(Evidence + Impact) Anterior vs. Lateral Approach in Hip Fracture Surgery: What's Best for Recovery? 🦴

Anterior vs. Lateral Approach in Hip Fracture Surgery: What's Best for Recovery? 🦴

In this inaugural episode of the AHF Podcast's new series 'Evidence and Impact,' host Joe Schwab delves into a recent award-winning paper by Woolnough and colleagues on the effectiveness of the anterior approach in hip arthroplasty for recovery. 📊 The study, titled 'The Anterior Approach Does Not Improve Recovery after Hemiarthroplasty for Hip Fractures,' was published in the Journal of Arthroplasty in 2025. The trial involves a comprehensive comparison between anterior and lateral surgical approaches, focusing on elderly hip fracture patients. 🏥 Joe dissects the methodology, findings, and limitations of the study, questioning whether the anterior approach truly offers a recovery advantage. 🧐 Key takeaways include the feasibility of randomized controlled trials in this demographic, the importance of functional outcomes, and the realization that surgical approach may not be a decisive factor for recovery. 🎓 Join the discussion in the comments and share your thoughts on this fascinating topic! 💬

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Study Paper

Woolnough T, Horton I, Garceau S, Beaulé PE, Feibel RJ, Gofton W, et al. The John Charnley Award: The Anterior Approach Does Not Improve Recovery after Hemiarthroplasty for Femoral Neck Fracture. A Randomized Controlled Trial. The Journal of Arthroplasty 2025;40:S17-S24.e1. https://doi.org/10.1016/j.arth.2025.04.030.

Additional resources used in preparing this video:

• Hsieh Y-W, Wang C-H, Wu S-C, Chen P-C, Sheu C-F, Hsieh C-L. Establishing the Minimal Clinically Important Difference of the Barthel Index in Stroke Patients. Neurorehabil Neural Repair 2007;21:233–8. https://doi.org/10.1177/1545968306294729.
• Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: a reliability study. Int Disabil Stud 1988;10:61–3. https://doi.org/10.3109/09638288809164103.
• Pedersen TJ, Lauritsen JM. Routine functional assessment for hip fracture patients. Acta Orthop 2016;87:374–9. https://doi.org/10.1080/17453674.2016.1197534.
• Pedersen TJ, Bogh LNB, Lauritsen JM. Improved functional outcome after hip fracture is associated with duration of rehabilitation, but not with waiting time for rehabilitation. Dan Med J 2017;64:A5348.
• Winters AM, Hartog LC, Roijen H, Brohet RM, Kamper AM. Relationship between clinical outcomes and Dutch frailty score among elderly patients who underwent surgery for hip fracture. Clin Interv Aging 2018;13:2481–6. https://doi.org/10.2147/CIA.S181497.
• Unnanuntana A, Jarusriwanna A, Nepal S. Validity and responsiveness of Barthel index for measuring functional recovery after hemiarthroplasty for femoral neck fracture. Arch Orthop Trauma Surg 2018;138:1671–7. https://doi.org/10.1007/s00402-018-3020-z.
• Marsault LV, Ryg J, Madsen CF, Holsgaard-Larsen A, Lauritsen J, Schmal H. Objectively Measured Physical Activity and Its Association with Functional Independence, Quality of Life and In-Hospital Course of Recovery in Elderly Patients with Proximal Femur Fractures: A Prospective Cohort Study. Rehabil Res Pract 2020;2020:5907652.

