INTRODUCTION

Femoral neck fractures are increasingly common in older adults, often resulting from falls on osteoporotic bones. Surgical intervention is crucial for management, focusing on rapid mobilization and restoring independence through either total hip arthroplasty or hemiarthroplasty. The effectiveness and complication rates of different surgical approaches, particularly the anterior and posterior methods, continue to be debated. However, when these approaches are executed proficiently, there are no significant long-term differences in outcomes. Therefore, the choice of surgical approach is primarily influenced by the surgeon's preference, experience, and the training received at their surgical school. Among the posterior approaches, the SPAIRE (saving piriformis and internus, repair of externus) technique has recently gained attention as a less invasive and more anatomically considerate option that reduces muscle damage during hip arthroplasty. This report discusses the case of a 79-year-old woman who underwent a right femoral neck fracture treatment using a bipolar prosthesis with the SPAIRE approach, resulting in excellent functional outcomes.

CASE REPORT

A 79-year-old woman who was active and independent before her accident, presented with a fall at home that resulted in severe pain and functional impairment of her right lower limb. Initial radiographs showed a transcervical fracture of the right femoral neck (Garden IV; AO classification, 31B2) (Fig. 1). After a multidisciplinary discussion and preoperative evaluation, which included geriatric and anesthetic assessments, a bipolar hemiarthroplasty was chosen. The procedure was carried out under spinal anesthesia using a posterolateral Moore approach with the SPAIRE technique. The patient was positioned in a lateral decubitus position on the operating table. A longitudinal incision was made on the posterolateral aspect of the hip, centered over the greater trochanter. The iliotibial band was longitudinally split along the axis of the skin incision, and dissection continued posteriorly with closed scissors along the fibers of the gluteus maximus muscle. The tendons of the short external rotators were exposed by internally rotating the hip by 15° to 20°. The interval between the conjoint tendon and the quadratus femoris tendon was identified, beneath which lay the tendon of the obturator externus. An instrument was introduced between the proximal external rotator tendons and the posterior capsular surface to better define the plane, followed by the placement of a Langenbeck retractor. The trochanteric branch of the medial femoral circumflex artery, which runs posterior to the piriformis, obturator internus, and gemelli tendons and anterior to the quadratus femoris tendon, was identified and cauterized. A deep reverse L-shaped capsulotomy was then performed, elevating the capsular flap in one block, extending the sectioning of the external obturator tendon and part of the quadratus femoris tendon. This flap was placed on a traction thread. A cervical cut was made with an oscillating saw above the lesser trochanter according to preoperative landmarks, and the femoral head was extracted and measured. After preparing the femur with successive raspers to ensure primary stability, stability tests were conducted with trial components before the final bipolar prosthesis was placed. The prosthesis was positioned optimally, achieving excellent stability and soft tissue balance. The SPAIRE surgical approach allowed for the preservation of the piriformis muscle tendon and the femoral insertion of the conjoint tendon of the superior gemellus, obturator internus, and inferior gemellus muscles (Fig. 2). At the end of the procedure, the joint capsule was carefully repaired, and the tendons of the obturator externus and quadratus femoris muscles were reinserted using transosseous sutures. The postoperative radiograph was satisfactory (Fig. 3), and the recovery was favorable. The patient was mobilized on the second postoperative day with full weight-bearing under the supervision of a physiotherapist. No dislocation or immediate postoperative complications were observed. At the 3-month follow-up, she was ambulating with a cane and reported excellent functional outcomes, as reflected by a Harris Hip Score of 85 out of 100.

Ethics statement

Informed consent for the publication of the research details and clinical images was obtained from the patient.

