Posterolateral or direct lateral approach for hemiarthroplasty after femoral neck fractures: a systematic review

Abstract

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.

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

“…Hemiarthroplasty is a common treatment for hip fractures. Preferences for surgical approach vary between surgeons, hospitals, and countries ( 2 ). A systematic review ( 2 ) comparing the posterolateral approach (PLA) and direct lateral approach (DLA) reported only 1 randomized study, which was ended prematurely ( 3 ).…”

Modes of failure of hip hemiarthroplasty for femoral neck fracture

“…implant type; and fixation method, 3,9,14,[16][17][18][19][20][21][22] whereas surgeon experience, operative volume and timing of surgery may or may not contribute to the frequency of complications and reoperation. 23,24 Although most hemiarthroplasties in the present study were uncemented unipolar and modular, variation of implant type has been reported, such as the common use of unipolar monoblock or modular stems in Australia 14 and bipolar stems in Norway, 25 with cemented fixation commonly used in Norway and the United Kingdom.…”

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

“…The posterolateral approach (PLA) and the direct lateral approach (DLA) are currently most used . A systematic review on outcomes most relevant for patients suggested that the PLA might be associated with advantages compared with DLA in HRQOL, abductor insufficiency, and walking problems . A meta-analysis concluded that the PLA had no advantages that counterbalanced its increased risk of dislocation and reoperation compared with DLA and the direct anterior approach .…”

“…5,6 A systematic review on outcomes most relevant for patients suggested that the PLA might be associated with advantages compared with DLA in HRQOL, abductor insufficiency, and walking problems. 7 A meta-analysis concluded that the PLA had no advantages that counterbalanced its increased risk of dislocation and reoperation compared with DLA and the direct anterior approach. 8 However, both systematic reviews were based primarily on observational studies and concluded that high-quality clinical trials were needed to confirm or refute their conclusions.…”