The direct anterior approach in total hip arthroplasty may be associated with lower short-term mortality compared to various other approaches: a Dutch arthroplasty register study comprising 379,108 procedures

Background: The association between primary total hip arthroplasty (THA) approaches and short-term mortality rates remained unexplored. This study aimed to compare short-term mortality rates between the direct anterior (DAA), posterolateral (PL), anterolateral (AL) and direct lateral (DL) approaches and determine associated factors. Methods: A registry study was conducted using data from 2007 to 2023 of the Dutch Arthroplasty Register. 30- and 90-day mortality were compared between approaches using the chi-square test and the logistic regression analysis to adjust for confounders (age, sex, patient’s physical status [ASA] classification, fixation method, body mass index [BMI] and smoking status). Multivariate regression models were used to determine factors associated with short-term mortality. Sensitivity analyses for time periods (2007–2012, 2013–2017, 2018–2023) were performed. Results: The study comprised 379,108 patients (mean age 69.9 ± 9.5, male 33.8%). The AL, PL and DL approaches demonstrated a significantly larger likelihood for 30-day mortality compared to the DAA after adjusting for confounders (DAA: reference; AL: OR 2.32 [1.52–3.57], p < 0.001; PL: OR 1.79 [1.36–2.36], p < 0.001; DL: OR 2.78 [1.69–4.57], p < 0 .001). In ASA I–II patients, likelihood for 90-day mortality for the AL, PL and DL approaches was significantly higher than the DAA approach (DAA: reference; AL: OR 2.293, p < 0.001; PL: OR 1.963, p < 0.001; DL: OR 2.016, p < 0.001). In ASA III–IV patients, differences were not significant, except when comparing the DL to the DAA approach (OR 1.484, p = 0.011). Increased age, male sex, surgical approach and cemented fixation were significantly associated with 30- and 90-day mortality. Conclusions: Findings were suggestive that the DAA provides a reduced likelihood for short-term mortality compared to the PL, AL and DL, after adjusting for confounding factors. Differences in mortality rate were more substantial in healthy patients and remained similar irrespective of time periods. Increased age, male sex, surgical approach, and cemented fixation increased likelihood on short-term mortality.