One-year mortality of the anterior approach compared with other approaches in elderly patients with hip fracture treated with hemiarthroplasty: a national registry study

Hip fractures in elderly patients present significant challenges to healthcare systems. The direct anterior approach (DAA) has shown advantages in total hip arthroplasty (THA) with regards to blood loss, postoperative mobilization, and hospital stay. How these potential benefits translate to outcomes in hemiarthroplasty (HHA), specifically for elderly and often frail patients with hip fractures, remains unclear. This study investigates whether the DAA associates with lower 1-year mortality rates in this fragile population compared with conventional surgical approaches for HHA. We emulated a target trial using data from the Dutch Arthroplasty Register (LROI). Patients aged ≥ 75 years undergoing HHA (2007–2021) for hip fractures were included. Propensity score matching was used to create comparable treatment arms based on surgical approach: DAA, posterolateral (PLA), anterolateral (ALA), and straight lateral (SLA). Primary outcome was 1-year mortality. Secondary outcomes included the prevalence of the analyzed surgical approaches over time. Statistical analyses were done with Cox proportional hazard models and illustrated by Kaplan–Meier survival curves. Overall, 40,981 eligible patients were included. In this population, the proportion of DAA for HHA increased from 0% in 2007 to 13% in 2020. After propensity score matching, 21,393 patients were successfully included for further analysis. The 1-year mortality rates were comparable across approaches: 26% (DAA), 26% (PLA), 26% (SLA), and 27% (ALA). Cox proportional hazard models showed no significant differences in mortality between approaches. This study found no significant differences in 1-year mortality between the DAA and conventional surgical approaches for HHA in elderly patients with hip fractures. Hence, the acknowledged DAA advantages in THA did not translate into reduced mortality for HHA in elderly hip fracture patients. Further research is required to explore other clinical outcomes which might substantiate the DAA’s potential benefit in this fragile population. Level III, retrospective cohort study, target trial emulation.