Robotic-assisted total hip arthroplasty using the direct anterior approach: A systematic review and meta-analysis

Hassaan Abdel Khalik; Syed Mustafa Nadeem; Michelle Cruickshank; Brian P. Chalmers; Brent Lanting; Thomas J. Wood

doi:10.1016/j.jor.2025.10.020

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71 (); 136-144

doi:

10.1016/j.jor.2025.10.020

Robotic-assisted total hip arthroplasty using the direct anterior approach: A systematic review and meta-analysis

Hassaan Abdel Khalik^a,, Syed Mustafa Nadeem^b, Michelle Cruickshank^b, Brian P. Chalmers^c, Brent Lanting^d, Thomas J. Wood^a

a Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada

b Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada

c Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA

d Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London Health Sciences Centre, University Hospital, London, Ontario, Canada

⁎Corresponding author: Hassaan Abdel Khalik. Hassaan.abdel-khalik@medportal.ca

Received: 2025-9-5, Accepted: 2025-10-26, Published: 2025-10-28

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

While several prior reviews have attempted to assess outcomes of robotic-assisted total hip arthroplasty (RA-THA) compared to manual technique, their findings lack generalizability due to several surgical techniques concurrently assessed. Therefore, the purpose of this study was to assess radiographic, clinical and patient reported outcomes following robotic-assisted total hip arthroplasty using the direct anterior approach.

MEDLINE, EMBASE and CENTRAL were searched from inception to March 8, 2025 for comparative studies comparing outcomes for RA-THA using the DAA compared to manual total hip arthroplasty (M-THA). Eligible levels of evidence were I to III. Intraoperative, radiographic, patient-reported outcomes (PROs) as well complications/reoperations were assessed. Meta-analysis was performed on outcomes reported across a minimum of three studies.

Twelve comparative studies (9938 hips) were included for analysis. Most RA-THAs were performed using the MAKO (76 %). Operative time was 14.92 min shorter in the M-THA group (p < 0.00001). Acetabular anteversion was 1.87° less in the RA-THA group (p = 0.0002), with meta-analysis demonstrating no significant differences across acetabular inclination or leg length discrepancy. Patient reported outcomes mostly demonstrated no significant differences across groups. RA-THA demonstrated a non-significant 43 % reduction in overall complications (p = 0.28), but a 75 % significant reduction in reoperations (p = 0.02).

RA-THA using the DAA does not lead to clinically significant improvements in acetabular component positioning, with potentially reduced rates of reoperations compared to M-THA. A notable disadvantage of RA-THA was prolonged operative time. Benefits in PROs were lacking with the strength of findings being limited by low levels of evidence and heterogenous instruments. Future high-quality trials with appropriately selected radiographic and patient reported outcomes are warranted. Clinically relevant outcomes to consider include the attainment of preoperative target component positioning, restoration of native patient biomechanics, as well as robot-specific complications.

III.

Keywords

Total hip arthroplasty

Direct anterior approach

Robotic-assisted

Total joint arthroplasty

Robotics

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1 Introduction

Total hip arthroplasty (THA) is a widely performed surgery for end-stage hip osteoarthritis, successfully improving function and relieving pain.¹ One of the primary goals of THA is restoring native hip biomechanics, achieved through proper component positioning, hip length, and hip offset.² While technical advancements in manual total hip arthroplasty (M-THA) have been made, accurate implant positioning remains a challenge.¹ Importantly, malpositioned implants in THA are a well-established risk factor for complications such as postoperative dislocations and revision surgery.³ Over the last decade, robotic-assisted total hip arthroplasty (RA-THA) has increased in popularity due to optimizing preoperative planning, improving the accuracy of implant positioning and reducing reoperation risk.^4–6 Furthermore, there has been an increase in public interest in RA-THA driven in part by patient perceptions of improved surgical accuracy, reduced complications, and enhanced recovery.⁷^,⁸

Several studies have demonstrated improved radiographic outcomes in favor of RA-THA.⁹ Moreover, accurate implant placement has been associated with a lower risk of dislocations, impingement, edge loading and leg length discrepancy.¹^,³ However, RA-THA's clinical benefits over the traditional M-THA remains debated, with limited evidence suggesting improvements in patient reported outcomes.⁵ Further, drawbacks of RA-THA include longer operative times, increased cost, as well as increased patient radiation exposure due to the use of preoperative computed-tomography scans in many image-based systems.¹^,¹⁰ Though several systematic reviews have sought to assess the efficacy of RA-THA over conventional technique, their generalizability is limited by the heterogeneity of surgical exposures utilized by included studies.⁴^,⁹^,¹¹ Of particular interest is the increasingly popular direct anterior approach (DAA).¹² While the DAA offers several benefits, such as reduced postoperative pain, faster functional recovery, and preservation of muscle tissue,¹³^,¹⁴ possible disadvantages include increased intraoperative radiation exposure, a higher risk of periprosthetic fractures, and potential injury to the lateral femoral cutaneous nerve.¹³^,¹⁵^,¹⁶

Therefore, the primary objective of this study was to compare RA-THA to M-THA performed via the DAA in terms of intraoperative, radiographic, and patient-reported outcomes as well as complications/reoperations. By focusing exclusively on the DAA, an increasingly adopted surgical approach, this study maximizes the external validity of findings across the population of interest. To our knowledge, there have been no systematic reviews or meta-analyses directly comparing RA-THA to conventional M-THA using the DAA.

2 Methods

This review was performed according to the guidelines set out the Cochrane handbook and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA).¹⁷^,¹⁸ No institutional review board (IRB) approval was required.

2.1

2.1 Comprehensive search strategy

Three electronic databases, MEDLINE, EMBASE and CENTRAL, were searched from database inception to March 8, 2025 for literature regarding RA-THA using the direct anterior approach. The search terms included “robotic-assisted”, “robotic-arm” and “total hip arthroplasty” (Supplemental Digital Content (SDC) Table 1).

Table 1 Study overview.

