CONCLUSION

Based on low-quality studies, PLA may be associated with more dislocations, but patients had less walking problems and a lower tendency to abductor insufficiency compared with DLA. Further clinical trials with methodology rigor are needed to determine which approach is more effective in terms of outcomes relevant to patients.

Clinical Outcomes of Total Hip Arthroplasty for Displaced Femoral Neck Fractures in Patients 80 Years of Age and Older Selected by Clinical Frailty Score

Purpose

The utility of total hip arthroplasty (THA) for the treatment of displaced femoral neck fractures in elderly patients (≥80 years of age) remains controversial as a patient's general condition is an essential factor impacting recovery. This study aims to determine if THA is a valuable option for appropriately selected elderly patients.

Materials and Methods

All patients underwent cementless THA using a direct lateral approach with a rectangular stem. Eighty-two patients ≥80 years of age underwent THA due to a displaced femoral neck. Clinical frailty scale (CFS) scores <5 were indicated for THA. The modified Harris hip score (mHHS), visual analogue scale (VAS), and patient satisfaction were used to assess outcomes.

Results

Nine of 82 patients died in the study period with another underlying disease. One, a 90-year-old male with pneumonia expired in the intensive care unit at 7-day postoperatively, while the other eight died due to causes unrelated to THA. Of the remaining 73 patients: (i) mean mHHS score increased to 80.57±21.36 at 1-year postoperatively; (ii) VAS was 2.3±0.9 points six-months postoperatively; and (iii) 78.7% of patients reported that they were very satisfied or satisfied 1-year postoperatively. The number of perioperative complications was 10.8% (9 hips) without the need for revision surgery.

Conclusion

The use of THA in patients ≥80 years of age with low CFS scores (<5) described here yielded favorable results and a relatively low rate of complications. However, a well-controlled comparative study or randomized trial is required to further refine selection criteria for THA in this patient population.

Survival Rate and Application Number of Total Hip Arthroplasty in Patients With Femoral Neck Fracture: An Analysis of Clinical Studies and National Arthroplasty Registers

BACKGROUND

Total hip arthroplasty (THA) is an increasingly popular treatment option for fractured neck of femur (NOF). The primary aim of this study is to systematically review all literature on primary THA and hemiarthroplasty (HA) after fractured NOF to calculate an overall revision rate. Furthermore, we wanted to compare primary THA implantations after fractured NOF between different countries in terms of THA number per inhabitant.

METHODS

All clinical studies on THA and HA for femoral neck fractures between 1999 and 2019 were reviewed and evaluated with a special interest on revision rate. Revision rate was calculated as "revision per 100 component years." THA registers were compared between different countries with respect to the number of primary implantations per inhabitant.

RESULTS

THA studies showed a mean revision rate of 11.8% after 10 years, which was lower than a 24.6% 10-year revision rate for HA. We identified 8 arthroplasty registers that revealed an annual average incidence of THA for fractured NOF of 9.7 per 100,000 inhabitants.

CONCLUSION

This study showed that patients with THA were less likely to be revised at 10 years compared to HA. We found similar annual numbers of THAs for fractured NOF per inhabitant across countries. The results of this analysis can be used to rank present and future national THA numbers within an international context.

Association between atrial fibrillation and hip fractures and the implications for hip fracture patients: a systematic review

BACKGROUND

Atrial fibrillation (AF) and hip fractures are both prevalent in the elderly population. The aim of this study was to systematically review the literature regarding the association between AF and hip fractures, and the impact of AF on hip fracture prognosis.

METHODS

The literature search was performed using PubMed, MEDLINE, Embase and Scopus. Inclusion was based upon the application of eligibility criteria in duplicate prior to data extraction with a standardized form.

RESULTS

A total of 42 studies met the inclusion criteria. AF prevalence was found to vary between 6.5% and 35% in cohorts. Large studies with broad inclusion criteria found the prevalence of AF in hip fracture patients to be approximately 12-15%. There were conflicting results as to whether patients with AF have an increased rate of hip fractures, as compared to patients without AF. Several studies demonstrated that hip fracture patients with AF have increased rates of mortality, both as an inpatient and following discharge, and increased readmission rates.

