Evaluation of Comparative Efficacy and Safety of Surgical Approaches

Original Investigation | Orthopedics
Evaluation of Comparative Efficacy and Safety of Surgical Approaches

for Total Hip Arthroplasty
A Systematic Review and Network Meta-analysis
Lei Yan, MD; Long Ge, PhD; Shengjie Dong, PhD; Kiran Saluja, PhD; Dijun Li, MD; K. Srikanth Reddy, PhD; Qi Wang, PhD; Liang Yao, PhD; Jiao Jiao Li, PhD;
Bruno Roza da Costa, PhD; Dan Xing, MD, PhD; Bin Wang, MD, PhD
Abstract Key Points

Question Which total hip arthroplasty
IMPORTANCE Each approach for primary total hip arthroplasty (THA) has a long learning curve, so
approach is associated with the best
a surgeon’s choice to change their preferred approach needs to be guided by clear justifications.
efficacy and acceptability?
However, current evidence does not suggest that any of the THA approaches are more beneficial
than others, and the choice of approach is mainly based on the knowledge and experience of the Findings In this systematic review and
surgeon and individual patient characteristics. meta-analysis of 63 randomized clinical
trials of surgical approaches for total hip
OBJECTIVE To assess the efficacy and safety associated with different surgical approaches for THA. arthroplasty with 4859 participants, all
surgical approaches except the direct
DATA SOURCES A comprehensive search of PubMed, EMBASE, and Cochrane databases from lateral approach were associated with
inception to March 26, 2022; reference lists of eligible trials; and related reviews. greater improvements of hip score when
compared with the posterior approach.
STUDY SELECTION Randomized clinical trials (RCTs) comparing different surgical approaches, The safety of different approaches did
including the 2-incision approach, direct anterior approach (DAA), direct lateral approach (DLA), not show significant differences.
minimally invasive direct lateral approach (MIS-DLA), minimally invasive anterolateral approach
Meaning These findings may support
(MIS-ALA), posterior approach (PA), minimally invasive posterior approach (MIS-PA), and
improved clinical decision-making
supercapsular percutaneously assisted total hip arthroplasty (SuperPath), for primary THA.
among health care professionals and
patients and also provide information
DATA EXTRACTION AND SYNTHESIS Following the Preferred Reporting Items for Systematic
for policy makers.
Reviews and Meta-Analyses, 2 reviewers independently extracted data on study participants,
interventions, and outcomes as well as assessed the risk of bias using the Cochrane risk of bias tool
and the certainty of evidence using the Grading of Recommendations, Assessment, Development, + Supplemental content
and Evaluation framework. A frequentist framework was used to inform a series of random-effects Author affiliations and article information are
network meta-analyses. listed at the end of this article.
MAIN OUTCOMES AND MEASURES The outcomes were hip score (range, 0-100, with higher
scores indicating better overall hip condition), pain score (range, 0-100, with higher scores indicating
more pain), hospitalization time, operation time, quality of life score, blood loss, cup abduction angle,
and cup anteversion angle.
RESULTS Of 2130 retrieved studies, 63 RCTs including 4859 participants (median [IQR] age, 64.0
[60.3-66.5] years; median [IQR] percentage male, 46.74% [38.64%-54.74%]) were eligible for
analysis. Eight surgical approaches were evaluated. For hip score, DAA (mean difference [MD], 4.04;
95% CI, 1.92 to 6.16; moderate certainty), MIS-ALA (MD, 3.00; 95% CI, 0.43 to 5.59; moderate
certainty), MIS-DLA (MD, 3.37; 95% CI, 1.05 to 5.68; moderate certainty), MIS-PA (MD, 4.46; 95% CI,
1.60 to 7.31; moderate certainty), PA (MD, 4.37; 95% CI, 1.87 to 6.88; high certainty), and SuperPath
(MD, 5.00; 95% CI, 0.58 to 9.42; high certainty) were associated with greater improvement in hip
(continued)
Open Access. This is an open access article distributed under the terms of the CC-BY License.
JAMA Network Open. 2023;6(1):e2253942. doi:10.1001/jamanetworkopen.2022.53942 (Reprinted) January 31, 2023 1/18
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JAMA Network Open | Orthopedics Comparative Efficacy and Safety Associate With Surgical Approaches for Total Hip Arthroplasty
Abstract (continued)
score compared with DLA. DLA was associated with lower decrease in pain score than SuperPath
(MD, 1.16; 95% CI, 0.13 to 2.20; high certainty) and MIS-DLA (MD, 0.90; 95% CI, 0.04 to 1.76;
moderate certainty). PA was associated with shorter operation times compared with 2-incision (MD,
−23.85 minutes; 95% CI, −36.60 to −11.10 minutes; high certainty), DAA (MD, −13.94 minutes; 95%
CI, −18.79 to −9.08 minutes; moderate certainty), DLA (MD, −10.50 minutes; 95% CI, −16.07 to −4.94
minutes; high certainty), MIS-ALA (MD, −6.76 minutes; 95% CI, −12.86 to −0.65 minutes; moderate
certainty), and SuperPath (MD, −13.91 minutes; 95% CI, −21.87 to −5.95 minutes; moderate
certainty). The incidence of 6 types of complications did not differ significantly between the
approaches.
CONCLUSIONS AND RELEVANCE In this study, moderate to high certainty evidence indicated that
compared with PA, all surgical approaches except DLA were associated with similar improvements
of hip score but longer operation time. DLA was associated with smaller improvement of hip score.
The safety of the different approaches did not show significant differences. These findings will help
health professionals and patients with better clinical decision-making and also provide references
for policy makers.
JAMA Network Open. 2023;6(1):e2253942. doi:10.1001/jamanetworkopen.2022.53942
Introduction
Total hip arthroplasty (THA), known as “the operation of the 21st century,”1 has shown great success
in relieving joint pain and disability2 and has been a procedure of choice for the treatment of
end-stage degenerative joint diseases and trauma.3,4 Kurtz et al5 noted a 50% increase in the
prevalence of THA in the United States from 1990 to 2002 and projected that the prevalence of total
hip replacement would increase from 208 600 in 2005 to 572 000 in 2030.6 Despite its high
success rate, surgeons continue to seek new treatment variations and perioperative options for THA
to further improve functional outcomes and shorten the length of hospital stay as well as to reduce
intrasurgical tissue damage.
The choice of operative approach can affect the efficacy and safety of THA.7 A variety of surgical
approaches can be used, including the 2-incision approach,8 direct anterior approach (DAA),9 direct
lateral approach (DLA),9 minimally invasive direct lateral approach (MIS-DLA),10 minimally invasive
anterolateral approach (MIS-ALA),11 posterior approach (PA),12 minimally invasive posterior approach
(MIS-PA),13 and supercapsular percutaneously assisted total hip arthroplasty (SuperPath).14 Among
them, DLA and PA are considered traditional approaches, while the other 6 are minimally invasive
approaches. The optimal surgical approach for THA remains inconclusive. According to the National
Institute for Health and Care Excellence 2020 guideline, current evidence does not suggest that any
of the THA approaches are more beneficial than others, and the choice of approach is mainly based
on the knowledge and experience of the surgeon and individual patient characteristics.15 Each
approach has a long learning curve, so a surgeon’s choice to change their preferred approach needs
to be guided by clear justifications.16-19
Most existing research compares only 2 approaches, and there is a lack of evidence for head-to-
head comparisons among all existing approaches for THA. Limited reviews have used rigorous
meta-analytical techniques to obtain quantitative estimates of the outcomes for different
approaches.20-22 The vague definitions of approaches in some studies can lead to classification errors
and hence inaccurate comparisons. In addition, existing meta-analyses have not assessed the
certainty or quality of evidence.23 Addressing these gaps, we performed a network meta-analysis of
randomized clinical trials (RCTs) to compare existing THA approaches of efficacy and safety through
comprehensive evidence synthesis of both direct and indirect comparisons. Patients who underwent