						Robotic Group				Manual Group
Author (Year)	Recruitment Period	Country	Study Design (LOE)	Follow-up, months	Robot Assessed	Total sample size, n hip	Mean age	Mean BMI	Mean Women, %	Total sample size, n hip	Mean age	Mean BMI	Mean Women, %	MINORS
Bendich et al. (2024)⁴	2016–2020	United States	Retrospective Cohort (III)	12	MAKO	226	64.5	26.1	56.6	2200	64.5	26.8	60.9	20
Buchan et al. (2023)-a¹⁵	April 2021–July 2022	United States	Retrospective Cohort (III)	N/A	ROSA	100	60.1	29.5	46	100	60.1	29	53	22
Buchan et al. (2023)-b²³	March 2021–July 2022	United States	Retrospective Cohort (III)	1.5	ROSA	107	60.5	29.8	47	107	60	29.1	53	22
Buchan et al. (2023)-c²⁴	March 2021–July 2022	United States	Retrospective Cohort (III)	1.5	ROSA	98	60.5	29.6	46.9	100	60.5	29.2	53	22
Buchan et al. (2024)-a²⁵	March 2021–July 2022	United States	Retrospective Cohort (III)	3	ROSA	107	60.5	29.8	46.7	105	59.9	29.1	52.4	22
Buchan et al. (2024)-b²⁶	September 2021–July 2022	United States	Retrospective Cohort (III)	12	ROSA	85	59.9	29.9	44	91	58.7	28.9	55	20
Foissey et al. (2023)²⁷	January 2015–December 2019	France	Retrospective Cohort (III)	12	MAKO	50	66.5	26.9	46	100	68	27.1	66	20
Incesoy et al. (2024)²⁸	October 2000–May 2022	Turkey	Retrospective Cohort (III)	12	MAKO	82	58.66	28.04	59	82	58.03	29.12	60	23
Lu et al. (2024)²⁹	March 2021–December 2021	China	Randomized Control Trial (I)	6	TRex-RS	72	58.14	25.18	51.39	73	55.26	25.28	39.73	N/A
Neitzke et al. (2024)³⁰	February 2016–August 2023	United States	Retrospective Cohort (III)	N/A	MAKO	1158	66	26.1	62	4333	64	26.3	65	20
Rogers et al. (2024)³¹	February 2019–November 2020	United States	Prospective Cohort (II)	12	MAKO	214	66.6	27.6^a	61.2	148	66	28.5^a	63.5	20
Stewart et al. (2022)³²	July 2014–March 2017	United States	Retrospective Cohort (III)	N/A	MAKO	100	62.2	29.6	54	100	58.7	30.9	60	19

a Median.

Inclusion criteria was as follows: (1) assessing RA-THA utilizing the direct anterior approach, (2) comparative study design with manual THA as the control group, (3) levels of evidence (LOE) I to III, (4) minimum of 5 hip per case series, (5) reporting on patient reported outcomes, objectives outcomes, intraoperative outcomes, radiologic outcomes or complications/reoperations, and (6) published in the English language. Manual THA included surgeries performed with or without the use of intraoperative fluoroscopy. Exclusion criteria included: (1) utilization of navigation-assistance, (2) cadaveric studies, and (3) biomechanical studies.

2.2

2.2 Study screening

Two authors (XX & XX) independently screened the titles and abstracts of the identified studies. Disagreements were automatically advanced to the full-text review stage to prevent any premature exclusions. If needed, the senior author (XX) resolved any full-text disagreement.

2.3

2.3 Assessment of study quality

Two authors (XX and XX) independently assessed the quality studies with conflicts resolved through consensus and/or discussion with a senior author (XX). The quality of observational studies was assessed using the Methodological Index for Non-randomized Studies (MINORS) questionnaire.¹⁹ Randomized controlled trials (RCTs) were assessed using the Cochrane Risk of Bias-2 tool with final decisions visualized using the robvis tool.²⁰^,²¹

2.4

2.4 Data abstraction from included studies

Two authors (XX and XX) independently abstracted data from half of the included studies with into a Google Sheets spreadsheet designed a priori (Google LLC, Mountain View, CA, USA), with the accuracy of data reviewed by a senior author (XX). Data abstracted included study characteristics, patient demographics, robot manufacturer as well objective and subjective outcomes. Levels of evidence were determined based on the Journal of Bone and Joint Surgery guidelines.²² In cases where multiple studies used the same sample of patients, overlapping outcomes were abstracted from the study with the more recent publication.

2.5

2.5 Outcomes

Eligible outcomes assessed by this review included subjective patient reported outcomes (PROs) using validated instruments, operative time, postoperative radiographic outcomes, as well as postoperative clinical outcomes. More specifically, eligible radiographic outcomes included acetabular component positioning (e.g. acetabular inclination and anteversion) as well as leg length discrepancy. Postoperative clinical outcomes included complications and reoperations.

2.6

2.6 Data analyses

Patient demographics were presented as pooled means and ranges. Pairwise meta-analyses were performed on all outcomes reported across a minimum of three studies using a Der-Simonian and Laird random effects model (Review Manager RevMan 5.3, Copenhagen, Denmark). Continuous outcomes were pooled using mean differences while dichotomous outcomes were pooled using risk ratios (e.g. relative risk). Heterogeneity was quantified using the χ2 test for heterogeneity and the I² statistic. Outcomes not eligible for meta-analysis were presented in a narrative fashion.

3 Results

3.1

3.1 Study characteristics and quality

The search strategy initially identified 1532 studies, with 876 remaining after exclusion of duplicates, and 12 included in the final analysis (Fig. 1).⁴^,¹⁵^,^23–32 The MINORS score for non-RCTs was 20.9 ± 1.3, indicating high quality (SDC Table 2). Risk of bias assessment for the sole RCT had an overall assessment of “some concern” secondary to concerns regarding the selection of reported results (SDC Fig. 1).

Table 2 Intraoperative outcomes.

