Direct lateral vs posterolateral approach to hemiarthroplasty for femoral neck fractures

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 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.

Fraturas intracapsulares do colo femoral no idoso

Currently, intracapsular femoral neck fracture (IFNF) is still a great challenge for orthopedists. In spite of the progress that has been made, a high mortality rate persists in the first year, especially in Brazil, where there is no awareness that such fractures in elderly patients should be treated as a medical emergency. The present article seeks to provide an update on the preoperative, surgical, and postoperative approaches.

Direct anterior approach provides better functional outcomes when compared to direct lateral approach in hip hemiarthroplasty following femoral neck fracture

PURPOSE

This study aims to compare the differences between direct anterior approach (DAA) and direct lateral approach (DLA) in hip hemiarthroplasty (HHA) after displaced femoral neck fracture (FNF) in early functional outcome, hospital length of stay, morbidity and mortality rates.

METHODS

This non-interventional retrospective study, carried out at a tertiary trauma centre within the Spanish National Health System, included all patients who underwent a bipolar HHA between 1st January 2018 and 31st December 2019 performed by 2 of our hip unit surgeons.

RESULTS

A total of 94 patients were included (40 in DAA group and 54 in DLA group). Median follow-up was 19.2 months (range 8-30.8 months). Postoperative degree of mobilisation showed statistically significant differences in favour of DAA group, where 35% of patients were able to walk with no assistance after surgery. DAA group had 1 day less of hospitalisation in contrast with DLA group overall (8 days vs 9 days, respectively, p < 0.05). Statistically significant differences were not detected in comparing postoperative complications, re-operations rates or 6-months mortality rate.

CONCLUSION

Our study highlights the benefits of DAA for HHA after displaced FNF in terms of postoperative mobilisation degree and hospitalisation length of stay when compared to DLA.

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.

Factors affecting dislocation after bipolar hemiarthroplasty in patients with femoral neck fracture

PURPOSE

This study aimed to investigate the anatomic risk factors associated with dislocation following bipolar hemiarthroplasty for the treatment of femoral neck fracture.

MATERIALS AND METHODS

We retrospectively reviewed 208 consecutive patients (133 women, 75 men) with femoral neck fractures who were treated with bipolar hemiarthroplasty between 2015 and 2018. A comparative analysis was performed between dislocation (n = 18) and non-dislocation (n = 190) groups in terms of patient demographics, surgical and pelvic morphologic factors, and clinical outcomes, including postoperative Harris and modified Harris hip scores. Independent risk factors affecting dislocation were also evaluated.

RESULTS

The mean follow-up period was 30.8 ± 2.0 (range, 12-48) months. The mean age was 79.2 ± 7.4 (range, 71-94) years. The dislocation rate was 8.6% (18/208), and the mean dislocation time after operation was 2.0 ± 1.1 (range, 1-4) months. Patient-related factors did not differ between the dislocated and non-dislocated groups. As regards dislocation, statistically significant difference was observed in surgical and pelvic morphologic factors, including femoral offset, residual femoral neck length, trochanter upper end and femoral head center distance, and height of the hip center of the operated side (p = 0.025, p = 0.013, p = 0.002, p = 0.008, respectively). Moreover, the femoral offset, height of the hip center, and femoral neck-shaft angle of the non-operated side are significantly different between the groups (p = 0.007, p = 0.001, p = 0.027, respectively). Decrease in the center edge (CE) angle, offset of prosthesis, and increase in femoral head extrusion index (FHEI) of the operated side and decrease in the height of the hip center of the non-operated side increased the risk of dislocation (p = 0.030, OR: 1,306; p = 0.041, OR: 8.15; p = 0.020, OR: 1.038; p = 0.010, OR: 2.02, respectively).

CONCLUSIONS

Pelvic morphologic features and surgical factors were found to affect dislocation. Patients with smaller OP, CE angle of the operated side, and higher FHEI and smaller height of the hip center of the non-operated side should be carefully monitored to decrease postoperative dislocation.

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.

The influence of bone cement and American Society of Anesthesiologists (ASA) class on cardiovascular status during bipolar hemiarthroplasty for displaced femoral-neck fracture: A multicenter, prospective, case-control study

BACKGROUND

Little is known about how bone cement and American Society of Anesthesiologists (ASA) classification influence the cardiovascular system in elderly patients with femoral-neck fractures treated with cemented hemiarthroplasty. Therefore, we performed a case-control study to investigate these questions and compared the following:≥ASA III with≤ASA II patients who underwent cemented hemiarthroplasty; and cemented with cementless hemiarthroplasty in≥ASA III patients.

HYPOTHESIS

ASA classification influences the cardiovascular system during cemented hemiarthroplasty and bone cement influences intraoperative blood pressure [IBP] in patients rated≥ASA III.

MATERIALS AND METHODS

This multicenter, prospective study included patients with acute displaced femoral-neck fractures. Baseline data, medical history, anesthesia, FiO₂, vasopressor use, femoral component, IBP, SpO₂, and complications were evaluated. Of 200 patients, 100 were cemented (mean age, 77±10 years), and 100 were cementless (mean age, 78±9 years). Cemented hemiarthroplasty employed a third-generation technique (plugging, irrigating, drying and filling the canal with cement under pressurization).

RESULTS

Systolic blood pressure (SBP) decreased significantly during cementing, versus pre-rasping in≤ASA II patients (from 117.9±24.5 [range, 65-199] to 106.9±20.3 [range, 59-172]; p=0.007), in≥ASA III patients (from 129.5±21.0 [range, 90-169] to 110.4±17.9 [range, 79-157]; p=0.006), and post-stem-insertion, versus pre-rasping in≤ASA II patients (from 117.9±24.5 [range, 65-199] to 103.9±20.7 [range, 53-178]; p=0.0004), and in≥ASA III patients (from 129.5±21.0 [range, 90-169] to 111.2±24.6 [range, 70-156]; p=0.009). In≥ASA III patients, SBP decreased significantly during cementing or rasping, versus pre-rasping in cemented patients (from 129.5±21.0 [range, 90-169] to 110.4±17.9 [range, 79-157]; p=0.006), in cementless patients (from 115.0±17.7 [range, 85-150] to 100.7±15.7 [range, 75-142]; p=0.004), and post-stem-insertion, versus pre-rasping in cemented patients (from 129.5±21.0 [range, 90-169] to 111.2±SD [range]; p=0.009), and in cementless patients (from 115.0±17.7 [range, 85-150] to 89.4±17.5 [range, 58-140]; p<0.0001). There were no lethal complications.

CONCLUSIONS

This study indicate a similar hemodynamic change intraoperatively between≤ASA II patients and≥ASA III patients in the cemented group, and between patients with cemented and cementless hemiarthroplasty in the≥ASA III patients. With modern hemiarthroplasty techniques, bone cement might be as safe as cementless techniques in elderly,≥ASA III patients.

LEVEL OF EVIDENCE

III, multicenter case-control cohort study.

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.