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

Background: 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. Methods: 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. Results: 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). 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 native patient biomechanics, as well as robot-specific complications. Level of evidence: III.