Adverse effects associated with the direct anterior approach for total hip arthroplasty: a Bayesian meta-analysis

The direct anterior approach (DAA) is an increasingly popular technique for performing total hip arthroplasty (THA). This muscle-sparing approach may yield functional benefits. However, DAA has been associated with an increased risk incidence (RI) of intra- and postoperative complications. A systematic review of the published literature was conducted to document the cumulative RI of intra- and postoperative complications, as well as the presence of a learning curve in subjects undergoing THA with a DAA. Study selection and data extraction were carried out independently in duplicate. A Bayesian zero-inflated random-effect model was used to calculate pooled estimates for the different endpoints. Thirty-eight studies (6485 patients) were analysed. RIs of 0.8 % [95 % confidence interval (CI): 0.4-1.6 %] and 0.5 % (95 % CI: 0.3-0.9 %) were found for intra-operative trochanter and femoral fractures, respectively, and of 0.9 % (95 CI: 0.3-2.6 %) for postoperative transient lateral cutaneous femoral nerve (LCFN) impairment. A clear RI for early revisions (2.1 %; 95 % CI: 1.4-2.8 %) and other surgical re-interventions (1.3 %; 95 % CI: 0.7-1.9 %) was present, but these values do not differ from reported RIs for THA overall. The RI for dislocation was low (0.6 %; 95 % CI: 0.4-0.9 %) compared with the reported literature. DAA is a technically demanding procedure, with outcomes possibly indicative of surgeon learning curve. A risk for intra-operative fractures and LCFN is evident, although the risk for other adverse effects is comparable to those with other approaches.