Study	Robotic Group		Conventional Group		P-value
Study	n	Mean ± SD	n	Mean ± SD	P-value
Operative Time, minutes
Buchan et al. (2023)-c²⁴	98	101.2 ± 12.7	100	101.2 ± 19.8	0.982
Foissey et al. (2023)²⁷	50	112.1 ± 21.9	100	93.1 ± 14.9R: 60–166	<0.0001
Lu et al. (2024)²⁹	72	106.71 ± 25.22	73	79.42 ± 16.16	<0.001
Neitzke et al. (2024)³⁰	1158	105.2 ± 24.0	4333	90.6 ± 23.9	<0.001
Rogers et al. (2024)³¹	214	114∗∗IQR: 104-125	148	101∗∗IQR: 92-111	<0.001
Estimated Blood Loss, mL
Incesoy et al. (2024)²⁸	82	1278.17 ± 575.38	82	970.61 ± 485.7	<0.0001
Fluoroscopy Dose (mGy)
Buchan et al. (2023)-a¹⁵	100	3 ± 1.4	100	1 ± 0.8	<0.001
Neitzke et al. (2024)³⁰	1158	0.4 ± 0.6	4333	2.5 ± 2.5	<0.001
Fluoroscopy Time (seconds)
Buchan et al. (2023)-a¹⁵	100	18.8 ± 5.9	100	6.3 ± 3.5	<0.001
Neitzke et al. (2024)³⁰	1158	4.3 ± 5.6	4333	21.8 ± 39.4	<0.001
Fluoroscopic Images, n
Buchan et al. (2023)-a¹⁵	100	7.5 ± 1.9	100	4.3 ± 1.3	<0.001

A total of 9938 hips were eligible for analysis, with 2399 hips (24 %) comprising the RA-THA group, and 7539 hip (76 %) comprising the M-THA group. In the RA-THA group, the mean age of patients was 64.1 years with 57.1 % of patients being women and mean BMI of 27.1. In the M-THA group, the mean age of patients was 63.7 years with 63 % of patients being women and mean BMI of 26.7. Of the M-THA control groups, nine studies explicitly reported the use of intraoperative fluoroscopy,⁴^,¹⁵^,^23–27^,³⁰^,³² two did not specify its use,²⁸^,²⁹ and one explicitly stated that intraoperative fluoroscopy was not used.³¹ The most commonly represented robot was the MAKO by Stryker (n = 1830 hips; 76 %), followed by the ROSA by Zimmer Biomet (n = 497 hips; 21 %) and the TRex-RS by Longwell Corp. (n = 72 hips; 3.0 %).

3.2

3.2 Intraoperative outcomes

Meta-analyses performed across four eligible studies demonstrated a significantly shorter operative time by 14.92 min in favor M-THA (95 %CI 5.70,24.15; p < 0.00001) (SDC Fig. 2).²⁴^,²⁷^,²⁹^,³⁰ Conflicting results were presented pertaining to intraoperative fluoroscopy dosage and duration. While Neitzke et al., which used the MAKO robot, demonstrated significant reductions in both fluoroscopy dosage and duration,³⁰ Buchanan et al.’s study, which used the ROSA robot, demonstrated the opposite (Table 2). Finally, Incesoy et al. demonstrated significantly higher estimated blood loss in the RA-THA group relative to the M-THA group.²⁸

Forest plot of complications meta-analysis.

3.3

3.3 Radiographic outcomes

Meta-analysis across four eligible studies reporting acetabular anteversion demonstrated a significant difference of −1.87° in favor of the RA-THA group (95 %CI -2.85, −0.89; p = 0.0002) (SDC Fig. 3).²⁴^,^27–29 Meta-analysis demonstrated no significant difference in acetabular inclination across four eligible studies (SDC Fig. 4),²⁴^,^27–29 as well as no significant different in leg length discrepancy across three eligible studies (SDC Fig. 5).^27–29 Additional radiographic outcomes assessed included postoperative anteversion relative to target,³² changes in acetabular, femoral and global offset,²⁷^,³² as well as lateral offset,²⁸ none of which demonstrated significant findings across groups (Table 3). Notably, Stewart et al. demonstrated significantly less deviation from target acetabular inclination in the RA-THA group (p = 0.007).³² Stewart et al. also assessed the frequency of acetabular components positioned in the Lewinnek safe zones and found no significant difference in the rates of acetabular inclination, anteversion, or both being in the safe zone.³² Conversely, Buchanan et al. demonstrated higher rates of combined anteversion and inclination being in the Lewinnek safe zone in favor of RA-THA relative to M-THA (81.6 vs 59 %, p < 0.001).²⁴

Forest plot of reoperations meta-analysis.

Table 3 Radiographic outcomes.

Study	Robotic Group		Conventional Group
Study	n	Mean ± SD	n	Mean ± SD	P-value
Cup Anteversion, °
Buchan et al. (2023)-c²⁴	98	18.5 ± 5.1	100	21.7 ± 6.7	<0.001
Foissey et al. (2023)²⁷	50	23.4 ± 3.5R: 14.3–30.9	100	24.3 ± 6.0R: 5.4–45.9	0.16
Incesoy et al. (2024)²⁸	82	14.19 ± 5.22	82	16.47 ± 8.01	0.043
Lu et al. (2024)²⁹	72	20.21 ± 3.96	73	21.68 ± 3.92	0.047
Δ Acetabular Anteversion Postoperative Outcome and Preoperative Goal,°
Stewart et al. (2022)³²	100	3.64 ± 3.13	100	3.78 ± 3.1	0.74
Cup Inclination, °
Buchan et al. (2023)-c²⁴	98	42.8 ± 5.2	100	42.8 ± 6.8	0.976
Foissey et al. (2023)²⁷	50	40.5 ± 3.4R: 32.8–47.2	100	41.8 ± 4.7R: 26.0–60.9	0.12
Incesoy et al. (2024)²⁸	82	39.23 ± 5.22	82	37.49 ± 8.7	0.122
Lu et al. (2024)²⁹	72	41.98 ± 6.69	73	39.73 ± 3.96	0.065
Δ Acetabular Inclination Postoperative Outcome and Preoperative Goal,°
Stewart et al. (2022)	100	3.8 ± 4.41	100	4.63 ± 3.15	0.0077
Δ Acetabular offset, °
Foissey et al. (2023)²⁷	50	−2.9 ± 2.9R: −12.4-2.6	100	−3.3 ± 3.8R: −18.2–12.7	0.64
Δ Femoral offset, mm
Foissey et al. (2023)²⁷	50	−0.1 ± 6.1R: −14.0–10.1	100	0.3 ± 5.7R: −28.8–17.5	0.12
Δ Global offset, mm
Foissey et al. (2023)²⁷	50	−3 ± 6.5R: −17.3–8.7	100	−2.9 ± 6.1R: −28.4–30.2	0.9
Stewart et al. (2022)³²	100	5.12 ± 4.0	100	5.09 ± 4.5	0.52
Leg Length Discrepancy, mm
Foissey et al. (2023)²⁷	50	2.7 ± 1.8R: 0.0–7.6	100	3 ± 3.4R: −3.0-22.5	0.047
Incesoy et al. (2024)²⁸	82	6.27 ± 5.76	82	8.49 ± 11.45	0.242
Lu et al. (2024)²⁹	72	5.28 ± 4.33	73	5.65 ± 5.41	0.686
Lateral offset, mm
Incesoy et al. (2024)²⁸	82	8.44 ± 7.07	82	9.24 ± 7.25	0.496

