Direct anterior approach versus posterior approach in total hip arthroplasty: A systematic review and meta-analysis.

Abstract

The optimal surgical approach for total hip arthroplasty (THA) is still debated. Recently, a growing surgical trend toward the utilization of minimally invasive techniques, such as the direct anterior approach (DAA), has emerged in the THA area. However, there are ongoing concerns regarding its technical complexity and perioperative outcomes relative to the posterior approach (PA). Therefore, we aim to compare DAA and PA regarding perioperative, functional, and safety outcomes. A comprehensive systematic search of PubMed, Web of Science, Scopus, and Cochrane Library was executed. We included randomized controlled trials (RCTs) and observational studies comparing DAA and PA in patients undergoing THA. The primary endpoints were all-cause surgery revision, dislocation, and fracture. Secondary endpoints encompassed the duration of hospital stay, incision length, functional recovery measured using the Harris Hip Score (HHS), and complications. Mean difference (M.D.) or Risk ratio (R.R.) with a 95 % confidence interval (C.I.) were employed to analyse the continuous or dichotomous outcomes. 27 studies constituted our meta-analysis, including 44,477 patients<b>,</b> with 7138 patients in the DAA cohort and 37,299 patients in the PA cohort. Our pooled analysis demonstrated comparable estimates of all-cause surgery revision (R.R. = 0.90, 95 % C.I. [0.71, 1.15], p = 0.40), dislocation (R.R. = 0.78, 95 % C.I. [0.53, 1.16], p = 0.22), intraoperative fracture (R.R. = 0.85, 95 % C.I. [0.51, 1.42], p = 0.54), and periprosthetic fracture (R.R. = 2.14, 95 % C.I. [0.85, 5.38], p = 0.11). Notably, DAA showed a significantly shorter hospital stay (M.D. = -0.31 days, 95 % C.I. [-0.55, -0.07], p = 0.01) and shorter incision length (M.D. = -33.75 mm, 95 % C.I. [-42.97, -24.54], p = 0.001) compared to the PA. No significant variations were noticed between the two approaches regarding HHS. Our meta-analysis highlighted that DAA is effective as PA in mitigating the risk of major complications following THA, such as all-cause surgery revision, dislocation, and fracture. In contrast, DAA showed better perioperative results, including shorter hospital stays and incision lengths, without compromising the safety outcomes compared to PA.