Use of the anterior approach (AA) in THA is associated with reduced post-operative pain and improved early mobility compared to the lateral (i.e. Hardinge) approach (LA). Evidence supporting the AA over the LA in patients undergoing hip arthroplasty for hip fracture, while promising, is inconsistent and largely retrospective. The purpose of this study was to compare the AA to the LA for early function, time to discharge, pain, and complication profile in patients undergoing hemiarthroplasty for low-energy traumatic intracapsular hip fracture. It was hypothesised that the AA would result in improved early function compared to the LA with a similar complication profile. A multi-surgeon, single center registered RCT was performed from July 2022 to August 2024. Patients undergoing hemiarthroplasty for acute femoral neck fractures were randomized to either AA or LA. All procedures were performed by fellowship-trained arthroplasty surgeons competent in both approaches with Exeter cemented stems (AA, 43/46, 93%; LA, 44/51, 86%) or Accolade II uncemented stems (AA, 3/46, 7%; LA, 7/51, 14%). Patients were followed for six months post-operatively and outcomes were assessed by research personnel blinded to grouping at 2-, 6-, 12-, 26-weeks. Age (mean 81 years, SD 7.6), BMI, pre-operative mobility, pre-operative function, ASA grade, anesthetic, time from admission to surgery, and stem fixation were similar between groups (p > 0.05). The primary outcome was patient function assessed using the Barthel-20 Index. Secondary outcomes included pain (Visual Analogue Scale Pain), EQ-5D global health assessment, length of stay, and complications. Barthel-20 Index score at did not differ between groups at 6 weeks (AA, 15.8 95% CI 14.1–17.4; LA, 15.8 95% CI [14.5–17.1, p = 0.9764) or at any other time. EuroQoL-5D scores were not different between AA and LA. No differences were found in VAS pain at any time. Acute care hospital length of stay (AA, 11.1 days 95% CI 8.9–13.4; LA, 9.4 days 95% CI 7.5–11.2, p = 0.226) and time from surgery to discharge home (AA, 31.3 days 95% CI 25.8–36.7; LA, 30.4 days 95% CI 22.5–38.3, p = 0.867) were not different. There was no difference in readmission/ED visit within 90 days (AA, 12/46, 26%; LA, 12/51, 24%, p = 0.858) or 90-day mortality (AA, 2/46, 4%; LA, 2/46, 4%, p = 0.916). There was no difference in hip-related complications (i.e. periprosthetic fracture, prosthetic joint infection) or medical complications. Previously reported merits associated with AA THA do not seem to translate to the hip fracture population. The results of the present study, in contrast with existing retrospective studies, do not support AA over LA in patients undergoing hip hemiarthroplasty for fracture. At present, without proven benefit, widespread adoption of the AA in this population is not recommended, particularly considering the learning-curve and specialized equipment requirements.
Woolnough et al. (Wed,) studied this question.