Comparative analysis of surgical approaches in total hip arthroplasty: a systematic review of comparative outcomes including primary and revision cases

Abstract

Background

The optimal surgical approach for total hip arthroplasty (THA) remains a subject of ongoing debate. Posterior, direct lateral, and direct anterior techniques differ in their soft-tissue handling, complication patterns, and applicability in complex reconstruction. This systematic review synthesizes contemporary evidence comparing functional outcomes, perioperative complications, and revision suitability across major THA approaches.

Methods

A systematic search of PubMed, Scopus, and Web of Science was conducted according to PRISMA guidelines. Eligible studies directly compared at least two THA approaches, reported clinical or functional outcomes with ≥ 12 months of follow-up, and were published between 2015 and 2025. Data were extracted on functional scores, early recovery parameters, dislocation rates, nerve injury profiles, intraoperative complications, and revision-specific considerations. Due to heterogeneity in outcome definitions, follow-up intervals, and incomplete reporting of numerical outcome data, a formal quantitative meta-analysis was not feasible. Therefore, the review provides a structured narrative synthesis rather than pooled effect estimates.

Results

Across comparative studies, the direct anterior approach (DAA) consistently demonstrated faster early functional recovery and reduced short-term pain compared with the posterior approach, although long-term functional outcomes were similar between approaches. Anterior-based approaches generally showed lower dislocation rates, while the direct lateral approach (DLA) provided intrinsic stability but was associated with a higher incidence of transient abductor weakness. Complication patterns were approach-specific: lateral femoral cutaneous nerve symptoms occurred predominantly with DAA, superior gluteal nerve irritation with DLA, and sciatic nerve palsy was rare and primarily associated with posterior THA. In revision and complex cases, the posterior approach remained favored due to its extensile exposure and ease of acetabular and femoral access.

Conclusions

All major surgical approaches for THA can achieve excellent long-term outcomes when performed by experienced surgeons. The DAA offers advantages in early recovery, whereas the posterior approach remains the most versatile for complex or revision arthroplasty. Selection of surgical approach should be individualized based on patient anatomy, surgeon expertise, and reconstructive requirements.

Trial registration

Not applicable. This study is a retrospective systematic review. The protocol was not registered in PROSPERO because data extraction had begun before submission, and retrospective registration is not permitted by the registry.

Introduction

Total hip arthroplasty (THA) remains a highly successful procedure, yet despite advances in implant design, bearing surfaces, and perioperative care, the optimal surgical approach continues to be debated due to multiple confounding factors influencing postoperative outcomes [1–6].

Despite the long history and widespread use of the posterior, direct lateral, and direct anterior approaches, no consensus exists on the optimal surgical route for THA because published evidence remains highly heterogeneous [7, 8]. Reported outcomes vary substantially across studies due to differences in surgeon experience, learning-curve effects, soft-tissue handling, patient selection, and evolving implant technology. Conflicting data on dislocation risk [9, 10], early functional recovery [11, 12], nerve injury patterns [13, 14], and feasibility in revision settings continue to fuel debate [15–18]. These inconsistencies highlight the need for an updated synthesis of contemporary evidence to clarify how each approach performs across functional, peri-operative, and revision-related outcomes.

Previous comparative reviews have been challenged by heterogeneity in study design, outcome reporting, and surgeon experience—limitations that remain inherent to most analyses in this field, including the present review [19, 20]. Furthermore, most focus on primary THA, whereas revision scenarios—requiring greater exposure and tissue management—are less extensively evaluated [21].

The aim of this meta-analytic review is to integrate current evidence comparing functional outcomes, perioperative complications, and revision-specific considerations among the major surgical approaches for THA. We hypothesized that anterior-based approaches offer early functional advantages, whereas the posterior approach remains the most widely used and adaptable in complex and revision contexts.

Materials and methods

Study design

This study is a systematic review conducted in accordance with the PRISMA guidelines. A protocol was developed prior to data extraction to ensure transparent identification, selection, and synthesis of the available evidence.

Search strategy

A comprehensive electronic search of PubMed/MEDLINE, Scopus, Cochrane Library, and Web of Science was performed, covering the period from January 2015 to February 2025. Manual screening of reference lists from relevant articles was additionally undertaken to identify studies not captured by the database search.

Search terms

The following Boolean combinations were used:

(“total hip arthroplasty” OR “THA”) AND.

(“posterior approach” OR “Moore” OR “Southern”) AND.

(“direct anterior approach” OR “Smith-Petersen” OR “DAA”) OR.

