Short-term outcomes vary by surgical approach in total hip arthroplasty: a network meta-analysis

Abstract

The direct anterior approach (DAA) has increased in popularity in recent years. Proponents cite its muscle-sparing approach and purported reduction in pain and improvement in function when compared to the traditional surgical approaches. There remains controversy surrounding the validity of these claims. The objective of this study was to compare the common total hip surgical approaches in terms of pain scores, functional outcomes, opioid use and complications within the first 12weeks postoperatively. A network meta-analysis of randomized controlled trials (RCT) comparing postoperative outcomes of different surgical approaches in primary THA up to 12weeks was performed. PubMed, MEDLINE, Embase, Web of Science and SCOPUS were systematically searched from inception to May 2020. Outcomes included pain scores, functional outcome scores, length of stay (LOS), complications and opioid consumption. Twenty-five RCTs (n = 2339) were included. The DAA demonstrated statistically significant improvement in Harris Hip Scores at 6weeks when compared to the posterior and direct lateral approaches. The DAA reduced pain scores on postoperative day 2 and at 2weeks compared to the direct lateral approach. The anterolateral approach was found to have a significantly shorter LOS compared to the other major surgical approaches. The differences in functional outcomes or pain scores did not surpass conventional cutoffs for a minimal clinically important difference. The DAA led to functional improvements at 6weeks compared to the posterior and direct lateral approaches and reduced postoperative pain compared to the direct lateral approach. However, these improvements failed to reach clinical significance. All major surgical approaches led to large improvements in function by 12weeks with relatively low complication rates. Whether a short-term statistically significant improvement in function is sufficiently patient important to recommend DAA as a standard remains uncertain.