Use of Surgical Approach Is Not Associated With Instability After Primary Total Hip Arthroplasty

A Meta-Analysis Comparing Direct Anterior and Posterolateral Approaches

Elina Huerfano, MD; Maria Bautista, MD, MSc; Manuel Huerfano, MD, MSc; Juan M. Nossa, MD

J Am Acad Orthop Surg. 2021;29(22):e1126-e1140.

Conclusion

The present meta-analysis intended to summarize the best evidence available to date. According to these results, the dislocation rate after THA is not different between PA and DAA. Furthermore, we did not find notable differences in the rate of dislocation associated with cup positioning in the safe zone through either approach, and when surgical factors related with prosthetic hip instability were assessed and compared for each approach. It can be concluded that the selection of surgical approach has little influence in the development of this complication.

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Table 1. Study and Patient Characteristics of the Included Studies Comparing DAA With PA
Study ID	Study Type	Sample Size	Age (yr)	Sex, Male	BMI (kg/m²)	Outcomes	Follow-up Periods (wk)
Study ID	Study Type	DAA/PA (n)	DAA/PA (Mean or Median)	DAA/PA (%)	DAA/PA (Mean or Median)	Outcomes	Follow-up Periods (wk)
Aggarwal et al¹⁵	RCS	1,329/1,657	63.3/62.5	43.0/45.5	27.7/30.1	Postoperative dislocation	Minimum 96
Barrett and colleagues^4,14	RCT	43/44	61.4/63.2	67.4/43.1	30.7/29.1	Postoperative dislocation	6, 12, 24, 48, 240
						Acetabular cup positioning
						Lewinnek's safe zone
Cheng et al⁵	RCT	35/37	59/62.5	43.0/47	27.7/28.3	Postoperative dislocation	2, 6, 12
						Acetabular cup positioning
						Lewinnek's safe zone
Graves et al¹⁶	PCS	86/135	61/61	43/39	30/28	Postoperative dislocation	48
Hamilton et al¹⁷	RCS	100/100	62.5/61.1	36/39	28.8/29	Postoperative dislocation	Minimum 96
						Acetabular cup positioning
Hananouchi et al¹⁸	RCS	20/20	55.1/57.0	11.1/11.1	22.2/21	Postoperative dislocation	3, 48
						Acetabular cup positioning
						Lewinnek's safe zone
Malek et al¹⁹	RCS	265/183	70.8/70	44.1/46.9	28.5/29.0	Postoperative dislocation	Mean 72.4
Martin et al²⁰	RCS	41/47	63/57	35/45	28.5/34.1	Postoperative dislocation	6, 24
						Acetabular cup positioning
						LLD
Nakata et al²¹	RCS	99/96	62.9/65.6	16.1/13.5	22.9/23.3	Postoperative dislocation	8, 24
						Acetabular cup positioning
						Lewinnek's safe zone
Petis et al²²	PCS	40/38	66.9/66.7	37.5/36.8	27.9/28.2	Postoperative dislocation	12
Rathod et al²³	RCS	453/372	61.8/60.6	28.6/33.8	26.4/25.9	Postoperative dislocation	64/120
						Acetabular cup positioning
Rodriguez et al²⁴	PCS	60/60	60/59	46.6/43.3	27.0/28.0	Postoperative dislocation	2, 6, 12, 48
						Acetabular cup positioning
						Lewinnek's safe zone
						LLD
Schwartz et al²⁵	RCS	211/201	66.3/66.6	37.9/42.3	29.6/30.1	Postoperative dislocation	Minimum 12
						Acetabular cup positioning
Schweppe 2013²⁶	RCS	100/100	61/62	46/53	29.1/31.3	Postoperative dislocation	12
						Acetabular cup positioning
						Lewinnek's safe zone
						LLD
Spaans et al²⁷	RCS	46/46	69/68	52.1/30.4	25.0/29.0	Postoperative dislocation	6, 12, 24, 48
						Acetabular cup positioning
						LLD
Sugano et al²⁸	RCS	33/39	56/57	12.1/7.6	23.0/23.0	Postoperative dislocation	24, 96
						Acetabular cup positioning
						Lewinnek's safe zone
Taunton et al²⁹	RCT	27/27	62.05/66.4	40.4/48.1	27.7/29.2	Postoperative dislocation	12, 24, 48
Taunton et al³⁰	RCT	52/49	65/64	51/51	29.0/30.0	Postoperative dislocation	2, 8, 48
						Acetabular cup positioning
						Lewinnek's safe zone
Tripuraneni et al³¹	RCS	66/66	60.2/60.2	39.3/39.3	27.6/27.8	Postoperative dislocation	Minimum 12
						Acetabular cup positioning
						Lewinnek's safe zone
Zawadsky et al³²	RCS	50/50	60.8/56.0	44.0/28.0	28.6/27.9	Postoperative dislocation	2, 6
Zhao et al³³	RCT	60/60	64.88/62.18	40/44	24.35/25.58	Postoperative dislocation	12, 24
						Acetabular cup positioning
Bergin et al³⁴	PCS	29/28	68.8/65.1	34/50	26.3/27.8	Acetabular cup positioning	4
Nam et al³⁵	RCS	110/110	66.7/66.8	35.4/40.9	28.3/27.4	Acetabular cup positioning	6
						Lewinnek's safe zone
Nam et al³⁶	RCS	90/90	67.5/68.0	41.1/40	28.7/28.4	LLD	6
Poehling-Monaghan et al³⁷	RCS	126/96	64.8/63.9	46/54	30.0/30.5	Acetabular cup positioning	2, 8
						LLD

