Comparative analysis of direct anterior approach versus posterior approach in primary total hip arthroplasty: evaluating minimum 5-year outcomes and clinical important thresholds
Author(s):Quesada-Jimenez R, Kingham YE, Kahana-Rojkind AH, Walsh EG, Domb BG.
DOI Link: 10.1177/11207000251349424
Background
The direct anterior approach (DAA) and posterior approach (PA) are commonly used in total hip arthroplasty (THA), with early literature suggesting potential advantages of the DAA. However, midterm comparative outcomes and clinically meaningful threshold achievement remain less well defined.
Methods
This Level 3 retrospective propensity-matched cohort study evaluated patients undergoing primary THA between 2009 and 2018 with minimum 5-year follow-up or documented endpoint. Patients were matched 1:1 based on age, sex, BMI, and use of robotic assistance. Outcomes included validated PROs, achievement of clinically relevant thresholds (MCID, PASS), complication rates, and revision surgery rates.
Key Findings
A total of 176 hips per group were analyzed.
Main findings:
- Both DAA and PA groups demonstrated significant and durable improvement across all PROs at midterm follow-up
- No significant differences in postoperative PROs between groups
- Comparable rates of MCID and PASS achievement in both cohorts
- The PA group demonstrated a significantly higher overall complication rate (P < .05)
- Revision rates were comparable between groups
Conclusion
At a minimum 5-year follow-up, both DAA and PA in THA provide equivalent functional outcomes and clinical threshold achievement. However, the DAA is associated with a lower complication rate, which may be a consideration in surgical approach selection.
What Does This Mean for Providers?
Both surgical approaches remain effective for achieving durable midterm outcomes in THA. While functional recovery and patient-reported outcomes are similar, the direct anterior approach may offer a modest safety advantage with fewer complications. Approach selection should therefore balance surgeon experience, patient anatomy, and complication risk profile rather than expected functional outcome differences alone.