Outcomes of Direct Anterior versus Posterior Approaches in Total Hip Arthroplasty: A Systematic Review

Background The ideal surgical approach for Total Hip Arthroplasty (THA) remains debated in orthopedic joint surgery. The Direct Anterior Approach (DAA) has gained popularity due to its potential to reduce operative complications, particularly dislocation, compared to the traditional Posterior Approach (PA). However, there is still no consensus on the superiority of DAA over PA, especially when considering regional tendencies, patient-reported outcome measures (PROMs), and individual patient perceptions. Purpose/Hypothesis This study aims to evaluate the current literature that directly compares the DAA to the PA in THA, with a focus on PROMs. It will also highlight the limitations and complications associated with each approach. The hypothesis is that DAA and PA are comparable regarding overall patient complications, success rates, and PROMs. Study Design Systematic Review Methods The study protocol was registered with PROSPERO (ID: CRD42024538589) and conducted following PRISMA guidelines. A comprehensive search of MEDLINE and PubMed databases was performed to locate studies comparing DAA and PA in THA, with eligibility criteria including randomized controlled trials, non-randomized clinical trials, prospective and retrospective cohort studies, and case-control studies. Data were extracted systematically, capturing study demographics, PROMs, and statistically significant outcomes. Results A total of 38 studies were included in this systematic review. Key findings include: Nine studies reported a significantly higher rate of dislocation in the PA compared to the DAA, while seven studies found no significant difference. Ten studies analyzed infection rates with mixed results—one reported higher infection rates in the PA, while five found no significant difference. Fifteen studies discussed hip revisions, with six showing higher revision rates for the PA and five showing higher rates for the DAA. Sixteen studies specifically discussed PROMs related to satisfaction and pain; eight found no significant difference between DAA and PA, while seven reported that DAA was superior. Eleven studies discussed satisfaction and pain, with six reporting higher satisfaction scores for the DAA and four finding no significant difference. Three studies reported shorter hospital stays for the DAA. Conclusion The review indicates that while the DAA may offer advantages such as reduced dislocation rates and shorter hospital stays, both approaches present comparable overall complication rates, long-term outcomes, and PROMs. Surgeon preference, influenced by residency teaching and tradition, and patient-specific factors, including PROMs, remain critical in selecting the appropriate surgical approach for THA. Future research should focus on prospective, multicenter RCTs, more extended follow-up periods, and the economic implications of each approach. The debate over the ideal approach in THA continues, with current evidence suggesting that DAA and PA are viable options depending on individual patient and surgeon factors.