Likhitha Veerapalli

Background: Total hip arthroplasty (THA) is an effective intervention in treating a variety of hip pathologies, including osteoarthritis, avascular necrosis, and trauma. There are several common surgical approaches, including the direct anterior (DAA), posterolateral (PLA), and direct superior (DSA) approaches. As THA prevalence continues to increase, choosing the best surgical approach is critical to improving patient outcomes, recovery time, and complication rates. This review evaluates which surgical approach optimizes early outcomes following THA.

Methods: A literature review was conducted using PubMed and Google Scholar. Search terms included “total hip arthroplasty,” “approach,” “early outcomes,” and “prospective.” Studies were selected based on relevance and direct comparison of surgical approaches, with emphasis on both patient-reported and objective outcomes.

Results: Across studies, early postoperative outcomes were consistently emphasized when comparing surgical approaches in total hip arthroplasty. The DAA demonstrated superior early recovery metrics, including faster time to ambulation, reduced postoperative pain, and higher early Harris Hip Scores compared to PLA, although these advantages were most pronounced in the immediate postoperative period and diminished long-term^1,2. PLA was associated with comparatively slower postoperative healing, delayed mobilization, and greater soft tissue disruption, but remains widely utilized due to reliable exposure and surgeon familiarity. DSA demonstrated early postoperative outcomes that were comparable to the DAA and generally favorable compared to PLA, including improved early functional scores and reduced early recovery time, though available evidence remains limited and heterogeneous³. Despite these differences in early recovery, long-term functional outcomes—including Harris Hip Score, range of motion, complication rates, and patient-reported satisfaction—were generally comparable across all surgical approaches, with no technique consistently demonstrating superior long-term function or implant survivorship⁴.

Conclusion: Early postoperative recovery with DAA demonstrated faster initial recovery, and PLA showed comparatively slower early outcomes. The DSA appears to balance favorable early recovery with reduced soft tissue disruption, though evidence for this approach remains limited. Despite these early differences, long-term functional outcomes and complication rates are comparable across approaches, suggesting no single technique is universally superior. Surgical approach selection should be individualized based on the surgeon’s expertise, patient factors, and available technology.

Works Cited:

1. Christensen, J. C., Judd, D. L., Forster, J. E., O’Malley, S., Hinrichs‐Kinney, L., Hogan, C. A., Dayton, M. R., Christiansen, C. L., & Stevens‐Lapsley, J. E. (2025). Comparing Direct Anterior Approach Versus Posterolateral Approach in Total Hip Arthroplasty on Physical Function Recovery: A Prospective Cohort Study. Journal of Orthopaedic Research, 44(2). https://doi.org/10.1002/jor.70065
2. Sarhan, O., Megalla, M., Imam, N., Ren, A. N., Redfern, R. E., & Klein, G. R. (2024). Improved patient-reported outcomes with the direct anterior approach versus the posterior approach for total hip arthroplasty in the early post-operative period. Archives of Orthopaedic and Trauma Surgery, 144(5), 2373–2380. https://doi.org/10.1007/s00402-024-05271-z
3. F. Soler, J. Hernandez, J. M. Lamo-Espinosa, I. Khalil, and G. Mariscal, “Comparing posterior, anterior, and direct superior approaches in total hip arthroplasty: a network meta-analysis,” HIP International, Mar. 2026, doi: 10.1177/11207000261426222.
4. Wei, Z., Xu, Y., Zhu, W., Weng, X., & Feng, B. (2025). Direct superior approach versus posterolateral approach in mid-term clinical outcomes of total hip arthroplasty: a prospective randomized controlled study. BMC Musculoskeletal Disorders, 26(1). https://doi.org/10.1186/s12891-024-08271-7