Transcript

Joseph M. Schwab: 0:01

Picture this. An 85-year-old woman living independently trips on a rug, falls down and breaks her hip. In the hospital, she's frightened in pain and her family is asking the same questions. We as surgeons hear every day, what's her recovery gonna look like? Will she walk again? Will she be able to go back home? As surgeons, we have to decide not only how to fix the fracture, but also how to give her the best possible chance at independence. And one of the debates has been whether the surgical approach itself anterior posterior lateral, can make that difference. Well, in today's episode, we're going to take a closer look at a recent award-winning paper that asks exactly that question. We'll walk through the study design, dig into the methods and the results, and by the end, I'll give you my three key takeaways. Hello and welcome to the AHF Podcast. I'm your host, Joe Schwab. Today we're launching something new. I call it evidence and Impact. It's like an AHF journal club where research meets reality. In this series, we'll be taking a close look at important papers in hip arthroplasty, especially those that shape how we think about anterior approach. The goal isn't just to summarize the data, but to dig into the methods and the results and the impact. We'll ask, what do these studies tell us? What do they leave unanswered and how should they influence the way we think and practice? If at all, and for the first episode, we're starting with the John Charley Award-winning paper by Woolnough and colleagues published in the Journal of Arthroplasty in 2025. The title, the"Anterior Approach, does not improve Recovery after Hemi Arthroplasty for Hip Fractures." I've added a link to the paper in the description, but just be aware it's not available. Open access, so you have to have a subscription to the Journal of Arthroplasty to read the full text. I've also added links to some additional references that I looked at in my preparation. Are you ready? Let's take a look. The author set up a randomized controlled trial comparing anterior approach, Hemi Arthroplasty with lateral approach. Hemi Arthroplasty in Hip Fracture Patients. This was a single center study carried out at the University of Ottawa, an academic tertiary care hospital in Canada. The trial involved multiple fellowship trained arthroplasty surgeons, all of whom regularly use their approach of choice in their elective practices. They enrolled just over a hundred patients, all with displaced femoral neck fractures, and an average age was around 81, so this was a typical elderly hip fracture population except. They excluded anyone with dementia or cognitive dysfunction. Two things we commonly see in this patient population. Most patients receive cemented stems, which I think reflects common practice in that sort of setting in Canada, in an academic practice. And the study design was pragmatic, aiming to mirror real world care as closely as possible. Now, the title of the paper is interesting, does not improve Recovery. Right away I found myself wondering, does their data really justify such a definitive claim, and what do they actually mean by recovery? Well, they defined recovery using functional scores like the Barthel Index and the EQ-5D. Both of those focus on independence and quality of life, which are important measures, but it's worth remembering that recovery is a pretty broad term. Surgeons, patients, and even families might define it differently. So what did they actually find? Well, when you look at the results, there really wasn't much to separate the two groups. The patients in the anterior approach arm didn't bounce back any better than those in the lateral approach arm. Their Barthel scores, their EQ-5D Quality of Life scores basically came out about the same, at least statistically complication rates like infection were also similar. Mortality at follow-up, similar, even length of hospital stay wasn't significantly different. So despite this reputation that anterior approach has in elective hip replacement, quicker recovery, yada, yada, yada, in this group of older, frail hip patients, that advantage wasn't there, at least according to the authors. Now, here's where things get a little more interesting. This is a prospective randomized control trial, which means they enrolled patients moving forward in time rather than reviewing a bunch of patients they had operated on in the past. In order to do that, they had to determine how many patients they needed to enroll in the study to answer their question. I'm sure you know this already, but researchers often do this by using previous data from other studies. Here's where the first red flag comes in. They powered the study to detect a three point or greater difference in the Barthel 20 score. But in hip fracture patients, the minimally clinically important difference is closer to two points. That means their study may have been too small to see a difference that actually matters. In fact, to really be confident in detecting a clinically meaningful difference. They probably would've needed something more like 90 or more patients in each group rather than the 47 per group that they calculated. And this is especially important when your results show no difference between your two groups because absence of evidence is not the same as evidence of absence, and that is the risk of a type two error. So where did that three point estimate come from? Well, the author cite a study in stroke patients. I don't have to tell you. Stroke patients are not hip fracture patients. Using that as the basis for your power calculation raises questions about whether this trial was designed to truly answer its own research question. Now, this may all seem a bit nitpicky on my part, but if you look at table two, you can actually see a gap between the anterior and lateral groups that seems to widen between six weeks and three months. With a larger cohort and the right minimally, clinically important difference. If that had been used, that difference might well have reached statistical significance. Now, do I know that it would have, Nope, but that's kind of the point. So to