Injury (1993) 24, (9), 611-613 Printed in Great Britain
Hemiarthroplasty of the hip - the anterior or
posterior approach? A comparison of surgical
approaches
G. S. Keene and M. J. Parker
Peterborough District Hospital, Peterborough, UK
A series of 531 patients presenting with a displaced subcapital femoral
fracture treated by hemiarthroplasty, were studied prospectively to
determine the optimal approach for surgery.
A fotal of 302 prostheses were inserted by an anterolaferal approach and
229 by a posterolaferul appmach. Cowrplications in these two broadly
comparable groups are discussed. Dislocation and thrombosis were more
common after a posterior approach. Operative time, blood loss, and
infection, weregreater affer an anterior approach. There was no significanf
difference in the length of hospital stay or mort&y.
Our findings suggest the favoured approach should be thaf at which the
surgeon feels most competent.
Introduction
The surgical approach to the hip joint for urgent hemiarthro-
plasty after displaced subcapital fractures of the femur has
long been a controversial subject. Thompson advocated the
anterior Smith-Peterson approach (Thompson, 19%) which
Moore found technically more difficult, developing the
alternative ‘Southern’ approach (Moore, 1957). Many re-
ports have since favoured a particular approach with
reference to increased stability (Moore, 1957; Chan and
Hoskinson, 1975; Kwok and Guess, 1982; Stewart and
Papagiannopoulos, 1986; Paton and Hirst, 1989), yet stabil-
ity is but one of many factors influencing the morbidity of
the procedure.
The aim of this paper is to determine the preferred
approach for urgent hemiarthroplasty to minimize the
operative and postoperative complications.
Patients and methods
From a consecutive series of 1821 patients presenting to two
centres with a proximal femoral fracture, the 546 intracapsu-
lar fractures treated by hemiarthroplasty were studied. Of
the 546 cases, 15 patients were excluded as the surgical
approach was either not specified or the operative notes
were not available. The remaining 531 patients were studied
prospectively with reference to the surgical approach.
Patients were admitted sequentially to the Birmingham
Accident Hospital and Peterborough District Hospital. The
number of cases operated on by the various grades of
surgeons were: consultant, 4 per cent; senior registrars, 2 per
cent; research registrars, 5 1 per cent; registrars, 41 per cent;
and senior house officers, 2 per cent. The anterolateral
I(‘8 I993 Butterworth-Hrinemann Ltd
0020~ 1383/93/OYO6 I I-03
611
approach favoured in 302 cases was almost exclusively that
of Hardinge, splitting gluteus medius (Hardinge, 1982). The
posterior approach was the ‘Southern’ posterior approach
(Moore, 1957) favoured in 229 cases. There were operations
using a direct lateral approach with a trochantenc osteo-
tomy. We reviewed the operative and postoperative com-
plications and mortality up to 1 year after operation.
The factors studied included operative time, operative
blood loss and intraoperative incidence of femoral fracture.
The postoperative complications studied included superfi-
cial and deep wound infections, deep vein thrombosis and
pulmonary embolism (confirmed either clinically or by
ultrasound, venogram, isotope lung scan or post-mortem),
dislocation rates, length of hospital stay and mortality rates.
The majority of patients received intravenous prophylac-
tic antibiotic at the time of operation, followed by two or
three postoperative doses. Operative blood loss was estim-
ated in theatre by the weighing of swabs and recording of
volumes in suction apparatus. Superficial infections were
defined as those wound infections requiring treatment with
antibiotics or surgical drainage. Deep infections were those
around the prosthesis.
The patients were admitted as emergencies with an even
distribution under the care of various consultants, who
employed comparable management programmes, mobiliz-
ing the vast majority of patients within 48 h postoperat-
ively, regardless of the surgical approach, reducing the bias
between the two groups. The Austin-Moore prosthesis was
used in 415 cases and the Thompson prosthesis in 116 cases;
of these, six Austin-Moore and 36 Thompson prostheses
were cemented with a polymethylmethacrylate cement.
Comparison is made for complication rates between the two
approaches using statistical analysis including the Fisher
exact test (FET), Student’s t test and the 2” test. P values of
> 0.05 were not considered to be statistically significant
(I%).
Results
The average age of ail patients was 81 years, of whom 86
per cent were female. There were 73 per cent admitted from
their own home, 20 per cent from residential homes and 7
per cent were long-stay hospital inpatients. The overall
results are summarized in Tillle I.
There were five dislocations after the anterior approach
and 10 after the posterior approach, which is marginally
612 Injury: International Journal of the Care of the Injured (1993) Vol. 24IN0.9

