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

Abstract

BackgroundThe relevance of femoral neck fractures (FNFs) increases with the ageing of numerous societies, injury-related decline is observed in many patients. Treatment strategies have evolved towards primary joint replacement, but the impact of different approaches remains a matter of debate. The aim of this trial was to evaluate the benefit of an anterior minimally-invasive (AMIS) compared to a lateral Hardinge (LAT) approach for hemiarthroplasty in these oftentimes frail patients.MethodsFour hundred thirty-nine patients were screened during the 44-months trial, aiming at the evaluation of 150 patients > 60 yrs. of age. Eligible patients were randomised using an online-tool with completely random assignment. As primary endpoint, early mobility, a predictor for long-term outcomes, was evaluated at 3 weeks via the “Timed up and go” test (TUG). Secondary endpoints included the Functional Independence Measure (FIM), pain, complications, one-year mobility and mortality.ResultsA total of 190 patients were randomised; both groups were comparable at baseline, with a predominance for frailty-associated factors in the AMIS-group. At 3 weeks, 146 patients were assessed for the primary outcome. There was a reduction in the median duration of TUG performance of 21.5% (CI [− 41.2,4.7], p = 0.104) in the AMIS-arm (i.e., improved mobility). This reduction was more pronounced in patients with signs of frailty or cognitive impairment. FIM scores increased on average by 6.7 points (CI [0.5–12.8], p = 0.037), pain measured on a 10-point visual analogue scale decreased on average by 0.7 points (CI: [− 1.4,0.0], p = 0.064). The requirement for blood transfusion was lower in the AMIS- group, the rate of complications comparable, with a higher rate of soft tissue complications in the LAT-group. The mortality was higher in the AMIS-group.ConclusionThese results, similar to previous reports, support the concept that in elderly patients at risk of frailty, the AMIS approach for hemiarthroplasty can be beneficial, since early mobilisation and pain reduction potentially reduce deconditioning, morbidity and loss of independence. The results are, however, influenced by a plethora of factors. Only improvements in every aspect of the therapeutic chain can lead to optimisation of treatment and improve outcomes in this growing patient population.Trial registrationwww.clinicaltrials.gov: NCT01408693 (registered August 3rd 2011).Electronic supplementary materialThe online version of this article (10.1186/s12877-018-0898-9) contains supplementary material, which is available to authorized users.

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

“…All four studies (5,20,26,32) concluded that no statistically significant difference in the risk of infection was observed between PA and AA, and we did not detect a statistically significant difference when we performed an aggregate analysis (OR: 1.85 95% CI: 0.77-4.43 I 2 = 0% P = 0.17 Figure 7A). We obtained the same conclusion in the PA and LA studies (19, 23, 27, 29, 34-36, 38, 42) (OR: 1.18 95% CI: 0.87-1.59 I 2 = 0% P = 0.28 Figure 7B).…”

“…Detailed descriptions of the characteristics and patient demographics for each study are listed in Table 1. Five were randomized controlled trials (5,(17)(18)(19)(20) (RCTs) including 588 hips and the others were cohort studies.…”

“…Hip arthroplasty is a clinically widespread surgical procedure for the therapy of severely aged femoral neck fractures (3). However, patients with a combination of multiple underlying illnesses, poor health conditions and lower functional demands are more appropriate for artificial femoral head hemiarthroplasty, which can reduce the operation time and allow patients to move early after surgery (4)(5)(6).…”

Direct Anterior Approach in Hip Hemiarthroplasty for Femoral Neck Fractures: Do Short-Term Outcomes Differ with Approach?

“…Eighteen studies in this systematic review and meta-analysis mentioned the experience of participating surgeons. Five studies described the number of years of experience of included surgeons 14,18,19,21,23 , 5 studies stated that surgeons were “experienced,” 13,17,26,27,30 , 3 studies described the primary approach used by surgeons in their practice 16,20,28 , 4 studies described the presence of arthroplasty fellowship training 22,24,25,29 , and 1 study stated that all of the surgeons were arthroplasty fellowship trainees in France 15 . Of the 4 studies that described the presence of arthroplasty fellowship training, only 2 described the approach that surgeons were trained to use 25,29 .…”

High risk of positive Trendelenburg test after using the direct lateral approach to the hip compared with the anterolateral approach

“…No statistically significant differences were found for any of the outcome measures. Saxer et al 34 compared the Smith-Petersen approach with a transgluteal approach, and found no statistically significant difference in the primary outcome, the TUG performance, at three weeks.…”