CONCLUSION

AF and hip fractures frequently coexist, and there is evidence to suggest AF is associated with increased readmission and mortality rates in hip fracture patients. Elements of the relationship between AF and hip fractures remain uncertain and further prospective studies on AF and hip fracture cohorts may clarify this relationship. Interventional studies targeting hip fracture patients with AF may be beneficial.

Mechanical failure of articulating polymethylmethacrylate (PMMA) spacers in two-stage revision hip arthroplasty: the risk factors and the impact on interim function

BACKGROUND

This study aimed to investigate the risk factors for mechanical failure of cement spacers and the impact on hip function after two-stage exchange arthroplasty for periprosthetic joint infection (PJI).

METHODS

Thirty-one patients (19 males and 12 females) with hip PJIs underwent resection arthroplasty and implantation of cement spacers from January 2014 to December 2015. Patients who encountered spacer-associated mechanical complications in the interim period (14 of 31) were compared with those without complications (17 of 31). Complications were defined as spacer dislocation, spacer fracture, spacer fracture with dislocation, and femoral fracture during or following spacer implantation. Hip functional outcome was assessed using the Harris hip score (HHS). Treatment success was defined according to the following criteria: (1) no symptoms or signs indicative of infection; (2) no PJI-related mortality; and (3) no subsequent surgical intervention for infection after reimplantation surgery. Multivariate logistic regression and Kaplan-Meier survival curves were used for analysis.

RESULTS

Fourteen patients (14/31 = 45%) suffered at least one spacer-related complication within the interim period. The development of spacer complications was associated with a younger age (odds ratio [OR] 0.91, 95% confidence interval [CI] 0.83-1.00, p = 0.045) and chronic PJI (OR 14.7, 95% CI 1.19-182, p = 0.036). Patients with spacer complications also had a lower median HHS (37 vs. 60, p < 0.001) before reimplantation in comparison to those without spacer complications. After reimplantation, the two groups had a similar median HHS (90 vs. 89, p = 0.945). Two patients did not undergo reimplantation due to extensive comorbidities, and subsequently retained the antibiotic spacer for definitive treatment. The 2-year treatment success rate was 84.6% in the spacer-complication group and 87.5% in the non-spacer-complication group (p = 0.81).

CONCLUSION

There was a high complication rate for articulating PMMA spacers during the interim period of two-stage revision total hip arthroplasty. A young age and chronic infection were the primary risk factors associated with mechanical complications. Patients at high risk of spacer-related mechanical complications should be advised accordingly by surgeons. Knowing the possible risk factors, surgeons should educate patients thoroughly to avoid spacer complications, thereby increasing patient satisfaction in the interim stage.

LEVEL OF EVIDENCE

Prognostic Level III.

High risk of positive Trendelenburg test after using the direct lateral approach to the hip compared with the anterolateral approach: a single-centre, randomized trial in patients with femoral neck fracture

Aims

The aim of this randomized trial was to compare the functional outcome of two different surgical approaches to the hip in patients with a femoral neck fracture treated with a hemiarthroplasty.

Patients and Methods

A total of 150 patients who were treated between February 2014 and July 2017 were included. Patients were allocated to undergo hemiarthroplasty using either an anterolateral or a direct lateral approach, and were followed for 12 months. The mean age of the patients was 81 years (69 to 90), and 109 were women (73%). Functional outcome measures, assessed by a physiotherapist blinded to allocation, and patient-reported outcome measures (PROMs) were collected postoperatively at three and 12 months.

Results

A total of 11 patients in the direct lateral group had a positive Trendelenburg test at one year compared with one patient in the anterolateral group (11/55 (20%) vs 1/55 (1.8%), relative risk (RR) 11.1; p = 0.004). Patients with a positive Trendelenburg test reported significantly worse Hip Disability Osteoarthritis Outcome Scores (HOOS) compared with patients with a negative Trendelenburg test. Further outcome measures showed few statistically significant differences between the groups.