primary THA for any indication were included in this analysis, and the outcome time point was set as
the follow-up end point.
Methods
A multidisciplinary panel consisting of orthopedic surgeons, rehabilitation physicians, an
epidemiologist, a systems evaluation expert, and a statistician provided input into the study protocol.
We registered our protocol on the PROSPERO (CRD42020221715) and reported our study following
the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and
PRISMA-2020 guidelines and the extension statement for network meta-analysis
(PRISMA-NMA).24,25
Literature Review
EMBASE, Medline, and the Cochrane Library (from inception to February 23, 2020) were searched
to identify studies on surgical approaches in THA. We updated our search on March 26, 2022, to
include recent eligible trials. In addition, ClinicalTrials.gov was searched to identify additional studies
and unpublished data. The detailed search strategy is shown in eAppendix 1 in Supplement 1. All
relevant meta-analyses and systematic reviews retrieved during our searches were assessed to
identify potentially eligible studies. Articles were exported to Endnote X9 and duplicates were
removed, after which teams of paired reviewers (D.L. and another researcher) independently
screened the titles and abstracts of studies to identify those eligible for inclusion. The full text of
potentially eligible studies was evaluated according to the inclusion and exclusion criteria. A third
reviewer (L.Y.) was consulted to resolve any disagreements.
Selection Criteria
The inclusion criteria were (1) studies that included patients undergoing primary THA surgery for any
indication; (2) studies that compared at least 2 surgical approaches for THA, without restricting the
control group setting; (3) studies presenting any relevant outcome measures (eTable 1 in
Supplement 1), with no limitation on follow-up time points; and (4) articles written in English. Studies
that had abstract only or unavailable full text were excluded.
Data Extraction
Using standardized, pilot-tested forms, each eligible trial underwent duplicate data abstraction by a
pair of reviewers (D.L. and another researcher) working independently. Reviewers addressed
discrepancies through adjudication by a third reviewer (L.Y.). If a study reported outcomes at several
time points, the longest follow-up was used for analysis.
We collected information regarding patient characteristics (including age, sex, body mass index,
country, and follow-up time), surgery details (such as indications, expertise of surgeon, anesthetic
regimes, incision length, implants used, and rehabilitation protocols), and all reported outcome
measures (such as hip score change, pain score change, hospitalization time, operation time, blood
loss, quality of life [QOL] score change, cup abduction angle, and cup anteversion angle). The
definitions of these 8 outcomes and 24 other outcomes are shown in eTable 1 in Supplement 1. If
multiple instruments were used to measure the same outcome domain (such as hip score and pain
score), we collected data from the most commonly reported instrument across trials included in our
review. In addition, we used pain at rest rather than on movement if both were reported. For adverse
events reported in the included trials, we selected 6 as being the most important to patients:
dislocation, fracture, infection, nerve injury, reoperation, and thromboembolism (eTable 1 in
Supplement 1).

Statistical Analysis
Data Analysis and Synthesis
We converted hip score and pain score to a common scale on a domain-by-domain basis for better
clinical interpretability26: (1) hip score to Harris hip score (0-100), where higher scores represent
better outcomes, and (2) pain score to the 100-mm visual analogue scale, where higher scores
represent worse outcomes. Since the different scales of QOL used across included studies could not
be converted to a single scale, the Hedges method was used to calculate the standardized mean
difference (SMD) for the QOL. The mean difference (MD) was calculated for all other indicators
except QOL.
We used change scores from baseline rather than end-of-study scores to account for
interpatient variability. When authors reported data as measures before and after intervention, we
used methods outlined in the Cochrane Handbook to calculate MD and SD for change.27 When SDs
were missing, we estimated them from SEs, P values, confidence intervals, or graphs. If none of these
methods was feasible, we derived SDs from other studies included in our network meta-analysis
using a validated imputation technique (eAppendix 2A in Supplement 1).28
Network meta-analysis was performed using the frequentist model with a graph-theoretical
method by R version 4.1.2 package netmeta (version 2.1-0) (R Project for Statistical Computing). We
used the networkplot command of Stata version 16.0 (StataCorp) to draw the network plots.29 The
estimator was based on weighted least-square regression with the Moore-Penrose pseudoinverse
method.30 We conducted pairwise meta-analysis with DerSimonian-Laird random-effects model to
estimate the variance in heterogeneity between studies and to obtain direct evidence.31 League
tables of the relative treatment effect sizes were used to visualize comparisons of network
estimations. Global and local statistical heterogeneity was assessed with generalized Cochran Q.32 All
comparisons were 2-tailed using a threshold of P ⱕ .05.
We compared distributions of characteristics across study groups, organized by approaches, to
assess the transitivity assumption of indirect comparisons. Local inconsistency of direct and indirect
results was assessed with the node-splitting method for all comparison loops, and indirect results
were derived from direct and network results by the back-calculation method.33,34 The detailed
methods of multiple sensitivity analyses are presented in eAppendix 2B in Supplement 1, and the
detailed methods of publication bias assessments are presented in eAppendix 2C in Supplement 1.
We performed a network metaregression assuming a common coefficient across comparisons to
explore the associations of covariates of interest with each outcome.35 The change from protocol is
displayed in eAppendix 2D in Supplement 1.
Certainty of Evidence
We rated the certainty of evidence for each network estimate using the Grading of
Recommendations, Assessment, Development, and Evaluation (GRADE) framework, which classifies
evidence as high, moderate, low, or very low certainty. The starting point for certainty in direct
estimates for RCTs is high, but it could be rated down based on limitations due to risk of bias,
imprecision, inconsistency (heterogeneity), indirectness, and publication bias.23 The Cochrane
Collaboration Risk of Bias 1 (ROB-1) tool36 was used independently by 2 reviewers (D.L. and another
researcher) to evaluate the risk of bias of included studies (eTable 2 in Supplement 1). Additional
details of the GRADE assessment are presented in eAppendix 2E in Supplement 1.
Results
We identified 2130 potential studies from database searches, of which 63 studies8,9,11-13,37-92 were
eligible for inclusion (Figure 1). These studies were published between 2005 and 2021 (eAppendix 3
in Supplement 1).