DISCUSSION

In hemiarthroplasty for femoral neck fractures, the posterior approach has traditionally been associated with a higher risk of dislocation compared to the anterior [1,2] or lateral approaches [2,3]. This higher risk is attributed to potential disruption of the posterior capsular and musculotendinous structures, which are essential for stability. However, comparative studies have not consistently shown significant differences in dislocation rates between the anterior and posterior approaches but have emphasized the theoretical stability advantages of the anterior approach, especially in patients at higher risk of dislocation [4,5]. The SPAIRE technique, as described by Hanly et al. [6], preserves the femoral attachments of the piriformis, superior gemellus, obturator internus, and inferior gemellus tendons during both total hip arthroplasty and hemiarthroplasty. A similar approach was reported by Han et al. [7] in patients with neurological conditions requiring hip hemiarthroplasty for femoral neck fracture, where this approach resulted in no dislocations. Nakamura et al. [8] achieved the same excellent result in a larger cohort of 320 patients, with no dislocations observed. This anatomically conservative evolution of the classic posterolateral approach offers several theoretical and practical advantages. By preserving the tendon insertions of these muscles, dynamic hip stability is enhanced, and the risk of dislocation is reduced. This risk is estimated at 0% to 0.3% for the SPAIRE technique [6,8,9], compared to 5.5% to 13% for the classic posterolateral approach [2,10], 0% to 2% for the anterior approach, and 0% to 3.3% for the lateral approach [11]. Biomechanical studies by Vaarbakken et al. [12,13] have shown that the piriformis and obturator internus (along with the gemelli) function as a single primary muscle for extension and abduction of the flexed hip. This muscle has been named quadriceps coxa due to the similarity of its functions, insertions, and innervations. It acts as the primary abductor and extensor from flexed positions, playing a major role in weight-bearing and propulsive movements. Their findings further specify that although the quadratus femoris and obturator externus are traditionally defined as external rotators of the hip (in the anatomical position), they contribute minimally to external rotation at their maximal strength positions. These data clarify how the SPAIRE technique facilitates better postoperative muscle function recovery, particularly by preserving preoperative mobility after the procedure, thereby accelerating rehabilitation [14]. By minimizing the denervation of deep stabilizing muscles, the SPAIRE technique decreases early postoperative pain [15] and reduces balance and gait disturbances as well as residual pain associated with prolonged muscle healing. Moreover, this minimally invasive approach requires no special equipment and can be easily converted to a classic posterolateral approach if necessary by selectively extending the release to the proximal tendons (obturator internus and the two gemelli) or distally (to the quadratus femoris tendon). In the debate between proponents of the posterior approach and the anterior approach, it is pointed out that the anterior approach requires release of the superior capsule, which can damage the trochanteric insertions of the piriformis and conjoint tendon without the possibility of repair under direct vision, whereas the classic posterolateral approach and the SPAIRE technique allow preservation of these tendons and secure repair when release is necessary [6]. By preserving the synergistic functional pair of the piriformis muscle and the conjoint tendon (quadriceps coxa), this approach effectively reduces operative time and bleeding while ensuring optimal stability, allowing patients to mobilize their hips with full weight-bearing. It thus eliminates the need for the specific restrictions traditionally associated with postoperative protocols of the posterior approach [15]. However, the SPAIRE technique requires perfect mastery of surgical anatomy and muscle planes, which may prolong the initial operative time for surgeons in the learning phase. In certain complex cases (obesity, anatomical deformities, comminuted fractures), the exposure provided by the SPAIRE approach may be insufficient, requiring the use of a more conventional posterolateral approach. In the present case, the use of the SPAIRE technique allowed for the combination of excellent joint stability and rapid recovery in a geriatric patient. The clinical outcomes in terms of function and stability confirm the clear advantages of this technique, which represents an interesting evolution of the posterolateral approach in hip prosthetic surgery, including for patients with neurological conditions. However, appropriate training is essential to optimize results and ensure reproducibility. Further studies, including larger cohorts and long-term follow-up, are also necessary to confirm the value of this technique in routine practice.

ARTICLE INFORMATION

Author contributions

Conceptualization: NS; Methodology: all authors; Investigation: all authors; Writing–original draft: NS; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Anteroposterior radiograph of the right hip showing a displaced transcervical fracture of the femoral neck (Garden IV; AO classification, 31B2).

Fig. 2.

Intraoperative photograph illustrating preservation of the quadriceps coxa with the SPAIRE (saving piriformis and internus, repair of externus) approach, and the prosthesis in place. One star indicates the piriformis tendon. Two stars indicate the conjoint tendon of the superior gemellus, obturator internus, and inferior gemellus muscles. Three stars indicate the release of the posterior capsule, along with the obturator externus tendon and quadratus femoris, which is detached from its femoral insertion.

Fig. 3.

Postoperative anteroposterior radiograph showing bipolar hemiarthroplasty with the SPAIRE (saving piriformis and internus, repair of externus) approach.

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