Table I. Results

Anterior Posterior
approach approach P value

Number of patients 302 229

Operative blood loss 251 ml 197ml 0.002 ttest
Operation time 56 min 48 min 0.003 t test
Dislocation 5 (1.7%) 10 (4.3%) 0.04 FET
Fracture at operation 6 (2.0%) 4 (1.7%) NS FET
Subsequent fracture’ 0 (0.0%) 8 (3.5%) 0.002 FET
Superficial infection 18 (6.0%) 6 (2.6%) 0.03 FET
Deep infection 6 (2.0%) 2 (0.9%) NS FET
Deep vein thrombosis 2 (0.7%) 15 (6.5%) 0.001 FET
Pulmonary embolism 2 (0.7%) 6 (2.6%) NS FET
Sciatic nerve palsy* 0 1
Mortality 30-day 7% 10% NS x2 test
6-month 24% 30% NS x2 test
1 -year 30% 37% NS ,$ test
Orthopaedic ward stay 21 days 20 days NS ttest
Total hospital stay 34 days 33 days NS ttest

‘Fracture around or below the prosthesis.

Total sciatic nerve lesion showing no signs of recovery postoperatively, which was associated with two episodes of dislocation. Revision was
not undertaken and the patient was discharged in a wheelchair to a nursing home.

