Comparison of surgical efficacy between direct anterior approach and posterolateral approach in the treatment of sarcopenia with femoral neck fractures

Abstract

Background

Femoral neck fracture (FNF) is a prevalent injury among the elderly, associated with significant morbidity and mortality. Total joint arthroplasty (TJA) has markedly enhanced the quality of life for many patients; however, the benefits of the direct anterior approach (DAA), which has gained popularity in recent years, remain a subject of debate. Sarcopenia frequently occurs in patients with FNF and is linked to adverse surgical outcomes. This study aims to compare the effects of the DAA and the posterolateral approach (PLA) on the efficacy of TJA surgery in patients with FNF who also present with sarcopenia.

Methods

This study retrospectively analyzed the clinical data of patients with FNF who underwent total hip arthroplasty (THA) using either DAA or PLA from December 2019 to December 2022. A total of 141 individuals were included, comprising 52 in the DAA group and 89 in the PLA group. The cross-sectional area (cm²) of the musculature at the pedicle level of the 12th thoracic vertebra (T12) was measured using chest computed tomography (CT). The skeletal muscle index (SMI) was calculated by dividing the cross-sectional area of the muscle at the T12 pedicle level by the square of the individual’s height. Sarcopenia was diagnosed when both grip strength and SMI values fell below the diagnostic cutoff. The study compared various factors, including age, gender, SMI, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, operation time, incision length, blood loss, blood transfusion, hemoglobin drop, albumin drop, postoperative time to ambulation, length of hospitalization, visual analogue scale (VAS) score, Harris score at one and six months post-surgery, complications, revision rate, one-year survival rate following surgery, and patient satisfaction.

Results

There were no statistically significant differences between the two groups regarding gender, age, SMI, BMI, ASA, operation time, blood transfusion, VAS score six months post-surgery, revision rate, satisfaction, and survival rate (P > 0.05). The incision length, blood loss, hemoglobin drop, albumin drop, hospitalization duration, VAS score, and complication rate one month after the operation in the DAA group were all significantly lower than those in the PLA group (P < 0.001). Additionally, the Harris scores at one month and six days post-operation were superior in the DAA group compared to the PLA group (P < 0.001). Furthermore, the incidence of complications in the DAA group was lower than that in the PLA group (P = 0.041). Univariate and multivariate Cox regression analyses indicated that age was an independent risk factor for patients’ mortality risk (95% CI: 1.064–1.479, P = 0.007).

Conclusion

DAA results in reduced surgical trauma, alleviates postoperative pain, decreases the incidence of complications, enhances the recovery of patients’ mobility functions, shortens hospital stays, and is particularly suitable for FNF patients with sarcopenia.

Introduction

As the global population ages, hip fractures, including femoral neck and trochanteric fractures (FNF), have emerged as a significant public health challenge worldwide. Statistics indicate that approximately 1.5 million hip fractures occur annually, with this number rising each year. Projections suggest that cases will increase to 2.6 million by 2025 and reach 4.5 million by 2050 [1]. When managing displaced FNF in the elderly, conservative treatment necessitates prolonged bed rest, which is associated with elevated mortality and complication rates [2,3,4]. Consequently, early surgical intervention to facilitate patient recovery has gained consensus among orthopedic surgeons. Among the surgical treatment options, hip replacement is often more advantageous than open reduction and internal fixation, as it enables elderly patients to engage in lower limb activities and functional exercises earlier. In contrast, the latter approach is generally more suitable for younger patients [5].

