Early clinical efficacy and safety of different surgical approaches in total hip arthroplasty: a systematic review and network meta-analysis

The choice of surgical approach in total hip arthroplasty (THA) significantly influences early recovery and complication rates. However, comprehensive evidence comparing the efficacy and safety of multiple contemporary approaches remains limited. We conducted a systematic review and network meta-analysis of randomized controlled trials (RCTs) from PubMed, Cochrane Library, Embase, and Web of Science (inception to July 2025). We included 85 RCTs (6,575 patients) comparing 13 surgical approaches. Frequentist framework NMA was performed, with effects reported as mean differences (MD), standardized mean differences (SMD), or risk ratios (RR) with 95% confidence intervals. Treatment rankings were assessed using surface under the cumulative ranking curve (SUCRA) values. The analysis of 85 RCTs (6,575 patients) demonstrated distinct performance profiles among the 13 surgical approaches. For functional recovery, the ranking probabilities suggested that minimally invasive anterolateral approach (MIS-ALA) was most likely to achieve the best early postoperative HHS (SUCRA = 88.7%), while modified direct anterior approach (DAA-Modified) ranked highest for medium-to-long-term HHS (SUCRA = 97.8%). regarding surgical efficiency, the minimally invasive posterolateral approach (MIS-PLA) was associated with the highest probability of having the shortest operative time (SUCRA = 98.4%), whereas MIS-ALA had the highest SUCRA value for blood loss control (SUCRA = 90.9%). For surgical trauma, MIS-PLA had the highest SUCRA value indicating the potential for the smallest postoperative CK increase (SUCRA = 82.4%), while anterior approaches (DAA-Modified, bikini direct anterior approach (DAA-Bikini), direct anterior approach (DAA)) ranked highest for suppressing CRP elevation (SUCRAs: 88.2%, 83.4%, and 80.8%). DAA had the highest SUCRA value for walking speed recovery (SUCRA = 91.8%), and supercapsular percutaneously-assisted total hip (SuperPath) had the highest SUCRA value for the physical component summary score (SUCRA = 95.4%). Safety analysis revealed direct lateral approach (DLA) had the highest SUCRA value for the lowest complication risk (SUCRA = 92.9%), while DAA-Bikini had the highest adverse event incidence. THA surgical approaches present distinct efficacy-safety profiles with varying probabilities of advantage. Clinical selection should be individualized based on patient characteristics and surgical expertise, as no single approach is universally superior across all outcomes.