(“direct lateral approach” OR “Hardinge” OR “trans gluteal”) OR.

(“anterolateral approach” OR “Watson-Jones”) AND.

(“outcomes” OR “revision” OR “complications”)

Eligibility criteria

Studies were included if they met the following criteria:

1. Directly compared at least two surgical approaches for total hip arthroplasty.

2. Reported clinical or functional outcomes and/or complication rates.

3. Included ≥ 100 patients per group or were randomized controlled trials.

4. Reported minimum 12-month follow-up.

5. Published in peer-reviewed journals, in English, between 2015 and 2025.

Exclusion criteria included case reports, cadaveric studies, technical notes, studies lacking comparators, and robotic-only or navigation-only series without traditional approach comparison.

PICO framework

To enhance methodological clarity, the study question was structured according to the PICO framework.

Population (P): adults undergoing primary or revision total hip arthroplasty.

Intervention (I): posterior, direct anterior, or direct lateral surgical approaches.

Comparison (C): at least one alternative THA approach reported within the same study.

Outcomes (O): functional outcomes (HHS, WOMAC, SF-36), complication rates (dislocation, nerve injury, intraoperative fracture), and revision-related parameters.

Study selection

The database search identified 452 records. After removing 98 duplicates, 354 records underwent title/abstract screening. Of these, 276 were excluded as irrelevant or not meeting eligibility criteria. The full text of 78 articles was assessed, and 32 were excluded (primarily due to insufficient sample size or lack of direct comparison). A total of 46 studies met all inclusion criteria and were retained for synthesis. The study selection process is presented in Fig. 1.

Fig. 1.

PRISMA 2020 flow diagram illustrating study identification, screening, eligibility, and inclusion. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses. This work is licensed under CC BY 4.0. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/

Source: Page MJ, et al. BMJ 2021;372:n71. doi: 10.1136/bmj.n71.

Data extraction

Two independent reviewers extracted data regarding study design and population, sample size, surgical approach, reported functional outcomes (Harris Hip Score, WOMAC, SF-36), complication rates (dislocation, nerve injury, intraoperative fracture), revision-related outcomes, and duration of follow-up. Disagreements were resolved by consensus.

Quality assessment

Risk of bias was evaluated using:

• MINORS criteria for non-randomized studies.

• Cochrane Risk of Bias Tool for randomized trials.

Given the substantial variability in outcome definitions, reporting intervals, follow-up durations, and methodological heterogeneity, formal subgroup analyses and GRADE certainty assessments were not feasible.

Data synthesis

Because numerical data across included studies were inconsistent—particularly for complication rates and continuous outcomes—a quantitative meta-analysis could not be performed.

Therefore, a structured narrative synthesis was conducted, focusing on:

• Comparative trends in functional recovery.

• Differences in dislocation risk.

• Approach-specific nerve injury patterns.

• Intraoperative complications.

• Applicability in revision arthroplasty.

All interpretations were based solely on results reported in the original studies; no additional statistical calculations were performed.

Use of artificial intelligence tools

ChatGPT (OpenAI, San Francisco, CA, USA) was used exclusively for language refinement and formatting consistency. No part of the data extraction, interpretation, or scientific content was generated by the tool. All authors assume full responsibility for the accuracy and integrity of the manuscript.

PROSPERO registration

This systematic review was not registered in PROSPERO. Although the protocol was developed a priori, data extraction had already commenced at the time PROSPERO registration was considered; therefore, prospective registration was no longer applicable.

Results

A total of 46 studies met the inclusion criteria, encompassing more than 180,000 primary and revision THAs. The included studies consisted of randomized controlled trials, prospective and retrospective cohort studies, and registry-based comparative analyses. Most studies compared the posterior approach (PA) with either the direct anterior approach (DAA) or the direct lateral approach (DLA). Fewer studies assessed the anterolateral or minimally invasive variants.

Of the 46 included studies, 38 reported at least one functional outcome measure: Harris Hip Score [22], WOMAC [23], or SF-36 [24], 35 reported dislocation or complication rates, and 12 provided data on nerve injury or abductor function.

1. Functional Outcomes.

Across the comparative literature, the direct anterior approach consistently demonstrated faster early functional recovery than the posterior approach. Several studies reported earlier ambulation, reduced pain, and higher early postoperative functional scores with DAA [25–28].

Findings from DLA studies showed functional outcomes broadly comparable to those of the posterior approach in mid- and long-term follow-up [29–31].