Although the widespread use of total joint arthroplasty (TJA) has significantly improved pain relief and quality of life for patients with FNF, the number of complications has also risen due to the increased frequency of surgical interventions. Traditional surgical approaches, such as the posterolateral approach (PLA) and the lateral direct approach (LDA), involve separating or incising the gluteus maximus, piriformis, and external rotator muscles to access the hip joint capsule. This can lead to increased postoperative pain and a higher rate of joint dislocation [6]. Studies indicate that the posterior dislocation rate following TJA ranges from 1 to 17%, often associated with the severing of relevant muscles during the procedure [5, 7]. To address the limitations of the PLA and LDA approaches, the minimally invasive direct anterior approach (DAA) has gained popularity among joint surgery experts in recent years. The DAA involves making an incision at the front of the hip joint to access the joint capsule through the space between the sartorius muscle and tensor fascia lata as well as rectus femoris and gluteus medius muscles, without cutting or splitting these muscles. This technique minimizes soft tissue damage, accelerates postoperative recovery, and reduces the dislocation rate [8, 9]. Furthermore, because the DAA adheres to the anatomical plane of the human interneuronal/muscle structure, it effectively avoids injury to critical blood vessels and nerves [10, 11]. Multiple reports have indicated that, compared to other surgical approaches, patients treated with the DAA experience less pain, reduced bleeding, shorter hospital stays [12], higher overall survival rates at follow-up [13], and improved early functional recovery [14, 15]. However, it is important to recognize that all surgical procedures carry inherent risks. It has been observed that these early postoperative advantages often diminish by 3 months and 1 year post-surgery [14, 15]. Some scholars argue that, in comparison to the DAA, the PLA has a shorter learning curve, entails less technical difficulty, and poses a lower risk of perioperative greater trochanter fractures [9]. Consequently, there remains considerable controversy regarding the appropriate cases for DAA, particularly in patients with obesity. Additionally, the presence of comorbidities such as osteoporosis and sarcopenia can significantly influence the prognosis of TJA [16,17,18].

Fragility fractures (FNF) frequently occur in elderly patients, and sarcopenia represents a significant concern in the comprehensive evaluation of this demographic. Sarcopenia was first defined by Rosenberg in 1989 as a ‘muscle wasting geriatric syndrome,’ characterized by a progressive loss of skeletal muscle mass and strength [19]. This condition increases the risk of falls, fractures, diminished quality of life, and mortality [20]. Studies indicate that the incidence of sarcopenia progressively rises with age, ranging from 5 to 13% among individuals aged 60 to 70 years, and escalating to between 11% and 50% in those over 80 years old [21]. In 2018, the European Working Group on Sarcopenia in Older People (EWGSOP) introduced the EWGSOP2 diagnostic criteria for sarcopenia, designating grip strength as the primary diagnostic factor [22]. Currently, commonly employed diagnostic methods for sarcopenia include Dual-Energy X-ray Absorptiometry (DEXA), Magnetic Resonance Imaging (MRI), Computed Tomography (CT), and Bioelectrical Impedance Analysis (BIA). DEXA is recommended for widespread use due to its low radiation exposure; however, its application is constrained by portability issues [23]. MRI and CT are considered the gold standards for non-invasive muscle mass measurement, yet their utility is similarly limited by concerns regarding portability and radiation exposure. BIA is an inexpensive, straightforward, and portable technology primarily used for sarcopenia screening, although its accuracy is relatively low [24, 25]. In our study, we utilized the method proposed by Nemec U et al. [26], which is based on the CT image of pedicle level of the 12th thoracic vertebra (T12), as elderly patients in our hospital routinely require lung CT scans to assess lung function and potential inflammation prior to surgical anesthesia. This approach allows for the diagnosis of sarcopenia using standard CT images without incurring additional radiation exposure or treatment costs for the patient. Results from a meta-analysis indicate that in patients undergoing TJA, sarcopenia significantly increases the risk of complications such as blood transfusions, urinary tract infections, prosthetic fractures, prosthetic dislocation, and mechanical loosening [27]. Therefore, it is of considerable clinical importance to further investigate the adverse effects of sarcopenia in TJA surgery.

As previously mentioned, the application scope of DAA has certain limitations, making it more suitable for thinner patients. Therefore, to investigate a more suitable surgical approach for patients with FNF combined with sarcopenia, this study compared surgical and prognostic indicators among DAA and PLA. The comparison included surgical indicators during hospitalization, laboratory results, postoperative rehabilitation indicators, incidence of complications, and mortality rates. This analysis aims to provide guidance for joint surgeons in selecting appropriate surgical approaches and to offer clinical insights for the early intervention and treatment of patients with sarcopenia.

