Elsevier

Injury

Volume 41, Issue 4, April 2010, Pages 365-369
Injury

A randomised clinical trial comparing minimally invasive surgery to conventional approach for endoprosthesis in elderly patients with hip fractures

https://doi.org/10.1016/j.injury.2009.10.002Get rights and content

Abstract

Background

In recent years, the concept of minimally invasive surgery has invaded the orthopaedic field and literature on the subject is spawning. Mini-incision surgery for total hip arthroplasty has been studied without a clear consensus on the efficacy, safety and advantage of that technique. To our knowledge, the efficacy and safety of mini-incisions in hip fracture surgery has not been studied in a randomised fashion.

Methods

This study is a prospective clinically randomised trial whose primary objective was to demonstrate the safety and efficacy of a single posterior mini-incision approach compared to a standard posterior approach for endoprosthesis in acute femoral neck fractures. The mini-incision was defined as less than 8 cm. 25 patients in the mini-incision surgery (MIS) group and 31 patients in the standard incision group (STD) were available for analysis. The following validated disease-specific outcome instruments were used: the Lower Extremity Measurement (LEM) and the Time Up and Go (TUG). Secondary endpoints of pain, function, and quality of life were assessed by the components of the Harris Hip Score (HHS) and SF-36. Radiographic outcomes were also evaluated as well as the rates of all reported complications and adverse events during the 2 years follow-up.

Results

There was no significant difference for operative time, blood losses, 72 h postoperative haemoglobin as well as the need for transfusion therapy between the two groups. Also, there was no difference between the groups for postoperative morphine use and pain evaluation with the Visual Analog Scale. The functional assessment using LEM and TUG did not demonstrate any statistically significant difference between mini- and standard incision. However, the HHS and the physical function component of the SF-36 were statistically better at 2 years in favour of the standard incision group.

Conclusion

Based on the results of the present study, we cannot recommend the use of a minimally invasive approach over a standard approach in the implantation of a cemented endoprosthesis.

Introduction

Hip fractures in the elderly population are associated with considerable morbidity and high socio-economic cost.17, 18 The elderly people frequently have multiple comorbidities that can complicate major surgical procedure with significant blood loss and prolonged recovery.22, 23 Physical function is one of the most important outcomes measured following the treatment of a hip fracture. A large proportion of patients with a hip fracture do not return to their previous level of physical function, and many are unable to return to community-dwelling.11, 24 Early ambulation has a direct impact on outcome not only by forestalling certain medical complications but also by increasing the potential for the individual patient to return to a functional life.27

In recent years, a new trend in favour of reducing incision length and soft tissue trauma during orthopaedic surgery – the Minimally Invasive Surgery (MIS) approach – has been popularised that could influence the outcome of hip fracture patients. The philosophy behind these approaches is to minimise the surgical dissection by decreasing the size of the incision and employing inter-muscular route to obtain adequate exposure. The potential advantages of MIS in hip replacement surgery include decreased surgical blood loss,12, 25, 30 decreased postoperative pain with quicker recovery, and faster rehabilitation and decreased hospital stay.7, 8, 5 Potential disadvantages include wound complications, neurovascular injuries, mal-alignment of the components with subsequent instability and iatrogenic fractures.7, 14 Multiple studies have demonstrated mainly short-term clinical advantages of doing total hip arthroplasty (THA) with a MIS approach4, 9, 13, 21, 33 while others have shown no difference.10, 12, 16, 26, 32

For intertrochanteric hip fractures, a minimally invasive technique using a dynamic hip screw had significantly less blood loss (P < 0.001), operative time (P < 0.001) and a trend to less morphine use according to Alobaid et al.1 The elderly patients generally have decreased physiological reserve and comorbidities and often cannot tolerate a major surgical procedure. We believe that the patient with hip fracture has the most to gain from a less invasive surgical procedure that allows quicker postoperative mobilisation, decreased pain and morphine consumption.

To the best our knowledge, the impact of MIS on the implantation of a cemented endoprosthesis in hip fracture surgery has never been studied in a randomised fashion. The primary purpose of this clinical trial was to determine the safety and effectiveness of MIS compared to a conventional surgical approach in cemented endoprosthesis for hip fractures in the elderly population.

Section snippets

Patients

From May 2004 to July 2006, a total of 56 patients were randomised by sealed envelope between the MIS group and the standard incision group. All patients who met the inclusion criteria (age from 55 to 100 years with a displaced femoral neck fracture, community ambulators before the fracture) and were able to understand their roles in the study were invited to participate on a voluntary basis. Patients were all followed for a minimum of 2 years after surgery.

Surgical technique

In-patient surgeries were performed

Primary outcome

Functional recovery was evaluated with the Lower Extremity Measure (LEM). The disease-specific questionnaire is validated and suitable for use in older adults with a hip fracture. The LEM measures functional status and is the best measure for detecting changes in physical function in this specific group of patients. This modified T.E.S.S. is a self-administered questionnaire consisting of 30 questions related to physical function with responses ranging from “impossible to do (score = 1)” to “not

Results

The preoperative demographic and physiological data are summarised in Table 1. The operative data as well as the postoperative physiological data are presented in Table 2.