Collectively, the evidence supports the following pattern:

• Early phase: DAA demonstrates the fastest functional recovery.

• Intermediate to long term: All three approaches achieve similar patient-reported outcomes.

• 2.Dislocation and Stability.

Dislocation rates varied notably by approach.

Posterior approach studies commonly described higher dislocation rates compared with anterior-based techniques when capsular repair was not performed [32, 33].

When posterior capsular and short external rotator repair were consistently performed, dislocation rates were substantially reduced, approaching those of DAA and DLA [34]. The direct lateral approach demonstrated intrinsically low dislocation rates, likely due to preserved posterior structures. Evidence from large comparative series and registries confirmed that surgical approach is a modifiable risk factor for instability, and that technique optimization (particularly capsular repair) plays a central role [35–37].

In the context of revision THA, the posterior approach remained the preferred option due to its reproducible exposure and extensile capacity, allowing safe management of complex acetabular and femoral reconstructions [38, 39].

• 3.Nerve Injury.

Nerve complications showed distinct approach-related patterns.

DAA: the most frequent neurologic issue was transient lateral femoral cutaneous nerve (LFCN) symptoms, with variable incidence across studies [40, 41].

DLA: associated with superior gluteal nerve irritation, occasionally contributing to postoperative abductor weakness [42].

PA: sciatic nerve palsy was rare in contemporary series [43].

Despite differing distributions, the majority of nerve injuries across all approaches were transient and non-debilitating.

• 4.Abductor Function and Gait.

DLA was most commonly associated with persistent abductor weakness, likely related to gluteus medius splitting [44, 45].

Several studies documented slower normalization of Trendelenburg gait after DLA compared with DAA and PA [46–48].

Conversely, DAA demonstrated more rapid recovery of gait parameters, although electromyographic analyses suggested that the mechanical demands of femoral elevation may occasionally stress adjacent anterior soft tissues [49].

• 5.Intraoperative Complications.

Comparative evidence showed:

• Higher early rates of intraoperative femoral fractures with DAA, especially during the initial learning curve phase, but these rates decreased in high-volume centers, reaching levels comparable with PA and DLA [50–52].

• Operative time and blood loss were slightly lower for PA in some multicenter reports, though these differences were not clinically significant [53].

• Infection rates were low and did not differ meaningfully between the three major approaches [54].

• 6.Revision and Complex Cases.

For revision THA and complex primary reconstructions, the posterior approach consistently demonstrated superior versatility due to:

• Extensive visualization of both acetabulum and femur,

• The ability to extend the exposure proximally or distally,

• Compatibility with modular and reconstruction implants.

DAA revisions were described in several studies but were generally more technically demanding, with limited extensibility and longer operative times [55–57].

Findings from multicenter revision cohorts highlighted the importance of adequate exposure and soft-tissue management, particularly in patients with significant comorbidities [58] (Table 1). Insights from limb-salvage and oncologic techniques reinforced the principle that safe extensile access contributes to reduced wound complications and improved construct stability [59].

Table 1.

Narrative comparative summary of key outcomes across THA surgical approaches

Surgical Approach	Early Function	Dislocation Profile	Nerve Injury Pattern	Typical Use
Direct Anterior (DAA)	Fastest early recovery	Low rates in most series	LFCN symptoms	Standard-risk patients, rapid recovery prioritization
Posterior (PA)	Slower early, equivalent long term	Higher if no capsular repair; comparable when repaired	Rare sciatic injury	Revision THA, extensile exposure
Direct Lateral (DLA)	Comparable long-term function	Intrinsically stable	Superior gluteal irritation	Elderly, high dislocation risk

Discussion

This systematic review, which synthesizes evidence from 46 comparative studies including over 180,000 primary and revision THAs, found that no single surgical approach demonstrates long-term superiority regarding functional outcomes, complication rates, or survivorship. The direct anterior approach (DAA) consistently showed faster early recovery, while the posterior approach (PA) remained the most commonly utilized technique for revision and complex reconstructions due to its extensile exposure. The direct lateral approach (DLA) maintained low dislocation rates but carried a higher risk of transient abductor dysfunction. Overall, long-term clinical outcomes converged across approaches, suggesting that patient anatomy and surgeon expertise play a greater role than any intrinsic superiority of one technique.