Methods

Patients

This retrospective, single-center study reviewed clinical data from patients with FNF who underwent total hip arthroplasty (THA) via the DAA or PLA between December 2019 and December 2022. The study included patients older than 65 years with FNF resulting from low-energy injury mechanisms, such as falls from standing height. Patients who experienced high-energy injuries were excluded from the study. Eligible participants were those diagnosed with displaced FNF according to the Orthopedic Trauma Society classification [28]. Conversely, individuals with pathological fractures, osteonecrosis due to femoral head collapse, femoral head fractures, intertrochanteric fractures, or subtrochanteric fractures were not included. Additionally, patients who did not undergo THA were excluded. All included patients were required to have a minimum follow-up period of one year. This study received approval from the Ethics Review Board of the Affiliated Jiangning Hospital with Nanjing Medical University, with written informed consent obtained from each participant. Simultaneously, the research was conducted in accordance with the ethical standards of the institutional and national research committees, as well as the 1964 Helsinki Declaration and its subsequent amendments.

Diagnosis of sarcopenia

The assessment of sarcopenia follows the recommendations established by the EWGSOP in 2018 [22]. An electronic grip strength device (Kangdu, Guangdong) is utilized to assess the grip strength of the dominant hand, taking the highest value from three attempts. If the grip strength falls below the diagnostic threshold (male < 27 kg, female < 16 kg), the next step is to calculate the skeletal muscle index (SMI). Images were examined using PACS 3.6 software (Philips, Germany), where the total muscle area—including the erector spinae, latissimus dorsi, internal oblique, external oblique, rectus abdominis, external intercostal, and intercostal muscles—was calculated at the pedicle level of the T12 on chest CT scans. The SMI is determined by dividing the total muscle area by the square of the patient’s height (cm²/m²). Two independent assessors, unaware of the patient identities, conducted the measurements. Diagnosis of sarcopenia was established at SMI < 42.6 cm²/m² for males or SMI < 30.6 cm²/m² for females [26, 29]. The diagnostic flowchart regarding sarcopenia in the study participants is illustrated in Fig. 1.

Fig. 1

Flowchart of the studied population

Surgical approach and perioperative protocols

All patients underwent preoperative examinations and received surgical treatment within three days of admission. The surgical approaches were categorized into DAA and PLA. All patients underwent hip replacement surgery under general anesthesia. Both groups utilized a cementless biological total hip prosthesis as the artificial joint material, featuring a stem designed with a double wedge.

Direct Anterior Approach (DAA)

The patient is positioned supine on a standard operating table, which permits varus angulation and hyperextension of the hip. Our procedure commenced with a transverse incision on the front side of the thigh. This incision began 5 cm below the anterior superior iliac spine and extended laterally by 10 cm on the thigh’s anterior surface. The direct anterior approach necessitated the exposure and division of the tensor fascia lata’s perimysium. The space between the sartorius and the tensor fascia lata was utilized for further dissection. The lateral head, or the reflected part, of the rectus muscle was pulled medially. An anterior capsulectomy was conducted, allowing for visibility of the fractured femoral neck. We executed an osteotomy at the fractured femoral neck stump, exposing the acetabulum, smoothing its surface with a ball file, and positioning the acetabular prosthesis at an abduction of 40° to 45° and an anterior tilt of 15° to 20°. The hip joint was retracted internally and externally rotated to ensure complete loosening of the lateral joint capsule surrounding the femoral neck. A medullary file was employed to widen the marrow cavity of the femur, the appropriate joint prosthesis type was selected, and subsequently, the femoral stem and head prosthesis were inserted while assessing the stability of the hip joint.

Posterolateral Approach (PLA)

The patient was positioned on the unaffected side, and a curved incision measuring approximately 10–15 cm was created, centered around the apex of the greater trochanter. The skin and subcutaneous tissue were incised in layers, following the line of the incision to access the fascia surrounding the muscles. The gluteal muscles and deep fascia were separated using blunt dissection. With the hip in internal rotation and flexion, the osteotomy plane was identified, leading to the excision of the femoral head, which was then extracted. The acetabulum was prepared, and the acetabular prosthesis was inserted at an abduction angle of 40°–45° combined with an anterior tilt of 15°–20°. An appropriate femoral prosthesis and head were chosen and placed, confirming satisfactory stability and range of motion without any signs of dislocation. Hemostasis was achieved in the surgical area. The external rotator muscles were sutured to the greater trochanter’s base using absorbable sutures, and the incision was meticulously closed in layers.