significant (P= 0.04). All were reduced by closed manipula-
tion, with seven patients suffering a second dislocation;
again all were reduced by closed manipulation; no revision
operation was required by this group during the study
period. The mortality rate after dislocation was high, at 8 per
cent in the first 30 days and 73 per cent in 6 months, with no
further deaths during the study period.
There was no significant difference in the incidence of
femoral fracture at operation; there were, however, eight
cases of fracture below the implant at a late stage (after
discharge) in the posterior approach group.
Both superficial and deep wound infections were greater
after the anterior approach, significantly so for superficial
infections (P= 0.003). Deep vein thrombosis and pulmonary
emboli were more common after a posterior approach,
significantly so for the former (P= 0.001). There may have
been more subclinical deep venous thromboses than those
detected. The operative blood loss was significantly greater
in the anterior approach (P= 0.002), which may represent
greater muscle damage during the more prolonged anterior
approach, where the operative time was significantly greater
(P= 0.003) than the average time for a posterior approach.
Discussion
Approaches to the hip joint for hemiarthroplasty were first
published in the 1950s (Thompson, 1954; Moore, 1957;
Breck et al., 1958). Thompson advocated an anterior
approach for his prosthesis, and initially he was reluctant to
recommend urgent hemiarthroplasty for subcapital frac-
tures, although he did accept there were infrequent indica-
tions (Thompson, 1954). Moore published an account of his
prosthesis shortly after Thompson; he found the anterior
approach advocated by Thompson to be more demanding,
and had experienced ‘one or two’ dislocations with an
anterior approach (Moore, 1957). Having redesigned his
prosthesis he reported no dislocations by the ‘Southern’
approach in his series of 159 cases, many of whom were
mentally ill. The characteristics of the Moore and Thompson
prostheses are, of course, different, with differing levels for
osteotomy of the femoral neck being required; technically
inadequate surgery is in part responsible for a higher
complication and failure rate (D’Arcy and Devas, 1976;
Kwok and Gus, 1982; Pryor, 1990). Thompson and Moore
both stressed the importance of siting the capsulotomy close
to the femoral neck and away from the acetabular margin to
improve stability.
Dislocation rates of this series (1.7 per cent anterior and
4.3 per cent posterior) must be compared with other series
which show a marked variation in dislocation rates from 0.9
per cent by an anterior approach to 14 per cent by a
posterior approach (Char-r and Hoskinson, 1975; Barnes et
al., 1976; Wood, 1980; Paton and Hirst, 1989). By contrast,
Salvati and Wilson (1973), who advocated the posterior
approach, reported no dislocations in a series of I15
hemiarthroplasties through a posterior approach; Sikorski
and Barrington (1981) found equal dislocation rates with the
different approaches. The lowest overall dislocation rate in
recent literature is reported by Blewitt and Mortimore
(1992) at 20 in 1000 hemiarthroplasties, although the
approach is not discussed in this retrospective study:
mortality rates among these 20 dislocations (65 per cent at 1
year), are comparable to this study. D’Arcy and Devas
(1976) observed technically inadequate surgery in all
patients sustaining a dislocation.
Posterior approach wounds lie near the perineum, and
one may anticipate that this will influence infection rates. An
infection rate of 41 per cent was reported in a study of
inmates of a hospital for the aged and infirm (Niemann and
Mankin, 1968), although such groups of patients distort the
overall figure. Some authors relate a higher infection rate to
instability, and have found a higher infection rate in those
patients suffering a dislocation (Lunt, 1971). Moore reported
only three superficial and one deep infection among his
series of 153 patients at a time when antibiotics were just
being introduced (Moore, 1957). Our infection rates are
lower in the posterior approach group (2.6 per cent versus 6.0
per cent) and a significant difference (P= 0.03) existed for
superficial infections, which is in keeping with certain oI
reports (Salvati and Wilson, 1973; Montgomery a.
Lawson, 1978; Sikorski and Barrington, 1981). By contrast,
the superficial infection rate appears to be two or three times
Keene and Parker:Hemiarthroplasty
higher with a posterior approach in reports where superficial
infections were noted in up to 18.5 per cent of cases (Chan
and Hoskinson, 1975; Wood, 1980).
The observed thrombosis rate is low, but significantly
higher after the posterior approach (P= O.OOl), although
this does not correlate with a significantly higher rate of
pulmonary embolism. The true subclinical deep venous
thrombosis rate is almost certainly greater, and more
accurate assessment with venograms or ultrasound would
have demonstrated the true subclinical incidence. The
posterior approach may expose the femoral vein to greater
trauma, leading to the higher thrombosis rate. The incidence
of operative femoral fracture was not significantly different;
however, there were eight fractures below the tip of the
prosthesis at a late stage after a posterior approach. There is
no obvious explanation for this; it may relate to near
perforation of the lateral cortex not previously identified, as
it was not routine to take lateral radiographs after operation.
The anterior approach is more time consuming, which
may account for the greater operative blood loss. This
finding contradicts that of Chan and Hoskinson (1975) who
found converse rates of blood loss. The sciatic nerve palsy
rate is mercifully negligible; the one palsy was a conse-
quence of recognized damage to the sciatic nerve which did
not recover postoperatively. Chan and Hoskinson (1975)
report three cases of foot drop after hemiarthroplasty by the
posterior approach, but there appear to be no other
references to neurological damage. Mortality figures are
comparable for both approaches and largely in keeping with
other reports already mentioned. There is clearly greater
mortality after a dislocation; however, this may be a feature
of the patients sustaining a dislocation who may express
greater morbidity with poor muscle tone, predisposing to
dislocation, rather than a direct consequence of dislocation.
In summary there are many factors influencing the
approach to the hip joint for urgent hemiarthroplasty. In the
anterior approach, dislocation and thrombosis rates are
lower, yet infection, operative time and blood loss are lower
with the posterior approach. The end result of hemiarthro-
plasty is dependent upon the technical adequacy of the
procedure and it would seem reasonable to advocate that
the most favoured approach to the hip joint for hemiarthro-
plasty is that with which the surgeon, usually a ‘trainee’, is
most familiar, enabling the most technically adequate
procedure to be performed in a reasonable time.
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Paper accepted 6 June 1993.
Requests for reprints should be addressed to: Mr G. S. Keene FRCS,
Department of Orthopaedics, Box 37, Addenbrookes Hospital,
Cambridge CB2 2QQ, UK.