The persistently active debate surrounding surgical approach selection arises largely from approach-specific anatomical and technical characteristics, rather than differences in long-term outcomes. The DAA benefits from an intermuscular and internervous interval, a small incision, and straightforward superficial dissection, all contributing to its popularity in minimally invasive hip programs [60]. In contrast, the posterior approach offers the most extensile and versatile exposure, enabling controlled acetabular and femoral preparation even in obese patients or in complex anatomical settings [61]. These soft-tissue and exposure-related differences explain much of the continued debate, as each approach presents distinct advantages in visualization, tissue preservation, and ease of component implantation.

A major source of approach-related variability arises from acetabular component orientation. Several studies demonstrate that anterior-based approaches tend to position the cup in greater anteversion compared with posterior techniques, an effect influenced by pelvic tilt, fluoroscopic perspective, and challenges in femoral elevation [62]. In contrast, the direct lateral approach has shown no consistent differences in cup anteversion or inclination when compared with the posterior approach, suggesting that exposure geometry rather than approach category determines reproducibility [63]. Recent implementation of robotic and navigation-assisted THA has reduced these discrepancies, helping achieve more standardized acetabular orientation across surgical approaches [64]. Nonetheless, conflicting evidence persists—some authors report that posterior approaches may actually produce greater functional anteversion than anterior-based approaches, highlighting how surgeon technique and anatomical interpretation remain influential determinants [65].

Implantation accuracy is further affected by patient-specific morphology. Surgeons frequently rely on the superior acetabular rim as a visual guide, a practice that may inadvertently cause retroversion or edge loading in dysplastic hips, where anatomical landmarks differ significantly from normal morphology [66, 67].

Subtle deviations in component positioning also have important tribological implications. Even minor changes in cup inclination, anteversion, or head–neck offset can alter lubrication regimes, increase contact stress, and accelerate wear over time—effects that become particularly relevant in dysplastic hips or in patients with high functional demands. Recent tribology-focused analyses have emphasized that optimal bearing performance depends not only on material properties but also on precise acetabular orientation and restoration of joint biomechanics. A contemporary review on total hip arthroplasty tribology further demonstrated that modern bearing surfaces perform best when implanted within narrow positional tolerances, reinforcing the importance of accurate component placement across all surgical approaches [68].

Additionally, the transverse acetabular ligament (TAL), traditionally used for cup version guidance, may be difficult to visualize in minimally invasive anterior or mini-lateral approaches, reducing its reliability in these settings [69]. These findings emphasize that approach selection inherently carries implantation biases and that tailoring acetabular positioning to each patient’s anatomy is essential to avoid instability, impingement, or increased wear.

Femoral preparation also varies substantially between approaches. The posterior approach generally provides the most straightforward access to the femoral canal and accommodates a wide range of implant geometries. However, biomechanical analyses suggest that traditional non-collared stems may be more prone to rotational malalignment when inserted through posterior exposures in obese patients or in those with limited soft-tissue compliance [60]. This has contributed to the wider adoption of triple-collared or alignment-guided stems that offer improved rotational stability. Conversely, anterior-based approaches require controlled external rotation and traction for femoral elevation, increasing the risk of intraoperative fracture or soft-tissue strain, particularly in stiff hips or altered femoral morphology. The direct lateral approach represents an intermediate option: it allows adequate canal visualization while preserving posterior structures, though abductor handling may limit femoral elevation in muscular or high-BMI patients.

Finally, postoperative instability, rehabilitation protocols, and ERAS pathways further shape the discussion surrounding approach selection. While dislocation risk has historically been higher with posterior approaches, modern capsular repair techniques and larger femoral heads have significantly reduced this discrepancy, making stability increasingly dependent on component positioning and soft-tissue integrity rather than on approach alone. Early rehabilitation advantages with DAA have contributed to its integration in some ERAS protocols, although long-term functional outcomes remain comparable.

Overall, the evidence suggests that the debate surrounding surgical approach selection in THA persists not because of differences in long-term performance, but because each approach carries unique anatomical, technical, and biomechanical implications that influence surgical execution. Optimizing patient outcomes requires selecting the approach that best aligns with individual anatomy, surgeon experience, and reconstructive complexity.

Strengths and limitations

The primary strength of this systematic review lies in its broad scope and methodological rigor, incorporating both primary and revision THA studies and synthesizing evidence from randomized trials, prospective cohorts, and large registry databases. By evaluating approach-specific functional outcomes, complication patterns, and implantation-related technical considerations, the review provides a multidimensional perspective that reflects real-world surgical decision-making. An additional strength is the explicit assessment of risk of bias and the structured extraction of effect size measures, which enhances the transparency and interpretability of comparative findings.

