global uptake of the direct anterior approach for total hip arthroplasty
Over the past two decades, advances in surgical technology including specialised traction tables, fluoroscopic guidance and minimally invasive techniques have driven growing interest in the direct anterior approach (DAA) for total hip arthroplasty (THA). Adopters of the DAA have demonstrated comparable clinical outcomes, improved patient reported outcome measures (PROMs) and accelerated postoperative recovery compared to other established THA approaches. Despite a growing number of comparative publications on arthroplasty approaches, the global pattern and uptake of the anterior approach remains unknown and incomplete. Global adoption has been far from uniform internationally and there is no study in the literature reviewing the global uptake of the DAA. Our aim was to investigate the global uptake of the anterior approach in THA in order to analyse adoption across different countries and regions.
Methods: A multi-method analysis was undertaken, combining a review of national arthroplasty registry data and orthopaedic society reports; a systematic narrative literature review conducted in accordance with the Scale for the Assessment of Narrative Review Articles (SANRA), searching PubMed, MEDLINE, Embase and the Web of Science Core Collection from inception to June 2025 without language restriction; and semi-structured interviews with practising orthopaedic surgeons across multiple continents.
Results: Thirty-one registries were identified, but only seven reported data specific to the anterior approach. Adoption varied internationally, with reported DAA useage ranging from approximately 1 to 2% in the United Kingdom to 41% in the Netherlands and 53.7% in Switzerland, while surgeon surveys reported the uptake in the United States of America is 56.2%. Variation reflected differences in healthcare infrastructure, training pathways, registry participation, institutional preference and equipment access.
Conclusions: Global DAA adoption is highly uneven, and registry capture is inconsistent and incomplete. Standardised, complete registry data and a dedicated global survey of arthroplasty practice are needed to clarify uptake and inform clinical practice and healthcare policy.
