‘Joint’ decision-making: how to determine the best approach for total hip arthroplasty

Osteoarthritis of the hip is a leading cause of chronic disability worldwide. Total hip arthroplasty reduces pain, increases mobility, and has very high patient-reported satisfaction rates postoperatively. Three of the common surgical techniques include the posterior approach, the direct lateral approach, and the direct anterior approach (DAA). The DAA is unique in that it utilises both an intermuscular and internervous plane; however, the procedure may come with drawbacks including a steeper surgical learning curve and increased risk of intraoperative fracture. The posterior approach is the most common technique with reports demonstrating shorter surgical times but greater dislocation rates. The direct lateral approach allows for greater exposure to the femur; however, it is associated with postoperative Trendelenburg gait. There remains no consensus among surgeons regarding the best technique or which outcomes are most important. Meta-analyses comparing these three techniques have mostly failed to determine the superiority of one over another, with the exception of one study supporting the direct lateral approach. There remains a need for more robust randomised controlled trials and a better defined standard for outcomes of interest in order to establish the most advantageous approach for both short- and long-term recovery, joint functionality, and pain reduction.