Characteristics of Included Studies

The included studies were RCTs that involved a total of 4859 patients, with a median (IQR) age of 64.0
(60.3-66.5) years, median (IQR) body mass index (calculated as weight in kilograms divided by height
in meters squared) of 27.00 (25.58-28.27), median (IQR) percentage male of 46.74% (38.64%-54.74%)
and median (IQR) follow-up time of 1.0 (0.5-2.0) years (eTable 3A in Supplement 1). The detailed char-
acteristics of included studies are shown in eTables 3B, C, D, and E in Supplement 1. Regarding the learn-
ing curve, 31 studies9,11,37-40,43,46,47,49,51,52,56,61,64-69,71,72,75,81-83,86,89,91-93 (49.2%) showed relevant
information, with surgeons in 7 studies39,51,52,61,65,75,92 (11.1%) in the learning phase and surgeons in the
remaining 28 studies9,11,37,38,40,43,46,47,49,56,64,66-69,71,72,81-83,86,89,91,93 (38.1%) experienced (eTable 3C
in Supplement 1).
The categories and descriptions of these 8 surgical approaches for THA are displayed in
eAppendix 4 in Supplement 1, and the schematic showing the entrance location of the 8 approaches
is shown in eFigure 1 in Supplement 1. To eliminate inconsistencies caused by different naming
methods among included studies, we redefined the naming of 8 approaches with specific text
descriptions (eTable 4 in Supplement 1). The network plot for the 8 outcome measures is shown in
Figure 2. The network plots for all other outcomes are shown in eFigure 2 in Supplement 1. The
evaluation results of ROB-1 are shown in eFigure 3 and eTable 5 in Supplement 1.
Outcomes
The GRADE assessment results showed that imprecision was the most frequent reason for
downgrading certainty of evidence (eTable 6 and eFigure 4 in Supplement 1). League tables for
outcome measures appear in Figure 3, Figure 4, and eTable 7 in Supplement 1. A corresponding
metaregression analysis was also conducted (eTable 8 in Supplement 1). Heterogeneity (eTable 9 in
Supplement 1), intransitivity (eFigure 5 in Supplement 1), and inconsistency (eFigure 6 in
Supplement 1) of the network meta-analysis were evaluated. Most outcomes showed no significant
publication bias (eFigure 7 in Supplement 1), and the sensitivity analyses all proved consistent with
Figure 1. Study Flow Diagram of Study Selection Process
139 RCTs identified from previous 1954 Records identified through database searching
systematic review 604 The Cochrane Library
253 Embase
1097 PubMed
75 Duplicate records removed

64 Records after duplicates removed 1410 Records after duplicates removed
33 Records excluded for 1294 Records excluded for

not being relevant not being relevant
31 Full-text articles assessed for eligibility 116 Full-text articles assessed for eligibility
134 Records after duplicates removed
71 Full-text articles excluded

27 Not RCT
18 Not in English
2 Duplicate data
20 Not obtainable
1 Outdated literature
3 Trial protocols
63 Studies included in quantitative synthesis

RCT indicates randomized clinical trials.

the primary results (eTable 10 in Supplement 1). The heat map illustrates the incidence rate of the 6
complication types for the 8 approaches (eFigure 8 in Supplement 1).
Hip Score Change

A total of 50 studies9,12,37-39,41-53,56,57,59-64,66-69,71,73,75-86,89-92 (79%) with 3882 participants (80%)
reported on hip score change from baseline to end point (Figure 3 and Figure 5). Compared with
Figure 2. Network Plots Comparing Approaches in Primary Total Hip Arthroplasty for 8 Outcome Measures
Hip score change Pain score change

DLA MIS-ALA
DAA DLA
MIS-ALA
MIS-DLA
MIS-DLA
2-incision DAA
MIS-PA
MIS-PA SuperPath
SuperPath
PA PA
Hospitalization time Operation time

DLA DLA
DAA MIS-ALA DAA

MIS-ALA
MIS-DLA MIS-DLA
2-incision 2-incision
SuperPath MIS-PA SuperPath

MIS-PA
PA PA
QOL score change Blood loss

DLA DLA
MIS-ALA DAA MIS-ALA DAA
MIS-DLA MIS-DLA
SuperPath MIS-PA SuperPath

MIS-PA
PA PA
Cup abduction angle Cup anteversion angle

DLA DLA
The line width is proportional to the number of studies
MIS-ALA DAA MIS-ALA DAA
comparing each pair of treatments, and the size of
each node is proportional to the number of
participants (sample size). DAA indicates direct
MIS-DLA MIS-DLA anterior approach; DLA, direct lateral approach;
MIS-ALA, minimally invasive anterolateral approach;
MIS-DLA, minimally invasive direct lateral approach;
MIS-PA, minimally invasive posterior approach; PA,
SuperPath SuperPath posterior approach; QOL, quality of life; SuperPath,
MIS-PA MIS-PA
supercapsular percutaneously assisted total hip
PA PA arthroplasty.

