Tol Maria C J M, van Beers Loes W A H, Willigenburg Nienke W, Gosens Taco, Heetveld Martin J, Willems Hanna C, Bhandari Mohit, Poolman Rudolf W
Department of Orthopaedic Surgery, OLVG, Amsterdam, The Netherlands.
Department of Orthopaedic Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.
Hip Int. 2021 Mar;31(2):154-165. doi: 10.1177/1120700020931766. Epub 2020 Jun 17.
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.
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.
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.
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.
后外侧入路（PLA）和直接外侧入路（DLA）是治疗股骨颈骨折时进行半髋关节置换术最常用的入路。最近的一项综述得出结论，常规使用PLA值得质疑，但这一结论本身也可能受到质疑。本研究的目的是提供现有证据的最新概述和批判性评价，重点关注与患者最相关的结果。
我们在MEDLINE、EMBASE数据库和Cochrane图书馆中对文献进行了全面检索。检索截至2018年6月的研究，以确定比较替代手术入路（PLA和DLA）的髋部骨折临床试验/比较研究。我们探讨了异质性来源，并在适当的时候进行了汇总分析。
共识别出264项潜在符合条件的研究，其中包括1项随机对照试验、3项前瞻性研究、3项注册数据研究和5项回顾性研究。该随机对照试验存在实施和失访偏倚。前瞻性/注册研究的平均MINORS评分为17.3（标准差3.5），5项回顾性研究的评分为13.8（标准差1.9）。所有结果的GRADE评分都很低。由于纳入研究中存在高度且多样的偏倚类型，我们未对数据进行汇总。没有研究评估日常生活功能。6项研究报告PLA组因脱位导致的脱位或再次手术明显更多，另外6项研究未发现差异。DLA患者更易发生外展肌功能不全，导致跛行，更需要助行器。与DLA患者相比，PLA患者的生活质量往往更好，疼痛更少，满意度更高。
基于低质量研究，PLA可能与更多脱位相关，但与DLA相比，患者行走问题较少，外展肌功能不全的倾向较低。需要进一步进行方法严谨的临床试验，以确定哪种入路在与患者相关的结果方面更有效。
