IMPORTANCE Hip fractures in older adults are serious injuries that result in disability, higher rates of illness and death, and a substantial strain on health care resources. High-quality evidence... Show moreIMPORTANCE Hip fractures in older adults are serious injuries that result in disability, higher rates of illness and death, and a substantial strain on health care resources. High-quality evidence to improve hip fracture care regarding the surgical approach of hemiarthroplasty is lacking. OBJECTIVE To compare 6-month outcomes of the posterolateral approach (PLA) and direct lateral approach (DLA) for hemiarthroplasty in patients with acute femoral neck fracture. DESIGN, SETTING, AND PARTICIPANTS This multicenter, randomized clinical trial (RCT) comparing DLA and PLA was performed alongside a natural experiment (NE) at 14 centers in the Netherlands. Patients aged 18 years or older with an acute femoral neck fracture were included, with or without dementia. Secondary surgery of the hip, pathological fractures, or patients with multitrauma were excluded. Recruitment took place between February 2018 and January 2022. Treatment allocation was random or pseudorandom based on geographical location and surgeon preference. Statistical analysis was performed from July 2022 to September 2022. EXPOSURE Hemiarthroplasty using PLA or DLA. MAIN OUTCOME AND MEASURES The primary outcome was health-related quality of life 6 months after surgery, quantified with the EuroQol Group 5-Dimension questionnaire (EQ-5D-5L). Secondary outcomes included dislocations, fear of falling and falls, activities of daily living, pain, and reoperations. To improve generalizability, a novel technique was used for data fusion of the RCT and NE. RESULTS A total of 843 patients (542 [64.3%] female; mean [SD] age, 82.2 [7.5] years) participated, with 555 patients in the RCT (283 patients in the DLA group; 272 patients in the PLA group) and 288 patients in the NE (172 patients in the DLA group; 116 patients in the PLA group). In the RCT, mean EQ-5D-5L utility scores at 6 months were 0.50 (95% CI, 0.45-0.55) after DLA and 0.49 (95% CI, 0.44-0.54) after PLA, with 77% completeness. The between-group difference (-0.04 [95% CI, -0.11 to 0.04]) was not statistically significant nor clinically meaningful. Most secondary outcomes were comparable between groups, but PLA was associated with more dislocations than DLA (RCT: 15 of 272 patients [5.5%] in PLA vs 1 of 283 patients [0.4%] in DLA; NE: 6 of 113 patients [5.3%]) in PLA vs 2 of 175 patients [1.1%] in DLA). Data fusion resulted in an effect size of 0.00 (95% CI, -0.04 to 0.05) for the EQ-5D-5L and an odds ratio of 12.31(95% CI, 2.77 to 54.70) for experiencing a dislocation after PLA. CONCLUSIONS AND RELEVANCE This combined RCT and NE found that among patients treated with a cemented hemiarthroplasty after an acute femoral neck fracture, PLA was not associated with a better quality of life than DLA. Rates of dislocation and reoperation were higher after PLA. Randomized and pseudorandomized data yielded similar outcomes, which suggests a strengthening of these findings. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04438226 Show less
Purpose The Dutch Hip Fracture Audit (DHFA), a nationwide hip fracture registry in the Netherlands, registers hip fracture patients and aims to improve quality of care since 2016. This study shows... Show morePurpose The Dutch Hip Fracture Audit (DHFA), a nationwide hip fracture registry in the Netherlands, registers hip fracture patients and aims to improve quality of care since 2016. This study shows trends in the data quality during the first 5 years of data acquisition within the DHFA, as well as trends over time for designated quality indicators (QI). Methods All patients registered in the DHFA between 1-1-2016 and 31-12-2020 were included. Data quality-registry case coverage and data completeness-and baseline characteristics are reported. Five QI are analysed: Time to surgery < 48 h, assessment for osteoporosis, orthogeriatric co-management, registration of functional outcomes at three months, 30-day mortality. The independent association between QI results and report year was tested using mixed-effects logistic models and in the case of 30-day mortality adjusted for casemix. Results In 2020, the case capture of the DHFA comprised 85% of the Dutch hip fracture patients, 66/68 hospitals participated. The average of missing clinical values was 7.5% in 2016 and 3.2% in 2020. The 3 months follow-up completeness was 36.2% (2016) and 46.8% (2020). The QI 'time to surgery' was consistently high, assessment for osteoporosis remained low, orthogeriatric co-management scores increased without significance, registration of functional outcomes improved significantly and 30-day mortality rates remained unchanged. Conclusion The DHFA has successfully been implemented in the past five years. Trends show improvement on data quality. Analysis of several QI indicate points of attention. Future perspectives include lowering the burden of registration, whilst improving (registration of) hip fracture patients outcomes. Show less
Background: The posterolateral approach (PLA) and direct lateral approach (DLA) are the most commonly used approaches for inserting a hemiarthroplasty in the treatment of femoral neck fractures. A... Show moreBackground: The posterolateral approach (PLA) and direct lateral approach (DLA) are the most commonly used approaches for inserting a hemiarthroplasty in the treatment of femoral neck fractures. A recent review concluded that the routine use of PLA should be questioned, but this conclusion itself can be questioned. The aim of this study is to provide an updated overview and critical appraisal of the available evidence, focussing on outcomes most relevant for patients. Methods: We conducted a comprehensive search of literature in the MEDLINE and EMBASE databases and Cochrane Library. Studies (till June 2018) to identify hip fracture clinical trials/comparative studies comparing alternative surgical approaches (PLA and DLA). We explored sources of heterogeneity and conducted pooled analyses when appropriate. Results: 264 potentially eligible studies were identified of which 1 RCT, 3 prospective, 3 registry data and 5 retrospective studies were included. The RCT consisted performance and attrition bias. The mean MINORS score of the prospective/register studies was 17.3 (SD 3.5) and 13.8 (SD 1.9) of the 5 retrospective studies. The GRADE score for all the outcomes was very low. Due to the high and various types of biases across the included studies, we did not pool the data. None of studies assessed the activities of daily living functionality. 6 studies reported significantly more dislocations or reoperations due to dislocation in the PLA group, 6 other studies found no differences. DLA patients were more likely to develop abductor insufficiency leading to limping and more need for walking aids. The PLA patients tended to have better quality of life, less pain and more satisfaction compared to the DLA patients. Conclusion: Based on low-quality studies, PLA may be associated with more dislocations, but patients had less walking problems and a lower tendency to abductor insufficiency compared with DLA. Further clinical trials with methodology rigor are needed to determine which approach is more effective in terms of outcomes relevant to patients. Show less
