The use of the SPAIRE technique in cases of cemented hemiarthroplasty in the management of displaced intracapsular neck of femur fractures – A pair-matched control study versus a direct lateral approach

Martin S. Davey; David O'Sullivan; Robert Woods; Paddy Kenny; Fintan Doyle; Adrian J. Cassar Gheiti

doi:10.1016/j.jorep.2024.100500

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Case Report

2025

:4;

100500

doi:

10.1016/j.jorep.2024.100500

The use of the SPAIRE technique in cases of cemented hemiarthroplasty in the management of displaced intracapsular neck of femur fractures – A pair-matched control study versus a direct lateral approach

Martin S. Davey^a,, David O'Sullivan^a, Robert Woods^a, Paddy Kenny^b, Fintan Doyle^b, Adrian J. Cassar Gheiti^b

a Royal College of Surgeons in Ireland, Dublin, Ireland

b James Connolly Memorial Hospital, Blanchardstown, Dublin, Ireland

⁎Corresponding author: Martin S. Davey. martindavey@rcsi.ie

Received: 2024-10-9, Accepted: 2024-10-22, Published: 2024-10-30

The Authors

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

A retrospective review of patients who underwent cemented hip hemiarthroplasty for displaced neck of femur fractures by a single surgeon using a SPAIRE technique over a two-year period between July 2019 and July 2021 was performed. These were subsequently pair matched in a 5:1 ratio for age, gender, ASA grade and residential status with a control group who underwent cemented hip hemiarthroplasty by 4 other surgeons using a direct lateral approach. Mobility levels, residential status, radiological outcomes as well as mortality data were analyzed and compared.

The study included a total of 240 patients (40 and 200 pair-matched to SPAIRE and control groups respectively), with a mean age of 81.0 ± 8.2 years (63–99) and a mean follow-up of 12 ± 3 months (3–30). There was no significant difference for mean age, gender, ASA grade and residential status between the two groups. Overall, there was no significant difference in any of the radiological or mortality outcome scores assessed between the SPAIRE and control groups (p > 0.05 for all). There was a significantly lower number of patients in the SPAIRE group who dropped a level of mobility from their pre-injury baseline at 30-days post-operatively (8.1 % versus 31.6 %; p = 0.003). However, this appeared to have resolved at 120-day follow-up with no significant differences between the groups in terms of those acquiring a new baseline mobility at 120-days post-operatively (2.7 % versus 13.2 %, p = 0.09).

In cases of cemented hip hemiarthroplasty for displaced intracapsular neck of femur fractures, the SPAIRE technique appears to offer patients an earlier return to levels of baseline pre-injury mobility when compared to a direct lateral approach. This study found that both techniques result in similarly acceptable clinical, radiological and mortality related outcomes in this high-risk patient cohort.

Keywords

Hip fracture

Hemiarthroplasty

SPAIRE

Mobility

Trauma

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1 Introduction

Representing 15 % of all fractures in osteoporotic patients, neck of femur (NOF) fractures are the second most common fractures suffered after distal radius fractures.¹ NOF fractures are a significant cause of morbidity and mortality, particularly in our ever-aging patient cohort, with the many patients seeing a reduction in their pre-injury mobility and the literature reporting potential mortality rates as high as 30 % at 1-year post-injury.²^,⁵^,⁶

The National Institute for Health & Care Excellence (NICE) institution have recently updated their guidelines suggesting that cemented implants should be utilized in cases of patients being treated with NOF fractures.³ Additionally, for over a decade these guidelines have recommended that an anterolateral approach be utilized in cases of cemented hemiarthroplasty in patients with displaced intracapsular NOF fractures. However on further in depth analysis, it becomes apparent that is recommendation is made on the results of only two studies on the basis that potential dislocation may be higher with a posterior approach.⁷^,¹⁶ Furthermore, a Cochrane Review by Jolles et al.¹¹ found no significant differences in dislocation rates in cases of total hip arthroplasty (THA) performed via a posterior approach when compared to a direct lateral approach, alongside significantly lower rates of pooled nerve injuries in patients operated using a posterior approach. Being associated with significant increases in patient morbidity and mortality, the authors note that potential dislocation or nerve injuries in patients undergoing cemented hemiarthroplasty for NOF fracture may often represent a potentially terminal event for these vulnerable patients.¹⁰

