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. 2025 Sep 26;20:837. doi: 10.1186/s13018-025-06227-8

Comparative efficacy of direct anterior approach versus conventional surgical approaches in total hip arthroplasty: a systematic review and meta-analysis of randomized clinical trials

Run Liu 1, Yaheng Zhao 1, Zhiming Yu 1, Changcheng Liu 1,✉, Qi Sun 1,✉, Xinyu Nan 2,✉
PMCID: PMC12465139  PMID: 41013681

Abstract

Background

Conventional approaches (CA) include the posterior approach (PA) and the lateral approach (LA). Although the direct anterior approach (DAA) and CA possess distinct advantages and limitations in clinical treatment outcomes, the existing literature provides conflicting descriptions. Therefore, this study conducted a systematic literature review and meta-analysis based on randomized clinical trials (RCTs) to compare the clinical outcomes of DAA and CA in total hip replacement (THR).

Methods

Up to May 2025, we executed a comprehensive literature search to compare RCTs of DAA and CA in THA. We assessed Surgical parameters, functional scores, and postoperative complications. Pooled statistical analysis was employed to quantify the therapeutic outcomes by comparing DAA and CA, with CA as the control group, using data extracted from the included RCTs. We used the Review Manager 5.4 software for assessing publication bias and data analysis, and I² (based on the DerSimonian-Laird method) to assess the heterogeneity among studies. We used the random-effects model for the pooled analysis.

Results

This study included 17 eligible RCTs comprising 1,575 patients, of which 4 were Level I evidence and 13 were Level II evidence. The meta-analysis revealed that DAA prolonged the operative time (random-effects model, mean difference [MD] = 14.5 min, 95% confidence interval [CI] 9.14 to 19.86, p < 0.01), resulted in lower posteroperative day 1 pain scores (random-effects model MD = -0.79, 95% CI -1.00 to -0.59, p < 0.01), demonstrated superior early functional outcomes (Harris Hip Score at 1 month postoperatively, random-effects model, MD = 3.41, 95% CI 0.29 to 6.53, p = 0.03), and was linked to an increased risk of postoperative nerve injury (relative risk [RR] = 7.37, 95% CI 2.52 to 21.51, p < 0.01). No comparable outcomes were found between DAA and CA methods in intraoperative blood loss, VAS score at 1 month postoperatively, Harris score after 3 months, and other complications (intraoperative fracture, intraoperative greater trochanter fracture, dislocation, infection, wound complications, thrombosis, etc.)..

Conclusion

Compared with CA, DAA reduced early postoperative pain levels and yielded superior early hip joint function. However, DAA was linked to longer operative durations and an elevated risk of nerve injury.

Keywords: Direct anterior approach, Posterior approach, Lateral approach, Complications, Efficacy

Graphical Abstract

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Introduction

Total hip arthroplasty (THA) provides good outcomes and longevity, since Charnley [1] introduced the modern concepts with sound principles of biomechanics. Surgeons strive to reduce complications by employing good surgical techniques, with different surgical approaches giving rise to differential challenges. Conventional surgical techniques for hip replacement encompass the posterior approach (PA) and the lateral approach (LA). The PA exposes the hip joint by dissecting the external rotator muscle group and the gluteus maximus tendon [2, 3]. The LA requires splitting the gluteus medius and minimus muscles [4, 5]. Both the PA and LA require muscle dissection, which results in muscle damage, causing early postoperative pain. The anterolateral approach, which enters the hip joint via the intermuscular plane between the gluteus medius and tensor fasciae latae, was not included in the CA. As an intermuscular approach, the direct anterior approach (DAA) was first proposed by Carl Hueter [6]. It gradually became popular with the use of a dedicated operating Tables [7, 8]. Clinical research on DAA focused on the management of complications and how to shorten the learning curve [9]. At the same time, the utility of the DAA expanded and was no longer limited to primary total hip arthroplasty, extending to include complex hip revision surgeries [10]. Although the popularity in the Asian region is relatively low, it is growing [11, 12]. Existing meta-analyses have conflicting descriptions regarding the early functional outcomes of DAA compared to traditional approaches. Some studies suggest that DAA has superior early functional outcomes [13–15], while others indicate that the two approaches are similar [16, 17]. Additionally, the existing meta-analyses failed to compare these outcomes against surgical complications, hence lacking in-depth analysis of the common complications [18–21]. This study aims to evaluate the comparative clinical outcomes of DAA and CA for hip disorders or injuries, restricted to high-level RCT evidence.

