Letter to the Editor Open Access
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. May 18, 2024; 15(5): 486-488
Published online May 18, 2024. doi: 10.5312/wjo.v15.i5.486
Debate on direct-anterior vs posterior approach for hip hemiarthroplasty: The authors’ insights
Deepak Kumar, Tarkik Thami, Manjunath Nishani, Department of Orthopedics, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
ORCID number: Deepak Kumar (0000-0003-0479-1164); Tarkik Thami (0000-0002-6836-4893).
Author contributions: Thami T and Kumar D have contributed equally to this work. The original article was read by Thami T, Kumar D, and Nishani M thoroughly. Kumar D and Thami T analyzed the data and wrote the original manuscript. The manuscript was revised by Thami T, Kumar D, and Nishani M collectively. All authors have read and approved the final manuscript.
Conflict-of-interest statement: The Authors declare that there are no potential conflicts of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Tarkik Thami, DNB, MBBS, MS, Attending Doctor, Department of Orthopedics, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India. thamitarkik@gmail.com
Received: February 3, 2024
Revised: March 3, 2024
Accepted: April 7, 2024
Published online: May 18, 2024
Processing time: 102 Days and 5.1 Hours

Abstract

We read and discussed the study entitled “Complication rates after direct anterior vs posterior approach for Hip Hemiarthroplasty in elderly individuals with femoral neck fractures” with great interest. The authors have done justice to the topic of comparison of anterior and posterior surgical approaches for bipolar hemiarthroplasty which has been an everlasting debate in the existing literature. However, there are certain aspects of this study that need clarification from the authors.

Key Words: Commentary; Direct anterior approach; Posterior approach; Hip hemiarthroplasty

Core Tip: The debate on an ideal approach for total hip arthroplasty/hemiarthroplasty is an everlasting one. The relatively newer approaches such as the direct anterior approach are appealing to many surgeons but lack long-term data to prove their benefits and efficacy. We found an article written of great significance to the above-mentioned topic. However, we sought to request the authors to clarify some points about this research article to further strengthen the message that is being conveyed.



TO THE EDITOR

We read and discussed the study entitled “Complication rates after direct anterior vs posterior approach (PL) for Hip Hemiarthroplasty in elderly individuals with femoral neck fractures” by Charles et al[1] with great interest. This appears to be a novel research with a structured study protocol for which all the authors should be applauded. The authors have adeptly addressed the ongoing debate in the existing literature regarding the comparison of anterior and posterior surgical approaches for total hip arthroplasty (THA), doing justice to the intricacies of the topic[2]. However, there are certain aspects of the study which need elaboration from the authors.

The higher rates of postoperative bipolar hemiarthroplasty dislocations in the PL group is out of proportion to the absence of dislocation in the direct anterior approach (DAA) group as there is considerable literature to support that posterior approach is not associated with higher rates of dislocation provided that short external rotators and the joint capsule have been repaired properly by applying transosseous sutures to the greater trochanter[2-4]. We believe that the authors should have mentioned femoral stem anteversion for all the included cases, as this information would’ve aided in understanding the reasons for a higher number of dislocations encountered in the PL group.

We would also like to emphasize that it is worth mentioning preoperative clinical details and co-morbidities of the patients undergoing Hemiarthroplasty by DAA and PL approaches. It is plausible that the reason for a higher incidence of dislocations in the PL group could be the preferential inclusion of frail patients with neuromuscular disorders or weak pelvic girdle muscles; and patients with Dementia or Delirium. It is well known that such patients are at a higher risk of dislocation postoperatively[5].

Furthermore, the authors have stated that implant revision was required in 8 out of the 14 hemiarthroplasties which got dislocated, but it has not been mentioned properly if these cases were revised again into a bipolar hemiarthroplasty or revised to a THA. This is especially relevant in cases of recurrent instability leading to distortion of Acetabular anatomy which might warrant revision into a THA[6].