Postoperative treatment

Patients received cefazolin sodium for two consecutive days following surgery to help prevent infections. In the postoperative phase, a combination of analgesia, anticoagulation, and various symptomatic treatments was administered. Once the patient regained consciousness, exercises such as isometric contractions of the quadriceps muscle and ankle pumps were carried out. On the first day after surgery, medical, nursing and rehabilitation physician team guided patients in using a walker to engage in limited activities, progressively enhancing both the duration and intensity of training. Patients should be instructed to use a walker to facilitate independent ambulation and to gradually wean themselves off the walker when appropriate. Additionally, it is important to inform patients to attend regular follow-up visits at the surgeon’s clinic for X-ray examinations and further rehabilitation guidance.

Outcome measurements and efficacy assessment

Data regarding patients and their demographic features were gathered, encompassing factors such as age, gender, SMI, body mass index (BMI), and American society of anesthesiologists (ASA) classification. Additionally, we recorded the following operative data: operation time (min), incision length (cm), blood loss (ml), blood transfusion (ml), hemoglobin drop (g/L), albumin drop (g/L), and postoperative time to ambulation (d). Postoperative recovery indicators included hospitalization days (d), visual analogue scale (VAS) score, and Harris score at one month and six months post-surgery. We also assessed the incidence of complications, revision rate, one-year survival rate following surgery, and patient satisfaction. Complications were defined as infection, dislocation, major neurovascular injury, loosening of the prosthesis, or periprosthetic fracture.

Statistical analysis

Relevant data were analyzed using SPSS 26.0 statistical software (IBM Corp., Armonk, NY, USA). Measurement data that conform to a normal distribution are expressed as mean ± standard deviation (SD), with the independent sample t-test employed for comparisons between groups. For measurement data that do not conform to a normal distribution, the non-parametric Wilcoxon rank sum test is utilized. Cohen’s d value and 95% confidence intervals (CI) are calculated. Count data are expressed as frequencies, with either the chi-square test or Fisher’s exact test applied for comparisons between groups; Phi values and odds ratios (OR) with 95% confidence intervals (CI) are also calculated. Survival analysis was conducted using the Kaplan-Meier method to generate survival plots and calculate survival rates, with comparisons of survival rates between groups performed using the Log-rank test. The Cox proportional hazards regression model was employed to compare survival status between groups under both single-factor and multi-factor conditions. Variables with P < 0.05 in single-factor analysis, along with those closely related to clinical prognosis, were included in the multi-factor analysis (forward: conditional), and hazard ratios (HR) with 95% CI were calculated. All tests were two-sided, with a significance level set at 0.05.

Results

Demographic data

All patients were followed for over one year. When data were ultimately collected during the follow-up, a total of eight patients were excluded due to incomplete information. Consequently, a total of 141 patients were included in this study, comprising 52 patients receiving DAA and 89 patients receiving PLA. The general information, including gender, age, SMI, BMI, and ASA of the two patient groups, was statistically compared, revealing no statistically significant differences between the groups (P > 0.05). The demographic data are reported in Table 1.

Table 1 General characteristics of patients in two groups

Surgical data and perioperative characteristics

There was no statistically significant difference in operation time between the two patient groups (P = 0.825). When comparing incision length and blood loss, the DAA exhibited smaller values than the PLA (P < 0.001). However, there was no statistically significant difference in blood transfusion rates between the two groups (P = 0.164). The drop in hemoglobin, drop in albumin, and length of hospitalization for patients in the DAA group were all less than those in the PLA group (P < 0.001). Regarding postoperative time to ambulation, there was again no statistically significant difference in blood transfusion rates between the two groups (P = 0.664). One month after surgery, the VAS score for DAA was significantly better than that for PLA (P < 0.001). However, at six months post-surgery, there was no statistically significant difference between the two VAS scores (P = 0.902). Notably, when comparing the Harris scores of the two groups at one month and six months after surgery, DAA demonstrated superior outcomes compared to PLA, with the difference being statistically significant (P < 0.001). The surgical data and perioperative characteristics of patients in both groups are shown in Table 2.