Methods

Reporting and registration

This study followed PRISMA-P guidelines. The study protocol was registered prospectively with PROSPERO on June 7, 2025, and was approved on June 8, 2025. The registration number is CRD420251069424.

Data sources and search strategy

The Electronic databases used for the search included PubMed, EMBASE, Web of Science, and the Cochrane Library. The search was conducted up to June 2025. The keywords used were: (1) “direct anterior approach” OR “DAA”; (2) “posterior approach” OR “PA”; (3) “lateral approach” OR “LA”; (4) “total hip replacement.” The search strategy was “(1) AND (2) AND (4)” OR “(1) AND (3) AND (4).” The search strategy was ((((posterior approach) OR (PA)) AND ((direct anterior approach) OR (DAA))) AND ((total hip replacement) OR (THA))) OR ((((lateral approach) OR (LA)) AND ((direct anterior approach) OR (DAA))) AND ((total hip replacement) OR (THA))). A total of 1,976 articles were retrieved, including 674 from PubMed, 313 from EMBASE, 872 from Web of Science, and 108 from Cochrane Library.

Study screening and selection

Titles and abstracts were screened independently by two reviewers for preliminary identification of relevant articles for full-text review. After screening the full texts of the remaining articles, the two reviewers again assessed to determine inclusion. Final inclusion determinations were reached jointly by both reviewers, with arbitration by a third reviewer in cases of disagreement. The screening process was applied independently to studies on DAA and CA, using the same method.

Inclusion criteria

(1) Randomized controlled trials (RCTs); (2) Patients with hip joint diseases or hip fractures; (3) Comparative studies evaluating DAA and CA; (4) Control groups included posterior or posterolateral approaches, direct lateral, or lateral approaches. Exclusion Criteria: (1) Lack of outcome measures of interest or incomplete data; (2) Minimally invasive small-incision approaches; (3) Use of computer navigation systems; (4) Hemiarthroplasty; (5) Anterolateral approach.

Data extraction and analysis

Two independent reviewers extracted data. Discrepancies were resolved through discussion, through consensus, or consultation with a third reviewer. Relevant data were extracted into Excel spreadsheets. Extracted data items included: first author, publication year, country, sample size, baseline patient characteristics, and target indicators.

Risk of bias and level of evidence

The risk of bias for included studies was assessed using the Cochrane Risk of Bias tool.

Statistical analysis

EndNote 21.5 software was used for literature management, Excel for data collection and extraction, and Review Manager 5.4 software for meta-analysis. Heterogeneity among studies was evaluated using the I2 statistic (based on the DerSimonian-Laird method). The random-effects model was used for the pooled analysis. Continuous outcomes were presented as mean differences (MD) with 95% confidence intervals (CI) were used to describe the data, and forest plots were generated to display the results. Sensitivity analyses were performed to examine the stability of the results. Funnel plots were generated to evaluate potential publication bias risk. Statistical significance was defined as p < 0.05 (two-sided).

Results

The study selection followed the details in the PRISMA flow diagram (Fig. 1). The completed PRISMA checklist is provided as a supplementary file. Following the removal of 750 duplicate articles, an initial screening identified 1,217 articles. After screening titles and abstracts, 57 articles were retained for full-text evaluation. After full-text reading and analysis, 17 RCTs were finally included, of which two were published in Chinese and 15 in English, published between 2013 and 2025, collectively enrolling 1,575 patients, with 785 patients receiving DAA and 790 patients receiving CA (320 patients with LA, 470 patients with PA), with sample sizes ranging from 46 to 164.

Fig. 1.

Fig. 1

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PRISMA flow diagram

Characteristics of the RCTs

A total of 17 RCTs comparing DAA and CA were included, involving 1,575 patients, as shown in the table. Primary preoperative indications included osteoarthritis, femoral neck fractures, and femoral head avascular necrosis.

Risk of bias and level of evidence

Study quality was appraised using the Cochrane risk of bias tool (Fig. 2). A summary of the assessment is presented in Table 1. Among the 17 studies, 4 were blinded RCTs, classified as Level Ⅰ evidence. The remaining 13 were non-blinded RCTs, categorized as Level Ⅱ evidence.

Fig. 2.

Fig. 2

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Risk of Bias assessment graph

Table 1.

