Clinical results of short external rotators preserving posterolateral approach for hemiarthroplasty after femoral neck fractures in elderly patients

Clinical effectiveness of a modified muscle sparing posterior technique compared with a standard lateral approach in hip hemiarthroplasty for displaced intracapsular fractures (HemiSPAIRE): a multicenter, parallel-group, randomized controlled trial

Objectives

Assess the effect of a modified muscle sparing posterior approach; SPAIRE (Save Piriformis and Internus, Repairing Externus), in hip hemiarthroplasty for displaced intracapsular fractures on postoperative mobility and function compared with a standard lateral approach.

Design

Pragmatic, superiority, multicenter, parallel-group, randomized controlled trial (with internal pilot). Participants, ward staff, and research staff conducting postoperative assessments were blinded to allocation. A CTU allocated treatments centrally using computer-generated lists.

Setting

Six hospitals in Southwest England, recruiting November 25, 2019-April 25, 2022.

Participants

244 adults (≥60 years) requiring hip hemiarthroplasty (122 allocated to each approach). 90 and 85 participants allocated to SPAIRE and lateral, respectively, had primary outcome data within the prespecified data collection window.

Interventions

Surgery using SPAIRE or standard lateral approach. Follow-up 3 days and 120 days postoperation.

Main outcome measure

Oxford Hip Score (OHS), via telephone at 120 days. Secondary outcomes: function and mobility (3 days), pain (3 days, 120 days), discharge destination, length of hospital stay, complications and mortality (within 120 days), quality of life and place of residence (120 days).

Results

Participants' mean age was 84.6 years (SD 7.2); 168 (69%) were women. Primary outcome: little evidence of a difference in OHS at 120 days; adjusted mean difference (SPAIRE-lateral) -1.23 (95% CI -3.96 to 1.49, p=0.37). Secondary outcomes: indication of lower participant-reported pain at 3 days in SPAIRE arm; no differences between arms for remaining outcomes.

Conclusions

Participants' mobility and function are similar in the short term (3 days) and longer term (120 days), whether receiving the SPAIRE or lateral approach. Neither approach confers benefit over the other in terms of length of hospital stay, return to prefracture residence, survival within 120 days, or quality of life at 120 days. Participants receiving SPAIRE approach may experience less pain in the early postoperative period. Modifying the posterior approach in hip hemiarthroplasty to the SPAIRE approach gives equivalent patient outcomes to the lateral approach within 120 days.

Trial registration number

NCT04095611.

Bipolar hip arthroplasty using conjoined tendon preserving posterior lateral approach in treatment of displaced femoral neck fractures

BACKGROUND

Hip fractures account for 23.8% of all fractures in patients over the age of 75 years. More than half of these patients are older than 80 years. Bipolar hemiarthroplasty (BHA) was established as an effective management option for these patients. Various approaches can be used for the BHA procedure. However, there is a high risk of postoperative dislocation. The conjoined tendon-preserving posterior (CPP) lateral approach was introduced to reduce postoperative dislocation rates.

AIM

To evaluate the effectiveness and safety of the CPP lateral approach for BHA in elderly patients.

METHODS

We retrospectively analyzed medical data from 80 patients with displaced femoral neck fractures who underwent BHA. The patients were followed up for at least 1 year. Among the 80 patients, 57 (71.3%) were female. The time to operation averaged 2.3 d (range: 1-5 d). The mean age was 80.5 years (range: 67-90 years), and the mean body mass index was 24.9 kg/m2 (range: 17-36 kg/m2). According to the Garden classification, 42.5% of patients were type Ⅲ and 57.5% of patients were type Ⅳ. Uncemented bipolar hip prostheses were used for all patients. Torn conjoined tendons, dislocations, and adverse complications during and after surgery were recorded.

RESULTS

The mean postoperative follow-up time was 15.3 months (range: 12-18 months). The average surgery time was 52 min (range: 40-70 min) with an average blood loss of 120 mL (range: 80-320 mL). The transfusion rate was 10% (8 of 80 patients). The gemellus inferior was torn in 4 patients (5%), while it was difficult to identify in 2 patients (2.5%) during surgery. The posterior capsule was punctured by the fractured femoral neck in 3 patients, but the conjoined tendon and the piriformis tendon remained intact. No patients had stem varus greater than 3 degrees or femoral fracture. There were no patients with stem subsidence more than 5 mm at the last follow-up. No postoperative dislocations were observed throughout the follow-up period. No significance was found between preoperative and postoperative mean Health Service System scores (87.30 ± 2.98 vs 86.10 ± 6.10, t = 1.89, P = 0.063).

CONCLUSION

The CPP lateral approach can effectively reduce the incidence of postoperative dislocation without increasing perioperative complications. For surgeons familiar with the posterior lateral approach, there is no need for additional surgical instruments, and it does not increase surgical difficulty.

Surgical drain has no benefits in hemiarthroplasty for femoral neck fractures in elderly patients

Femoral neck fracture is a common osteoporotic fracture in elderly patients and is effectively managed with arthroplasty. However, the benefits and risks of a surgical drain after arthroplasty in these patients are still debatable. Hence, we conducted this study to investigate the necessity of a surgical drain after hemiarthroplasty in elderly patients with femoral neck fracture. This study enrolled elderly patients (aged ≥ 70 years) who underwent cementless bipolar hemiarthroplasty for femoral neck fracture between April 2016 and December 2021. The patients were divided into two groups; the control group (199 patients) with a surgical drain after surgery performed between April 2016 and June 2020 and the study group (134 patients) with no surgical drain between July 2020 and December 2021. The demographics, perioperative data, and postoperative complications were compared between the two groups. Estimated blood loss, perioperative transfusion volume and rate, and length of hospital stay were significantly lower in the study group than in the control group (p < 0.001, p < 0.001, p = 0.008, and p < 0.001, respectively). Although there were no significant intergroup differences in the length of intensive care unit stay and in-hospital, 1-month, and 1-year mortalities, the incidence of postoperative medical complications was significantly lower in the study group than the control group (p = 0.001). A surgical drain may be unnecessary after hemiarthroplasty in elderly patients with femoral neck fracture considering less blood loss and transfusion, lower incidence of postoperative medical complications, and shorter hospital stay in the study group with no surgical drain.

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.