3.4

3.4 Patient reported outcomes

Meta-analysis across three eligible studies reporting the Harris Hip Score demonstrated no significant difference across RA-THA and M-THA groups (MD -0.48; 95 %CI -2.40, 1.44; p = 0.62) (SDC Fig. 6).^27–29 Additional postoperative PROs assessed included the HOOS-PS,²⁶^,³¹ HOOS-Pain,²⁶^,³¹ HOOS-JR,³¹ UCLA Activity,²⁶^,³¹ VR-12 MCS,²⁶^,³¹ VR-12 PCS,²⁶^,³¹ VAS Pain,²⁶^,²⁹ and WOMAC scores,²⁸ none which demonstrated significant differences across groups (SDC Table 3). Buchan et al. further assessed changes in various PROs and demonstrated significant greater improvements in HOOS-PS and HOOS-Pain scores in favor of the RA-THA group.²⁶ The majority of PROs were reported at 1-year postoperatively, with Buchanan et al. notably reporting on VAS pain scores within 6-weeks postoperatively in the context of acute postoperative opioid utilization.²⁶

3.5

3.5 Complications and reoperations

Meta-analysis across five eligible studies demonstrated a non-significant 43 % reduction in complications in favor of RA-THA (RR 0.57; 95 %CI 0.21, 1.56; p = 0.28) (Fig. 2).⁴^,¹⁵^,^27–29 When isolating for intraoperative fractures, there was a non-significant 30 % reduction in risk in favor of RA-THA (RR 0.70; 95 %CI 0.17, 2.84, p = 0.78).⁴^,¹⁵^,^27–29 Rates of intraoperative fractures ranged from 0 to 1.2 % and 0–2.4 % across RA-THA and M-THA groups. Further, a significant 75 % reduction in reoperations was found in favor of the RA-THA group (RR 0.25; 95 %CI 0.08, 0.77; p = 0.02).⁴^,¹⁵^,³¹ Reporting of complications and reoperations was heterogenous across included studies with further details provided in Tables 4 and 5, respectively.

Table 4 Complications data.

Study	RA-THA	M-THA
Bendich et al. (2024)⁴Follow-up:12 monthsP-value: NR	Intraoperative fracture = 1Postoperative fracture = 0Dislocation = 0Infection = 1Other = 0Total = 2/226 (0.9 %)	Intraoperative fracture = 8Postoperative fracture = 8Dislocation = 2Infection = 10Other = 2Total = 30/2200 (1.4 %)
Buchan et al. (2024)-a²⁵Follow-up:3 monthsP-value: 0.029	Major complication (e.g. fracture, dislocation, infection) = 0Wound healing = 0DVT without PE = 1Delirium = 0Hematoma = 0Total = 1/107 (0.9 %)	Major complication (e.g. fracture, dislocation, infection) = 0Wound healing = 2DVT without PE = 3Delirium = 1Hematoma = 1Total = 7/105 (6.7 %)
Foissey et al. (2023)²⁷Follow-up:12 monthsP-value: 0.27	Intraoperative fracture = 0Fracture or dislocation = 0Subsidence or loosening = 0Iliopsoas impingement = 0Infection = 2Total = 2/50 (4 %)	Intraoperative fracture = 0Fracture or dislocation = 0Subsidence or loosening = 0Iliopsoas impingement = 0Infection = 1Total = 1/100 (1 %)
Incesoy et al. (2024)²⁸Follow-up:12 monthsP-value: NR	Intraoperative fracture = 1Total = 1/82 (1.2 %)	Intraoperative fracture = 2Total = 2/82 (2.4 %)
Lu et al. (2024)²⁹Follow-up:6 monthsP-value: NR	Dislocation, wound infection, DVT = 0Intraoperative fracture = 0Total = 0/72 (0 %)	Dislocation, wound infection, DVT = 0Intraoperative fracture = 1Total = 1/74 (1.4 %)

Table 5 Reoperations data.

Study	RA-THA	M-THA
Bendich et al. (2024)⁴Follow-up:12 monthsP-value: NR	Superficial I&D = 1Total = 1/226 (0.4 %)	Femoral revision for PPFx = 4Femoral revision for subsidence post intraoperative fracture = 1Femoral revision for aseptic implant failure = 2Greater trochanter ORIF for PPFx = 1Acetabular cup revision for fracture = 1Superficial I&D = 61-stage exchange = 12-stage exchange = 2Closed reduction in OR for dislocation = 1Head/liner exchange for dislocation = 1I&D + head/liner exchange for dislocation = 2Total = 25/2200 (1.1 %)
Buchan et al. (2024)-a²⁵Follow-up:3 monthsP-value: 0.152	Revision surgery or I&D = 0Total = 0/107 (0 %)	Revision surgery or I&D = 0Wound closure = 2Total = 2/105 (1.9 %)
Rogers et al. (2024)³¹Follow-up:12 monthsP-value: 0.04	Revision surgery for PPFx = 2Total = 2/214 (0.9 %)	Revision surgery for PPFx = 3Wound closure = 1Management of PJI = 2Management of iliopsoas bursitis = 1Total = 7/148 (4.7 %)

4 Discussion

Despite prior systematic reviews being published on RA-THA,⁵^,⁹^,¹¹ the generalizability of findings is limited by the heterogenous surgical approaches assessed. The primary findings of our focused review included significantly longer operative times when utilizing RA-THA, a lack of significant differences in patient-reported outcomes across RA-THA and M-THA groups, as well as possibly reduced risks of complications and reoperations in favor of RA-THA. Importantly, findings were largely based on observational studies, with only one included study being of randomized design,²⁹ highlighting the need for high-quality prospective studies.

