Direct Anterior or Posterolateral Approach for Primary Total Hip Arthroplasty? A Systematic Review of Early Recovery, Long-Term Outcomes, and Surgical Complications

The optimal surgical approach for primary total hip arthroplasty (THA) remains debated. The direct anterior approach (DAA) has been associated with faster early recovery, whereas its potential advantages over posterior or posterolateral approaches (PA/PLA) in terms of longer-term outcomes and complications remain uncertain. This systematic review aimed to compare DAA with PA/PLA across early recovery, functional, perioperative, and complication-related outcomes. PubMed/MEDLINE, Embase, and CENTRAL were searched for primary comparative studies published from January 2005 to December 2025. Randomized and non-randomized studies comparing DAA with an identifiable PA/PLA group in adults undergoing primary THA were eligible. Companion publications from the same trial or cohort were consolidated into single study units. Risk of bias was assessed using RoB 2 for randomized studies and ROBINS-I for non-randomized studies. Owing to substantial clinical and methodological heterogeneity, findings were synthesized narratively. The search identified 2216 records; 111 reports underwent full-text assessment, 89 were eligible, and eight companion reports were consolidated, resulting in 81 primary comparative study units. Fourteen were randomized and 67 were non-randomized. Across the evidence base, DAA was frequently associated with modest advantages in selected early postoperative outcomes, including pain, mobilization, functional recovery, and hospital length of stay. These differences generally diminished with longer follow-up, with medium- to long-term functional outcomes largely comparable between approaches. Findings for operative time, blood loss, and individual complications were heterogeneous. No consistent overall advantage was identified for major complications, revision, or implant survival, although the approaches showed different profiles for specific complications. Interpretation of the observational evidence was limited particularly by confounding, patient selection, surgeon experience, and differences in perioperative pathways. DAA may accelerate selected aspects of early recovery after primary THA, but these advantages generally diminish over time. Current comparative evidence does not demonstrate a consistent long-term functional or major-complication advantage over contemporary PA/PLA. Surgical approach should therefore be individualized according to patient characteristics, surgeon experience, and institutional practice.