However, several limitations must be acknowledged. First, substantial heterogeneity existed among the included studies with respect to patient selection, surgeon experience, implant design, and reporting standards. This variability constrained the ability to perform a complete pooled quantitative meta-analysis, particularly for complication rates, where definitions, follow-up duration, and denominators differed markedly across studies. Second, although subgroup analyses were attempted based on reported surgeon experience, inconsistent reporting in the source studies prevented a formal comparative evaluation. Third, publication bias could not be fully excluded given the predominance of high-volume academic centers in the available literature. Finally, minimally invasive and robotic-assisted variants were underrepresented in long-term comparative studies, limiting the generalizability of conclusions regarding newer technologies.

This review was not registered in PROSPERO, which may reduce transparency compared with registered protocols.

Clinical implications and future directions

The findings of this review highlight that surgical approach selection in THA should be guided less by theoretical superiority and more by patient-specific anatomical factors, comorbidity profiles, and surgeon expertise. The posterior approach remains indispensable in revision arthroplasty and complex reconstructions because it consistently allows adequate visualization for reconstruction in cases requiring more extensive access. Conversely, anterior-based minimally invasive techniques offer meaningful advantages in early recovery and soft-tissue preservation, provided they are performed within the surgeon’s established learning curve and applied to appropriately selected patients.

These results also underscore the need for heightened awareness of approach-specific implantation biases, particularly regarding acetabular orientation and femoral preparation. As tribological performance and long-term implant survivorship are critically influenced by component positioning, integrating patient-specific anatomy into preoperative planning is essential for minimizing instability, impingement, or accelerated wear.

Future research should prioritize high-quality prospective studies that directly compare surgical approaches using standardized outcome measures, uniform complication definitions, and rigorous reporting of surgeon experience. Randomized trials incorporating robotic assistance, computer navigation, and imaging-based planning hold particular promise for reducing variability in component positioning and clarifying whether technology can mitigate approach-dependent biases. Long-term follow-up of minimally invasive and technology-assisted approaches is especially needed to determine whether early functional benefits translate into improved survivorship.

In summary, contemporary evidence indicates that long-term functional equivalence among surgical approaches is achievable when techniques are executed with precision and individualized to patient anatomy. Thus, approach selection should remain flexible, evidence-based, and grounded in surgeon expertise rather than in a universal preference for any single technique.

Conclusion

This systematic review demonstrates that all major surgical approaches for total hip arthroplasty—posterior, direct lateral, and direct anterior—achieve similarly excellent long-term outcomes when performed by experienced surgeons. The direct anterior approach offers measurable early postoperative advantages, including faster recovery and reduced short-term pain, although these benefits are tempered by a learning curve and an increased incidence of transient lateral femoral cutaneous nerve symptoms. The direct lateral approach provides inherent stability and remains valuable in patients at high risk of dislocation, but may predispose to abductor weakness and superior gluteal nerve irritation.

The posterior approach, historically associated with instability, now achieves comparable stability when capsular repair is performed and continues to be the most commonly utilized route in revision THA because it provides reliable visualization and access for complex acetabular and femoral reconstruction. Ultimately, surgical approach selection should be individualized—guided by surgeon expertise, patient anatomy, and the specific reconstructive demands of each case—rather than by the perceived superiority of any single technique.

Future work should prioritize prospective comparative studies integrating robotic assistance, three-dimensional preoperative planning, and functional gait analysis to refine technique selection and enhance safety across minimally invasive and revision hip arthroplasty.

Author contributions

A.L.D. and R.E. conceived the study and designed the review protocol.E.G.P. and C.E.G. performed the literature search and data extraction.M.G.R. and D.E. contributed to data analysis and interpretation.A.L.D. drafted the initial manuscript.All authors reviewed, revised, and approved the final version of the manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

All data generated or analyzed during this systematic review are included in this published article and its supplementary information files.The full search strategy and PRISMA checklist are available as supplementary materials.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable. No individual personal data, images, or videos are included in this manuscript.

LLM use statement

Large Language Models (LLMs), including ChatGPT (OpenAI), were used exclusively to assist with language refinement and organization. All data extraction, interpretation, and scientific conclusions were performed entirely by the authors, who assume full responsibility for the content.

Competing interests

The authors declare no competing interests. This study is a systematic review and meta-analysis based exclusively on previously published data and did not involve the collection, analysis, or reporting of any new data from human participants or animals. As such, formal ethical approval and informed consent were not required.