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Direct anterior approach for total hip arthroplasty with patients in the lateral decubitus vs supine position: A systematic review and meta-analysis
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DOI：10.1016/j.jor.2026.04.002.png)
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Abstract
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Background: The direct anterior approach (DAA) for total hip arthroplasty (THA) is increasingly utilised due to its muscle-sparing nature and potential for accelerated recovery. Accurate component positioning and leg length restoration are critical to optimise outcomes and minimise complications. The DAA may be performed in either the supine (S-DAA) or lateral decubitus (L-DAA) position; however, the influence of patient positioning on clinical and radiographic outcomes remains uncertain. Methods: A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. PubMed, Embase, and Cochrane CENTRAL were searched from inception to September 2025 for comparative studies evaluating L-DAA versus S-DAA in adults undergoing primary THA. Risk of bias was assessed using ROB 2 for randomised trials and ROBINS-I for non-randomised studies. Random-effects meta-analyses were performed where appropriate. The protocol was registered on PROSPERO (CRD420251168168). Results: Five studies (one randomised controlled trial and four retrospective cohort studies) comprising 375 hips (189 L-DAA, 186 S-DAA) were included. Meta-analysis demonstrated no significant between-group differences in Harris Hip Score at one month (MD -0.39; 95% CI -1.41 to 0.63; I2 = 0%) or at final follow-up (MD -0.61; 95% CI -1.97 to 0.76; I2 = 15%). Length of stay was also similar (MD -0.30 days; 95% CI -1.09 to 0.48; I2 = 38%). Radiographic outcomes were synthesised descriptively due to heterogeneity, but final postoperative cup inclination and anteversion were broadly comparable. In fluoroscopy-guided cohorts, supine positioning demonstrated more consistent intra-operative measurement agreement, while lateral positioning facilitated femoral exposure and, in selected studies, was associated with shorter operative time and lower blood loss. Conclusion: Available comparative evidence suggests that S-DAA and L-DAA yield similar short-to mid-term functional outcomes after DAA THA. Supine positioning may offer advantages for fluoroscopic measurement reliability, whereas lateral positioning may improve femoral exposure and operative efficiency in selected settings.
Keywords:
Total hip arthroplasty
Direct anterior approach
Supine position
Lateral decubitus
Patient positioning
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