Moderate evidence supports higher dislocation rates with a posterior approach in the treatment of displaced femoral neck fractures with hip arthroplasty.

Management of Hip Fractures in the Elderly
Endorsed by: OTA, AGS, AAPM&R, ASBMR, USBJI, The Hip Society, AACE, ORA
Moderate Evidence MODERATE EVIDENCE
Rationale
Two moderate strength articles (Biber et al 92 and Skoldenberg et al93) compared the posterior approach to the direct lateral approach for arthroplasty in femoral neck fracture surgery.   Alternative nomenclature for the posterior approach to the hip identified in the literature includes the Southern, the posterior, the Moore or the dorsal approach.  Similarly, the direct lateral approach can also be called the anterolateral, the transgluteal or more commonly the Modified Hardinge approach.  While neither of the included studies specifically addressed any functional outcomes, they both demonstrated statistically significant differences in dislocation rates, favoring the Modified Hardinge approach.  
 
Risks and Harms of Implementing this Recommendation
There is no inherent harm in either approach or any associated complications other than the primary outcome of dislocation of the prosthesis postoperatively. This information should be considered in the context of both patient and surgeon specific factors when deciding on a surgical approach.
 
Future Research
The existing evidence only compares posterior and lateral approaches and only allows comparison of dislocation as the primary end point.  Future well designed RCTs should include a comparison of the increasingly popular anterior approach with either the posterior and/or the lateral approach.  Any future studies related to surgical approach should also include functional data associated with the approaches.  This may have important implications for patient selection and recovery needs such as assistive devices or therapy needs.
 
 
  1. (92) Biber R, Brem M, Singler K, Moellers M, Sieber C, Bail HJ. Dorsal versus transgluteal approach for hip hemiarthroplasty: an analysis of early complications in seven hundred and four consecutive cases. Int Orthop 2012;36(11):2219-2223.
  2. (93) Skoldenberg O, Ekman A, Salemyr M, Boden H. Reduced dislocation rate after hip arthroplasty for femoral neck fractures when changing from posterolateral to anterolateral approach. Acta Orthop 2010;81(5):583-587.