Table 2 Surgery-related data of patients in two groups

Post-discharge follow-up data

The complications assessed in this study primarily include infection, dislocation, major neurovascular injury, prosthesis loosening, and periprosthetic fracture occurring within one year post-surgery. The results indicated that the incidence rate of complications in the DAA group was 3 out of 52 (5.769%), which was significantly lower than the 16 out of 89 (17.977%) observed in the PLA group (P = 0.041). Furthermore, no statistically significant differences were found in revision rates and satisfaction between the two groups at one year (P = 1.000 and P = 0.620, respectively). One year after surgery, the survival rate was 49 out of 52 (94.230%) in the DAA group compared to 81 out of 89 (91.011%) in the PLA group, with the difference between the two groups not reaching statistical significance (P = 0.628). The post-discharge follow-up data are indicated in Table 3. The Kaplan-Meier survival analysis indicated no significant difference in the 1-year survival rate between the two patient groups (χ² = 0.235, P = 0.628), as illustrated in Fig. 2. A single-factor Cox regression analysis was conducted to evaluate the effects of various variables—including surgical approach, gender, age, BMI, SMI, operation time, blood loss, incision length, blood transfusion, postoperative time to ambulation, hospitalization days, hemoglobin drop, albumin drop, complications, and revisions—on the risk of subsequent mortality following femoral neck fracture (FNF) surgery. The results demonstrated that age, BMI, SMI, operation time, blood loss, blood transfusion, postoperative time to ambulation, hospitalization days, hemoglobin drop, albumin drop, complications, and revisions may influence the risk associated with FNF surgery. These variables were subsequently incorporated into a multivariate Cox regression analysis model, which revealed that age serves as an independent risk factor for mortality one year after FNF surgery. Specifically, for each additional year of age, the patient’s risk of death increased by 1.255 times (95% CI: 1.064–1.479) (P = 0.007), as implied in Table 4.

Table 3 1-year follow-up data of patients in two groups

Fig. 2

Survival analysis of two groups of patients

Table 4 Univariate and multivariate Cox regression analysis of 1-year postoperative mortality

Discussion

FNF is a prevalent type of fracture among the elderly population. THA can facilitate early mobility and promote rapid recovery in these patients [30, 31]. Recently, minimally invasive hip joint surgery, particularly the DAA, has gained popularity as a surgical technique. Sarcopenia, characterized by age-related declines in muscle mass and function, is closely associated with the occurrence of fragility fractures and the prognosis of surgical outcomes [27, 29]. Although previous studies have compared DAA with other surgical methods for hip replacement, there is a notable lack of research focusing on patients with FNF and sarcopenia. This study aimed to compare surgical indicators and early prognoses between DAA and the PLA in elderly patients presenting with FNF combined with sarcopenia [13, 32]. Our findings indicated no significant differences in gender, age, skeletal muscle index (SMI), body mass index (BMI), or American Society of Anesthesiologists (ASA) classification between the DAA and PLA groups. Due to the exposure of the hip joint through the muscle gap, the DAA approach resulted in less muscle damage, leading to smaller surgical incisions, reduced blood loss, and lesser drops in hemoglobin and albumin levels. Consequently, patients in the DAA group experienced shorter hospital stays and reported lower Visual Analog Scale (VAS) scores one month post-surgery. Additionally, limb function showed greater recovery, with higher Harris hip scores at both one and six months after surgery. In terms of complication rates, DAA demonstrated lower rates compared to PLA; interestingly, revision rates, satisfaction rates, and one-year postoperative survival rates were comparable between the two groups.

The increasing incidence of hip fractures is placing significant pressure on healthcare systems worldwide [33, 34]. TJA is widely utilized in the treatment of FNF due to its considerable surgical efficacy for patients. However, as the application of this surgical intervention continues to grow, so too has the controversy surrounding the preferred surgical approach. Compared to the traditional PLA, the currently favored DAA is generally the Smith-Petersen approach [35, 36], which accesses the anterior hip joint capsule through intermuscular and interneural planes [6, 37]. The DAA approach is positioned superficially between the sartorius and tensor fascia lata muscles, and deeply between the gluteus medius, gluteus minimus, and rectus femoris muscles. This intermuscular strategy minimizes muscle damage and preserves the integrity and stability of the soft tissues surrounding the joint. In contrast, while PLA facilitates easier exposure of the joint capsule, it results in damage to the posterior gluteus maximus and external rotator muscles during surgery. This damage can compromise the posterior stability of the joint and increase the risk of postoperative pain and joint dislocation [6].

