Surgical Approach

One high quality study (Ugland 2018), eight moderate quality studies (Jianbo 2019, Li 2017, Parker 2015, Repantis 2015, Saxer 2018, Ugland 2019, Verzellotti 2019) and two low quality studies (Biber 2012, Skoldenberg 2010) were included in the evidence for this recommendation.  

The high quality study (Ugland 2019) compared hemiarthroplasty with the anterolateral approach to hemiarthroplasty with the direct lateral approach and reported that while there were elevated levels of serum creatine kinase (CK) observed in the anterolateral approach group, no correlation between CK levels and the Timed Up and Go test or the Trendelenburg sign at 3 months were found.

There were also 8 citations on the subject of surgical approach in the surgical treatment of femoral neck fractures with moderate evidence strength. Jianbo (2019) reported on a prospective, randomized study of 100 patients. They specifically compared the clinical outcomes and complications of using either the conventional posterior approach, or with using a minimally invasive (MIS) and muscle preserving approach (the Suprapath approach). There was less blood loss, and low transfusion rate in the MIS group. There was less pain, and better function within the first week in the minimally invasive group, but no differences between the groups at the 3-month interval. Repantis (2015) reported on the comparative results of a prospective, randomized study in 80 patients using either a MIS approach or in using the posterior approach. It was a single-surgeon series. There was less pain in the MIS group in the short term. There was no difference in any of the other outcomes or complications up to 4 years of follow up. In another comparative study, Saxer (2018) reported on the results of 190 patients using either a MIS or using the lateral approach. There was less pain, and faster ambulation in the first 3 weeks in the MIS group. There was no difference in any of the other outcomes, or in the complications between the groups. Verzellotti (2019) reported on the comparative results of using the direct anterior (DA) which is muscle preserving, or in using the posterior approach in 100 patients. There was less pain in the DA group in the first month after surgery. There was no difference in the other outcomes or complications between the groups. The operative time was longer in the DA group. Parker (2015) reported the comparative results of a multi-center, prospective, randomized study in 216 patients using either the posterior or the lateral approach. There was no difference in any of the outcome measures analyzed between the groups. In a prospective, randomized study in 150 patients, Ugland (2018) reported higher risk of post-surgery Trendelenburg gait when the arthroplasty was done using the lateral approach in contrast to using the anterolateral approach (more abductor muscle preserving). Two low strength articles (Biber 2012, Skoldenberg 2010) compared the posterior approach to the direct lateral approach for performing arthroplasty in the patients with femoral neck fractures. While neither of the included studies specifically addressed any functional outcomes, they both demonstrated statistically significant differences in dislocation rates, favoring the direct lateral approach. 

The data in these newer studies show no difference in the dislocation rates between the different surgical approaches, including the posterior approach. This is in contrast to the earlier data in older publications which showed higher dislocation rate with the posterior approach in comparison to the lateral approach in particular.

Benefits/Harms of Implementation

While some studies showed less pain in the early postoperative period for less invasive surgical approaches, operative time may be longer with a less invasive approach and there was no clear difference in functional outcomes. 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 does not support superiority of one surgical approach. Future well designed RCTs should include a comparison of the anterior approach with the posterior and the lateral approach. Any future studies related to surgical approach should also include pain and functional data associated with the approaches. This may have important implications for patient selection and recovery needs such as assistive devices or therapy needs.