DLA, DAA (MD, 4.04; 95% CI, 1.92-6.16; moderate certainty), MIS-ALA (MD, 3.00; 95% CI, 0.43-5.59;
moderate certainty), MIS-DLA (MD, 3.37; 95% CI, 1.05-5.68; moderate certainty), MIS-PA (MD, 4.46;
95% CI, 1.60-7.31; moderate certainty), PA (MD, 4.37; 95% CI, 1.87-6.88; high certainty), and
SuperPath (MD, 5.00; 95% CI, 0.58-9.42; high certainty) showed significant improvement in hip
score. However, no statistical differences were found between other approaches. Analysis of short-
and long-term follow-up results of hip score showed that SuperPath (MD, 6.72; 95% CI, 1.16-12.28)
and DAA (MD, 4.81; 95% CI, 0.42-9.19) were associated with better short-term results than PA, while
there were no statistical differences in the long-term result (eTable 7 in Supplement 1).
Figure 3. League Tables of Hip Score Change, Pain Score Change, Hospitalization Time, and Operation Time
Certainty of evidence
High Moderate Low Very low
Hip score change (1-100, mean difference)
–1.34 –5.38 –2.38 –2.01 –0.92 –1.01 –0.38

2-incision (–7.52 to (–11.72 to (–8.62 to (–8.40 to (–6.82 to (–7.14 to (–7.46 to
4.84) 0.96) 3.87) 4.37) 4.97) 5.13) 6.69)
–4.04 –1.04 –0.67 0.42 0.33 0.96
NA DAA (–6.16 to (–3.58 to (–3.02 to (–1.95 to (–1.71 to (–3.21 to
–1.92) 1.51) 1.68) 2.79) 2.38) 5.13)
Pain score change (1-100, mean difference)
–0.51 3.00 3.37 4.46 4.37 5.00

NA (–1.15 to DLA (0.43 to (1.05 to (1.60 to (1.87 to (0.58 to
0.14) 5.59) 5.68) 7.31) 6.88) 9.42)
–0.47 0.04 0.36 1.45 1.37 2.00
NA (–1.25 to (–0.69 to MIS-ALA (–2.20 to (–1.54 to (–1.23 to (–2.49 to
0.32) 0.77) 2.93) 4.45) 3.98) 6.48)
0.39 0.90 0.86 1.09 1.01 1.63
NA (–0.27 to (0.04 to (–0.04 to MIS-DLA (–1.92 to (–1.67 to (–2.89 to
1.06) 1.76) 1.77) 4.09) 3.69) 6.16)
–0.04 0.47 0.43 –0.43 –0.08 0.54
NA (–0.63 to (–0.37 to (–0.52 to (–1.20 to MIS-PA (–2.26 to (–3.56 to
0.56) 1.31) 1.38) 0.34) 2.10) 4.65)
0.16 0.67 0.63 –0.23 0.20 0.62
NA (–0.40 to (–0.12 to (–0.28 to (–0.98 to (–0.40 to PA (–3.09 to
0.73) 1.46) 1.54) 0.52) 0.80) 4.34)
0.66 1.16 1.12 0.26 0.69 0.49
NA (–0.21 to (0.13 to (–0.01 to (–0.74 to (–0.15 to (–0.21 to SuperPath
1.52) 2.20) 2.25) 1.26) 1.54) 1.19) The relative effect sizes are measured as a mean
difference along with 95% CIs. Bold indicates
Hospitalization time (days; mean difference) statistical significance. The color of each cell indicates
the certainty of evidence according to Grading of
–1.04 –0.45 –0.49 –0.81 0.01 –1.06 –2.37
2-incision (–2.41 to (–1.98 to (–2.06 to (–2.40 to (–1.22 to (-2.44 to (–4.04 to
Recommendations, Assessment, Development, and
0.33) 1.08) 1.08) 0.79) 1.24) 0.32) –0.70) Evaluation. The treatments are listed in alphabetical
9.92 0.59 0.55 0.24 1.05 –0.02 –1.33 order. Comparisons between treatments should be
(–3.10 to DAA (–0.24 to (–0.76 to (–0.75 to (0.26 to (–0.70 to (–2.54 to read from left to right and the estimate is in the cell in
22.93) 1.43) 1.87) 1.22) 1.84) 0.66) –0.11) common between the column-defining treatment and
Operation time (minutes; mean difference)
13.35 3.43 –0.04 –0.36 0.46 –0.61 –1.92 the row-defining treatment. For pain score change,
(0.09 to (–1.63 to DLA (–1.35 to (–1.33 to (–0.67 to (–1.68 to (–3.39 to
hospitalization time, and operation time, a mean
26.62) 8.50) 1.27) 0.61) 1.58) 0.45) –0.45)
difference lower than 0 favors the column-defining
17.10 7.18 3.75 –0.32 0.50 –0.57 –1.88
(3.89 to (1.01 to (–2.30 to MIS-ALA (–1.65 to (–0.94 to (–2.01 to (–3.62 to treatment. For hip score change, a mean difference
30.31) 13.35) 9.79) 1.01) 1.93) 0.86) –0.13) lower than 0 favors the row-defining treatment. In the
21.06 11.14 7.70 3.96 0.81 –0.26 –1.56 left lower half, a mean difference lower than 0 favors
(7.72 to (5.14 to (2.05 to (–2.33 to MIS-DLA (–0.42 to (–1.44 to (–3.11 to the column-defining treatment and in the upper right
34.39) 17.14) 13.36) 10.24) 2.04) 0.93) –0.01) half, a mean difference lower than 0 favors the
21.69 11.77 8.34 4.59 0.63 –1.07 –2.38 row-defining treatment. DAA indicates direct anterior
(9.92 to (5.72 to (1.68 to (–2.33 to (–6.16 to MIS-PA (–1.79 to (–3.55 to
approach; DLA, direct lateral approach; MIS-ALA,
33.46) 17.82) 14.99) 11.52) 7.42) –0.35) –1.20)
minimally invasive anterolateral approach; MIS-DLA,
23.85 13.94 10.50 6.76 2.80 2.17 –1.31
(11.10 to (9.08 to (4.94 to (0.65 to (–3.27 to (–3.21 to PA (–2.36 to minimally invasive direct lateral approach; MIS-PA,
36.60) 18.79) 16.07) 12.86) 8.87) 7.54) –0.25) minimally invasive posterior approach; NA, not
9.94 0.03 –3.41 –7.15 –11.11 –11.74 –13.91 applicable; PA, posterior approach; SuperPath,
(–4.66 to (–9.09 to (–12.93 to (–16.97 to (–20.88 to (–20.61 to (–21.87 to SuperPath supercapsular percutaneously assisted total hip
24.55) 9.15) 6.11) 2.66) –1.34) –2.88) –5.95)
arthroplasty.