The literature to-date generally demonstrates increases in operative times following the integration of robotics in TJA, especially in the learning phase of adoption.⁹ Our study demonstrated significantly longer operative duration by approximately 15 min in the RA-THA group. This is an especially clinically relevant finding considered prolonged operative time may be associated with risk of postoperative infection.³³ Nonetheless, a recent review by Hecht et al. demonstrated a learning curve for RA-THA ranging between 12 and 17 cases, with reductions in operative time ranging from 6 to 35 min.³⁴ It is likely that operative time using RA-THA is highly variable due to multiple factors including surgeons’ learning curve, surgical team familiarity with workflow as well as the robot utilized. Moreover, understanding where efficiencies can be leveraged in RA-THA compared to M-THA can further maximize the likelihood for achieving comparable operative times.³⁵ With ever increasing pressures to improve efficiency in arthroplasty, continued efforts should be made to report operational insights in RA-TJA research.

Improved accuracy of component positioning remains a commonly agreed upon benefit of RA-THA.⁹ While our study demonstrated a significant difference in acetabular anteversion, this difference of 1.87° is unlikely of clinical significance. The Lewinnek safe zones are commonly used to assess acetabular component positioning following THA despite their clinically utility being recently called into question.³⁶^,³⁷ Our study demonstrated conflicting findings regarding the efficacy of RA-THA over M-THA in component placement in these safe zones.²⁴^,³² Specifically, Buchan et al.’s study, which utilized the ROSA, demonstrated a significantly higher rate of components placed in the safe zones in favor of the RA-THA group (81.6 vs 59.0 %, p < 0.001),²⁴ while Stewart et al.’s study, using the MAKO, failed to demonstrate a difference (85 vs. 87 %, p = 0.81).³² Ultimately, there are additional patient-specific considerations pertaining to component positioning enabled by RA-THA that are not captured by standardized radiographic targets. For example, in patients with prior lumbar fusion surgery and limited spinopelvic mobility, RA-THA may allow for more functional component positioning through technology-enabled dynamic assessment of impingement.³⁸^,³⁹ Therefore, a more clinically relevant measure to be assessed by future high-quality studies would be achieving the surgical plan as informed by patient-specific factors.

Demonstrating improved patient reported outcomes in favor of robotic-assisted technologies remains challenging in total joint arthroplasty (TJA).⁶ While a prior meta-analysis demonstrated a significantly higher Harris Hip Score in favor of the RA-THA group, it failed to exceed the minimally clinically important difference.⁹ Conversely, our study failed to demonstrate a significant difference across the HSS, though the meta-analysis was limited by a small number of studies. Importantly, the lack of differences across several PROs across groups may further be confounded by methodological limitations. For example, ceiling effects across utilized PROs may fail to capture the full benefit of RA-THA. Notably, Wagner et al.’s systematic review demonstrated that over half of assessed studies using the Harris Hip Score presented with ceiling effects.⁴⁰ This highlights the importance of selecting appropriate PRO instruments that can delineate outcomes in our increasingly active aging population. Future studies should incorporate validated and commonly utilized PROs that have also been demonstrated to have low ceiling effects in active patient populations.⁴¹^,⁴²

While our study demonstrated non-significant and significant reductions in postoperative complications and reoperations, respectively, these findings should be interpreted in the context of highly heterogenous reporting and a lack of adequate power analysis. Moreover, a limited number of events precluded performing meta-analyses across relevant complication (e.g. dislocation), with no significant difference found across rates of intraoperative fractures. On further analysis, these rates of intraoperative fractures (0–2.4 %) are within previously reported rates in the literature,⁴³^,⁴⁴ and are unlikely directly related to the use of robotic-assisted technology. This trend persisted in the reoperations data, and highlights the importance of performing adequately powered trials with adjudication of complications and revision surgeries.

The adoption of RA-THA may also present with several additional benefits in favor of the healthcare team and payors. For example, Caba et al.’s cadaveric study demonstrated that surgeons performing RA-THA experienced less physical and mental demands relative to conventional THA using the DAA.⁴⁵ This is especially relevant given almost two-thirds of adult reconstruction surgeons reporting prior work-related injuries.⁴⁶ Another potential benefit of RA-THA is reduction of intraoperative radiation exposure.³⁰ While intraoperative radiation for the DAA has generally been demonstrated to be safe,⁴⁷ not all healthcare professionals may be comfortable with radiation exposure depending on their current health status (e.g. during pregnancy). Further, the lack of intraoperative fluoroscopy can reduce operational costs by eliminating the need for radiation technologists and necessary equipment. Finally, accurate component placement may reduce the most common cause of revision surgery following THA, dislocation, a significant cost burden often requiring readmission and morbid revision surgery.⁴⁸

This study is not without its limitations. First, the majority of evidence was of non-randomized controlled studies. Nonetheless, quality assessment demonstrated high quality observational studies. Second, included studies were of heterogenous outcomes preventing further pooling of outcomes in meta-analyses which are easier to interpret relative to narrative descriptions of the data. Third, multiple robot manufacturers were included in the analysis, a common limitation of RA-TJA research, which may explain the broad range of heterogeneity (I²) reported in the meta-analysis. Due to a limited number of included studies and heterogenous outcomes assessed, sensitivity analysis was not feasible. Nonetheless, the majority of included studies in this review utilized the MAKO. Fourth, the manual THA group included cohorts with and without the use of intraoperative fluoroscopy, which is a unique consideration in the direct anterior approach. However, prior literature demonstrates generally comparable radiographic outcomes irrespective of the use of fluoroscopy when M-THA is performed by an experienced surgeon.⁴⁹^,⁵⁰ Finally, only three studies evaluated reoperation rates, with Buchan et al. only following patients to three months.²⁵ As such, long-term study designs are warranted to further evaluated reoperations following RA-THA using the DAA. Despite the aforementioned limitations, this is the first review assessing outcomes of RA-THA utilizing the DAA both providing an up-to-date perspective on the literature as well as insights that may aid in the design of much needed high-quality trials.

5 Conclusion

RA-THA using the DAA does not lead to clinically significant improvements in acetabular component positioning, with potentially reduced rates of reoperations compared to M-THA. A notable disadvantage of RA-THA was prolonged operative time. Benefits in PROs were lacking with the strength of findings being limited by low levels of evidence and heterogenous instruments. Future high-quality trials with appropriately selected radiographic and patient reported outcomes are warranted. Clinically relevant outcomes to consider include the attainment of preoperative target component positioning, restoration of patient native biomechanics as well as robot-specific complications.