Conclusion

The direct lateral approach in patients with a femoral neck fracture appears to be associated with more positive Trendelenburg tests than the anterolateral approach, indicating a poor clinical outcome.

Cite this article: Bone Joint J 2019;101-B:793–799.

Hip precautions not meaningful after hemiarthroplasty due to hip fracture. Cluster-randomized study of 394 patients operated with direct anterolateral approach

AIMS

We aimed to compare two treatment regimes, one with and one without postoperative precautions in hemiarthroplasty patients, in terms of dislocation rate and patient-reported outcome. Direct lateral approach was used.

PATIENTS AND METHODS

394 patients were included in a cluster-randomized study 2010-2014. Depending on which ward they were admitted to, they were allotted to free rehabilitation (non-precaution group, NPG, n = 226) or our conventional regime with precautions and mandatory assistive equipment (precaution group, PG, n = 168). Patients were followed during hospital stay, at 6 weeks (postal questionnaire), 3 month (visit) and 6 months (reading of medical records) by means of function tests, health-related quality of life (EQ-5D) and other patient-reported outcome measures (PROM).

RESULTS

One patient in each group had dislocation(s). We found no statistically significant differences regarding in-hospital-mortality, severe adverse events, EQ5D index or other PROM. In the NPG, rehabilitation personnel had significantly shorter work effort during hospital stay (p < 0.001). 7 in the NPG and 13 of the PG had reoperations (p = 0.038), 4 and 8 had deep infections, 3 and 5 periprosthetic fractures.

CONCLUSION

Rehabilitation precautions are not needed for preventing dislocation when direct lateral approach is used. Without precautions, rehabilitation personnel implement significantly shorter work effort during hospital. We found no statistically significant differences regarding PROM and complications except for somewhat more reoperations in total in the precaution group.

A scoping review comparing two common surgical approaches to the hip for hemiarthroplasty

Background

Hemiarthroplasty for hip fracture is a common surgical procedure. A number of distinct approaches are used to access the hip joint. The most commonly used are the direct lateral approach (DLA), and the posterior approach (PA). Internationally there is little consensus on which of these approaches to use. Current guidance is based on a limited selection of evidence and choice of approach is frequently based on surgeon preference. Historically, recommendations have been made based on dislocation rates. In light of technical advancements and greater recognition of patient priorities, outcomes such as post-operative function and pain may be considered more important in the modern context. The aim of this scoping review was to summarise the literature pertaining to the comparison of common surgical approaches to the hip for hemiarthroplasty.

Methods

A scoping review methodology was used to examine the range and nature of primary research. Using systematic methods we searched for studies that directly compared the DLA and PA. Studies reporting the following outcomes were considered; dislocation, mortality, pain, activities of daily living, functionality, health-related quality of life, length of stay, surgeon assessment of difficulty, and adverse events. MEDLINE, EMBASE and The Cochrane Library were searched. Relevant information was extracted and synthesis of the retrieved data followed a basic content analytical approach.

Results

A total of 13 studies were retrieved: 12 observational studies and 1 randomised trial. The majority of studies were based at single sites. Larger observational studies using multi-site and national registry data have emerged in recent years. Reporting of technique and outcomes is inconsistent. A trend for higher rates of dislocation using the PA was observed and eight studies recommended the use of the DLA over the PA.

Conclusions

This scoping review demonstrates that the existing evidence is highly heterogeneous in nature and not of a sufficient quality to inform practice recommendations. This issue would be best addressed by additional RCTs, and high quality national-level observational data. Standardisation of the recording of patient risk factors, surgical and post-operative intervention protocols, and outcomes in all study designs would strengthen the potential for valid comparison of future findings.

Complications following 250 cemented modular hip hemiarthroplasties

Background and Aims:

Hemiarthroplasty is a common method of treating displaced femoral neck fractures, especially among elderly non-active patients with frailty syndrome. Complications arising from the use of a modern, modular hemiendoprosthesis via a posterior approach have been poorly reported in this population. The aim of this study was to evaluate complications and mortality associated with the use of Lubinus sp II cemented, unipolar hemiarthroplasty prosthesis and posterior approach during a 9-year follow-up.