BMI = body mass index, DAA = direct anterior approach, LLD = leg length discrepancy, PA = posterolateral approach, PCS = prospective comparative study, RCS = retrospective comparative study, RCT = randomized controlled trial

Table 2. Methodological Quality Assessment for Risk of Bias in Nonrandomized Controlled Trials Included Studies
Study ID	Selection				Comparability	Outcome
Study ID	Representativeness of the Exposed Cohort	Selection of the Nonexposed Cohort	Ascertainment of Exposure	Demonstration That Outcome of Interest Was Not Present at the Start of the Study	Comparability of Cohorts on the Basis of the Design or Analysis	Assessment of Outcome	Was Follow-up Long Enough for Outcomes to Occur	Adequacy of Follow-up of Cohorts	Total Score
Graves et al¹⁶	1	1	1	1	1	1	1	0	7
Aggarwal et al¹⁵	1	1	1	1	2	1	1	1	9
Hamilton et al¹⁷	1	1	1	1	1	1	1	0	7
Hananouchi et al¹⁸	1	1	1	1	1	1	1	1	8
Malek et al¹⁹	1	1	1	1	2	1	0	1	8
Martin et al²⁰	1	1	1	1	1	1	0	1	7
Nakata et al²¹	1	1	1	1	2	1	0	1	8
Petis et al²²	1	1	1	1	2	1	0	1	8
Rathod et al²³	1	1	1	1	2	1	1	1	9
Rodriguez et al²⁴	1	1	1	1	2	1	1	1	9
Schwartz et al²⁵	1	1	1	1	2	1	0	0	7
Spaans et al²⁷	1	1	1	1	1	1	1	1	8
Sugano et al²⁸	1	1	1	1	1	1	1	1	8
Tripuraneni et al³¹	1	1	1	1	1	1	0	1	7
Zawadsky et al³²	1	1	1	1	1	1	0	1	7
Schweppe 2013²⁶	1	1	1	1	1	1	0	1	7
Bergin et al³⁴	1	1	1	1	1	1	1	1	8
Nam et al³⁵	1	1	1	1	1	1	1	1	8
Nam et al³⁶	1	1	1	1	1	1	1	1	8
Poehling-Monaghan et al³⁷	1	1	1	1	2	1	1	1	9