CRediT author statement

Hassaan Abdel Khalik – investigation, formal analysis, writing (original draft).

Syed Mustafa Nadeem - investigation, writing (original draft).

Michelle Cruickshank - investigation, writing (original draft).

Brian P. Chalmers - writing (review & editing).

Brent Lanting - writing (review & editing).

Thomas J. Wood – conceptualization, writing (review & editing), supervision.

Ethical statement

Due to being a systematic review and bibliometric analysis, no ethics board approval was required as data for this manuscript was publicly available.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References

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[Google Scholar]
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[Google Scholar]
Buchan G.B.J., Ong C.B., Hecht Ii C.J., DeCook C.A., Spencer-Gardner L.S., Kamath A.F., . Use of a fluoroscopy-based robotic-assisted total hip arthroplasty system produced greater improvements in patient-reported outcomes at one year compared to manual, fluoroscopic-assisted technique. Arch Orthop Trauma Surg. 2024;144(4):1843-1850.
[Google Scholar]
Foissey C., Batailler C., Coulomb R., et al . Image-based robotic-assisted total hip arthroplasty through direct anterior approach allows a better orientation of the acetabular cup and a better restitution of the centre of rotation than a conventional procedure. Int Orthop. 2023;47(3):691-699.
[Google Scholar]
Incesoy M.A., Yildiz F., Pulatkan M.A., et al . CT-based, robotic-arm assisted total hip arthroplasty (Mako) through anterior approach provides improved cup placement accuracy but no difference in clinical outcomes when compared to conventional technique. Technol Health Care. 2024;32(5):3681-3691.
[Google Scholar]
Lu X., Zhang Z., Xu H., Wang W., Zhang H., . A new designed full process coverage robot-assisted total hip arthroplasty: a multicentre randomized clinical trial. Int J Surg. 2024;110(4):2141-2150.
[Google Scholar]
[Google Scholar]
Rogers N., Rullán P.J., Pasqualini I., et al . Lower 90-day inpatient readmission and 1-year reoperation in patients undergoing robotic versus manual total hip arthroplasty through an anterior approach. Technol Health Care. 2024;32(5):3769-3781.
[Google Scholar]
Stewart N.J., Stewart J.L., Brisbin A., . A comparison of component positioning between fluoroscopy-assisted and robotic-assisted total hip arthroplasty. J Arthroplast. 2022;37(8):1602-1605.e3.
[Google Scholar]
Wang Q., Goswami K., Shohat N., Aalirezaie A., Manrique J., Parvizi J., . Longer operative time results in a higher rate of subsequent periprosthetic joint infection in patients undergoing primary joint arthroplasty. J Arthroplast. 2019;34(5):947-953.
[Google Scholar]
Hecht C.J., Porto J.R., Sanghvi P.A., Homma Y., Sculco P.K., Kamath A.F., . Contemporary analysis of the learning curve for robotic-assisted total hip arthroplasty emerging technologies. J Robot Surg. 2024;18(1):160.
[Google Scholar]
[Google Scholar]
Lewinnek G.E., Lewis J.L., Tarr R., Compere C.L., Zimmerman J.R., . Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am. 1978;60(2):217-220.
[Google Scholar]
Abdel M.P., von Roth P., Jennings M.T., Hanssen A.D., Pagnano M.W., . What safe zone? The vast majority of dislocated THAs are within the lewinnek safe zone for acetabular component position. Clin Orthop Relat Res. 2016;474(2):386-391.
[Google Scholar]
Fontalis A., Raj R.D., Kim W.J., et al . Functional implant positioning in total hip arthroplasty and the role of robotic-arm assistance. Int Orthop. 2023;47(2):573-584.
[Google Scholar]
Stefl M., Lundergan W., Heckmann N., et al . Spinopelvic mobility and acetabular component position for total hip arthroplasty. Bone Joint Lett J. 2017;99-B(1 Supple A):37-45.
[Google Scholar]
Wamper K.E., Sierevelt I.N., Poolman R.W., Bhandari M., Haverkamp D., . The Harris hip score: do ceiling effects limit its usefulness in orthopedics? Acta Orthop. 2010;81(6):703-707.
[Google Scholar]
Domzalski T., Cook C., Attarian D.E., Kelley S.S., Bolognesi M.P., Vail T.P., . Activity scale for arthroplasty patients after total hip arthroplasty. J Arthroplast. 2010;25(1):152-157.
[Google Scholar]
Talbot S., Hooper G., Stokes A., Zordan R., . Use of a new high-activity arthroplasty score to assess function of young patients with total hip or knee arthroplasty. J Arthroplast. 2010;25(2):268-273.
[Google Scholar]
Cohen E.M., Vaughn J.J., Ritterman S.A., Eisenson D.L., Rubin L.E., . Intraoperative Femur fracture risk during primary direct anterior approach cementless total hip arthroplasty with and without a fracture table. J Arthroplast. 2017;32(9):2847-2851.
[Google Scholar]
Lee G.C., Marconi D., . Complications following direct anterior hip procedures: costs to both patients and surgeons. J Arthroplast. 2015;30(9 Suppl):98-101.
[Google Scholar]
Caba M., Gains C., Nessler J., et al . Physical and mental demand during direct anterior total hip arthroplasty: comparison of robotic-assisted and conventional techniques. J Orthop. 2025;62:126-132.
[Google Scholar]
Alqahtani S.M., Alzahrani M.M., Tanzer M., . Adult reconstructive surgery: a high-risk profession for work-related injuries. J Arthroplast. 2016;31(6):1194-1198.
[Google Scholar]
Pomeroy C.L., Mason J.B., Fehring T.K., Masonis J.L., Curtin B.M., . Radiation exposure during fluoro-assisted direct anterior total hip arthroplasty. J Arthroplast. 2016;31(8):1742-1745.
[Google Scholar]
Hinton Z.W., Wu C.J., Ryan S.P., Cunningham D.J., Green C.L., Lachiewicz P.F., . Current trends in revision hip arthroplasty: indications and types of components revised. J Arthroplast. 2022;37(7S):S611-S615.e7.
[Google Scholar]
Lin T.J., Bendich I., Ha A.S., Keeney B.J., Moschetti W.E., Tomek I.M., . A comparison of radiographic outcomes after total hip arthroplasty between the posterior approach and direct anterior approach with intraoperative fluoroscopy. J Arthroplast. 2017;32(2):616-623.
[Google Scholar]
Johns B., Selznick A., Wood T., et al . Comparison of acetabular and femoral component positioning with and without fluoroscopy in direct anterior approach total hip arthroplasty. J Orthop. 2025;70:166-172.
[Google Scholar]