Pain Score Change

A total of 26 studies9,11-13,43,49,53,55,57,59-61,63,66,67,75-77,83-86,90-93 (41%) with 1936 participants (40%)
reported on pain score change from baseline to endpoint (Figure 3 and Figure 5). DLA was associated
with a lower decrease in pain score than SuperPath (MD, 1.16; 95% CI, 0.13-2.20; high certainty) and
MIS-DLA (MD, 0.90; 95% CI, 0.04-1.76; moderate certainty).
Hospitalization Time
A total of 33 studies9,12,39,41-43,45-50,52,55,57,60-62,66,67,71-73,76,78,79,82,86,89,91-93 (52%) with 2702
participants (56%) reported on hospitalization time (Figure 3 and Figure 5). MIS-PA was associated
Figure 4. League Tables of Quality of Life Score Change, Blood Loss, Cup Abduction Angle,
and Cup Anteversion Angle
Certainty of evidence
High Moderate Low Very low
Quality of life score change (standardized mean difference)
0.17 0.16 0.50 0.92 0.21 0.42 0.58

0.97) 1.00) 1.36) 1.84) 0.85) 1.19) 1.54)
–1.27 –0.01 0.32 0.74 0.04 0.25 0.41
(–139.60 to DAA (–0.39 to (–0.24 to (0.19 to (–0.43 to (–0.20 to (–0.37 to
137.07) 0.37) 0.88) 1.29) 0.51) 0.69) 1.19)
–71.71 –70.44 0.33 0.75 0.05 0.26 0.42
Blood loss (milliliters; mean difference)
(–211.84 to (–122.54 to DLA (–0.18 to (0.11 to (–0.48 to (–0.22 to (–0.39 to

68.42) 18.34) 0.85) 1.39) 0.58) 0.74) 1.23)
83.83 85.10 155.54 0.42 –0.29 –0.07 0.09
(–52.03 to (8.30 to (78.99 to MIS-ALA (–0.31 to (–0.86 to (–0.58 to (–0.74 to
219.69) 161.90) 232.09) 1.15) 0.29) 0.43) 0.92)
79.50 80.77 151.21 –4.33 –0.70 –0.49 –0.33
(–59.35 to (16.09 to (86.19 to (–82.38 to MIS-DLA (–1.37 to (–1.10 to (–1.23 to
218.36) 145.45) 216.24) 73.73) –0.04) 0.11) 0.56)
67.63 68.90 139.34 –16.20 –11.87 0.21 0.37
(–58.58 to (0.33 to (65.66 to (–95.13 to (–81.33 to MIS-PA (–0.20 to (–0.33 to
193.85) 137.48) 213.03) 62.73) 57.59) 0.63) 1.08)
13.39 14.66 85.10 70.44 –66.12 –54.25 0.16
(–117.28 to (–41.38 to (21.54 to (–141.61 to (–129.71 to (–100.29 to PA (–0.53 to
144.06) 70.69) 148.65) 0.72) 2.52) –8.21) 0.85)
55.11 56.38 126.82 28.72 24.40 –12.53 41.72
(–86.95 (–27.26 to (38.24 to (–122.58 to (–112.05 to (–82.94 to (–21.60 to SuperPath
197.17) 140.01) 215.40) 65.14) 63.26) 57.89) 105.04)
Cup abduction angle (mean difference) The league tables show the relative effect sizes of each
approach, measured as a standardized mean
0.14 –0.33 –0.30 0.23 –0.37 –0.29 2.08
difference for quality of life score change and mean
6.96) 6.46) 6.19) 7.16) 6.50) 6.55) 9.42) difference for all other outcomes, along with 95% CIs.
–1.08 –0.47 –0.44 0.10 –0.51 –0.43 1.94 Bold indicates statistical significance. The color of each
(–10.46 to DAA (–2.38 to (–2.53 to (–2.57 to (2.21 to (–2.17 to (–1.23 to cell indicates the certainty of evidence according to
8.30) 1.43) 1.65) 2.76) 1.20) 1.31) 5.10) Grading of Recommendations, Assessment,
–2.08 –1.00 0.03 0.57 –0.03 0.05 2.41
Cup anteversion angle (mean difference)
Development, and Evaluation. Treatments are listed in

(–11.76 to (–5.63 to DLA (–1.98 to (–1.61 to (–2.29 to (–2.10 to (–1.02 to
alphabetical order. Comparisons between treatments
7.59) 3.63) 2.05) 2.75) 2.23) 2.19) 5.85)
should be read from left to right, and the estimate is in
–1.90 –0.82 0.18 0.53 –0.07 0.01 2.38
(–10.55 to (–4.44 to (–4.15 to MIS-ALA (–1.86 to (–2.30 to (–2.15 to (–1.06 to the cell in common between the column-defining
6.75) 2.80) 4.51) 2.93) 2.17) 2.17) 5.81) treatment and the row-defining treatment. For the
–0.90 0.18 1.18 1.00 –0.60 –0.52 1.84 quality of life score change, blood loss, and cup
(–11.28 to (–6.59 to (–5.99 to (–4.72 to MIS-DLA (–3.48 to (–3.32 to (–2.03 to abduction angle, a mean difference lower than 0
9.48) 6.95) 8.36) 6.72) 2.27) 2.27) 5.72) favors the column-defining treatment. For cup
–1.65 –0.57 0.43 0.25 –0.75 0.08 2.44 anteversion angle, a mean difference lower than 0
(–11.16 to (–3.18 to (–4.29 to (–3.69 to (–7.70 to MIS-PA (–1.54 to (–0.51 to
favors the row-defining treatment. DAA indicates
7.86) 2.04) 5.15) 4.20) 6.20) 1.70) 5.40)
direct anterior approach; DLA, direct lateral approach;
–1.75 –0.67 0.33 0.15 –0.85 –0.10 2.37
(–11.06 to (–3.15 to (–3.85 to (–3.30 to (–7.53 to (–2.49 to PA (–0.46 to MIS-ALA, minimally invasive anterolateral approach;
7.56) 1.81) 4.51) 3.60) 5.83) 2.29) 5.19) MIS-DLA, minimally invasive direct lateral approach;
–1.94 –0.86 0.14 –0.04 –1.04 –0.29 –0.19 MIS-PA, minimally invasive posterior approach; PA,
(–11.75 to (–4.67 to (–5.09 to (–4.66 to (–8.40 to (–3.73 to (–3.38 to SuperPath posterior approach; SuperPath, supercapsular
7.86) 2.95) 5.37) 4.57) 6.31) 3.15) 3.00) percutaneously assisted total hip arthroplasty.

