Minimally invasive anterior muscle-sparing versus a transgluteal approach for hemiarthroplasty in femoral neck fractures-a prospective randomised controlled trial including 190 elderly patients

Direct anterior and direct lateral approach in patients with femoral neck fractures receiving a total hip arthroplasty: a randomized controlled trial

BACKGROUND AND PURPOSE

 The optimal approach to the hip joint in patients with displaced femoral neck fractures (dFNF) receiving a total hip arthroplasty (THA) remains controversial. We compared the direct lateral approach (DLA) with the direct anterior approach (DAA) primarily on Timed Up and Go (TUG), and secondarily on the Forgotten Joint Score (FJS), the Oxford Hip Score (OHS), EQ5D-5L, and the EQ5D-VAS.

METHODS

 Between 2018 and 2023, we conducted a randomized controlled trial including elderly patients with dFNFs treated with THA. The primary outcome was the difference in TUG at 6 weeks postoperatively. Key secondary outcomes were TUG at 2, 12, and at 52 weeks postoperatively, and FJS, OHS, EQ5D-5L, and EQ5D-VAS at 2, 6, 12, and at 52 weeks postoperatively.

RESULTS

 130 patients with a mean age of 78.6 (standard deviation 1.2) were allocated to DAA (n = 64) or DLA (n = 66). There was no statistically significant difference in TUG times at 6 weeks postoperatively between the DAA and the DLA, 16.0 s (95% confidence interval [CI] 13.2-18.7) vs 17.8 s (CI 15.1-20.4), estimated mean difference -1.8 s (CI -5.7 to 2.0). However, patients who underwent DAA had a significantly higher FJS at 2, 6, and 12 weeks.

CONCLUSION

 Among elderly patients with dFNF we found no difference between DAA or DLA regarding crude mobility as demonstrated with the TUG test, but patients treated with DAA showed better outcomes in the FJS in the early post-fracture period though not at 52 weeks.

Enhancing recovery: surgical techniques and rehabilitation strategies after direct anterior hip arthroplasty

Total hip arthroplasty (THA) is a common surgical procedure for hip joint pathologies, with the direct anterior approach (DAA) gaining popularity due to potential benefits in postoperative recovery. This review aims to provide a comprehensive analysis of rehabilitation strategies following DAA THA, focusing on surgical techniques, postoperative care, and outcomes. The evolution of the DAA to THA is discussed, highlighting historical advancements and comparisons with other surgical approaches. Surgical techniques and considerations specific to the DAA are detailed, including outcomes and complications compared to alternative approaches. The role of the surgical technique in influencing postoperative rehabilitation is explored, emphasizing the importance of optimizing surgical procedures for enhanced recovery. Postoperative care and rehabilitation models following DAA THA are examined, with a focus on the impacts of different rehabilitation protocols on patient outcomes. The review underscores the significance of tailored rehabilitation programs in promoting optimal recovery and patient satisfaction. Current evidence from recent studies, meta-analyses, and clinical trials is critically analyzed to provide insights into the effectiveness of postoperative rehabilitation strategies. The review identifies gaps in the existing literature and proposes recommendations for future research to improve rehabilitation protocols and enhance outcomes. In conclusion, this review highlights the importance of postoperative rehabilitation in the context of DAA THA. By synthesizing historical perspectives, current evidence, and future directions, the review offers a comprehensive understanding of rehabilitation strategies following DAA THA. The findings underscore the need for personalized rehabilitation programs and ongoing research to optimize postoperative recovery and improve outcomes in the field of THA.

Indirect comparison in network meta-analysis between SuperPATH, direct anterior and conventional approach hemiarthroplasty in patients with femoral neck fracture

BACKGROUND

The aim of the study was to compare the short-term outcome of SuperPATH, direct anterior (DAA) and conventional approach (CA) hemiarthroplasty (HA) in patients with femoral neck fractures using a network meta-analysis.

