Surgical approaches in hemiarthroplasty for hip fracture : results of 48,222 hemiarthroplasties in the Norwegian Hip Fracture Register

Raymond Tellefsen; Torbjørn B Kristensen; Eva H Dybvik; Jan-Erik Gjertsen; Lars Nordsletten; Terje Ugland; Håvard Visnes; Lene B Solberg

doi:10.1302/2633-1462.610.BJO-2025-0099.R1

Surgical approaches in hemiarthroplasty for hip fracture : results of 48,222 hemiarthroplasties in the Norwegian Hip Fracture Register

Bone Jt Open. 2025 Oct 22;6(10):1311-1320. doi: 10.1302/2633-1462.610.BJO-2025-0099.R1.

Authors

Raymond Tellefsen^{1

2}, Torbjørn B Kristensen³, Eva H Dybvik³, Jan-Erik Gjertsen^{3

4}, Lars Nordsletten^{1

2}, Terje Ugland⁵, Håvard Visnes⁵, Lene B Solberg¹

Affiliations

¹ Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.
² Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
³ The Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.
⁴ Department of Clinical Medicine, University of Bergen, Bergen, Norway.
⁵ Division of Orthopaedic Surgery, Sorlandet Hospital Kristiansand, Kristiansand, Norway.

PMID: 41120102
PMCID: PMC12539978
DOI: 10.1302/2633-1462.610.BJO-2025-0099.R1

Abstract

Aims: The aim of this study was to compare the direct lateral approach (DLA) with the anterolateral approach (ALA) and posterior approach (PA) using data on hemiarthroplasties (HAs) reported to the Norwegian Hip Fracture Register. The primary endpoint was reoperations within 12 months post-surgery. Secondary endpoints included mortality, patient-reported outcome measures (PROMs; EuroQol five-dimension three-level questionnaire (EQ-5D-3L) and EuroQol visual analogue scale (EQ-VAS)), and intraoperative complications.

Methods: A total of 39,905 HA patients aged 60 years or older who were operated on using DLA from January 2005 to December 2023 were compared to 2,813 patients operated on with ALA and 5,504 with PA in the same period. Hazard rate ratios (HRRs) for reoperations and mortality were calculated using Cox regression adjusted for age, sex, American Society of Anesthesiologists classification, cognitive status, and fixation method. Patients reported EQ-5D-3L and EQ-VAS 12 months postoperatively.

Results: The reoperation rate was 3.7% for DLA, 3.0% for ALA (HRR 0.79 (0.64 to 0.99)), and 5.9% for PA (HRR 1.54 (1.37 to 1.74)). PA was associated with an increased dislocation rate compared to DLA (HRR 3.92 (3.28 to 4.67)). Fewer infections were observed with ALA (1.5%, HRR 0.68 (0.50 to 0.93)) and PA (1.6%, HRR 0.74 (0.59 to 0.92)) compared to DLA (2.2%). Similar 30-day mortality rates were found for all approaches and marginally lower one-year mortality was found for the PA. Patients operated on with the DLA reported significantly lower EQ-5D-3L index score and EQ-VAS at 12 months post-surgery compared to ALA and PA. Fewer intraoperative fractures were found using the PA.

Conclusion: This study indicates that PA is associated with a higher reoperation rate after HA compared to the two other approaches. This is primarily due to high dislocation rate, despite a higher infection rate with DLA. EQ-5D-3L and EQ-VAS appear to favour ALA and PA 12 months post-surgery. Based on this study, traditional PA should be avoided in this patient group. ALA seems to be a safe alternative to the DLA.