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[1] Kayani B., Konan S., Ayuob A., Ayyad S., Haddad F.S., . The current role of robotics in total hip arthroplasty. EFORT Open Rev. 2019;4(11):618-625.
[Google Scholar]

[2] Vigdorchik J.M., Sharma A.K., Jerabek S.A., Mayman D.J., Sculco P.K., . Templating for total hip arthroplasty in the Modern Age. J Am Acad Orthop Surg. 2021;29(5):e208-e216.
[Google Scholar]

[3] Perets I., Walsh J.P., Close M.R., Mu B.H., Yuen L.C., Domb B.G., . Robot-assisted total hip arthroplasty: clinical outcomes and complication rate. Int J Med Robot. 2018;14(4)
[Google Scholar]

[4] Bendich I., Chiu Y.F., Sarpong N., Gonzalez Della Valle A., Su E., McLawhorn A., . Robotic-assistance and computer-navigation have similar rates of intraoperative fracture and return to the operating room within 1 year to fluoroscopy-only direct anterior total hip arthroplasty. Hip Int. 2025;35(2):116-123.
[Google Scholar]

[5] [Google Scholar]

[6] Karunaratne S., Duan M., Pappas E., et al . The effectiveness of robotic hip and knee arthroplasty on patient-reported outcomes: a systematic review and meta-analysis. Int Orthop. 2019;43(6):1283-1295.
[Google Scholar]

[7] Abdel Khalik H., Selznick A., Bali K., Amini Y., Tate I., Wood T.J., . Perceptions and attitudes regarding robotic total hip arthroplasty: a patient stakeholder survey. J Robot Surg. 2024;19(1):22.
[Google Scholar]

[8] Chang J., Wu C., Hinton Z., et al . Patient perceptions and interest in robotic-assisted total joint arthroplasty. Arthroplast Today. 2024;26
[Google Scholar]

[9] Ng N., Gaston P., Simpson P.M., Macpherson G.J., Patton J.T., Clement N.D., . Robotic arm-assisted versus manual total hip arthroplasty : a systematic review and meta-analysis. Bone Joint Lett J. 2021;103-B(6):1009-1020.
[Google Scholar]

[10] Sousa P.L., Sculco P.K., Mayman D.J., Jerabek S.A., Ast M.P., Chalmers B.P., . Robots in the operating room during hip and knee arthroplasty. Curr Rev Musculoskelet Med. 2020;13(3):309-317.
[Google Scholar]

[11] Samuel L.T., Acuña A.J., Mahmood B., Emara A.K., Kamath A.F., . Comparing early and mid-term outcomes between robotic-arm assisted and manual total hip arthroplasty: a systematic review. J Robot Surg. 2022;16(4):735-748.
[Google Scholar]

[12] Abdel M.P., Carender C.N., Berry D.J., . Current practice trends in primary hip and knee arthroplasties among members of the American association of hip and knee surgeons. J Arthroplast. 2023;38(10):1921-1927.e3.
[Google Scholar]

[13] Driesman A., Yang C.C., . Clinical outcomes of DAA and related techniques in hip arthroplasty. Arthroplasty. 2023;5(1):42.
[Google Scholar]

[14] Free M.D., Owen D.H., Agius P.A., Pascoe E.M., Harvie P., . Direct anterior approach total hip arthroplasty: an adjunct to an enhanced recovery pathway: outcomes and learning curve effects in surgeons transitioning from other surgical approaches. J Arthroplast. 2018;33(11):3490-3495.
[Google Scholar]

[15] Buchan G., Ong C., Hecht C., et al . Equivalent radiation exposure with robotic total hip replacement using a novel, fluoroscopic-guided (CT-free) system: case-control study versus manual technique. J Robot Surg. 2023;17(4):1561-1567.
[Google Scholar]

[16] Homma Y., Baba T., Sano K., et al . Lateral femoral cutaneous nerve injury with the direct anterior approach for total hip arthroplasty. Int Orthop. 2016;40(8):1587-1593.
[Google Scholar]

[17] Higgins J.P.T., Thomas J., Chandler J., et al . Cochrane Handbook for Systematic Reviews of Interventions Version 6.1 (Updated September 2021) 2019
[Google Scholar]

[18] Moher D., Liberati A., Tetzlaff J., Altman D.G., . Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336-341.
[Google Scholar]

[19] Slim K., Nini E., Forestier D., Kwiatkowski F., Panis Y., Chipponi J., . Methodological index for non-randomized studies (MINORS): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712-716.
[Google Scholar]

[20] McGuinness L.A., Higgins J.P.T., . Risk-of-bias VISualization (robvis): an R package and shiny web app for visualizing risk-of-bias assessments. Res Synth Methods. 2021;12(1):55-61.
[Google Scholar]

[21] Sterne J.A.C., Savović J., Page M.J., et al . RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366
[Google Scholar]

[22] Wright J., . Levels of evidence and grades of recommendations: an evaluation of literature. J Am Acad Orthop Surg 2005:16-18.
[Google Scholar]

[23] Buchan G.B.J., Bernhard Z., Hecht C.J., Davis G.A., Pickering T., Kamath A.F., . Improved perioperative narcotic usage patterns in patients undergoing robotic-assisted compared to manual total hip arthroplasty. Arthroplasty. 2023;5(1):56.
[Google Scholar]

[24] Buchan G.B.J., Hecht C.J., Liu D., Mokete L., Kendoff D., Kamath A.F., . Improved accuracy of a novel fluoroscopy-based robotically assisted THA system compared to manual THA. J Robot Surg. 2023;17(5):2073-2079.
[Google Scholar]

[25] Buchan G.B.J., Hecht C.J., Sculco P.K., Chen J.B., Kamath A.F., . Improved short-term outcomes for a novel, fluoroscopy-based robotic-assisted total hip arthroplasty system compared to manual technique with fluoroscopic assistance. Arch Orthop Trauma Surg. 2024;144(1):501-508.
[Google Scholar]

