EXPOSURE APPROACH

This strength of recommendation was downgraded from strong to moderate for several reasons including the heterogeneity in the data, indirectness of comparative studies, and the potential for future research to alter the recommendation.

Several high-quality and three moderate-quality studies are included in this review. Each of the studies compares one specific approach against another. None of the studies compare multiple approaches. The definition of each approach was also not well defined in a majority of studies. Taunton (2014) indicated that direct anterior approach had significantly positive effects on Western Ontario McMaster Arthritis Index (WOMAC) Total scores and days discontinued all walking aids compared to the mini-posterior approach, but other high-quality papers by Barrett (2019), Parvizi (2016), and Xie (2017) suggests excellent results utilizing other approaches. There is no one definitive study comparing prospectively all approaches regarding activity, complications, and patient satisfaction.

Benefits/Harms of Implementation
Each surgical approach in total hip arthroplasty is associated with specific risks and benefits. Certain risks or benefits may be more associated with one approach over another. For example, a posterior approach is associated with an increased risk of dislocation and an anterior approach associated with an increased risk of wound complications. The decision to use a specific approach should be based on a surgeon’s training and experience with the approach and should be individualized to each patient. The decision to proceed with a particular approach should be made by each individual patient and surgeon after an informed decision-making process where the risks and benefits of each approach for that individual patient are discussed.

Outcome Importance
As the incidence and prevalence of osteoarthritis of the hip continues to rise, the number of total hip arthroplasty procedures performed is increasing as well.

Cost Effectiveness/Resource Utilization
No studies specifically addressed associated costs and resource utilization in a cost comparative approach. The approach in total hip arthroplasty does not incur any direct costs. Some approaches may be performed with special instrumentation or equipment that may be associated with an increase in cost. However, there is limited comparative data on the cost-effectiveness of the different approaches in total hip arthroplasty.

Acceptability
This recommendation should be readily implemented as it does not influence a major change in clinical practice. A variety of approaches are utilized in total hip arthroplasty.

Feasibility
All approaches to the hip are feasible for most surgeons. Thus, this recommendation should be easily implemented with no apparent barriers to adoption.

Future Research
Future studies level I prospective randomized controlled trials are needed to compare the different approaches in total hip arthroplasty. Future studies are also needed to establish differences in adverse events or clinical outcomes within certain subgroups and populations.