METHODS

PubMed, China National Knowledge Infrastructure, Epistemonikos, and Embase were searched until May 31, 2024. In a network meta-analysis, mean differences with 95% confidence intervals were calculated using the Hartung-Knapp-Sidik-Jonkman method and a fixed/random effects model for continuous outcomes, and odds ratios with 95% confidence intervals were calculated using the Mantel-Haenszel method and a fixed/random effects model for dichotomous outcomes.

RESULTS

The literature search identified a total of 9 randomized controlled trials on SuperPATH with 762 patients and 8 randomized controlled trials on DAA with 641 patients. In the overall ranking, SuperPATH was placed first, DAA second and CA third. SuperPATH HA was best in 7, second best in 2 and third best in 1 of the 10 outcome parameters. DAA HA was best in 2 and second best in 8 of the 10 outcome parameters. CA HA was best in 1 and third best in 9 of the 10 outcome parameters. In the indirect comparison between SuperPATH HA and DAA HA, SuperPATH HA had a 1.36 point lower visual analog scale at 2 to 7 days postoperatively and a 0.17 lower overall complication rate compared to DAA.

CONCLUSION

For the treatment of patients with femoral neck fractures, SuperPATH HA ranked first, DAA HA ranked second and CA HA ranked third. Based on the results, we recommend that trauma surgeons increase their use of minimally invasive hip HA techniques. It should be noted that SuperPATH HA had a significantly lower overall complication rate compared to DAA HA when the minimally invasive technique was chosen.

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.

Frailty as an Effect Modifier in Randomized Controlled Trials: A Systematic Review

BACKGROUND

The effect of clinical interventions may vary by patients' frailty status. Understanding treatment effect heterogeneity by frailty could lead to frailty-guided treatment strategies and reduce overtreatment and undertreatment. This systematic review aimed to examine the effect modification by frailty in randomized controlled trials (RCTs) that evaluate pharmacological, non-pharmacological, and multicomponent interventions.

METHODS

We searched PubMed, Web of Science, EMBASE, and ClinicalTrial.gov, from their inception to 8 December 2023. Two reviewers independently extracted trial data and examined the study quality with senior authors.

RESULTS

Sixty-one RCTs that evaluated the interaction between frailty and treatment effects in older adults were included. Frailty was evaluated using different tools such as the deficit accumulation frailty index, frailty phenotype, and other methods. The effect of several pharmacological interventions (e.g., edoxaban, sacubitril/valsartan, prasugrel, and chemotherapy) varied according to the degree of frailty, whereas other treatments (e.g., antihypertensives, vaccinations, osteoporosis medications, and androgen medications) demonstrated consistent benefits across different frailty levels. Some non-pharmacological interventions had greater benefits in patients with higher (e.g., chair yoga, functional walking, physical rehabilitation, and higher dose exercise program) or lower (e.g., intensive lifestyle intervention, psychosocial intervention) levels of frailty, while others (e.g., resistance-type exercise training, moderate-intensive physical activity, walking and nutrition or walking) produced similar intervention effects. Specific combined interventions (e.g., hospital-based disease management programs) demonstrated inconsistent effects across different frailty levels.

DISCUSSION

The efficacy of clinical interventions often varied by frailty levels, suggesting that frailty is an important factor to consider in recommending clinical interventions in older adults.

REGISTRATION

PROSPERO registration number CRD42021283051.

Complications and early recovery following hip hemiarthroplasty through the direct anterior approach: a systematic review and meta-analysis

PURPOSE

Minimizing complications is an important focus in hip hemiarthroplasty (HHA) for femoral neck fracture (FNF) patients given the associated high morbidity and mortality rates. This systematic review and meta-analysis aimed to compare the clinical and functional outcomes associated with the direct anterior approach (DAA) compared to other surgical approaches used for HHA.

