Comparing Postoperative Leg Length Discrepancy and Femoral Offset Using Two Different Surgical Approaches for Hemiarthroplasty of the Hip

The direct anterior approach (DAA) and anterolateral approach (ALA) may be used for hip hemiarthroplasty (HHA) as a treatment for femoral neck fractures. The DAA often utilizes intraoperative fluoroscopy to determine leg length and offset, while the ALA traditionally utilizes an intraoperative clinical exam to determine offset and leg length. This study will evaluate two techniques: the "grid fluoroscopy [GF] technique" and the "intraoperative exam [IE] technique," each performed by one of two separate surgeons, and compare each technique's accuracy to restore leg length and femoral offset in a patient population that underwent HHA.

Two investigators retrospectively reviewed charts of 208 randomly selected patients who had an HHA from either a DAA or ALA performed by two different surgeons for the treatment of femoral neck fractures. Postoperative AP pelvis radiographs were measured to determine offset and leg length compared with the non-operative extremity. Non-normal continuous variables were provided by median and interquartile range. Data were analyzed with the Mann-Whitney U test and Student's t-test.

After inclusion and exclusion criteria, data were reviewed on 173 hemiarthroplasties. The mean age was 80.3 years (± 11.2 years). Of the surgical patients, 65.9% were female, and 70.9% identified their ethnicity as white. The DAA was used in 93 patients and ALA in 80 patients. Analysis comparing the two techniques demonstrated no statistically significant differences in median leg length between GF technique (1.02 IQR -0.1, 2.0 mm) and IE technique (1.25 IQR -2.4, 1.3 mm,) (p=0.67). There was also no statistically significant difference in offset between GF technique (1.3 IQR 0.2, 2.1 mm) and IE technique (0.6 IQR -2.7 mm, 3.2 mm) (p=0.13). However, a difference was found in mean length of surgery that was statistically significant. We found that the mean length of surgery for the IE technique was 74.8 ± 24.7 minutes versus the GF technique, which was 95.1 ± 23.0 minutes, (p<0.0001).

There was no significant difference between leg length and offset with the use of intraoperative fluoroscopy with DAA compared to no intraoperative imaging with ALA. Our study suggests that DAA and ALA are equally effective approaches for re-establishing symmetric leg length and offset in HHA for femoral neck fractures. In this study, the ALA had a shorter surgical time compared to DAA, potentially due to the utilization of intraoperative fluoroscopy for this particular technique during the DAA.