[26] Buchan G.B.J., Ong C.B., Hecht Ii C.J., DeCook C.A., Spencer-Gardner L.S., Kamath A.F., . Use of a fluoroscopy-based robotic-assisted total hip arthroplasty system produced greater improvements in patient-reported outcomes at one year compared to manual, fluoroscopic-assisted technique. Arch Orthop Trauma Surg. 2024;144(4):1843-1850.
[Google Scholar]

[27] Foissey C., Batailler C., Coulomb R., et al . Image-based robotic-assisted total hip arthroplasty through direct anterior approach allows a better orientation of the acetabular cup and a better restitution of the centre of rotation than a conventional procedure. Int Orthop. 2023;47(3):691-699.
[Google Scholar]

[28] Incesoy M.A., Yildiz F., Pulatkan M.A., et al . CT-based, robotic-arm assisted total hip arthroplasty (Mako) through anterior approach provides improved cup placement accuracy but no difference in clinical outcomes when compared to conventional technique. Technol Health Care. 2024;32(5):3681-3691.
[Google Scholar]

[29] Lu X., Zhang Z., Xu H., Wang W., Zhang H., . A new designed full process coverage robot-assisted total hip arthroplasty: a multicentre randomized clinical trial. Int J Surg. 2024;110(4):2141-2150.
[Google Scholar]

[30] [Google Scholar]

[31] Rogers N., Rullán P.J., Pasqualini I., et al . Lower 90-day inpatient readmission and 1-year reoperation in patients undergoing robotic versus manual total hip arthroplasty through an anterior approach. Technol Health Care. 2024;32(5):3769-3781.
[Google Scholar]

[32] Stewart N.J., Stewart J.L., Brisbin A., . A comparison of component positioning between fluoroscopy-assisted and robotic-assisted total hip arthroplasty. J Arthroplast. 2022;37(8):1602-1605.e3.
[Google Scholar]

[33] Wang Q., Goswami K., Shohat N., Aalirezaie A., Manrique J., Parvizi J., . Longer operative time results in a higher rate of subsequent periprosthetic joint infection in patients undergoing primary joint arthroplasty. J Arthroplast. 2019;34(5):947-953.
[Google Scholar]

[34] Hecht C.J., Porto J.R., Sanghvi P.A., Homma Y., Sculco P.K., Kamath A.F., . Contemporary analysis of the learning curve for robotic-assisted total hip arthroplasty emerging technologies. J Robot Surg. 2024;18(1):160.
[Google Scholar]

[35] [Google Scholar]

[36] Lewinnek G.E., Lewis J.L., Tarr R., Compere C.L., Zimmerman J.R., . Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am. 1978;60(2):217-220.
[Google Scholar]

[37] Abdel M.P., von Roth P., Jennings M.T., Hanssen A.D., Pagnano M.W., . What safe zone? The vast majority of dislocated THAs are within the lewinnek safe zone for acetabular component position. Clin Orthop Relat Res. 2016;474(2):386-391.
[Google Scholar]

[38] Fontalis A., Raj R.D., Kim W.J., et al . Functional implant positioning in total hip arthroplasty and the role of robotic-arm assistance. Int Orthop. 2023;47(2):573-584.
[Google Scholar]

[39] Stefl M., Lundergan W., Heckmann N., et al . Spinopelvic mobility and acetabular component position for total hip arthroplasty. Bone Joint Lett J. 2017;99-B(1 Supple A):37-45.
[Google Scholar]

[40] Wamper K.E., Sierevelt I.N., Poolman R.W., Bhandari M., Haverkamp D., . The Harris hip score: do ceiling effects limit its usefulness in orthopedics? Acta Orthop. 2010;81(6):703-707.
[Google Scholar]

[41] Domzalski T., Cook C., Attarian D.E., Kelley S.S., Bolognesi M.P., Vail T.P., . Activity scale for arthroplasty patients after total hip arthroplasty. J Arthroplast. 2010;25(1):152-157.
[Google Scholar]

[42] Talbot S., Hooper G., Stokes A., Zordan R., . Use of a new high-activity arthroplasty score to assess function of young patients with total hip or knee arthroplasty. J Arthroplast. 2010;25(2):268-273.
[Google Scholar]

[43] Cohen E.M., Vaughn J.J., Ritterman S.A., Eisenson D.L., Rubin L.E., . Intraoperative Femur fracture risk during primary direct anterior approach cementless total hip arthroplasty with and without a fracture table. J Arthroplast. 2017;32(9):2847-2851.
[Google Scholar]

[44] Lee G.C., Marconi D., . Complications following direct anterior hip procedures: costs to both patients and surgeons. J Arthroplast. 2015;30(9 Suppl):98-101.
[Google Scholar]

[45] Caba M., Gains C., Nessler J., et al . Physical and mental demand during direct anterior total hip arthroplasty: comparison of robotic-assisted and conventional techniques. J Orthop. 2025;62:126-132.
[Google Scholar]

[46] Alqahtani S.M., Alzahrani M.M., Tanzer M., . Adult reconstructive surgery: a high-risk profession for work-related injuries. J Arthroplast. 2016;31(6):1194-1198.
[Google Scholar]

[47] Pomeroy C.L., Mason J.B., Fehring T.K., Masonis J.L., Curtin B.M., . Radiation exposure during fluoro-assisted direct anterior total hip arthroplasty. J Arthroplast. 2016;31(8):1742-1745.
[Google Scholar]

[48] Hinton Z.W., Wu C.J., Ryan S.P., Cunningham D.J., Green C.L., Lachiewicz P.F., . Current trends in revision hip arthroplasty: indications and types of components revised. J Arthroplast. 2022;37(7S):S611-S615.e7.
[Google Scholar]

[49] Lin T.J., Bendich I., Ha A.S., Keeney B.J., Moschetti W.E., Tomek I.M., . A comparison of radiographic outcomes after total hip arthroplasty between the posterior approach and direct anterior approach with intraoperative fluoroscopy. J Arthroplast. 2017;32(2):616-623.
[Google Scholar]

[50] Johns B., Selznick A., Wood T., et al . Comparison of acetabular and femoral component positioning with and without fluoroscopy in direct anterior approach total hip arthroplasty. J Orthop. 2025;70:166-172.
[Google Scholar]

Robotic-assisted total hip arthroplasty using the direct anterior approach: A systematic review and meta-analysis

Abstract