Showed the authors, years, country, sample sizes, and basic characteristics of the samples of the included articles

study country Sample size, n Surgical approach Mean Age, y(SD) Gender (M/F), n BMI, kg/m2(SD)
DA CA DA CA DA CA DA CA
Barrett, 2013 [22] American 87 43 44(PA) 61.4 ± 9.2 63.2 ± 7.7 29/14 19/25 30.7 ± 5.4 29.1 ± 5
Rodriguez, 2014 [23] American 120 60 60(PA) 60 ± 10 59 ± 6 28/32 26/34 27 ± 4 28 ± 4
Christensen, 2015 [24] American 51 28 23(PA) 64.3 ± 9.1 65.2 ± 9.1 13/15 11/12 31.1 ± 5.1 30.4 ± 3.6
De Anta-Diaz, 2016 [25] Spain 99 50 49(LA) 64.8 ± 10.1 63.5 ± 12.5 26/24 26/23 26.6 ± 3.9 26.9 ± 3.1
Luo, 2016 [26] China 104 52 52(PA) 61.5 ± 7.2 63.7 ± 6.8 17/35 22/30 22.7 ± 4.4 24.1 ± 3.7
Rykov, 2017 [27] Netherlands 46 23 23(PA) 62.8 ± 6.1 60.2 ± 8.1 8/15 11/12 29 ± 5.6 29.3 ± 4.8
Zhao, 2017 [28] China 120 60 60(PA) 64.88 ± 12.13 62.18 ± 14.72 24/36 26/34 24.35 ± 3.1 25.58 ± 2.83
Zomar, 2018 [29] London 78 36 42(LA) 60.78 ± 9.26 59.54 ± 8.4 21/15 20/22 28.38 ± 4.51 30.89 ± 5.43
Bon, 2019 [30] France 100 50 50(PA) 67.26 ± 10 68.98 ± 7.93 21/29 23/27 26.46 ± 3.58 26.69 ± 3.12
Mjaaland, 2019 [31] Norway 164 84 80(LA) 67 ± 9 66 ± 9 25/59 30/50 28 ± 4 28 ± 4
Moerenhout, 2020 [32] Canada 55 28 27(PA) 70.4 ± 9.1 68.9 ± 8.8 11/17 18/9 27.6 ± 4.4 26.5 ± 4.3
Cao, 2020 [33] China 130 65 65(PA) 61.4 ± 12.8 62.4 ± 8.3 27/38 28/37 24.7 ± 1.9 25.1 ± 1.8
Iorio, 2021 [34] Italy 60 29 31(LA) 62.7 ± 4.9 67.2 ± 8.8 14/15 17/14 28.7 ± 3.4 29.9 ± 3.1
Nambiar, 2021 [35] Australia 52 23 29(PA) 64 ± 11 66 ± 10 11/12 13/16 27 ± 3 28 ± 4
Zhang, 2021 [36] China 128 62 66(PA) 61.7 ± 7.1 63.3 ± 8.2 35/27 40/26 24.6 ± 3 25 ± 3.4
Yunchun, 2024 [37] China 51 28 23(PA) 65.26 ± 5.89 64.47 ± 5.12 10/18 11/12 23.45 ± 3.12 24.03 ± 3.3
Hoseth, 2025 [38] Norway 130 64 66(LA) 78.1 ± 1.2 79.1 ± 1.2 22/42 25/41 25 ± 0.6 23.8 ± 0.5
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Clinical and statistical heterogeneity

In terms of baseline characteristics (including gender, age, and body mass index [BMI]), no clinically relevant baseline differences were found between the experimental group (DAA) and the control group (CA) patients (see Table 1). Statistical heterogeneity measures for all outcomes are presented in Figs. 3, 4, 5 and 6.

Fig. 3.

Fig. 3

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Displays the forest plots for VAS scores on the first postoperative day and at one month postoperatively

Fig. 4.

Fig. 4

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The forest plot shows the Harris hip scores at one month, three months, and one year postoperatively

Fig. 5.

Fig. 5

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The forest plot shows the complications, including periprosthetic infection and wound complications

Fig. 6.

Fig. 6

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The forest plot displays the complications, including dislocation rate, nerve injury, thrombosis, and revision rate within one year

Surgical outcomes (Figs. 3 and 7)

Fig. 7.

Fig. 7

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Displays the forest plots for operative time and blood loss

Operation time

In the analysis of DAA and CA, data from 822 patients in 9 RCTs were included (I² = 94%, p < 0.01, see Fig. 7). Using the random-effects model, DAA had a longer operative time by 14.5 min compared to CA (MD = 14.5, 95% CI 9.14 to 19.86, p < 0.01).

