To systematically evaluate the clinical outcomes of direct anterior approach (DAA), supercapsular percutaneously assisted total hip ( SuperPATH) approach (SPA) and posterolateral approach (PLA) for total hip arthroplasty (THA) in the treatment of hip diseases.

All the randomized controlled trial ( RCT) articles and observational research articles about the curative effect of THA through SuperPATH approach ( SPA) and direct anterior approach (DAA) versus posterolateral approach (PLA) for treatment of hip diseases that published at home and abroad from database establishing to October 2018 were retrieved from PubMed, Excerpt Medica Database (EMbase), China National Knowledge Infrastructure (CNKI), WanFang, China Science and Technology Journal Database (VIP) and other databases. Two researchers independently completed the article selection (excluding the comparison of THA without DAA, SPA and PLA, the total sample sizes were less than 30 cases, no mention of allocation method, blind method, non-Chinese or English literature), data extraction, and meta-analysis using RevMan 5.3 and indirect treatment comparison (ITC) software after evaluating the methodological quality of articles based on Cochrane risk bias assessment tool.

A total of 501 articles were initially detected, and six articles were included after strict screening, all of which were randomized controlled studies. A total of 478 subjects were included, including 241 in the experimental group and 237 in the control group. The meta-analysis results showed that there was no statistically significant difference in the incision length between the DAA and PLA [WMD= -1.30, 95%CI(-3.27, 0.67)]. The incision length in the SPA group was smaller than that in the PLA group [WMD=-7.07, 95%CI(-8.21, -5.93)]. There was no statistically significant difference in the operative time of THA in DAA [WMD=2.37, 95%CI(-30.19, 34.93)], SPA [WMD=12.26, 95%CI(-3.22, 27.74)] and PLA. There was no significant difference in intraoperative bleeding volume between DAA and PLA in THA [WMD=-37.70, 95%CI(-91.14, 15.75)]. Intraoperative bleeding in the SPA group was less than that in the PLA group [WMD=-171.56, 95%CI(-252.92, -90.20)]. In the DAA group [WMD=7.10, 95%CI (5.54, 8.66)] and SPA group [WMD=5.80, 95%CI (0.10, 11.50)], the Harris hip function score one month after surgery was higher than that in the PLA group. Indirect comparison of correction: the incision length of the DAA group was smaller than that of the SPA group [MD=5.77, 95%CI(3.94, 8.046)]. There was no statistically significant difference in operative time between the two groups [MD=-9.89, 95%CI(-45.943, 26.163)]. Intraoperative blood loss in the DAA group was lower than that in the SPA group [MD=133.86, 95%CI(36.79, 230.93)]. There was no statistically significant difference in Harris hip function scores one month after surgery between the two groups [MD=1.3, 95%CI (-4.61, 7.21)].

Among the three different approaches for the treatment of hip diseases, the hip function of DAA is better than PLA only after the operation. Other aspects may be related to the long DAA learning curve and the difficulty of proximal femur exposure, leading to no significant difference. The SPA is superior to the PLA in terms of incision length, intraoperative blood loss and postoperative hip function. While DAA and SPA are indirectly compared using PLA as control, DAA shows advantages in terms of incision length and intraoperative blood loss, but its medium-and long-term clinical efficacy still needs further studies and confirmation of more high-quality articles.