Posterolateral or direct lateral approach for cemented hemiarthroplasty after femoral neck fracture (APOLLO): protocol for a multicenter randomized controlled trial with economic evaluation and natural experiment alongside

Tol, Maria C J M; Willigenburg, Nienke W.; Willems, Hanna C.; Gosens, Taco; Rasker, Ariena; Heetveld, Martin J.; Schotanus, Martijn G.M.; Dongen, Johanna M. van; Eggen, Bart J. L.; Kormos, M; Pas, Stéphanie van der; Vaart, Aad W Van der; Poolman, Rudolf W.; group, On behalf of the APOLLO research

doi:10.2340/17453674.2022.4547

Cited by 3 publications

(16 citation statements)

References 24 publications

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“…An ALA was associated with greater blood loss (mL) compared with a PA (MD, 5.8098; 95% CI, 4.11-7.50; p < 0.001). A total of 7 studies (63.6%) with 1,186 patients (78.4%) reported complications 7-9,11,13,26,27 (Figs. 4-C and 5).…”

Section: Resultsmentioning

confidence: 99%

“…4-B and 5). A DAA had longer operative duration (MD, 1.8889; 95% CI, 0.08-3.69; p = 0.040) compared with a PA. A total of 3 studies (27.3%) with 678 patients (44.8%) reported blood loss 7,12,26 (Figs. 4-B and 5).…”

Section: Resultsmentioning

confidence: 99%

“…There were no differences in 1-year mortality among the 4 approaches. A total of 7 studies (63.6%) with 1,236 patients (81.7%) reported postoperative superficial or deep infections 7-9,11,13,24,26 (Figs. 4-E and 6).…”

Section: Resultsmentioning

confidence: 99%

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A Comparison of Surgical Approaches for Hip Hemiarthroplasty Performed for the Treatment of Femoral Neck Fracture

Gusho,

Hoskins,

Ghanem

2024

JBJS Reviews

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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.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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A Comparison of Surgical Approaches for Hip Hemiarthroplasty Performed for the Treatment of Femoral Neck Fracture

Gusho,

Hoskins,

Ghanem

2024

JBJS Reviews

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“…Data from this study suggest that the PL approach exposes the patient to an increased risk of dislocation than the other three surgical approaches analyzed. Tol et al stated that the PL approach, compared with the DL approach, is associated with more dislocations, but patients have less walking problems and a lower risk of abductor insufficiency [ 60 ]. In addition, lateral patient positioning has the advantage of needing fewer operators for the procedure [ 61 ].…”

Section: Discussionmentioning

confidence: 99%

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

Filippini,

Bortoli,

Montanari

et al. 2023

Medicina

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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.

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“…To detect a minimally clinically important difference of 0.08 in the primary outcome (EQ-5D-5L utility score) with an SD of 0.3, we needed 555 patients based on a 2-sided significance level of α = .05 with 80% power and a loss to follow-up of 20% after 6 months …”

Section: Methodsmentioning

confidence: 99%

Posterolateral or Direct Lateral Surgical Approach for Hemiarthroplasty After a Hip Fracture

Tol,

Willigenburg,

Rasker

et al. 2024

JAMA Netw Open

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ImportanceHip fractures in older adults are serious injuries that result in disability, higher rates of illness and death, and a substantial strain on health care resources. High-quality evidence to improve hip fracture care regarding the surgical approach of hemiarthroplasty is lacking.ObjectiveTo compare 6-month outcomes of the posterolateral approach (PLA) and direct lateral approach (DLA) for hemiarthroplasty in patients with acute femoral neck fracture.Design, Setting, and ParticipantsThis multicenter, randomized clinical trial (RCT) comparing DLA and PLA was performed alongside a natural experiment (NE) at 14 centers in the Netherlands. Patients aged 18 years or older with an acute femoral neck fracture were included, with or without dementia. Secondary surgery of the hip, pathological fractures, or patients with multitrauma were excluded. Recruitment took place between February 2018 and January 2022. Treatment allocation was random or pseudorandom based on geographical location and surgeon preference. Statistical analysis was performed from July 2022 to September 2022.ExposureHemiarthroplasty using PLA or DLA.Main Outcome and MeasuresThe primary outcome was health-related quality of life 6 months after surgery, quantified with the EuroQol Group 5-Dimension questionnaire (EQ-5D-5L). Secondary outcomes included dislocations, fear of falling and falls, activities of daily living, pain, and reoperations. To improve generalizability, a novel technique was used for data fusion of the RCT and NE.ResultsA total of 843 patients (542 [64.3%] female; mean [SD] age, 82.2 [7.5] years) participated, with 555 patients in the RCT (283 patients in the DLA group; 272 patients in the PLA group) and 288 patients in the NE (172 patients in the DLA group; 116 patients in the PLA group). In the RCT, mean EQ-5D-5L utility scores at 6 months were 0.50 (95% CI, 0.45-0.55) after DLA and 0.49 (95% CI, 0.44-0.54) after PLA, with 77% completeness. The between-group difference (−0.04 [95% CI, −0.11 to 0.04]) was not statistically significant nor clinically meaningful. Most secondary outcomes were comparable between groups, but PLA was associated with more dislocations than DLA (RCT: 15 of 272 patients [5.5%] in PLA vs 1 of 283 patients [0.4%] in DLA; NE: 6 of 113 patients [5.3%]) in PLA vs 2 of 175 patients [1.1%] in DLA). Data fusion resulted in an effect size of 0.00 (95% CI, −0.04 to 0.05) for the EQ-5D-5L and an odds ratio of 12.31 (95% CI, 2.77 to 54.70) for experiencing a dislocation after PLA.Conclusions and RelevanceThis combined RCT and NE found that among patients treated with a cemented hemiarthroplasty after an acute femoral neck fracture, PLA was not associated with a better quality of life than DLA. Rates of dislocation and reoperation were higher after PLA. Randomized and pseudorandomized data yielded similar outcomes, which suggests a strengthening of these findings.Trial RegistrationClinicalTrials.gov Identifier: NCT04438226

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Posterolateral or direct lateral approach for cemented hemiarthroplasty after femoral neck fracture (APOLLO): protocol for a multicenter randomized controlled trial with economic evaluation and natural experiment alongside

Cited by 3 publications

References 24 publications

A Comparison of Surgical Approaches for Hip Hemiarthroplasty Performed for the Treatment of Femoral Neck Fracture

A Comparison of Surgical Approaches for Hip Hemiarthroplasty Performed for the Treatment of Femoral Neck Fracture

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

Posterolateral or Direct Lateral Surgical Approach for Hemiarthroplasty After a Hip Fracture

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