Material and Methods:

All patients (244) who received hemiarthroplasty due to an acute fracture of the femoral neck in Central Finland Hospital, Jyvaskyla, Finland, during 2007 and 2008 were included. Patient records were retrospectively reviewed for intraoperative and postoperative complications.

Results and Conclusion:

Women composed 70% (n = 171) of the study population. Mean age was 83 years for women and 80 years for men. A total of 31 (12%) complications were found in 30 patients. These were 12 dislocations (5% of all patients), 5 (2%) periprosthetic fractures, 2 (0.8%) superficial and 5 (2%) deep infections, 1 (0.4%) protrusion of the prosthesis, 2 (0.8%) intraoperative fractures, and 2 (0.8%) partial sciatic nerve palsies. Conversion to total hip replacement was performed in 9 cases (4%) and a reoperation was required in 15 (6%) cases. Mortality rate at 9 years was 78% (95% confidence interval = 72%–83%). The overall rate of complications was acceptable although mortality was high in this comorbid patient population. The need for conversion to total hip arthroplasty and reoperation is low.

Hip Hemiarthroplasty in Neurologic or Cognitively Impaired Patients: A Case Series of Post-operative Dislocations

Introduction:

Hemiarthroplasty is the operation of choice for displaced intracapsular neck of femur fracture in elderly patients with low physical demands. Dislocation in this frail patient cohort can have devastating consequences. The patients with neurological and cognitive impairment are at additional risk secondary to imbalance of muscle tone and a reduced ability to engage with rehabilitation.

Case Report:

We present three cases of early post-operative dislocation of hip hemiarthroplasties, all of whom suffered from neurological and cognitive impairment, and highlight the uncontrollable patient factors that contributed to dislocation.

Conclusion:

The posterior approach was associated with all cases of dislocation in patients who also were neurologic or cognitively impaired. Posterior approach is safe to perform in the general population for hip hemiarthroplasty; however, the surgeon should consider avoiding the use of the posterior approach in this high-risk group.

Surgical Approaches and Hemiarthroplasty Outcomes for Femoral Neck Fractures: A Meta-Analysis

BACKGROUND

The lateral approach (LA), posterior approach (PA), and anterior approach (AA) are conventional surgical access routes for hemiarthroplasty in proximal femoral fractures. This meta-analysis assesses and compares the outcomes and attempts to identify the best approach for hemiarthroplasty in the treatment of proximal femoral fractures.

METHODS

An electronic search was performed from inception to October 25, 2017, for comparative studies including at least 2 of the conventional approaches. Outcomes including operation time, surgical blood loss, perioperative fractures, wound infections, dislocations, and hospital length of stay were plotted in forest plots.

RESULTS

Twenty-one eligible studies were selected including 3 randomized, controlled trials, 7 prospective and 11 retrospective cohort studies. The odds ratio (OR) for dislocations was significantly higher for the PA compared with the AA (OR, 2.61; 95% confidence interval [CI], 1.26 to 5.43; P = .01) and the LA (OR, 2.90; 95% CI, 1.63 to 5.14; P = .0003). The PA had a higher risk of reoperation compared to the AA (OR, 1.25; 95% CI, 1.12 to 1.41; P < .0001). No significant differences were found concerning perioperative fractures, wound infections, and hospital length of stay. Some studies suggest a better short-term functional outcome using the AA compared to the PA.

CONCLUSION

The PA for hemiarthroplasty in proximal femoral fractures poses an increased risk of dislocation and reoperation compared to the LA and AA. There are no evident advantages of the PA and its routine use for fracture-related hemiarthroplasty should be questioned.

Posterior hip approach yields better functional results vis-à-vis anterolateral approach in total hip arthroplasty for patients with severe hip dysplasia: A prospective randomized controlled clinical study

OBJECTIVES

We aimed to compare functional outcomes of two common hip approaches for patients with severe hip dysplasia in total hip replacement (THR) surgery.