Blood loss

In the comparison of DAA versus CA, data from 311 patients in 3 RCTs were pooled (I² = 98%, p < 0.01, see Fig. 7). Using the random-effects model, intraoperative blood loss was comparable between groups (MD = 60.85, 95% CI -10.52 to 132.22, p = 0.09).

VAS 1 day postoperatively

In the evaluation of DAA versus CA, data from 337 patients in 3 RCTs were pooled (I² = 11%, p < 0.01, see Fig. 3). Using the random-effects model, DAA had a lower VAS score on postoperative Day 1 compared to CA (MD = -0.79, 95% CI -1.00 to -0.59, p < 0.01).

At 1 month postoperatively, comparing DAA and CA yielded pooled data from 454 patients in 5 RCTs, which were pooled (I² = 94%, p < 0.01, see Fig. 3). Using the random-effects model, there was no difference in postoperative VAS scores at 1month (MD = -0.14, 95% CI -0.74 to 0.45, p = 0.64).

Functional outcomes (Fig. 4)

Harris 1 month

In the assessment of DAA and CA, data from 483 patients in 5 RCTs were combined (I² = 75%, p < 0.01, see Fig. 4). Using the random-effects model, DAA had a higher Harris score at 1 month post-surgery compared to CA (MD = 3.41, 95% CI 0.29 to 6.53, p = 0.03).

Harris 3 months

In the analysis of DAA versus CA, data from 789 patients in 8 RCTs were pooled (I² = 92%, p < 0.01, see Fig. 4). Using the random-effects model, Harris score were comparable at 3 months (MD = 1.73, 95% CI -0.17 to 3.64, p = 0.07).

Harris 1 year

In the comparison between DAA and CA, data from 489 patients in 5 RCTs (I² = 0%, p = 0.72, see Fig. 4). Using the random-effects model, no significant difference was observed in the Harris score at 1 year postoperatively (MD = -0.3, 95% CI -1.36 to 1.96, p = 0.72).

Complications outcomes (Figs. 5, 6 and 8)

Fig. 8.

Fig. 8

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The forest plot displays the complications, including intraoperative fractures and greater trochanter fractures

Periprosthetic joint infection

In the comparison between DAA and CA, data from 285 patients in 3 RCTs (I²= 0%, p = 0.7, see Fig. 5). Using the random-effects model, the incidence of periprosthetic joint infection was comparable between groups (RR = 0.70, 95% CI 0.11 to 4.35, p = 0.70).

Wound complications

In the comparison between DAA and CA, data from 381 patients in 3 RCTs (I2 = 0%, p = 0.61, see Fig. 5). Using the random-effects model, there was no difference in wound complication incidence (RR = 0.99, 95% CI 0.17 to 5.67, p = 1.00).

Dislocation

In the comparison between DAA and CA, data from 799 patients in 7 RCTs were pooled (I² = 0%, p = 0.34, see Fig. 6). Using the random-effects model, dislocation rates were similar (RR = 0.58, 95% CI 0.19 to 1.78, p = 0.34).

Nerve injury

In the comparison between DAA and CA, data from 858 patients in 8 RCTs were pooled (I² = 14%, p = 0.32, see Fig. 6). Using the random-effects model, DAA demonstrated a significantly increased risk of nerve injury relative to CA (RR = 7.37, 95% CI 2.52 to 21.51, p < 0.01).

Thrombus formation

In the comparison between DAA and CA, data from 466 patients in 4 RCTs were combined (I² = 0%, p = 0.96, see Fig. 6). Using the random-effects model, the incidence of lower limb thrombosis was similar (RR = 1.04, 95% CI 0.24 to 4.50, p = 0.96).

Revision within 1 year

In the comparison between DAA and CA, data from 337 patients in 3 RCTs were pooled (I² = 0%, p = 0.55, see Fig. 6). Using the random-effects model, no significant difference in revision rates within 1 year (RR = 0.79, 95% CI 0.15 to 4.06, p = 0.78).

Intraoperative fracture

In the assessment of DAA and CA, data from 754 patients in 7 RCTs were included (I²= 0%, P = 0.76, see Fig. 8). Using the random-effects model, there was no difference in intraoperative fracture incidence (RR = 1.24, 95% CI 0.39 to 3.97, p = 0.72).

