Debate on direct-anterior vs posterior approach for hip hemiarthroplasty: The authors’ insights

Abstract

We read and discussed the study entitled “Complication rates after direct anterior vs posterior approach for Hip Hemiarthroplasty in elderly individuals with femoral neck fractures” with great interest. The authors have done justice to the topic of comparison of anterior and posterior surgical approaches for bipolar hemiarthroplasty which has been an everlasting debate in the existing literature. However, there are certain aspects of this study that need clarification from the authors.

Key Words: Commentary, Direct anterior approach, Posterior approach, Hip hemiarthroplasty

Core Tip: The debate on an ideal approach for total hip arthroplasty/hemiarthroplasty is an everlasting one. The relatively newer approaches such as the direct anterior approach are appealing to many surgeons but lack long-term data to prove their benefits and efficacy. We found an article written of great significance to the above-mentioned topic. However, we sought to request the authors to clarify some points about this research article to further strengthen the message that is being conveyed.

TO THE EDITOR

We read and discussed the study entitled “Complication rates after direct anterior vs posterior approach (PL) for Hip Hemiarthroplasty in elderly individuals with femoral neck fractures” by Charles et al[1] with great interest. This appears to be a novel research with a structured study protocol for which all the authors should be applauded. The authors have adeptly addressed the ongoing debate in the existing literature regarding the comparison of anterior and posterior surgical approaches for total hip arthroplasty (THA), doing justice to the intricacies of the topic[2]. However, there are certain aspects of the study which need elaboration from the authors.

The higher rates of postoperative bipolar hemiarthroplasty dislocations in the PL group is out of proportion to the absence of dislocation in the direct anterior approach (DAA) group as there is considerable literature to support that posterior approach is not associated with higher rates of dislocation provided that short external rotators and the joint capsule have been repaired properly by applying transosseous sutures to the greater trochanter[2-4]. We believe that the authors should have mentioned femoral stem anteversion for all the included cases, as this information would’ve aided in understanding the reasons for a higher number of dislocations encountered in the PL group.

We would also like to emphasize that it is worth mentioning preoperative clinical details and co-morbidities of the patients undergoing Hemiarthroplasty by DAA and PL approaches. It is plausible that the reason for a higher incidence of dislocations in the PL group could be the preferential inclusion of frail patients with neuromuscular disorders or weak pelvic girdle muscles; and patients with Dementia or Delirium. It is well known that such patients are at a higher risk of dislocation postoperatively[5].

Furthermore, the authors have stated that implant revision was required in 8 out of the 14 hemiarthroplasties which got dislocated, but it has not been mentioned properly if these cases were revised again into a bipolar hemiarthroplasty or revised to a THA. This is especially relevant in cases of recurrent instability leading to distortion of Acetabular anatomy which might warrant revision into a THA[6].

Paradoxically, a statistically significant difference in 30 d mortality rates was found when ASA 1 and 2 and ASA 3 and 4 patients were analyzed in groups while the same was not significant when applied to individual surgical approach groups. Interestingly, the same paradox continued when a log-linear model was applied. The data on ASA (Table 1) also needs elaboration from the authors.

Table 1 Demographic data, mean ± SD.

	Direct anterior approach (n = 109)	PL (n = 171)	P value
Age (yr)	82.3 ± 7.2	82.6 ± 8.2	0.72
Sex (M/F, %)	29 (27)/80 (73)	50 (29)/121 (71)	0.63
BMI (kg/m2)	23.1 ± 5.4	23.6 ± 4.5	0.91
ASA score (%)			0.87
ASA 1	0	0
ASA 2	33 (30)	68 (40)
ASA 3	69 (63)	90 (53)
ASA 4	90 (53)	8 (5)

BMI: Body mass index.

We also noticed a mention in the results section that anesthesia was required to manage complications in 5.7% of patients in the DAA group and 25.3% of patients in the PL group and the difference was statistically significant. This statement requires clarification as it lacks specificity regarding the utilization of anesthesia in addressing complications associated with THA. The authors should explicitly outline the complications necessitating anesthesia for their resolution. Additionally, the authors must justify the significance of the aforementioned statement within the context of the study.

The authors believe that addressing the subsequent comments will enhance the robustness of this study and increase its relevance to the orthopedic practice of the readers.