Direct anterior approach versus posterolateral approach for total hip arthroplasty in the treatment of femoral neck fractures in elderly patients: a meta-analysis and systematic review.

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Abstract

[Indexed for MEDLINE] Conflict of interest statement: The authors declare that the research was conducted without any commercial or financial relationships that might be regarded as a potential conflict of interest. 8. J Bone Joint Surg Am. 2022 Jun 15;104(12):1068-1080. doi: 10.2106/JBJS.21.01171. Epub 2022 Apr 22. Creation of a Total Hip Arthroplasty Patient-Specific Dislocation Risk Calculator. Wyles CC(1), Maradit-Kremers H(1), Larson DR(2), Lewallen DG(1), Taunton MJ(1), Trousdale RT(1), Pagnano MW(1), Berry DJ(1), Sierra RJ(1). Author information: (1)Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota. (2)Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota. Comment in J Bone Joint Surg Am. 2022 Jun 15;104(12):1129. doi: 10.2106/JBJS.22.00384. BACKGROUND: Many risk factors have been described for dislocation following total hip arthroplasty (THA), yet a patient-specific risk assessment tool remains elusive. The purpose of this study was to develop a high-dimensional, patient-specific risk-stratification nomogram that allows dynamic risk modification based on operative decisions. METHODS: In this study, 29,349 THAs, including 21,978 primary and 7371 revision cases, performed between 1998 and 2018 were evaluated. During a mean 6-year follow-up, 1521 THAs were followed by a dislocation. Patients were characterized, through individual-chart review, according to non-modifiable factors (demographics, indication for THA, spine disease, prior spine surgery, and neurologic disease) and modifiable operative decisions (operative approach, femoral head diameter, and type of acetabular liner [standard, elevated, constrained, or dual-mobility]). Multivariable regression models and nomograms were developed with dislocation as a binary outcome at 1 year and 5 years postoperatively. RESULTS: Dislocation risk, based on patient-specific comorbidities and operative decisions, was wide-ranging-from 0.3% to 13% at 1 year and from 0.4% to 19% at 5 years after primary THA, and from 2% to 32% at 1 year and from 3% to 42% at 5 years after revision THA. In the primary-THA group, the direct anterior approach (hazard ratio [HR] = 0.27) and lateral approach (HR = 0.58) decreased the dislocation risk compared with the posterior approach. After adjusting for the approach in that group, the combination of a ≥36-mm-diameter femoral head and an elevated liner yielded the largest decrease in dislocation risk (HR = 0.28), followed by dual-mobility constructs (HR = 0.48). In the patients who underwent revision THA, the adjusted risk of dislocation was most markedly decreased by the use of a dual-mobility construct (HR = 0.40), followed by a ≥36-mm femoral head and an elevated liner (HR = 0.88). The adjusted risk of dislocation after revision THA was decreased by acetabular revision (HR = 0.58), irrespective of whether other components were revised. CONCLUSIONS: Our patient-specific dislocation risk calculator, which was strengthened by our use of a robust multivariable model that accounted for comorbidities associated with instability, demonstrated wide-ranging patient-specific risks based on comorbidity profiles. The resultant nomograms can be used as a screening tool to identify patients at high risk for dislocation following THA and to individualize operative decisions for evidence-based risk mitigation. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated. DOI: 10.2106/JBJS.21.01171 PMCID: PMC9587736