sum up, the main finding was no statistically significant difference in recovery between anterior and lateral approaches for hemi arthroplasty in hip fracture patients. The more accurate interpretation is that no difference was detected, and that is not the same as proving the anterior approach has no benefit. Phew. So let's just pause for a second and catch our breath. We've talked about what the authors meant by recovery, and we've raised some questions about sample size and the risk of a type two error. But what do you think do these choices affect how you read the results? Drop me a comment below with your thoughts. I would really like to know, and I wanna say, I'm not saying the authors did a bad job or that there's nothing valuable here far from it. In fact, this paper won the coveted Sir John Charley Award. That's a scientific award from the Hip Society for innovative research, both clinical and basic encompassing important advances in the management of hip disorders. There are definitely some strong points in this paper, but there are some real limitations. So why don't we take a closer look at the good, the bad, and the ugly. First the good. This was a strong randomized design. A true RCT in hip fracture patients is no small feat, and the authors deserve credit for pulling it off, and they focused on outcomes that really matter. They didn't get lost in surgical details like blood loss or operative time. Instead, they looked at measures of independence and quality of life, outcomes that are meaningful for patients and families. And the clinical question is super clear. They didn't overcomplicate things. They asked directly, does the anterior approach actually help hip fracture patients recover better? That kind of focus is refreshing. Now, the bad. The trial was definitely underpowered for functional outcomes in this population. The sample size was simply not large enough to detect smaller, but still meaningful differences, and that's a real barrier to a meaningful conclusion. Also, there are reasonable questions about how generalizable this study is. These results reflect a specific patient population, hip fracture, patients with no cognitive dysfunction. A specific group of surgeons and one health system. It's hard to say whether the same findings would hold true in different countries with different rehab resources or different levels of surgeon experience, let alone in hip fracture patients with some form of cognitive dysfunction, which is common. To their credit, the authors talk about this in their limitation section and simply put, the conclusions are overstated. The authors conclude that quote. The results of the study show equivalence, but not superiority of the anterior approach over lateral approach in patients undergoing hip hemi arthroplasty for fracture. But the more accurate way to put it is that no difference was detected because those statements are not the same. Finally the ugly. So the ugly truth is this, when it comes to hip fracture patients, the choice of surgical approach may not be the dominant factor in recovery. Hip fracture patients are incredibly complex. They're frail. They often have multiple comorbidities and many are cognitively impaired. Even if one surgical approach has technical advantages, the patient's overall condition may simply overwhelm the signal. So if you've made it this far, you probably want to know what we can actually learn from this study. Well, I think there are three big takeaways. First, RCTs in hip fracture are possible. This study shows that even in frail elderly patients, we can run a randomized controlled trial and get meaningful data. That's encouraging'cause it opens the door for more high quality research in this space. Second, functional outcomes matter. At the end of the day, patients and families care less about incision length or operative time than they do about whether someone can get out of bed, walk and live independently. Using validated tools like the Barthel Index and the EQ-5D helps us measure something that really matters. And third surgical approach may not be a silver bullet, and we should remember that at least based on this trial. The anterior approach doesn't clearly give patients a recovery advantage after hip fracture. That means our efforts are probably better spent on a bigger picture, optimizing perioperative care, rehab, and multidisciplinary support, rather than focusing only on which way we get into the hip joint. Do your key takeaways differ from mine? Drop them in the comments so we can continue the discussion. And that brings me back to our patient, that 85-year-old woman who tripped on a rug. She doesn't really care whether her incision is anterior or lateral. What she and her family care about is whether she'll walk again. Whether she'll go home and whether she can get back to her normal life. This study suggests that approach may not be the biggest driver of recovery, but based on its limitations, I would say the jury is still out. So what do you think? Do you agree with this review or do you see it differently? Was there something I missed or an angle you think deserves more attention? I'd love to hear your thoughts, drop your comments, critiques or ideas below, and we'll keep that conversation going. And since this is our very first evidence and impact episode, I'd really value your input. Did you like this format? Do you have any suggestions for how we can make future evidence and impact episodes even better? Or maybe there's a paper you'd like to see us review here? Let me know. Your feedback will help shape our direction. Thank you for joining me for this episode of the AHF podcast. As always, please take a moment to like and subscribe so we can keep the lights on and keep sharing great content. Just like this. Please also drop any topic ideas or feedback in the comments below. You can find the AHF podcast on Apple Podcasts, Spotify, or in any of your favorite podcast apps, as well as in video form on YouTube slash at anterior hip foundation. All one word, episodes of the AHF podcast come out on Fridays. I'm your host, Joe Schwab, asking you to keep those hips happy, healthy, and fracture free.