Clinical and Safety Outcomes after Direct Anterior Total Hip Arthroplasty Compared with Conventional Approaches: A Systematic Review and Meta-Analysis.

Introduction: The direct anterior approach (DAA) is promoted as a muscle-sparing technique for primary total hip arthroplasty (THA), but comparative benefits and safety remain debated across settings and study designs. Materials and Methods: We performed a Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020-guided systematic review of PubMed, EMBASE, Scopus, Web of Science, MEDLINE, DOAJ, EBSCOhost, and SCIE from inception through 31 December 2023. We included comparative clinical studies of adults undergoing primary THA that directly compared DAA with posterior/posterolateral (and lateral, where available) approaches. Risk of bias was assessed using risk of bias 2 (RoB 2) for randomized trials and a ROBINS-I-aligned framework for observational studies. Random-effects meta-analysis (DerSimonian-Laird) was conducted when ≥2 studies reported comparable outcomes at aligned timepoints. Discussion: The search identified 2,548 records; after removing 632 duplicates, 1,916 records were screened and 178 full texts were assessed. Seven studies (1 randomized trial and 6 observational cohorts; 4,685 participants) met the inclusion criteria. For the primary pooled outcome (pain, Visual Analog Scale at 3 months; 2 studies; 437 participants), DAA showed lower pain versus comparator (mean difference [MD] -0.49, 95% confidence interval [CI] -0.66 to -0.32; I Conclusion: DAA may offer modest early improvements in pain and function after primary THA, with uncertain effects on operative efficiency outcomes that vary by context. Overall certainty of evidence is limited by few poolable studies, mixed designs, and residual confounding; further well-designed pragmatic randomized trials and standardized prospective cohorts are needed.