Several scholars have analyzed the factors influencing the efficacy of THA in treatment of FNF, proposing that the DAA may predict improved short-term outcomes [38]. Wang et al. [39] found that, compared to the PLA, patients in the DAA group experienced less postoperative pain and bleeding, along with higher postoperative hemoglobin levels. The observed decline in these parameters was minimal, and patients in the DAA group were able to ambulate for the first time sooner after surgery, had shorter hospital stays, demonstrated better early hip joint function, and exhibited faster recovery. Although their study did not specifically target patients with sarcopenia, the conclusions largely align with our findings. The lower postoperative bleeding and minimal decreases in hemoglobin and albumin levels in patients undergoing DAA may be attributed to the smaller incision and reduced muscle damage associated with this surgical approach. As DAA patients experience fewer changes in laboratory indicators and reduced pain postoperatively, they may be discharged home or to a rehabilitation facility sooner, thereby shortening their hospitalization period. However, it is noteworthy that in our study, there was no significant difference in the time taken to ambulate, which may be due to our rehabilitation doctors guiding patients on when to commence ambulation exercises as per the prescribed timeline. Furthermore, the variation in pain levels does not appear to influence the timing of initial ambulation. Notably, earlier ambulation may be closely linked to the recovery of joint function and the reduction of complications and mortality [40,41,42]. We found that the VAS score of the DAA group was superior to that of the PAL one month post-surgery; however, this advantage was no longer statistically significant at six months post-surgery. This change may be attributed to the patients gradually adapting to the pain in the hip joint. Additionally, some scholars have suggested that DAA patients exhibit lower serum creatine kinase levels (a marker of muscle damage) and reduced concentrations of inflammatory mediators, such as TNF-α, after surgery, which may also contribute to the observed decrease in pain [43]. According to the Harris score, hip joint function in DAA patients was better than in PAL patients at both one month and six months post-surgery. Our analysis posits that this improved function is not only due to better muscle protection in the DAA group but also linked to the preservation of the posterolateral muscles in DAA patients. The integrity of the joint is maintained, alleviating concerns regarding joint dislocation during daily activities. Furthermore, some studies have indicated that the duration of DAA surgeries is shorter and the rate of blood transfusion is reduced [39, 44, 45], which contrasts with the findings of our study. Although we observed that DAA can reduce intraoperative blood loss, it does not significantly lower the blood transfusion rate. This discrepancy may be closely related to the use of autologous blood transfusion during surgery and the established criteria for blood transfusion.

Interestingly, Ron Ben Elyahu et al. reached different conclusions [46]. They found no significant change in the blood loss rate within the DAA group and observed no significant differences in pain scores at discharge and during the 6-week follow-up. They propose that blood loss in FNF is primarily determined by the degree of fracture displacement, with no evident correlation to the surgical approach. Additionally, postoperative pain is also influenced by the fracture itself. Regarding operation time and hospitalization duration in the DAA group, their findings align with our conclusions. However, we noted that DAA did not significantly reduce operation time, which may be attributed to the experience level of the surgical team, as DAA is known to have a steep learning curve. Consequently, the literature presents a wide variation in average operative times, reported as 52.3 min [47], 80 min [9], 85.6 min [48]. The average operation time for most reported cases of DAA is approximately 85 min, closely matching our finding of 84.33 min. Key technical points for DAA include fully exposing the proximal femur and adequately releasing the femoral insertion point of the anterolateral hip capsule. Furthermore, aspects such as patient positioning and the use of traction hooks necessitate close cooperation among the surgical team. The DAA approach imposes certain limitations on the exposure of the surgical field, which can significantly impair the accuracy of prosthesis placement, thereby requiring the surgeon to possess extensive surgical experience.