with longer hospitalization time than PA (MD, 1.07 days; 95% CI, 0.35-1.79 days; moderate certainty).
SuperPath was associated with the shortest hospitalization time among all approaches.
Metaregression analysis showed that increased incision length and more recent year of publication
were associated with shorter hospitalization time (eTable 8 in Supplement 1).
Operation Time
A total of 45 studies9,12,13,38,39,41-44,47-50,52-61,63,64,66-68,70,72,73,76-83,88-91,93,94 (71%) with 3437
participants (71%) reported on operation time (Figure 3 and Figure 5). PA was associated with
showed shorter operation time compared with 2-incision (MD, −23.85 minutes; 95% CI, −36.60 to
−11.10 minutes; high certainty), DAA (MD, −13.94 minutes; 95% CI, −18.79 to −9.08 minutes;
moderate certainty), DLA (MD, −10.50 minutes; 95% CI, −16.07 to −4.94 minutes; high certainty),
MIS-ALA (MD, −6.76 minutes; 95% CI, −12.86 to −0.65 minutes; moderate certainty), and SuperPath
(MD, −13.91 minutes; 95% CI, −21.87 to −5.95 minutes; moderate certainty). Metaregression analysis
showed that more recent year of publication was associated with shorter operation time (eTable 8 in
Supplement 1).
QOL Score Change

A total of 21 studies9,11,12,37,38,47,48,51,57,61,71,72,75-77,84-86,90,92,93 (33%) with 1904 participants (31%)
reported on QOL score change from baseline to end point (Figure 4 and Figure 5). MIS-DLA was
associated with a higher QOL score change than DAA (SMD, 0.74; 95% CI, 0.19-1.29; high certainty),
DLA (SMD, 0.75; 95% CI, 0.11-1.39; high certainty), and MIS-PA (SMD, 0.70; 95% CI, 0.04-1.37; high
certainty). Metaregression analysis showed that increased incision length was associated with lower
QOL score (eTable 8 in Supplement 1).
Figure 5. Summary of Relative Effect Sizes for Outcomes of Total Hip Arthroplasty Approaches on 8 Outcomes
High or moderate certainty evidence Low or very low certainty evidence

Among the best Definitely better than PA May be better than PA
Intermediate-possibly better Possibly better than PA Might be better than PA
Intermediate-possibly worse Possibly no better than PA Might be no better than PA
Among the worst Definitely no better than PA May be no better than PA
Cup
Hip score Pain score Hospitalization Operation Quality of life Cup abduction
Blood loss anteversion
change change time time score change angle angle
MD (95% CI)
MD (95% CI) MD (95% CI) MD (95% CI) MD (95% CI) SMD (95% CI) MD (95% CI) MD (95% CI)
1.01 1.06 23.85 –0.42 13.39 0.29 –1.75

2-incision (–5.13 to NA (–0.32 to (11.10 to (–1.19 to (–117.28 to (–6.55 to (–11.06 to The certainty of evidence was rated by Grading of
7.14) 2.44) 36.60) 0.34) 144.06) 7.13) 7.56)
Recommendations, Assessment, Development, and
–0.33 0.16 0.02 13.94 0.25 14.66 0.43 –0.67 Evaluation criteria, including imprecision. Imprecision
DAA (–2.38 to (–0.40 to (–0.66 to (9.08 to (–0.69 to (–41.38 to (–1.31 to (–3.15 to was rated down only when the 95% CI crossed null
1.71) 0.73) 0.70) 18.79) 0.20) 70.69) 2.17) 1.81) effect. Approaches were categorized and certainty of
–4.37 0.67 0.61 10.50 –0.26 85.10 –0.05 0.33 evidence was rated in 1 of 2 ways: whether the
DLA (–6.88 to (–0.12 to (–0.45 to (4.94 to (–0.74 to (21.54 to (–2.19 to (–3.85 to intervention was clearly better or worse than the
–1.87) 1.46) 1.68) 16.07) 0.22) 148.65) 2.10) 4.51) posterior approach (PA; the mean effect size
exceeding or less than the null effect and the 95% CI
–1.37 0.63 0.57 6.76 0.07 –70.44 –0.01 0.15
MIS-ALA (–3.98 to (–0.28 to (–0.86 to (0.65 to (–0.43 to (–141.61 to (–2.17 to (–3.30 to not crossing the null effect threshold) or possibly
1.23) 1.54) 2.01) 12.86) 0.58) 0.72) 2.15) 3.60) better or worse than PA (the point estimate greater or
less than the null effect and the 95% CI crossing the
–1.01 –0.23 0.26 2.80 0.49 –66.12 0.52 –0.85
threshold). Bold text represents statistical significance.
MIS-DLA (–3.69 to (–0.98 to (–0.93 to (–3.27 to (–0.11 to (–129.71 to (–2.27 to (–7.53 to
1.67) 0.52) 1.44) 8.87) 1.10) -2.52) 3.32) 5.83) DAA indicates direct anterior approach; DLA, direct
lateral approach; MIS-ALA, minimally invasive
0.08 0.20 1.07 2.17 –0.21 –54.25 –0.08 –0.10 anterolateral approach; MIS-DLA, minimally invasive
MIS-PA (–2.10 to (–0.40 to (0.35 to (-3.21 to (–0.63 to (–100.29 to (–1.70 to –2.49 to
(-
2.26) 0.80) 1.79) 7.54) 0.20) –8.21) 1.54) 2.29)
direct lateral approach; MIS-PA, minimally invasive
posterior approach; MD, mean difference; NA, not
0.62 –0.49 –1.31 13.91 0.16 –41.72 2.37 0.19 available; SMD, standardized mean difference;
SuperPath (–3.09 to (–1.19 to (–2.36 to (5.95 to (–0.53 to (–105.04 to (–0.46 to (–3.00 to
SuperPath, supercapsular percutaneously assisted
4.34) 0.21) –0.25) 21.87) 0.85) 21.60) 5.19) 3.38)
total hip arthroplasty.