Paradoxically, a statistically significant difference in 30 d mortality rates was found when ASA 1 and 2 and ASA 3 and 4 patients were analyzed in groups while the same was not significant when applied to individual surgical approach groups. Interestingly, the same paradox continued when a log-linear model was applied. The data on ASA (Table 1) also needs elaboration from the authors.

Table 1 Demographic data, mean ± SD.

Direct anterior approach (n = 109)
PL (n = 171)
P value
Age (yr)82.3 ± 7.282.6 ± 8.20.72
Sex (M/F, %)29 (27)/80 (73)50 (29)/121 (71)0.63
BMI (kg/m2)23.1 ± 5.423.6 ± 4.50.91
ASA score (%)0.87
    ASA 100
    ASA 233 (30)68 (40)
    ASA 369 (63)90 (53)
    ASA 490 (53)8 (5)

We also noticed a mention in the results section that anesthesia was required to manage complications in 5.7% of patients in the DAA group and 25.3% of patients in the PL group and the difference was statistically significant. This statement requires clarification as it lacks specificity regarding the utilization of anesthesia in addressing complications associated with THA. The authors should explicitly outline the complications necessitating anesthesia for their resolution. Additionally, the authors must justify the significance of the aforementioned statement within the context of the study.

The authors believe that addressing the subsequent comments will enhance the robustness of this study and increase its relevance to the orthopedic practice of the readers.

Footnotes

Provenance and peer review: Unsolicited article; Externally peer reviewed.

Peer-review model: Single blind

Corresponding Author's Membership in Professional Societies: Indian Orthopedics Association, No. LM14697.

Specialty type: Orthopedics

Country/Territory of origin: India

Peer-review report’s classification

Scientific Quality: Grade C

Novelty: Grade B

Creativity or Innovation: Grade B

Scientific Significance: Grade B

P-Reviewer: Yang FC, China S-Editor: Qu XL L-Editor: A P-Editor: Zhao YQ

References
1.  Charles T, Bloemers N, Kapanci B, Jayankura M. Complication rates after direct anterior vs posterior approach for hip hemiarthroplasty in elderly individuals with femoral neck fractures. World J Orthop. 2024;15:22-29.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 3]  [Reference Citation Analysis (0)]
2.  Christensen TH, Egol A, Pope C, Shatkin M, Schwarzkopf R, Davidovitch RI, Aggarwal VK. How Does Surgical Approach Affect Characteristics of Dislocation After Primary Total Hip Arthroplasty? J Arthroplasty. 2023;38:S300-S305.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in F6Publishing: 1]  [Reference Citation Analysis (0)]
3.  Tripuraneni KR, Munson NR, Archibeck MJ, Carothers JT. Acetabular Abduction and Dislocations in Direct Anterior vs Posterior Total Hip Arthroplasty: A Retrospective, Matched Cohort Study. J Arthroplasty. 2016;31:2299-2302.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 33]  [Cited by in F6Publishing: 32]  [Article Influence: 4.0]  [Reference Citation Analysis (0)]
4.  Kwon MS, Kuskowski M, Mulhall KJ, Macaulay W, Brown TE, Saleh KJ. Does surgical approach affect total hip arthroplasty dislocation rates? Clin Orthop Relat Res. 2006;447:34-38.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 241]  [Cited by in F6Publishing: 218]  [Article Influence: 12.1]  [Reference Citation Analysis (0)]
5.  Konan S, Duncan CP. Total hip arthroplasty in patients with neuromuscular imbalance. Bone Joint J. 2018;100-B:17-21.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 13]  [Cited by in F6Publishing: 14]  [Article Influence: 2.3]  [Reference Citation Analysis (0)]
6.  Rajkumar N, Soundarrajan D, Ram G, Dhanasekararaja P, Rajasekaran S. Outcomes of Total Hip Replacement for Failed Hemiarthroplasty. Indian J Orthop. 2023;57:679-688.  [PubMed]  [DOI]  [Cited in This Article: ]  [Reference Citation Analysis (0)]