Transition from Straight Lateral to Direct Anterior Approach in Hip Hemiarthroplasty: Preservation of Independent Living and Lower 1-Year Mortality

<b>Background/Objectives</b>: Hip hemiarthroplasty (HHA) for femoral neck fractures (FNFs) can be performed via the posterolateral approach (PLA), straight lateral approach (SLA) or direct anterior approach (DAA). However, the optimal approach remains unclear. This study evaluated mortality and return-to-home rates following an institutional transition from SLA to DAA. <b>Methods</b>: This retrospective observational cohort study included patients who underwent primary cemented unipolar hip hemiarthroplasty for FNF during a period of transition in surgical approach (2015-2023). Clinical outcomes between the straight lateral and direct anterior approach were compared. Primary outcomes were the mortality and return-to-home rates. Secondary outcomes included perioperative parameters and complications. A subgroup analysis was performed using Fracture Mobility Score (FMS) and Katz activities of daily living (ADL) index to compare functional outcomes. <b>Results</b>: Over a 9-year period, a total of 762 HHA were performed, of which 411 SLA and 333 DAA. Mortality at 90 days (14.1% vs. 8.7%, <i>p</i> = 0.029) and 1 year (26.5% vs. 17.7%, <i>p</i> = 0.005) were significantly higher in the SLA group. Among patients living at home preoperatively, return-to-home after surgery was lower for SLA compared to DAA (23.2% vs. 41.4%, <i>p</i> < 0.001). In terms of complications, SLA had significantly lower rates of periprosthetic joint infections (SLA <i>n</i> = 6 (1.5%) vs. DAA <i>n</i> = 15 (4.6%), <i>p</i> = 0.024). The decline in Katz ADL score at three months was significantly greater in the SLA group than in the DAA group (ΔKatz ADL -0.73 ± 1.57 vs. -0.11 ± 1.60, <i>p</i> = 0.036). <b>Conclusions</b>: Transitioning from SLA to DAA in HHA was associated with improved preservation of independent living, higher return-to-home rates and lower 90-day and 1-year mortality. However, DAA was also associated with higher rates of PJI.