MATERIALS AND METHODS

Seventy hips of 68 patients randomized into two groups with regard to hip approach as posterior (group I) and anterolateral (group II). All patients underwent THR surgery with femoral shortening osteotomy. The groups were compared for operation time, preoperative and 6 months after abductor muscle strengths (AMSs), gait disorders, union time of the osteotomied site and dislocation rates.

RESULTS

There were two early dislocations in group I, and two early and one late dislocations in group II. No significant difference was observed regarding hip dislocations. Mean union time of the osteotomied site was 113.9 ± 51 days in group I while 111.1 ± 29.3 days in group II ( p = 0.774). Six months after surgery, group I had higher AMS than group II ( p < 0.0001). More patients in group II had Trendelenburg gait pattern ( p = 0.043), while no difference was observed regarding antalgic and deviated gait patterns between groups.

CONCLUSION

THR surgery for patients with severe developmental dysplasia of hip is a challenging procedure, and posterior approach provides better functional outcomes regarding gait and AMSs.

Lateral and Posterior Approaches in Hemiarthroplasty

PURPOSE

Hemiarthroplasty is a common treatment for patient with a fragility displaced femoral neck fracture. We compared lateral and posterior approaches with respect to need for mobility aids, mobility level, living arrangements, pain, hip dislocation, and survival 12 months after hip fracture.

METHODS

A total of 393 fragility femoral neck fracture patients aged 65 years or more who underwent hemiarthroplasty were observed for 12 months. Patient information was collected on admission, during hospitalization, and by telephone interview 1 year after the hip fracture. A total of 269 patients were included in the final analysis.

RESULTS

At 1 year after hip fracture, more patients undergoing hemiarthroplasty with the posterior approach (22%) survived without mobility aids compared to those with the lateral approach (12%; p = 0.026). Multivariate logistic regression analysis revealed that the need for mobility aids 1 year after hip fracture was significantly predicted by the use of mobility aids before the fracture (odds ratio = 13.46, 95% confidence interval = 4.29-42.25), age ≥85 years (odds ratio = 3.85, 95% confidence interval = 1.09-13.44), male sex (odds ratio = 3.59, 95% confidence interval = 1.05-12.22), and lateral approach (odds ratio 2.73, 95% confidence interval 1.15-6.50). The posterior approach resulted in four (3.4%) dislocated hips, compared with none by the lateral approach. Survival, mobility level, pain in the operated hip, and living arrangements 1 year postoperatively were not significantly different between groups.

CONCLUSION

Hemiarthroplasty using a lateral approach predisposed to the need for ambulatory aids 1 year after hip fracture. The posterior approach, however, predisposed to hip dislocation. Patient selection must be considered when deciding the appropriate surgical approach.

Reduced revision rate and maintained function after hip arthroplasty for femoral neck fractures after transition from posterolateral to direct lateral approach

Background and purpose - The direct lateral (DL) approach to the hip for femoral neck fractures (FNF) has been shown to reduce the rate of dislocation and reoperations. We evaluate the effect of transition from the posterolateral (PL) to DL approach on reoperation and dislocation rates and patients' reported outcome. Patients and methods - In a prospective cohort study between 2012 and 2015, we enrolled 362 patients (median age 83 years, 70% women, mean follow-up 25 months) with a displaced FNF. The first group of 146 patients were operated using the PL and the second group of 216 patients with a DL approach, after change of our routines. A multivariable Cox regression analysis was used to evaluate factors associated with dislocation and reoperation. A generalized linear model was used to evaluate the functional outcome by comparing WOMAC and Harris hip scores between the 2 groups. Results - The reoperation rate was reduced from 13% in the PL to 6% in the DL group and the dislocation rate from 13% to 4%. Cox proportional hazard analysis identified the PL approach as the only factor associated with an increased risk of reoperation (hazard ratio =2.5, 95% CI 1.2-5.2). Age, sex, ASA classification, type of arthroplasty, cognitive dysfunction, or the experience of the surgeon had no effect on the risk of reoperation. Patient-reported outcome was similar between the 2 groups. Interpretation - In patients with FNF we have reduced the reoperation and dislocation rates by changing the surgical approach used for hip arthroplasty without affecting the patient-reported functional outcome.