In 2017, Hanly et al.⁹ from the Exeter group in the United Kingdom described an adaptation of the traditional posterior ‘Southern Moore’ approach to the hip known as the ‘Saving Piriformis And Internus, Repair of Externus’ (SPAIRE) technique.¹⁴ This reproducible, tendon-sparing technique is centered on the concept of developing an interval between gemellus inferior and quadratus femoris whilst allowing the tendinous insertions of gemellus inferior, obturator internus, gemellus superior and piriformis to remain intact throughout the procedure. Charity et al.⁴ subsequently reported the clinical outcomes of patients undergoing cemented hemiarthroplasty for displaced NOF fractures in a designer centre where all operating surgeons perform a SPAIRE approach as standard when operating on such patients, with a reported faster recovery to mobilise when compared to other conventional approaches.

The aim of this study was to analyze and compare clinical, radiological and mortality outcomes of patients who underwent cemented hip hemiarthroplasty for displaced neck of femur fractures using a SPAIRE technique when compared to a pair-matched control cohort who underwent the same procedure using the direct lateral approach. Our hypothesis was that patients who underwent cemented hip hemiarthroplasty for displaced neck of femur fractures using a SPAIRE technique would achieve and maintain their pre-injury baseline mobility significantly faster than those who underwent the same procedure via a direct lateral approach, with no significant differences in the rates of dislocations.

2 Methods

2.1

2.1 Patient selection

A retrospective review was carried out to identify all patients who underwent isolated cemented hemiarthroplasty for intracapsular neck of femur using a SPAIRE technique by a single surgeon (F.D.) between July 2019 and July 2021. The operative notes of all patients who underwent cemented hemiarthroplasty using a SPAIRE technique were analyzed. The inclusion criteria for this study were (1) patients with displaced intracapsular neck of femur fractures, (2) treated with hemiarthroplasty using cemented Exeter™ (Stryker, Mahwah, N.J.) femoral stems, and (3) via a SPAIRE technique. Any patient treated with intracapsular neck of femur treated with cemented hemiarthroplasty with contrasting implants. A power analysis was performed and it was found that a minimum of 216 patients would be required to ensure minimum study power is achieved. Of those excluded on the basis of undergoing cemented hemiarthroplasty using a direct lateral approach, subsequent patient matching for a control group in a ratio of 5:1 based on patient characteristics including patient age, patient gender, ASA grading and residential status was performed retrospectively to generate a comparable control arm.

2.2

2.2 Surgical technique

A single surgeon (F.D.) performed cemented hemiarthroplasty in patients with displaced intracapsular neck of femur fractures using the SPAIRE technique as previously outlined by Hanley et al., in 2017.⁹

2.3

2.3 Outcomes of interest

Evaluation of postoperative clinical outcomes was carried out by an advanced nurse practitioner with respect to the Irish Hip Fracture Database outcomes of interest.¹⁵ These outcomes were analyzed at (a) pre-injury level, (b) day-30 post-operatively, (c) day-120 post-operatively, and (d) thereafter. Outcomes of interested included but were not limited to; (1) patient age in years at time of surgery, (2) patient gender, (3) residential status, such as (a) home dweller, (b) nursing home resident, or (c) rehab institution, (4) American Society of Anaesthesiologists (ASA) grading, (5) level of mobility, (6) radiological loosening or subsidence, and (7) mortality rates. Evaluation of all collected data was further evaluated and validated by two independent reviewers (M.S.D. and D.O.S.). Thereafter, a retrospective review of medical notes was carried out for outcomes including; (1) postoperative complications, and (2) further operations to the ipsilateral hip.

2.4

2.4 Statistical analysis

Statistical analysis was carried out using IBM SPSS Statistics for Windows Version 22 (IBM Corp). For all continuous and categorical variables, descriptive statistics were calculated. Continuous variables were reported as weighted mean and estimated standard deviation, whereas categorical variables were reported as frequencies with percentages. Categorical variables were analyzed using Fisher exact or chi-square test. The independent or paired t-test was performed for normally distributed variables, and the nonparametric Mann-Whitney U test or Wilcoxon signed-rank test was performed to compare continuous variables. A value of P < 0.05 was considered to be statistically significant.