Hip dislocation is a significant complication following TJA surgery, with reported dislocation rates ranging from 3.2–16% [5, 49] and a recurrence rate exceeding 60% [50]. In patients undergoing DAA, the dislocation rate decreases to between 0% and 2% [51], a finding supported by additional studies [49, 52]。Given that some patients with hip fractures may have dementia or cognitive impairment, the lower dislocation rate associated with DAA is particularly advantageous for this population [52,53,54]. Studies have indicated that while dislocation is not uncommon following a posterior surgical approach to the hip, piriformis-preserving surgical techniques can significantly improve the stability of the hip joint, thereby decreasing the incidence of dislocation [55, 56]. In our study, we defined major complications as dislocation, infection, major neurovascular injury, prosthetic loosening, and periprosthetic fracture, and found that the DAA could reduce the incidence of these complications. However, a meta-analysis indicates that there is no significant difference in perioperative or postoperative complication rates between the DAA approach and other surgical methods [49, 57]. Some researchers suggest that joint dislocation is linked to an increased six-month mortality rate [5, 49, 58]. Furthermore, previous studies have reported that the one-year mortality rate for patients with femoral neck fractures (FNF) ranges from 15–30% [59, 60]. Cichos et al. [13] highlighted that, compared to other surgical approaches for hip replacement, the DAA is associated with an improvement in postoperative overall survival. The reported 1-year mortality rate for the DAA cohort was 5%, which is similar to our finding of 3 out of 52 patients (5.769%). However, we observed no significant difference in the 1-year postoperative mortality rate between DAA and PLA patients. This lack of difference may be attributed to factors such as patient age, sample size, and underlying conditions, including the presence of sarcopenia. Furthermore, our univariate and multivariate Cox regression analyses indicated that age is an independent risk factor for mortality in patients with FNF and sarcopenia; older age correlates with a higher risk of death. Importantly, we found no significant relationship between the risk of death and the choice of surgical approach. Nevertheless, some researchers have expressed concerns, noting that DAA not only failed to demonstrate superior functional outcomes compared to PLA at 3 months and 1 year post-surgery but also increased the risk of intraoperative complications [61]. Consequently, the clinical application of DAA remains a subject of debate.

The development of sarcopenia presents an urgent challenge to the healthcare system. Among individuals over 60 years of age, the prevalence of sarcopenia ranges from 8–40% [62]. The incidence of sarcopenia has been extensively studied in various surgical patient populations. For instance, approximately one-third of patients undergoing laparoscopic gastrostomy are affected by sarcopenia [63]. Furthermore, the prevalence of sarcopenia in patients undergoing total knee arthroplasty (TKA) and THA is reported to be 20% and 5.2%, respectively [27]. It is a well-established fact that sarcopenia is associated with negative clinical outcomes. Sarcopenia not only leads to an increased incidence of fragility fractures and mortality following thoracolumbar surgery but also elevates the risk of periprosthetic fractures and joint infections [29, 64, 65]. Furthermore, the occurrence of sarcopenia is linked to blood transfusion requirements in TKA patients. Similar findings have been reported in free flap surgery for head and neck cancer [66]. The incidence of urinary tract infections is significantly higher in sarcopenic patients undergoing TJA [67]. Therefore, aggressive intervention targeting sarcopenia is regarded as a beneficial strategy for improving surgical outcomes. However, our current understanding of the underlying causes and mechanisms of sarcopenia remains incomplete, and effective treatments are still lacking. Potential risk factors for sarcopenia include metabolic abnormalities, insulin signaling issues, hormonal alterations, mitochondrial dysfunction, inflammation, and impaired protein balance [68,69,70]. Recent research underscores the effectiveness of dietary pattern modification and exercise interventions in mitigating sarcopenia [70]. Vitamin D is essential for the proliferation and differentiation of skeletal muscle, as well as for bone metabolism. Multiple studies have demonstrated that patients with sarcopenia undergoing hip fracture surgery are more likely to be vitamin D deficient compared to their non-sarcopenic counterparts. Therefore, vitamin D supplementation may serve as an effective preventive and therapeutic strategy for sarcopenia [71, 72]. Surgeons should carefully consider the impact of sarcopenia on surgical outcomes when developing surgical plans.

Limitations

This study acknowledges its potential limitations. The CT diagnostic values for sarcopenia utilized in this research are based on population data from European and American countries. Currently, there is no unified diagnostic cut-off value for sarcopenia in China. Furthermore, as this study was retrospective, we were unable to implement early interventions for patients. Additionally, the short follow-up period and the absence of continuous monitoring of changes in laboratory indicators may introduce bias into the results. Future prospective studies with longer follow-up durations and larger sample sizes are necessary to further validate our conclusions.

Conclusion

In summary, our research findings indicate that due to its minimally invasive nature, DAA can minimize damage to muscles and joint capsules, alleviate postoperative pain in patients, decrease the incidence of complications, and enhance the recovery of mobility functions. This makes DAA particularly suitable for patients with sarcopenia and those with FNF. However, it is important to consider the clinical experience of the surgeon.