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

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. 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. 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. 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. 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.