METHODS

Studies evaluating HHA-treated FNFs using the DAA were compared through meta-analysis to all other surgical approaches combined and as distinct subgroups. Outcomes included overall complication rate, mortality rate, dislocation rate, reoperation rate, periprosthetic fracture rate, infection rate, length of stay (LOS), mobility, perioperative blood loss, operative time, and postoperative pain.

RESULTS

Nineteen studies met the inclusion criteria, totaling 2,018 HHAs. DAA significantly reduced the overall complication rate (odds ratio (OR) = 0.73, 95% confidence interval (CI) 0.57 to 0.94, p = 0.01), dislocation rate (OR = 0.34, 95% CI 0.15 to 0.77, p = 0.01), and LOS (mean difference (MD) = -1.31 days, 95% CI  - 2.12 to  - 0.50, p = 0.002). Findings from studies that were not appropriate for meta-analysis were qualitatively summarized and suggested improved mobility and reduced postoperative pain with the DAA. Significant differences were not detected in any of the remaining outcomes.

CONCLUSION

The DAA HHA appears to be safer, reduces hospital stay, and may improve early functional recovery. This article supports the DAA HHA as a safe option for the management of displaced intracapsular FNFs.

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.

Direct Anterior Approach in Hip Hemiarthroplasty for Femoral Neck Fractures: Do Short-Term Outcomes Differ with Approach?: A Systematic Review and Meta-Analysis

BACKGROUND

Hip hemiarthroplasty (HA) is commonly used to treat femoral neck fractures, but it remains unclear if the surgical approach impacts patient outcomes for this commonly performed procedure. The objective of this systematic review and meta-analysis was to assess early postoperative outcomes in patients undergoing HA for femoral neck fracture with the direct anterior approach (DAA) compared with other approaches.

METHODS

The Cochrane Central Registry of Controlled Trials, MEDLINE, and Google Scholar databases were searched for randomized controlled trials, prospective nonrandomized trials, and retrospective studies published prior to September 7, 2021, comparing DAA with other approaches (anterolateral approach [ALA], direct lateral approach [DLA], and posterior-based approach [PA]) in HA for femoral neck fractures. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcomes included functional outcomes, total complications, prosthetic dislocation, periprosthetic fracture, periprosthetic joint infection (PJI), reoperation, mortality, pain, operative time, and perioperative blood loss. Fixed effect odds ratios, along with their 95% confidence intervals, were used to analyze dichotomous variables. Significance was set at p < 0.05. Meta-analysis was conducted with Review Manager 5.4.

RESULTS

In total, 19 studies were included for qualitative analysis and 16 studies were included for quantitative analysis, with a total of 1,604 cases analyzed (723 DAA, 215 ALA, 301 DLA, and 365 PA). Compared with other approaches, the use of the DAA for HA was associated with improved early postoperative functional outcomes, lower early postoperative pain scores, fewer total complications, and fewer prosthetic hip dislocations. The rates of periprosthetic fracture, PJI, and reoperation, pain scores beyond 40 days, operative time, perioperative blood loss, and mortality were not significantly different between surgical approaches.

CONCLUSIONS

Utilizing the DAA while performing HA for femoral neck fractures is associated with improved functional outcomes, lower early postoperative pain scores, lower incidence of prosthetic hip dislocation, and potentially fewer total complications.

LEVEL OF EVIDENCE

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

Increased risk of high-grade heterotopic ossification using direct lateral approach versus a muscle-sparing anterolateral approach to the hip: radiological results from a randomised trial in patients with a femoral neck fracture treated with hemiarthroplasty

BACKGROUND AND PURPOSE

Hemiarthroplasty is a common treatment in patients with displaced femoral neck fracture. Due to positive claims of less pain, earlier mobilisation and favourable functional outcome, the anterior approaches to the joint are gaining in popularity. This randomised controlled trial investigated if component placement and heterotopic ossification differed between a muscle sparing anterior approach and a direct lateral approach.

