Comparing direct anterior approach versus posterior approach or lateral approach in total hip arthroplasty: a systematic review and meta-analysis

James Jia Ming Ang; James Randolph Onggo; Christopher Michael Stokes; Anuruban Ambikaipalan

doi:10.1007/s00590-023-03528-8

Comparing direct anterior approach versus posterior approach or lateral approach in total hip arthroplasty: a systematic review and meta-analysis

Eur J Orthop Surg Traumatol. 2023 Oct;33(7):2773-2792. doi: 10.1007/s00590-023-03528-8. Epub 2023 Apr 3.

Authors

James Jia Ming Ang¹, James Randolph Onggo^{2

3}, Christopher Michael Stokes^{3

4}, Anuruban Ambikaipalan^{3

4}

Affiliations

¹ Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia. james_angjiaming@hotmail.com.
² Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia.
³ Department of Orthopaedic Surgery, Box Hill Hospital, Victoria, Australia.
⁴ Department of Orthopaedic Surgery, Royal Melbourne Hospital, Victoria, Australia.

Abstract

Background: There are several approaches to THA, and each has their respective advantages and disadvantages. Previous meta-analysis included non-randomised studies that introduce further heterogeneity and bias to the evidence presented. This meta-analysis aims to present level I evidence by comparing functional outcomes, peri-operative parameters and complications of direct anterior approach (DAA) versus posterior approach (PA) or lateral approach (LA) in THA.

Patients and methods: A comprehensive multi-database search (PubMed, OVID Medline, EMBASE) was conducted from date of database inception to 1st December 2020. Data from randomised controlled trials comparing outcomes of DAA versus PA or LA in THA were extracted and analysed.

Results: Twenty-four studies comprising 2010 patients were included in this meta-analysis. DAA has a longer operative time (MD = 17.38 min, 95%CI: 12.28, 22.47 min, P < 0.001) but a shorter length of stay compared to PA (MD = - 0.33 days, 95%CI: - 0.55, - 0.11 days, P = 0.003). There was no difference in operative time or length of stay when comparing DAA versus LA. DAA also had significantly better HHS than PA at 6 weeks (MD = 8.00, 95%CI: 5.85, 10.15, P < 0.001) and LA at 12 weeks (MD = 2.23, 95%CI: 0.31, 4.15, P = 0.02). There was no significant difference in risk of neurapraxia for DAA versus LA or in risk of dislocations, periprosthetic fractures or VTE between DAA and PA or DAA and LA.

Conclusion: The DAA has better early functional outcomes with shorter mean length of stay but was associated with a longer operative time than PA. There was no difference in risk of dislocations, neurapraxias, periprosthetic fractures or VTE between approaches. Based on our results, choice of THA approach should ultimately be guided by surgeon experience, surgeon preference and patient factors.

Level of evidence i: Meta-analysis of randomised controlled trials.

Keywords: Direct anterior approach; Lateral approach; Posterior approach; Posterolateral approach; Total hip arthroplasty; Total hip replacement.

Publication types

Meta-Analysis
Systematic Review
Review

MeSH terms

Arthroplasty, Replacement, Hip* / adverse effects
Arthroplasty, Replacement, Hip* / methods
Humans
Joint Dislocations*
Periprosthetic Fractures*
Treatment Outcome
Venous Thromboembolism*