Comparison of intra and post-operative complication rates among surgical approaches in Total Hip Arthroplasty: A systematic review and meta-analysis

Various surgical approaches exist for Total Hip Arthroplasty (THA), but approach specific complication rates remain unknown. The purpose of this systematic review and meta-analysis was to compare rates of common complications between surgical approaches. Four electronic databases (Medline, Embase, AMED, Ovid Healthstar) were searched from inception to June 2019. Three pairs of reviewers were involved in determining eligibility, rating internal and external validity, and data extraction. Pooled estimates were generated using a random-effects model and relative risk (RR) was calculated for dislocation, intraoperative and early postoperative fracture, early infection, deep vein thrombosis (DVT), wound complication, and failure of implant ingrowth between four approaches (posterior, anterior, direct lateral, and anterolateral). Sixty-nine studies (n = 283,036) were included with nineteen randomized control trials, fourteen prospective cohort, and thirty-six retrospective cohort studies (included studies ranged from 1987 to 2019). When compared to the posterior approach, the risk for dislocation was significantly lower in the anterior (RR 0.66, 95% CI 0.54–0.77, p < 0.01), anterolateral (RR 0.50, 95% CI 0.32–0.77, p = 0.03) and lateral (RR 0.74, 95% CI 0.58–0.96, p = 0.02). When compared to the posterior approach, we found higher risk of loosening in the anterolateral (RR 1.89, 95% CI 1.59–2.25, p < 0.01) and lateral (RR 1.21, 95% CI 1.02–1.44, p = 0.03). Overall, evidence was deemed very low and low-quality following GRADE assessment. Our findings reveal that the posterior approach was associated with a higher risk of dislocation (compared to the anterior, lateral, and anterolateral) but lower risk of loosening (compared to the lateral and anterolateral approach). However, the large number of cohorts and imprecision due to low sample size for most pooled comparisons was still insufficient to confidently conclude that one approach is superior to another. Each approach has its own strengths and weaknesses, and surgeons can use the approach they are most comfortable with.