Evaluating the direct superior approach compared to the traditional posterior approach for hip arthroplasty: A systematic review and meta-analysis

Ralph Abdallah; Mauz Asghar; Sadek Jaber; Anthony Chalfoun; Ali Ghosn; Charbel Chaiban; Hadi Soukarieh; Ahmad Chokr; Maher Ghandour; Ümit Mert

doi:10.1016/j.jor.2025.05.062

Evaluating the direct superior approach compared to the traditional posterior approach for hip arthroplasty: A systematic review and meta-analysis

J Orthop. 2025 May 27:68:219-229. doi: 10.1016/j.jor.2025.05.062. eCollection 2025 Oct.

Authors

Ralph Abdallah¹, Mauz Asghar², Sadek Jaber^{3

4}, Anthony Chalfoun⁵, Ali Ghosn⁶, Charbel Chaiban⁶, Hadi Soukarieh⁴, Ahmad Chokr⁷, Maher Ghandour⁸, Ümit Mert⁸

Affiliations

¹ Faculty of Arts and Science, University of Toronto, Toronto, Canada.
² University of Saskatchewan College of Medicine, Saskatchewan, Canada.
³ Orthopaedic Surgery Department, University Hospital of Nimes, Nimes, France.
⁴ Orthopaedic Surgery Department, Lebanese University, Beirut, Lebanon.
⁵ Department of Orthopaedic Surgery, Saint Georges University Medical Center, Beirut, Lebanon.
⁶ Department of Orthopaedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon.
⁷ Department of Orthopaedic &Spine Surgery, Hospital Caritas Dominikus, Berlin, Germany.
⁸ Department of Trauma and Orthopaedic Surgery, Helios University Hospital Wuppertal, University of Witten/Herdecke, Wuppertal, Germany.

PMID: 40530325
PMCID: PMC12169778 (available on 2026-10-01)
DOI: 10.1016/j.jor.2025.05.062

Abstract

Background: The direct superior approach (DSA) has recently emerged as a minimally invasive substitute for the posterior approach (PA) in hip arthroplasty (HA), with the potential to provide better perioperative and functional outcomes. Nevertheless, the current evidence comparing the two approaches is limited and conflicting. Hence, we carried out this study to assess the DSA compared to PA in patients undergoing HA.

Methods: A comprehensive search, encompassing PubMed, Scopus, Web of Science, and Cochrane Library, was conducted from inception until April 2025. Studies that compare DSA to PA for patients undergoing HA were included. The primary outcome was the duration of hospital stay, while the secondary outcomes were incision length, functional outcomes, discharge, surgery revision rates, and complications. Mean difference (MD) with a 95 % confidence interval (C.I.) was employed for pooling the continuous variables, while the categorical data were analysed as risk ratio (RR) with a 95 % CI.

Results: Twelve studies, incorporating 147,098 patients, constituted our review. Our pooled estimate favored the DSA in decreasing the duration of hospital stay (MD = -0.95, 95 % CI [-1.32 to -0.57], p = 0.001), and shortening the incision length (MD = -5.16, 95 % CI [-6.48 to -3.85], p = 0.001) compared to the PA. Furthermore, DSA showed notably lower VAS pain scores (MD = -0.39, 95 % CI [-0.69 to -0.09], p = 0.01) and a reduced risk of discharge to rehabilitation (RR = 0.55, 95 % CI [0.40 to 0.75], p = 0.001). However, our pooled analysis did not detect significant differences between the two approaches regarding functional scores, such as HOOS subscales, HHS, OHS, WOMAC, revision rate, and complications.

Conclusion: DSA was associated with a lower hospital stay, shorter incision length, and lower VAS pain scores than the PA. Additionally, no substantial differences were detected regarding functional parameters or complications.

Keywords: Direct superior approach; Hip arthroplasty; Minimally invasive hip surgery; Posterior approach.

Publication types

Review