Short-term Clinical Outcomes After Hip Hemiarthroplasty For Advanced Femoral Neck Fractures Treated With Direct Anterior Approach

Background: The direct anterior approach(DAA)in total hip arthroplasty is generally accepted with a lot of advantages,such as less surgery damage,faster postoperative recovery,and lower dislocation rate.Hip hemiarthroplasty is performed for femoral neck fracture in the elderly,who always have serious diseases of heart,brain,lung and other systems,and poor ability to endure surgery.Those elderly patients often suffer from neuromuscular disease,resulting in poor muscle strength,poor balance ability,poor compliance,cognitive impairment and so on,thus they have the request for less surgery damage,early postoperative functional rehabilitation,and low dislocation rate.Purpose: Aim of this study comparing with DAA and the most commonly used posterior approach(PA)is to research short-term clinical outcomes after hip hemiarthroplasty(HHA)for advanced femoral neck fractures treated with direct anterior approach.Materials and methods: A total of 70 patients who underwent HHA at the Joint Surgery Department of the Second Affiliated Hospital of Dalian Medical University from September 2016 to September 2017,were assigned to DAA or PA.Data were collected for age,gender,BMI,ASA score before the surgery.Pain was evaluated by visual analogue score(VAS).Duration of surgery,blood loss,difference of hemoglobin before and after operation,postoperative blood transfusion cases,external length of incision,and length of hospitalization were recorded in detail to evaluate the surgery damage.Postoperative pelvic plain film and femur lateral radiographs were used to evaluate the imaging of the hip.Harris hip function score was used to evaluate thefunctional rehabilitation.The postoperative complications were recorded in detail.Told the patients coming back to the hospital one month after the surgery and 3 months after the surgery,with the follow-up completed by the same examiner.Use SPSS 22.0software to analyze data,measurement data using mean ± SD,and data between the two groups were compared using t-test.Results: There were 38 patients in the DAA group,including 9 males and 29 females.The preoperative ASA score was II in 8 cases,III in 29 cases,IV in 1 case,and 21 cases(55.3%)suffered from Parkinson's disease,myasthenia gravis,Hemiplegia and other neuromuscular diseases.There were 32 patients in PA group,including 11 males and 21 females.The preoperative ASA score was II in 9 cases,III in 20 cases,IV in 3 cases,and 13 cases(40.6%)combined with cerebral thrombosis sequelae,cerebral infarction and other neuromuscular diseases.There was no significant difference in the age,BMI,preoperative VAS score,Harris score before injury(p(29)0.05).DAA group had better results in terms of intraoperative blood loss,preoperative and postoperative hemoglobin difference,surgical incision length and length of hospitalization(p(27)0.05),but the operation time was longer than that of PA group(p(27)0.05).In terms of postoperative blood transfusion,eight patients in the DAA group achieved post-transfusion indications,and the number of transfusions in the PA group was 13(21.1% vs 40.6%).In imaging evaluation,the differences in lower extremity length were(1.0?2.2)mm in the DAA group and(2.8?4.0)mm in the PA group(p = 0.031).There was no significant difference in VAS score between the two groups on the first day,the second day,the third day,the first month and the third month after surgery(p <0.05),that were significantly improved compared with the preoperative.In terms of functional rehabilitation,the negative rate of one-legged standing test in DAA group was significantly better than that of PA group(63.2% vs25%)one month after operation,and the negative rate of one-legged standing test in the three-month postoperative group was much the same(89.5% vs 87.5%),the abandoning walker time,the first postoperative straight leg raising time,the first postoperative time and postoperative Harris score in DAA group were better than PA group(p <0.05),But Harris scores had no significant difference between the twogroups at 3 months(p = 0.131).Postoperative complications included 4 cases of pre-femoral pain,2 cases of lateral femoral cutaneous nerve,1 case of postoperative delirium,delayed wound healing in 2 cases,electrolyte imbalance in 3 cases and respiratory failure of type II in 2 cases in DAA group.Complications in DAA group occurred in 14 patients with an overall complication rate of 36.8%.In the PA group,severe incisional wounds occurred in 3 cases,delayed wound healing in 2 cases,acute myocardial infarction in 1 case 10 days after operation,and electrolyte in 3 cases disorder,1 case of dislocation,PA combination of total 10 cases of postoperative complications,the overall complication rate was 31.3%.Conclusion: The direct anterior approach in hip hemiarthroplasty is an intermuscular approach to reach the hip joint,and the operation has a good surgical perspective,ideal placement of the prosthesis,with less tissue damage,light postoperative pain,good early recovery,good gait,stable prosthesis position,low dislocation rate and no postoperative taboo posture,etc,which is suitable for elderly patients with femoral neck fracture,and fit the "enhanced recovery" concept perfectly.