Blood Loss
A total of 33 studies9,12,13,38,39,41,45,47-54,56,57,59,60,63,64,66,70,71,73,76-79,82,83,88,91 (52%) with 2702
participants (56%) reported on blood loss (Figure 4 and Figure 5). DAA was associated with greater
blood loss than MIS-ALA (MD, 85.10 mL; 95% CI, 8.30-161.90 mL; high certainty), MIS-DLA (MD,
80.77 mL; 95% CI, 16.09-145.45 mL; high certainty), and MIS-PA (MD, 68.90 mL; 95% CI, 0.33-137.48
mL; high certainty). DLA was associated with greater blood loss than DAA (MD, 70.44 mL; 95% CI,
18.34-122.54 mL; high certainty), MIS-ALA (MD, 155.54 mL; 95% CI, 78.99-232.09 mL; high
certainty), MIS-DLA (MD, 151.21 mL; 95% CI, 86.19-212.24 mL; moderate certainty), MIS-PA (MD,
139.34 mL; 95% CI, 65.66-213.03 mL; high certainty), PA (MD, 85.10 mL; 95% CI, 21.54-148.65 mL;
high certainty), and SuperPath (MD, 126.82 mL, 95% CI, 38.24-215.40 mL; high certainty). PA was
associated with greater blood loss than MIS-DLA (MD, 66.12 mL; 95% CI, 2.52-129.71 mL; high
certainty) and MIS-PA (MD, 54.25 mL; 95% CI, 8.21-100.29 mL; high certainty).
Cup Abduction Angle and Cup Anteversion Angle

A total of 30 studies12,38,42,45,48,49,51-59,61,62,64,66,67,70,75,79,82,83,85,86,89,91,93 (48%) with 2364
participants (49%) reported on cup abduction angle, and 18 studies12,38,49,52-57,59,66,67,85,86,91,93
(26%) with 1392 participants (29%) reported on cup anteversion angle (Figure 4 and Figure 5). No
significant differences were found among the 8 approaches for cup abduction angle or cup
anteversion angle.
Discussion
In this study, 63 RCTs including 4859 patients were analyzed to compare 8 commonly used
approaches for primary THA. We found through moderate to high certainty evidence that PA was
associated greater improvement in hip score than DLA. All sensitivity analyses proved consistent
with the primary results. Regression analysis revealed a negative trend between publication year and
hospitalization time. Metaregression analysis also showed that a longer incision length was
associated with shorter hospitalization time and lower QOL score.
The high blood loss for DLA could be related to the amputation of the whole gluteus minimus
and gluteus medius muscles, which could also be the reason for the poor hip score and pain score
seen with this approach.37 The high incidence of nerve injury in DAA is mainly due to neurapraxia of
the lateral thigh cutaneous nerve,93,95,96 which is probably still underestimated97 due to the wide
anatomical variations in this nerve.98 Male gender and higher BMI are recognized factors for more
challenging DAA cases.99 Although nerve injury is a common complication of DAA,100,101 one
study102 showed it does not affect hip functionality. The longer operation time associated with DAA
might be caused by its greater learning curve, or generally the increased complexity of this approach,
as found in other studies.94,103,104 PA was associated with shorter operation time and more blood
loss in our analysis. This may be related to the cutoff of obturator internus, piriformis, gemellus
inferior, and gemellus superior muscles, providing the surgeon with a relatively large
operating space.38
D’Arrigo et al39 found that whether the surgeon was on a learning curve for DAA, MIS-DLA, and
MIS-ALA was associated with the operation time but not the efficacy and safety of THA. Moreover,
Pagnano et al105 reported a 14% complication rate and 5% reoperation rate for the 2-incision
approach that was not associated with the learning curve. Conversely, some researchers have
pointed out increased complication rates of DAA during the learning curve phase.17,106,107 In this
study, sensitivity analysis showed that whether the surgeon was in the learning phase or not did not
have a significant association with the results. These conflicting findings suggest that there is
controversy surrounding whether learning curves can affect surgical outcomes, and more high-
quality studies and meta-analyses are needed to resolve this in the future.
We recommend that experts who wish to conduct RCT studies related to THA approaches focus
more on minimally invasive approaches as well as compare 2 approaches that currently lack direct

comparison, such as DAA vs SuperPath. The outcome measures should ideally include the 8 patient-
important outcomes reported in our study. It is recommended that studies include patients with a
single indication (such as osteoarthritis) and that all procedures are performed by the same
experienced surgeon to improve the comparability of data. In addition, we recommend using the
same incision appearance to achieve double-blinding. Finally, we advise larger sample sizes and
longer follow-up periods to obtain more reliable long-term results.
Limitations
We also note several limitations in our study. First, publication bias was detected in some of the
outcomes, the consequences of which could be reduced by adequate retrieval. Second, the
heterogeneity of different implants and surgeon expertise across the included studies was not
accounted for in our analysis. Third, our analysis did not include the cost of each approach. Fourth,
some of the approaches lacked evidence for direct comparisons, which may have affected our
findings. The findings of our study should be interpreted with consideration given to these
limitations.
Conclusions
This systematic review and network meta-analysis provides important information for the choice of
surgical approach for primary THA. Moderate to high certainty evidence indicated that compared
with PA, all surgical approaches except DLA were associated with similar improvements in hip score
but longer operation time. DLA was associated with lower improvement in hip score and higher blood
loss. These findings will aid clinicians in balancing the risks and benefits of available approaches for
primary THA and provide key evidence for producing recommendations for clinical practice.
ARTICLE INFORMATION
Accepted for Publication: December 12, 2022.
Published: January 31, 2023. doi:10.1001/jamanetworkopen.2022.53942
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Yan L et al.
JAMA Network Open.
Corresponding Authors: Bin Wang, MD, PhD, Department of Orthopaedic Surgery, The First Affiliated Hospital,
Zhejiang University School of Medicine, Qingchun Road No. 79, Hangzhou, China ([email protected]); Dan
Xing, MD, PhD, Arthritis Clinic & Research Center, Peking University People’s Hospital, Peking University, Beijing,
China ([email protected]).
Author Affiliations: Department of Orthopaedic Surgery, The First Affiliated Hospital, Zhejiang University School
of Medicine, Hangzhou, China (Yan, B. Wang); Second Clinical Medical College, Shanxi Medical University, Taiyuan,
China (Yan, D. Li); Department of Orthopedics, The Second Hospital of Shanxi Medical University, Taiyuan, China
(Yan, D. Li); Evidence Based Social Science Research Centre, School of Public Health, Lanzhou University, Lanzhou,
China (Ge); Department of Social Medicine and Health Management, School of Public Health, Lanzhou University,
Lanzhou, China (Ge); Department of Health Research Methods, Evidence and Impact, McMaster University,
Hamilton, Ontario, Canada (Ge); Orthopedic Department, Yantaishan Hospital, Yantai, China (Dong); Bruyere
Research Institute, University of Ottawa, Ottawa, Ontario, Canada (Saluja); School of Epidemiology and Public
Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada (Reddy); World Health Organization,
Geneva, Switzerland (Reddy); Health Policy PhD Program and McMaster Health Forum, McMaster University,
Hamilton, Ontario, Canada (Q. Wang); Department of Health Research Methods, Evidence, and Impact, Faculty of
Health Sciences, McMaster University, Hamilton, Ontario, Canada (Q. Wang, Yao); School of Biomedical
Engineering, Faculty of Engineering and IT, University of Technology Sydney, Sydney, New South Wales, Australia
(J. J. Li); Institute of Health Policy, Management, and Evaluation, Department of Medicine, University of Toronto,
Toronto, Ontario, Canada (Roza da Costa); Applied Health Research Centre (AHRC), Li Ka Shing Knowledge
Institute of St Michael's Hospital, Toronto, Ontario, Canada (Roza da Costa); Arthritis Clinic & Research Center,
Peking University People’s Hospital, Peking University, Beijing, China (Xing).

