Comparative efficacy of direct anterior approach versus conventional surgical approaches in total hip arthroplasty: a systematic review and meta-analysis of randomized clinical trials.

Abstract

Background: Conventional approaches (CA) include the posterior approach (PA) and the lateral approach (LA). Although the direct anterior approach (DAA) and CA possess distinct advantages and limitations in clinical treatment outcomes, the existing literature provides conflicting descriptions. Therefore, this study conducted a systematic literature review and meta-analysis based on randomized clinical trials (RCTs) to compare the clinical outcomes of DAA and CA in total hip replacement (THR).

Methods: Up to May 2025, we executed a comprehensive literature search to compare RCTs of DAA and CA in THA. We assessed Surgical parameters, functional scores, and postoperative complications. Pooled statistical analysis was employed to quantify the therapeutic outcomes by comparing DAA and CA, with CA as the control group, using data extracted from the included RCTs. We used the Review Manager 5.4 software for assessing publication bias and data analysis, and I² (based on the DerSimonian-Laird method) to assess the heterogeneity among studies. We used the random-effects model for the pooled analysis.

Results: This study included 17 eligible RCTs comprising 1,575 patients, of which 4 were Level I evidence and 13 were Level II evidence. The meta-analysis revealed that DAA prolonged the operative time (random-effects model, mean difference [MD] = 14.5 min, 95% confidence interval [CI] 9.14 to 19.86, p < 0.01), resulted in lower posteroperative day 1 pain scores (random-effects model MD = -0.79, 95% CI -1.00 to -0.59, p < 0.01), demonstrated superior early functional outcomes (Harris Hip Score at 1 month postoperatively, random-effects model, MD = 3.41, 95% CI 0.29 to 6.53, p = 0.03), and was linked to an increased risk of postoperative nerve injury (relative risk [RR] = 7.37, 95% CI 2.52 to 21.51, p < 0.01). No comparable outcomes were found between DAA and CA methods in intraoperative blood loss, VAS score at 1 month postoperatively, Harris score after 3 months, and other complications (intraoperative fracture, intraoperative greater trochanter fracture, dislocation, infection, wound complications, thrombosis, etc.)..

Conclusion: Compared with CA, DAA reduced early postoperative pain levels and yielded superior early hip joint function. However, DAA was linked to longer operative durations and an elevated risk of nerve injury.