Intraoperative greater trochanter fracture

In the comparison between DAA and CA, data from 404 patients in 3 RCTs were pooled (I² = 0%, p = 1.00, see Fig. 8). Using the random-effects model, although there was no statistical difference in the intraoperative greater trochanteric fracture rate (RR = 2.95, 95% CI 0.47 to 18.54, p = 0.25), the aggregated data suggested a consistent upward trend in the incidence of greater trochanteric fractures during DAA across different studies.

Discussion

The advancement in surgical techniques for total hip arthroplasty is reflected in artificial intelligence applications [39, 40] and the improvement of surgical approaches. In this study, a quantitative analysis of the efficacy of DAA compared to CA in THA was performed. We examined surgical time, intraoperative blood loss, postoperative pain levels, functional scores, and postoperative complications (intraoperative fracture, intraoperative greater trochanter fracture, dislocation, infection, wound complications, thrombosis, etc.) to evaluate the relative risks and benefits of each approach.

Our pooled analysis demonstrated that patients undergoing DAA required longer operative times compared to the control group (MD = 14.5 min, 95% CI 9.14 to 19.86, p < 0.01). The results are similar to those of previously published meta-analyses [20]. The DAA has a steep learning curve, which can lead to prolonged surgical time, and the surgical outcomes stabilized after 100 cases [41, 42]. In the 9 studies included in this meta-analysis, 5 studies declared that the surgeons had completed at least 100 DAAs before starting the study, and the remaining four studies all declared that the surgeons were experienced experts with stable skills. Therefore, this suggests that an average increase in surgical time of 14.5 min still exists even when the surgery is performed by experienced experts. The DAA group reported significantly less severe postoperative pain on day 1 (VAS MD = -0.79, 95% CI -1.00 to -0.59, p < 0.01), and better early function (Harris hip score at 1 month postoperatively, MD = 3.41, 95% CI 0.29 to 6.53, p = 0.03). The DAA is associated with less postoperative pain and faster functional recovery, which reduces patients’ length of hospital stay and economic burden [43]. However, this also poses challenges to rehabilitation centers. Studies have shown that the probability of DAA patients being transferred to rehabilitation centers after surgery was significantly lower than that of patients who underwent the PA [44]. The advantages in pain and functional scores disappeared at 1 month (VAS at 1 month postoperatively, MD = -0.14, 95% CI -0.74 to 0.45, p = 0.64) and 3 months postoperatively (Harris score at 3 months, MD = 1.73, 95% CI -0.17 to 3.64, p = 0.07), respectively. The advantage in the Harris score also disappeared at 1 year postoperatively (MD = -0.3, 95% CI -1.36 to 1.96, p = 0.72). However, the DAA was associated with a significantly higher rate of postoperative nerve injury than CA (relative risk RR = 7.37, 95% CI 2.52 to 21.51, p < 0.01). This is a well-known and expected result based on the anatomical location of the lateral femoral cutaneous nerve. It is worth noting that this nerve is a sensory nerve, and such an injury is usually benign, with minimal impact on patient-reported outcomes and long-term function [45]. Statistically significant differences were not observed between groups for intraoperative blood loss and other complication rates.

Compared with previous studies, our study not only focused on pain perception and hip joint functional scores but also paid close attention to the incidence of postoperative complications, providing a more comprehensive assessment of the incidence of complications pertaining to both approaches.

In the meta-analysis of lower limb thrombosis formation, a total of 4 RCTs were included. In our research findings, there was no significant statistical difference between the DAA and the CA in this complication. However, none of the 4 studies explicitly described the postoperative anticoagulation regimen. It is worth noting that different doses of anticoagulation regimens can have varying effects on patients [46, 47], such as an increased risk of postoperative bleeding.

Although DAA has minimally invasive characteristics compared with CA, exposing the femoral side during surgery is one of the challenges. Some studies have suggested that insufficient femoral exposure may increase the risk of femoral fractures [48]. Jewett and Matta [49, 50] reported several cases of greater trochanter fractures occurring during femoral exposure using the DAA. However, Zhao Wang et al. [51] reported in a 2018 meta-analysis incorporating 9 RCTs totaling 754 THAs, comparing DAA with PA. The results showed comparable rates of intraoperative fractures between the two groups. This conflicting result is noteworthy. In our study, we not only compared the overall intraoperative fracture rates between DAA and CA but also specifically analyzed the incidence of greater trochanter fractures. The meta-analysis results showed no statistical differences between DAA and CA in either overall intraoperative fracture rates or greater trochanter fracture rates (Intraoperative fracture, RR = 1.16, 95% CI 0.43 to 3.15, p = 0.77; Intraoperative greater trochanter fracture, RR = 2.95, 95% CI 0.47 to 18.54, p = 0.25). The results were similar to the meta-analysis results reported by Miller et al. [52]. However, in this meta-analysis, a consistent upward trend in the incidence of greater trochanteric fractures was observed across different studies. The exposure of the femoral side is a surgical technique issue, which can be resolved by improving surgical skills. We should not attribute intraoperative fractures to the approach itself. Meanwhile, the increasing trend of greater trochanteric fractures also reminds surgeons to pay more attention to the exposure of the femoral side when performing DAA.