Evidence based management of intracapsular neck of femur fractures

Neck of femur fractures are occurring at an increased incidence. Functionally independent patients without cognitive impairment can expect reasonable life expectancy. This indicates the need for a durable surgical option that optimises the chance to return to pre-injury functional status, with minimal risk of complications and reoperation. Most fractures are displaced. Surgical options include internal fixation, hemiarthroplasty or total hip arthroplasty (THA). Evidence is conclusive that arthroplasty options outperform internal fixation in terms of function, quality of life and reoperation rates. In anyone other than young patients where head preserving surgery is required, arthroplasty is the standard of care. Hemiarthroplasty is the heavily favoured arthroplasty option for surgeons. However, in patients other than the extreme elderly, medically infirm, neurologically impaired, or with little or no ambulatory capacity, the evidence to support hemiarthroplasty is lacking. In functionally independent patients without cognitive impairment, THA should be considered the gold standard, producing better functional and quality of life outcomes, lower reoperation rates and better cost effectiveness, with no difference in complications or mortality. An increased risk of dislocation does exist. This may be reduced with modern surgical technique and implant options. Low amounts of research have been afforded to undisplaced fractures. For this fracture type, surgery is the standard of care. Despite a higher risk of reoperation, internal fixation is the preferred option for all age groups. Further study is required to identify the difference between internal fixation and THA, in particular, for unstable fracture patterns in elderly patients.

A systematic review and meta-analysis of the direct anterior approach for hemiarthroplasty for femoral neck fracture

BACKGROUND

We performed a systematic review and meta-analysis to assess whether the direct anterior approach (DAA) is associated with improved functional and clinical outcomes compared to other surgical approaches for hemiarthroplasty for displaced femoral neck fractures.

MATERIALS AND METHODS

Randomized trials and cohort studies of hemiarthroplasty performed via DAA versus another surgical approach (anterolateral, lateral, posterolateral, posterior) were included. Our primary outcome was postoperative functional mobility. Secondary outcomes included overall complication rate, dislocation rate, perioperative fracture, infection rate, re-operation rate, overall mortality, operative time, pain, intra-operative blood loss, and length of stay.

RESULTS

Nine studies met inclusion criteria, comprising a total of 698 hips (330 direct anterior, 57 anterolateral, 89 lateral, 114 posterolateral, 108 posterior approach). With regard to functional mobility, DAA was favored in 4 studies, and no study favored another approach over DAA. DAA had a significantly lower dislocation rate compared to posterior capsular approaches. Analysis of other secondary outcomes did not identify statistically significant differences.

CONCLUSION

This is the first systematic review and meta-analysis of the DAA for hemiarthroplasty. Available evidence suggests superior early functional mobility with the DAA. The DAA is associated with a significantly lower dislocation rate compared to posterior capsular approaches for hemiarthroplasty.

Posterior versus lateral approach for hemiarthroplasty after femoral neck fracture: Early complications in a prospective cohort of 583 patients

AIM

To compare early complications after the posterior and the direct lateral (transgluteal) approach, when using hemiarthroplasty in the treatment of displaced femoral neck fractures in the elderly.

PATIENTS AND METHODS

A prospective clinical study from four Norwegian hospitals, consisting of 583 patients with 1year follow-up. All the hospitals used the same uncemented femoral stem and bipolar heads. Data were collected for gender, age, surgical approach, prosthetic dislocation, postoperative infection, perioperative fracture, duration of surgery, ASA score, diabetes, alcoholism, cognitive failure, BMI, 30-day mortality and 1-year mortality.

RESULTS

Mean age was 83 years (SD 7.8) and 434/583 (74%) were female. There were no relevant differences between the treatment groups. A higher risk was found for prosthetic dislocation in the posterior group compared to the lateral group (15/186 (8%) vs. 4/397 (1%); RR=8.0, 95% CI 2.7-23.8, p-value<0.001), both as a one-time event and for the risk of recurrent dislocations (9/186 (5%) vs. 2/395 (0.5%); RR 9.6, 95% CI 2.1-44.0, p-value=0.001). 11/19 patients with dislocation had recurrent dislocations. 10/11 patients with more than one dislocation needed further open surgery. Of those 6/10 needed more than one additional open procedure. Three patients had a resection arthroplasty and one patient had a chronic infection as final result after a dislocation. No other risk factor for dislocation than surgical approach was identified. There were no differences between the approach groups for other complications.

