RecommendationConsider an anterolateral approach in favour of a posterior approach when inserting a hemiarthroplasty.
Relative values of different outcomesFunctional status, reoperation rate, and quality of life were considered the main outcomes. Pain, wound infection, dislocations, length of stay in secondary care and mortality were also considered.
Trade off between clinical benefits and harmsThe cohort study showed a significantly higher dislocation rate with a large effect size with the posterior approach compared to the anterolateral approach. This reduces the potential complications of re-operation or revision surgery. An old RCT data showed a significantly lower impaired mobility at 6 months with a posterior approach, a doubling of mortality and no difference in dislocations compared to an anterolateral approach. However, the operations had been carried out by trainees with varying degrees of experience. Also, the group operated on with an antrolateral approach were allowed to mobilise straight away and the group operated on with a posterior approach had two weeks postoperatively bed rest.

None of the other outcomes were reported.
Economic considerationsAn anterolateral approach is likely to result in cost savings because of their lower dislocation rates, and hence less revision surgery.
Quality of evidenceBoth the studies available are of very low quality. The RCT is an old study where the operations were mostly carried out by surgical trainees. This RCT also treated patients differently, with those receiving a posterior approach being nursed flat in bed for two weeks after surgery as a precaution against dislocation and had a much higher mortality in the posterior group. The cohort study, which adjusted for important factors in their results, is a recent study and shows a large effect size in favour of an anterolateral approach.
Other considerationsThe GDG considered this evidence along with the GDG opinions and decided the recent evidence is more relevant. They therefore recommend the anterolateral approach over the posterior. It is also recognized that the posterior approach may well be as safe in preventing dislocation in those surgeons with a large experience of using it. However, the GDG believe the majority of surgeons who perform the surgery do not regularly perform posterior approaches. It is also noted that all the RCTs comparing hemiarthroplasty and total hip replacement utilized the anterolateral approach in all of the studies.

From: 10, Surgical procedures

Cover of The Management of Hip Fracture in Adults
The Management of Hip Fracture in Adults [Internet].
NICE Clinical Guidelines, No. 124.
National Clinical Guideline Centre (UK).
Copyright © 2011, National Clinical Guideline Centre.

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