The incidence of periprosthetic joint infection and wound complications associated with the DAA has been a topic of discussion. The surgical incision for DAA is close to the inguinal area, where skin folds can accumulate, making it a relative contraindication for patients with high BMI. Harold I Salmons et al. [53] published a multicenter retrospective study in 2024, which included 17,111 patients, with 11,585 undergoing lateral-based approaches (including lateral and posterior approaches) and 5,526 undergoing DAA. The risk of wound complications was significantly elevated in DAA patients (3.6%) versus those receiving traditional approaches (2.6%). Connor, Acuña, et al. [54, 55] published 2 meta-analyses showing that DAA is not linked to an elevated risk of periprosthetic joint infection. In our study, we compared the incidence of these complications and the results showed no statistical differences between DAA and CA in either wound complications (RR = 0.99, 95% CI 0.17 to 5.67, p = 1.00) or periprosthetic joint infection (RR = 0.70, 95% CI 0.11 to 4.35, p = 0.70), In the 3 studies pooled for the analysis of PJI, the average BMI of all groups was less than 28 kg/m². Therefore, the results of this study can not be used to consider DAA for obese patients. In today’s literature, there are still limitations in the application of DAA among patients with higher BMI, and this study was not designed to challenge this view.

Since DAA preserves the posterior soft tissue structure, it is theoretically thought to reduce dislocation risk. John V. Horberg et al. [56] reviewed a non-selective consecutive cohort involving 2,205 patients with 2,831 hip joints. There were 11 dislocations (0.38%) within 1 year postoperatively, and a total of 13 dislocations (0.46%) at the final follow-up, indicating a low dislocation risk even in patients with instability risk factors. However, the PA, after technical modifications, posterior soft tissue reconstruction combined with modern large-diameter prosthetic heads, has significantly reduced the dislocation rate. Whether the DAA reduced dislocation risk compared to the PA remains inconclusive. A recent meta-analysis [57] demonstrated comparable dislocation rates between DAA and PA or LA. Similarly, in our study, dislocation rates did not differ statistically between DAA and CA (RR = 0.56, 95% CI 0.21 to 1.49, p = 0.24).

Several limitations warrant consideration. This study endeavored to include all complications following THA comprehensively, but due to the limited number of studies, certain complications, such as heterotopic ossification and pseudotumor formation [58], were not included. This study applied the DerSimonian-Laird method to assess heterogeneity, which carries the risk of producing overly optimistic results [59]. The relatively limited number of eligible studies may have contributed to substantial heterogeneity, potentially affecting the precision of the pooled estimates. There may also be unidentifiable confounding factors that could influence the results. For example, variations in patient populations, surgeon expertise, and operative techniques among the included studies may impact the outcomes. Such confounding factors may introduce bias into our results, and therefore, the study findings warrant cautious interpretation. Finally, the included studies exhibited heterogeneity in design, methodological quality, and reporting standards, introducing potential biases. Inconsistencies in outcome definitions and reporting, along with missing data, may affect the consistency and comparability of the results. Consequently, our results should be interpreted cautiously. Further research featuring larger cohorts, extended follow-up, and standardized outcome measures is required to validate these findings and enhance understanding of the comparative effectiveness and safety profiles of DAA and CA for THA .

Author contributions

RLand YHZ drafted the main manuscript, ZY was responsible for organizing the data, CCL, QS, XYN served as the three reviewers responsible for the selection of the included literature in this study.

Funding

This study was not supported by any funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Changcheng Liu, Email: liuchangcheng3022@hebmu.edu.cn.

Qi Sun, Email: 59003946@hebmu.edu.cn.

Xinyu Nan, Email: 19101797@hebmu.edu.cn.

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Data Availability Statement

No datasets were generated or analysed during the current study.

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