CONCLUSION

There was an 8-fold increased risk for prosthetic dislocations after the posterior approach compared to lateral approach. There was a high risk for recurrent prosthetic dislocations and a subsequent risk for further surgeries and a poor end result. The potential advantages of the posterior approach have not been demonstrated after femoral neck fractures and we advise against its continued use.

Quantifying Blood Loss and Transfusion Risk After Primary vs Conversion Total Hip Arthroplasty

BACKGROUND

Primary total hip arthroplasty (THA) and conversion THA may result in substantial blood loss, sometimes necessitating transfusion. Despite the complexities of the latter, both are grouped in the same category for quality assessment and reimbursement. This study's purpose was to compare both blood loss and transfusion risk in primary and conversion THA and identify their associated predictors.

METHODS

A total of 1616 patients who underwent primary and conversion THA at a single hospital from 2009-2013 were reviewed (primary THA = 1575; conversion THA = 41). Demographics, comorbidities, and perioperative data were collected from electronic records. Blood loss was calculated using a validated method. Transfusion triggers were based on standardized criteria. Separate multivariable regression models for blood loss and transfusion were performed.

RESULTS

Conversion THA patients were younger (P = .002), had lower age-adjusted Charlson scores (P = .006), longer surgeries (P < .001), higher blood loss (P < .001), and more transfusions (P < .001). Primary and conversion THA groups were different in terms of surgical approach (P < .001), anesthesia type (P = .002), and venous thromboembolism prophylaxis (P = .01). Compared to primary THA, conversion THA had an average 478.9 mL higher blood loss (P = .003) and increased adjusted odds ratio of 3.2 (P = .019) for transfusion.

CONCLUSION

Conversion THA leads to higher blood loss and transfusion compared with primary THA. These differences were quantified in the present study and showed consistent results between the 2 metrics. The differences between these procedures should be addressed during quality assurance because conversion THA is associated with higher resource utilization, which is important in the allocation of resources and tiered reimbursement strategies.

Posterior approach compared to direct lateral approach resulted in better patient-reported outcome after hemiarthroplasty for femoral neck fracture

Background and purpose - Hemiarthroplasty (HA) is the most common treatment for displaced femoral neck fractures in many countries. In Norway, there has been a tradition of using the direct lateral surgical approach, but worldwide a posterior approach is more often used. Based on data from the Norwegian Hip Fracture Register, we compared the results of HA operated through the posterior and direct lateral approaches regarding patient-reported outcome measures (PROMs) and reoperation rate. Patients and methods - HAs due to femoral neck fracture in patients aged 60 years and older were included from the Norwegian Hip Fracture Register (2005-2014). 18,918 procedures were reported with direct lateral approach and 1,990 with posterior approach. PROM data (satisfaction, pain, quality of life (EQ-5D), and walking ability) were reported 4, 12, and 36 months postoperatively. The Cox regression model was used to calculate relative risk (RR) of reoperation. Results - There were statistically significant differences in PROM data with less pain, better satisfaction, and better quality of life after surgery using the posterior approach than using the direct lateral approach. The risk of reoperation was similar between the approaches. Interpretation - Hemiarthroplasty for hip fracture performed through a posterior approach rather than a direct lateral approach results in less pain, with better patient satisfaction and better quality of life. The risk of reoperation was similar with both approaches.

Direct lateral vs posterolateral approach to hemiarthroplasty for femoral neck fractures

INTRODUCTION

Adopting the direct lateral (DL) instead of the posterolateral (PL) approach in hip arthroplasty for femoral neck fracture (FNF) patients could lower the rate of prosthetic dislocation. However, little is known about how the approach influences the functional outcome.