PATIENTS AND METHODS

150 patients operated with an uncemented hemiarthroplasty, were randomised to anterolateral or direct lateral approach and assessed postoperatively radiologically. Measurements included leg-length discrepancy, femoral offset, femoral stem position, canal fill ratio and the presence of heterotopic ossification after 12 months.

RESULTS

There was an increased risk of high-grade heterotopic ossification in the direct lateral approach (p < 0.05). We found no statistically significant differences in leg-length discrepancy, femoral stem position or femoral offset.

CONCLUSIONS

Hemiarthroplasty performed in the direct lateral approach resulted in a higher incidence of Brooker grade 3 heterotopic ossification. Our results support equal geometrical restoration and similar component placement with both approaches.

CLINICAL TRIAL REGISTRY

ClinicalTrials.gov Identifier: NCT03974698Uncemented Hemiarthroplasty, Radiological Features Comparing Lateral Versus Anterolateral Approach https://www.clinicaltrials.gov/ct2/show/NCT03974698?term=raymond+tellefsen…draw=2…rank=1.

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.

Direct anterior approach versus direct lateral approach in total hip arthroplasty and bipolar hemiarthroplasty for femoral neck fractures: a retrospective comparative study

BACKGROUND

In the current literature, there is no consensus on the best surgical approach in hip replacement for femoral neck fractures (FNFs).

AIM

The aim of this study is to compare the direct anterior approach (DAA) and the direct lateral approach (DLA) in patients treated with bipolar hemiarthroplasty (BHA) and total hip arthroplasty (THA) for FNFs.

MATERIALS AND METHODS

Patients with displaced FNFs (Garden type III and IV) treated operatively using BHA and THA were enrolled. The surgical approach techniques DAA and DLA are compared. The analysed variables are: mean surgery time, number of blood units transfused perioperatively, percentage of patients transfused, perioperative complications, pain and functional outcomes at 1 and 6 months and mortality at 1, 3 and 12 months.

RESULTS

Between 2015 and 2017, 37 patients underwent BHA by the DAA and 38 patients underwent BHA by the DLA, 69 patients underwent THA by the DAA and 60 patients underwent THA by the DLA. For THA, the DAA compared to the DLA had a higher mean surgery time (100.8 min vs. 97.7 min), a lower mean number of blood units transfused perioperatively (1.4 U vs. 1.9 U), a significantly lower percentage of patients transfused (53.6% vs. 71.7%), a higher rate of perioperative complications (10.1% vs. 1.6%), a lower pain referred and better functional outcomes in the first 6 postoperative months and a significantly lower mortality rate at 12 months (2.9% vs. 16.7%). For BHA, the advantages of the DAA over DLA are not as significant.

CONCLUSIONS

The direct anterior approach in THA for FNFs provides significant benefits in the early post-operative period compared to the direct lateral approach in terms of functional recovery, residual pain, blood loss and mortality rate in the elderly active population.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

[Perioperative patient blood management in the aged-more than only transfusion? : Review of the 4th symposium of the working group on anemia on the occasion of the annual meeting of the German Geriatric Society in Frankfurt 2019]

Anemia is frequent in older people with one in two geriatric inpatients being affected. Therefore, in elective surgery, such as endoprosthetic treatment it is very likely that anemia is already present in a preoperative setting. So far there are no particular guidelines about perioperative management of anemia in geriatric patients. The existing recommendations of the Patient Blood Management (PBM) network cooperation and the current Association of the Scientific Medical Societies in Germany (AWMF) S3 guidelines on preoperative anemia refer to all patients aged >18 years but without particular consideration of the growing number of oldest old orthogeriatric patients. This is more problematic as anemia in the aged has been shown to be different from anemia in younger patients in terms of diagnostics and treatment. Based on several interdisciplinary lectures, this year the symposium of the working group on anemia of the German Geriatric Society (DGG) focused on the problems of perioperative PBM in orthogeriatric patients and encouraged the discussion about developing PBM treatment recommendations for this patient group.

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.