Author Contributions: Drs B. Wang and Yan had full access to all of the data in the study and take responsibility for
the integrity of the data and the accuracy of the data analysis. Drs Yan and Ge contributed equally to the study. Drs
B. Wang and Xing share last authorship.
Concept and design: Yan, Ge, Dong, Yao, Xing, B. Wang.
Acquisition, analysis, or interpretation of data: Yan, Ge, Dong, Saluja, D. Li, Reddy, Q. Wang, J. Li, da Costa, B. Wang.
Drafting of the manuscript: Yan, Xing, B. Wang.
Critical revision of the manuscript for important intellectual content: Ge, Dong, Saluja, D. Li, Reddy, Q. Wang, Yao, J.
Li, da Costa, Xing, B. Wang.
Statistical analysis: Yan, Ge, Dong, D. Li, J. Li, Xing, B. Wang.
Obtained funding: Xing, B. Wang.
Administrative, technical, or material support: Reddy, J. Li, da Costa.
Supervision: Ge, Yao.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by the National Natural Science Foundation of China (grants
81802204 and 81973606) and by Zhejiang University School of Medicine, The First Affiliated Hospital’s
Foundation (grant G2022010-18), Alibaba Cloud, Zhejiang Medical and Health Science and Technology Project
(grant 2023RC010), and Natural Science Foundation of Zhejiang Province (grant LTGY23H060007).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and
decision to submit the manuscript for publication.
Data Sharing Statement: See Supplement 2.
Additional Contributions: We thank Weiya Zhang, PhD (Academic Rheumatology, University of Nottingham,
Nottingham UK), Cristián Mansilla, PhD (Department of Health Research Methods, Evidence, and Impact, Faculty
of Health Sciences, McMaster University, Hamilton, Ontario, Canada), and Tiago V. Pereira, PhD (Department of
Health Sciences, University of Leicester, Leicester, UK) for their suggestions to our manuscript. We thank Xiaoke Li,
MD (Shanxi Medical University), and Zijuan Fan, MD (Shanxi Medical University), for their help with cleaning data
and table preparation. None of these people were compensated for their work on the manuscript. Written
permission has been obtained for all names mentioned.
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SUPPLEMENT 1.
eTable 1. Definition of Outcomes
eTable 2. Classification of Individual Risk of Bias Items
eTable 3. Characteristics of Included Studies
eTable 4. Approach Name Redefinition of Articles Included
eTable 5. Risk of Bias Results and Judgment Basis for Each Article
eTable 6. Certainty of Evidence for Direct, Indirect, and Network Estimates
eTable 7. League Table for Outcome Measures
eTable 8. Results of Regression Analysis
eTable 9. Heterogeneity Assessments
eTable 10. Results of Sensitivity Analyses
eFigure 1. Schematic Showing the Entrance Location of the 8 Surgical Approaches for THA
eFigure 2. Network Plots for Other Outcome Measures
eFigure 3. Risk of Bias Assessments
eFigure 4. Contribution Matrices
eFigure 5. Intransitivity Assessments
eFigure 6. Inconsistency Assessments
eFigure 7. Publication Bias: Funnel Plot
eFigure 8. Incidence Rate (Sample Size) of 6 Complication Types
eAppendix 1. Search Strategy
eAppendix 2. Supplementary Methods
eAppendix 3. Reference List of Eligible Studies
eAppendix 4. Categories and Description of 8 Surgical Approaches in THA
SUPPLEMENT 2.
Data Sharing Statement

Evaluation of Comparative Efficacy and Safety of Surgical Approaches

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Original Investigation | Orthopedics

Evaluation of Comparative Efficacy and Safety of Surgical Approaches

Abstract Key Points

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JAMA Network Open. 2023;6(1):e2253942. doi:10.1001/jamanetworkopen.2022.53942

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Characteristics of Included Studies

Figure 1. Study Flow Diagram of Study Selection Process

75 Duplicate records removed

64 Records after duplicates removed 1410 Records after duplicates removed

33 Records excluded for 1294 Records excluded for

13 Duplicate records removed

134 Records after duplicates removed

71 Full-text articles excluded

63 Studies included in quantitative synthesis

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Hip Score Change

Hip score change Pain score change

Hospitalization time Operation time

DAA MIS-ALA DAA

SuperPath MIS-PA SuperPath

QOL score change Blood loss

MIS-ALA DAA MIS-ALA DAA

SuperPath MIS-PA SuperPath

Cup abduction angle Cup anteversion angle

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Hip score change (1-100, mean difference)

–1.34 –5.38 –2.38 –2.01 –0.92 –1.01 –0.38

–0.51 3.00 3.37 4.46 4.37 5.00

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Pain Score Change

Quality of life score change (standardized mean difference)

0.17 0.16 0.50 0.92 0.21 0.42 0.58

(–211.84 to (–122.54 to DLA (–0.18 to (0.11 to (–0.48 to (–0.22 to (–0.39 to

Development, and Evaluation. Treatments are listed in

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QOL Score Change

High or moderate certainty evidence Low or very low certainty evidence

1.01 1.06 23.85 –0.42 13.39 0.29 –1.75

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Cup Abduction Angle and Cup Anteversion Angle

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