HYPOTHESIS

We hypothesized that both approaches would give comparable results.

MATERIAL AND METHODS

In a prospective cohort study, we enrolled 185 hips (183 patients, 128 women, median age 84 years) with a displaced FNF. Subjects were assigned to treatment using DL (n=102) or PL approach (n=83) with a hemiarthroplasty (HA). Functional outcome was assessed by Harris Hip Score (HHS), Western Ontario and McMaster Universities Arthritis (WOMAC) index, pain numeric rating scale (PNRS) for pain, mortality and hip complications. Patients were followed-up after 1 year.

RESULTS

The HHS was 71 (SD 18) in the DL group and 72 (SD 17) in the PL group (P=0.59). We found no difference in WOMAC, PNRS and mortality. Seven patients (6.9%) in the DL group and 11 patients (13.3%) in the PL group had undergone a major reoperation (adjusted OR 0.51; 95% CI, 0.18-2.07; P=0.23).

DISCUSSION

In this prospective cohort study, patients treated with HA for FNF using either the DL or PL approaches had comparable functional outcome after 1 year. The PL approach had a tendency towards a higher reoperation rate.

TYPE OF STUDY

Prospective cohort study.

LEVEL OF PROOF

Level 2.

The surgical approach for hemiarthroplasty does not influence patient-reported outcome

Aims

Hemiarthroplasty of the hip is usually carried out through either a direct lateral or posterior approach. The aim of this prospective observational study was to determine any differences in patient-reported outcomes between the two surgical approaches.

Patients and Methods

From the Swedish Hip Arthroplasty Register we identified patients of 70 years and above who were recorded as having had a hemiarthroplasty during 2009. Only patients who had been treated with modern prostheses were included. A questionnaire was posted to those who remained alive one year after surgery. A total of 2118 patients (78% of those available) with a mean age of 85 years (70 to 102) returned the questionnaire.

Results

Patients who had undergone surgery through a posterior approach reported a higher health-related quality of life (HRQoL, EQ-5D mean 0.52 versus 0.47, p = 0.009), less pain (visual analogue scale mean 17 versus 19, p = 0.02) and greater satisfaction with the result of surgery (visual analogue scale mean 22 versus 24, p = 0.02) than those who had a direct lateral approach. However, after adjusting for age, gender, cognitive impairment and American Society of Anesthesiologists grade, no association was found between surgical approach and HRQoL, residual pain or patient satisfaction. Take home message: The surgical approach for hemiarthroplasty does not seem to affect the patient-perceived HRQoL, residual pain or patient satisfaction one year after surgery on elderly patients. The choice of approach should be based on other factors, such as the risk of dislocation. Cite this article: Bone Joint J 2016;98-B:542–7.

Hip arthroplasty for the treatment of displaced fractures of the femoral neck in elderly patients

This review summarises the evidence for the treatment of displaced fractures of the femoral neck in elderly patients. Results from randomised clinical trials and national register studies are presented when available.

The advantages of arthroplasty compared with internal fixation are supported by several studies. A number of studies contribute to the discussions of total hip arthroplasty (THA) versus hemiarthroplasty and unipolar versus bipolar hemiarthroplasty, but no clear-cut evidence-based recommendation can be made. THA may be particularly advantageous for active, lucid patients with a relatively long life expectancy. For patients who are physiologically older, hemiarthoplasty is probably satisfactory, and for the oldest patients with more comorbidities, unipolar implants are considered to be sufficient. If the hospital can support emergency THA surgery in sufficient numbers and quality, there may be few patients who warrant bipolar hemiarthroplasty.

The direct lateral approach reduces the risk of dislocation compared with the posterior approach. Cemented implants lower the risk of periprosthetic fracture and its subsequent morbidity and mortality. As the risk of peri-operative death related to bone cement can be reduced by adequate measures, cemented implants are recommended in fracture cases.

Take home message: There remains a great variation in the surgical management of patients with a hip fracture, and an evidence-based approach should improve the outcomes for this vulnerable patient group.

Cite this article: Bone Joint J 2016;98-B:291–7.