3 Results

3.1

3.1 Patient characteristics

In total, 540 patients underwent treatment of NOF fractures in our institution during the aforementioned 2-year study time frame. Of these, 278 were patients presenting with displaced intracapsular NOF fractures, of which 258 underwent cemented hemiarthroplasty. Of these, 40 underwent a hemiarthroplasty using a cemented Exeter™ (Stryker, Mahwah, N.J.) femoral stem using a SPAIRE technique by a single fellowship-trained arthroplasty and trauma surgeon (F.D.). After analysis, 200 of the remaining 218 patients who underwent cemented hemiarthroplasty via a direct lateral approach were pair-matched as a comparison to the SPAIRE group. Mean follow-up was 12 ± 7.1 months (3–30) months. There were no significant differences in patient characteristics between the groups. A comparison of patient characteristics between the SPAIRE and pair-matched control groups is further illustrated in Table 1.

Table 1 Patient demographics.

	SPAIRE Group	Control Group	P- Value
Total	40	200	–
Gender (Female)	27 (67.5 %)	135 (67.5 %)	>0.99
Follow-up (Months)	68.1 ± 10.1	65.4 ± 11.2	>0.99
Mean Age (Years)	79.9 ± 10.3	81.2 ± 7.7	0.36
Home (%)	29 (72.5 %)	122 (61 %)	0.22
NH Res (%)	9 (22.5 %)	48 (24 %)	>0.99
ASA Score 1	2 (5 %)	6 (3 %)	0.62
ASA Score 2	9 (22.5 %)	71 (35.5 %)	0.14
ASA Score 3	29 (72.5 %)	113 (56.5 %)	0.08
ASA Score 4	0 (0 %)	10 (5 %)	0.22

3.2

3.2 Clinical, radiological & mortality outcomes

At final follow-up, there was a significantly lower number of patients in the SPAIRE group who dropped a level of mobility from their pre-injury baseline at 30-days post-operatively (8.1 % versus 31.6 %; p = 0.003). However, this appeared to have resolved at 120-day follow-up with no significant differences between the groups in terms of those acquiring a new baseline mobility at 120-days post-operatively (2.7 % versus 13.2 %, p = 0.09). There were no dislocations noted in the SPAIRE cohort, nor was there subsidence noted which required surgical revision (both p > 0.99). Additionally, there was no significant difference between the SPAIRE and control groups with respect to discharge destinations (p > 0.05 for all discharge destinations). There were no significant differences between patients newly admitted to nursing homes or inpatient mortality rates post-operatively (both p > 0.05 for both). These findings are further illustrated in Tables 2 and 3 respectively.

Table 2 Clinical & radiological outcomes.

	SPAIRE Group	Control Group	P- Value
Total	40	200	–
LOS (Days)	11.4 ± 6.2	13.5 ± 16.8	0.44
New MobilityLevel D-30	3 (8.1 %)	60 (31.6 %)	0.003
New MobilityLevel D-120	1 (2.7 %)	25 (13.2 %)	0.09
Dislocations	0 (0 %)	2 (1 %)	>0.99
Revisions	0 (0 %)	1 (0.5 %)	>0.99

Table 3 Discharge destination & mortality outcomes.

	SPAIRE Group	Control Group	P- Value
Total	40	200	–
Home	10 (25 %)	30 (18.8 %)	0.67
Rehab	18 (45 %)	105 (48.2 %)	0.39
NH	10 (25 %)	42 (26.3 %)	0.84
New NH Adm	1 (2.5 %)	12 (3 %)	0.70
RIP D30	2 (5 %)	10 (5 %)	>0.99
RIP D120	4 (10 %)	31 (15.5 %)	0.47

4 Discussion

The most important finding in this study is that in patients with NOF fractures treated with cemented hemiarthroplasty using a SPAIRE technique, these patients were significantly more likely to return to their pre-injury baseline mobility more quickly than those operated via a standard direct lateral approach at 30-days post-operatively. However, this study does show that there is no significant difference in the number of patients who ultimately do return to pre-injury baseline mobility, nor is there a significant increase in patients who acquire a lower mobility level following cemented hemiarthroplasty for NOF fracture between either approach.

In recent years, an increasing number of patients are undergoing cemented hemiarthroplasty for NOF fractures using a posterior approach.¹² In their study of 20′000 of such patients from the Norwegian Hip Fracture Register, Kristensen et al.¹² reported that patients who underwent hemiarthroplasty using a posterior approach were found to have significantly lower report pain scores, with significantly better reported quality of life scores and satisfaction level when compared to those operated using a direct lateral approach. Furthermore, Viberg et al.¹⁹ reported their study comparing 527 patients operated using either a traditional or piriformis-preserving posterior approach in cases of hemiarthroplasty. They found a significant reduction in the number of post-operative dislocations in the piriformis-preserving posterior approach group when compared to the control (4.7 % versus 11.6 %).¹⁹