Our primary outcome measure was the Lower Extremity Measurement. Preoperatively, our two test groups had similar LEM scores. The postoperative LEM scores were also comparable between the two groups at all time points, as summarised in Table 3. The “return-to-baseline” for the LEM at 12 months was similar in both groups, as

Discussion

The goal of hip fracture surgery, regardless of the technique used, is to return the patient to his previous functional level. Our combined results show however that only 34.2% of patients return to their subjective pre-injury functional level at one year post-fracture. Cree et al.11 looked at the functional dependence of patients after hip fracture. In adjusting for covariates, the patients were dichotomised between a “high mental status” group and a “low mental status” group. Since one of our

Conclusion

Doing hip fracture surgery through a smaller incision is appealing but can lead to technical challenges resulting in less than perfect cementing of the components. Literature on THA seems to demonstrate no clear advantage of MIS versus standard incision. Based on the results of the present study, with a sample consisting of an elderly community-ambulating population with hip fractures, we cannot recommend the use of a minimally invasive approach over a more standard approach in the implantation

Conflict of interest

The authors have declared no conflict of interest.

Acknowledgment

We thank Mrs. Josee Delisle, BscN, Msc, for her assistance in preparing the review.

References (33)

  • R.L. Barrack et al.

    Improved cementing techniques and femoral component loosening in young patients with hip arthroplasty. A 12-year radiographic review

    J Bone Joint Surg [Br]

    (1992)
  • R.A. Berger et al.

    Rapid rehabilitation and recovery with minimally invasive total hip arthroplasty

    Clin Orthop Relat Res

    (2004)
  • D.J. Berry

    “Minimally invasive” total hip arthroplasty

    J Bone Joint Surg [Am]

    (2005)
  • D.J. Berry et al.

    Minimally invasive total hip arthroplasty. Development, early results, and a critical analysis. Presented at the Annual Meeting of the American Orthopaedic Association, Charleston, South Carolina, USA, June 14, 2003

    J Bone Joint Surg [Am]

    (2003)
  • K.C. Bertin

    Minimally invasive outpatient total hip arthroplasty: a financial analysis

    Clin Orthop Relat Res

    (2005)
  • M. Cree et al.

    Functional dependence after hip fracture

    Am J Phys Med Rehabil

    (2001)
  • Cited by (22)

    • No benefits of minimally invasive total hip arthroplasty via Watson-Jones approach: A retrospective cohort study

      2021, Surgeon
      Citation Excerpt :

      Both MIS and SIS were performed by two independent surgeons; although both surgeons were well beyond their learning curve, this may limit generalizability. Previous reports evidenced controversial results in both surgical duration and the estimated blood lost between the two approaches with inconsistent conclusions4,6,10,30,37,46–57. However, in the present study, the surgical duration and the estimated blood loss were not analysed, representing a further limitation.

    • Early results of displaced femoral neck fragility fractures treated with supercapsular percutaneous-assisted total hip arthroplasty

      2019, Arthroplasty Today
      Citation Excerpt :

      The physiologic and anatomic rationale for our observations may stem from preserving and primarily closing the capsulotomy, as well as preservation of the short external rotators. Randomized prospective studies of MIS posterior approaches for hemiarthroplasty have not demonstrated reduced rates of dislocation, but in these studies the short external rotator muscles were sacrificed [33,34]. Another retrospective analysis of a modified, short external rotator-preserving posterior approach reported significantly lower dislocation rates than a standard posterior approach (0% vs 7.7%) [35].

    • Surgical Approaches and Hemiarthroplasty Outcomes for Femoral Neck Fractures: A Meta-Analysis

      2018, Journal of Arthroplasty
      Citation Excerpt :

      Clinically relevant differences in the treatment outcomes between the surgical techniques within each of the 3 main groups are poorly studied, but cannot be ruled out. Such differences, for example, have been found in pain and mobility for the anterolateral and direct LA [52], but not for the posterior minimal invasive surgery vs the conventional PA [53]. Finally, only a few studies were available for comparisons with the LA.

    • Total hip replacement for elderly neck of femur fracture patients

      2016, Orthopaedics and Trauma
      Citation Excerpt :

      However, the clinical benefits over conventional approaches remain unproven.36 Roy et al. performed a prospective randomized clinical trial comparing a posterior MIS approach to a conventional posterior approach for THR in acute femoral neck fractures and reported no differences in operating time, blood loss or pain relief at 2 years.37 Notably, hip function and quality of life was better with the conventional approach.

    • Total hip arthroplasty with minimal invasive surgery in elderly patients with neck of femur fractures: our institutional experience

      2015, Injury
      Citation Excerpt :

      This technique is reliable, reproducible and as safe as with conventional approaches and the accuracy of the implant positioning is the same. Early, medium and long term results are favourable [6] but they are to be confirmed in longer series [30] for generalizing this approach and establishing its best indications. This concept of lesser surgical aggression by limiting surgical tissue dissection can reduce blood loss, pain and muscle wastage, and minimize the risk of prosthetic dislocation.

    View all citing articles on Scopus
    c

    Tel.: +1 514 332 6025x223; fax: +1 514 338 3542.

    d

    Tel.: +1 613 737 8774; fax: +1 613 737 8837.

    View full text