What did the study look at?
Fractures around the trochanter at the top of the thigh bone are common in older age. In elderly patients with osteoporosis and an unstable fracture (Evans type IV–V), these fractures can be treated with a partial hip replacement, known as bipolar hemiarthroplasty. One important problem after this operation is the implant coming out of place (dislocation).
The study compared two surgical routes: the classic posterolateral approach, in which the joint capsule and the muscles that turn the hip outwards are cut, and the transtrochanteric (transfracture) approach, in which the femoral neck is reached directly through the fracture line while the capsule and those muscles are preserved. The main aim was to compare dislocation rates.
How was it done?
- This was a retrospective comparative study based on hospital records.
- 264 hip fractures operated on between 2014 and 2017 were screened; 112 patients with Evans type IV–V fractures who received a partial replacement were included.
- Group 1 comprised 48 patients operated on with the posterolateral approach before June 2015; Group 2 comprised 64 patients operated on with the transtrochanteric approach after that date.
- Mean ages were 86.5 and 87.1 years. The groups were similar in sex, body mass index, cognitive disorder, anaesthetic risk class and implant type; only follow-up time differed.
- Dislocation, operating time, blood transfusion, deep infection, 90-day mortality and non-union of the trochanteric fragment were compared.
What did it find?
- Dislocation occurred in 8 of 48 patients (16.7%) in the posterolateral group and 3 of 64 (4.7%) in the transtrochanteric group; the difference was statistically significant (p=0.035).
- Operating time was shorter in the transtrochanteric group (mean 60.0 versus 66.6 minutes).
- There were no significant differences in blood transfusion, deep infection, 90-day mortality or trochanteric non-union.
- Cognitive disorder, trochanteric non-union and use of the posterolateral approach were identified as independent risk factors for dislocation.
- Dislocation did not differ between cemented and uncemented implants, nor by implant head size.
The authors' conclusion
The authors conclude that the transtrochanteric approach through the fracture line, preserving the anterior and posterior structures, is effective in minimising possible complications after hemiarthroplasty in suitable patients, especially dislocation.
Limitations
- The study was retrospective; the authors state that prospective randomised studies comparing hip approaches are needed.
- Mean follow-up times differed between the two groups.
- Some patient-related factors, such as acetabular coverage and offset, could not be measured on the available radiographs and were not assessed.
Reference
Gürsoy S, Simsek ME, Akkaya M, Dogan M, Bozkurt M. Transtrochanteric approach can provide better postoperative care and lower complication rate in the treatment of hip fractures. Clinical Interventions in Aging. 2019;14:137–143. Published under a Creative Commons Attribution-NonCommercial 3.0 (CC BY-NC 3.0) licence.
DOI: 10.2147/cia.s194880
Free full text: PubMed Central – PMC6336027
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