Building subsequently on previously described prior modifications of the posterior approach to the hip,⁸^,²⁰ the SPAIRE technique was first described by Hanly et al.⁹ Previous literature has discussed modifying the conventional posterior approach in which preservation of the tendinous insertions of piriformis, gemellus superior and obturator internus, with thorough capsular repair being prioritised.⁸^,¹⁴^,²⁰ As this technique aimed to minimize soft tissue disruption whilst ensuring hip joint stability, it was noted by Williams et al.²⁰ in their series of 150 patients undergoing cemented hemiarthroplasty using Austin Moore prosthesis via this approach, that the 1 % dislocation rates made it an optimal technique in very co-morbid patients or those suffering from pre-existing neurological disorders.

Describing their mantra of ‘Saving Piriformis And Internus, Repair of Externus’, Lee et al.¹³ reported the first 25 patients treated for NOF fractures using cemented Exeter™ (Stryker, Mahwah, N.J.) femoral stems using a SPAIRE approach. Their study found the SPAIRE technique to be feasible and safe, with none of the included patients required post-operative transfusion, dislocations or return to theatre following a SPAIRE technique in cases of cemented hemiarthroplasty for NOF fracture.¹³

Furthermore, a cadaveric study by Vaarbakken et al.¹⁸ reported the significance of the short external rotators primarily in the fully functioning pre-injury hip, allowing abduction and extension of the flexed hip. Therefore, the preservation of this musculature may be paramount in optimizing post-operative rehabilitation in such a vulnerable patients cohort with NOF fractures. The findings of this study support the use of a SPAIRE technique as a potential method of allowing early return to pre-injury baseline mobility, as the patients in this study were significantly more likely to return to their pre-injury baseline mobility more quickly than those operated via a standard direct lateral approach at 30-days post-operatively. These findings are further supported by the study by Charity et al.,⁴ as they found similar findings with respect to patients returning to pre-injury mobility in over 250 patients operated via a SPAIRE technique.

Although there is growing evidence in support of utilizing a SPARE technique in cases of hemiarthroplasty, the authors acknowledge the current recommendations from NICE with respect to managing patients with displaced intracapsular NOF fractures.³ Therefore, it is the recommendation of this group that surgeon discretion be utilized on a case-by-case basis in the management of whom already are high risk patients, pre-disposed to significant morbidity and mortality on the basis of their injury.²^,⁵ However, the authors await the results of the ongoing ‘HemiSPAIRE’ trial currently underway at the Exeter group in the United Kingdom with great anticipation.¹⁷ With this two-arm, assessor-blinded randomised control trial, the authors are hopeful to further definitively characterize the post-operative clinical outcomes following a SPAIRE technique for cases of cemented hemiarthroplasty for patients with NOF fractures, versus the traditional direct lateral approach.

4.1

4.1 Limitations

This study represents a retrospective cohort study, which thereafter possesses numerous limitations inherent of such a design. This investigation sought to analyze patients as a study arm alongside a matched control group; it should be acknowledged that although the authors have attempted to make statistical allowances by ensuring adequate powering of the control group, discrepancies inherently exist between both the SPAIRE group and the pair-matched control group. Additionally, although all patients were matched for age, gender, ASA grade and residential status, slight, albeit non-statistically significant, differences in were found between the SPAIRE cohort and the pair-matched control for all variables. However, the authors do feel that these variables were matched in as much of a non-biased fashion as much as reasonably possible. Furthermore, this study reports the outcomes of a single-surgeon cohort in the SPAIRE group, and although four surgeons’ patients were included in the control group, generalizability may be limited in the study arm. Finally, this study represents is a series of cemented hemiarthroplasty procedures carried out via a novel technique, however the authors are aware that this is a relatively small patient cohort, and although sufficiently powered, certain significant differences may potentially be found in analyzing larger patient cohorts in both groups.

5 Conclusion

Author contribution

Martin S. Davey – Conceptualization, Manuscript Drafting; David O'Sullivan – Data Collection, Analysis; Robert Woods – Data Collection, Analysis; Paddy Kenny – Redrafting, Supervision; Fintan Doyle – Conceptualization, Supervision; Adrian J. Cassar Gheiti – Conceptualization, Supervision.

Consent

Not required.

Ethical approval

Not Applicable (Data Collected as part of Irish Hip Fracture Database as per the National Office of Clinical Audit)

Funding

Nil.

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