Beyond robotics: a systematic review of technology integration in direct anterior approach total hip arthroplasty

Technology-assisted implant positioning has emerged as a strategy to improve component placement accuracy in total hip arthroplasty (THA). However, the comparative effectiveness of navigation, robotic-assisted, and artificial intelligence-assisted systems remains unclear, particularly for the technically demanding direct anterior approach (DAA).To systematically review and meta-analyze the comparative effectiveness of technology-assisted versus conventional manual DAA THA with respect to acetabular cup positioning accuracy and secondary outcomes. A systematic review was conducted following PRISMA 2020 guidelines (PROSPERO: CRD420261356027). MEDLINE, EMBASE, and Cochrane CENTRAL were searched from inception through February 2025, with a supplementary search in March 2026. Eligible studies included prospective and retrospective cohorts (no randomized controlled trials were identified) comparing technology-assisted (robotic, navigation, augmented reality, or AI-assisted) versus conventional manual DAA THA. Primary outcome was mean postoperative cup inclination angle. Secondary outcomes included safe zone compliance, outlier rates, operative time, radiation exposure, and complications. Risk of bias was assessed using ROBINS-I; evidence certainty was evaluated using GRADE methodology. Thirty-five studies encompassing 12,847 hips were included (34 from initial search; 1 from supplementary search). Navigation-assisted DAA achieved a mean difference of +1.16° (95% CI: -0.73 to +3.04; n=1,451 hips, k=7) in cup inclination compared to manual DAA, with substantial heterogeneity (I2=91.0%). Robotic-assisted DAA showed a mean difference of +0.20° (95% CI: -1.65 to +2.04; n=289 hips, k=3) compared to manual DAA (I2=67.8%). Across all pools, navigation systems demonstrated accelerated learning curves (typically 5-15 cases), whereas robotic systems showed earlier competency achievement. Operative time increased by a median of 9.4 minutes with navigation and 15-20 minutes with robotic systems. Radiation exposure varied substantially: CT-based navigation systems involved preoperative imaging burden, whereas fluoroscopic navigation and robotic systems minimized or eliminated fluoroscopy during implantation. While technology-assisted systems improve certain aspects of cup positioning accuracy and reduce outlier rates in specialized centers, evidence certainty is LOW for navigation-assisted and VERY LOW for robotic-assisted DAA THA due to substantial heterogeneity and risk of bias. Current evidence does not support routine adoption of technology-assisted direct anterior approach total hip arthroplasty solely to improve mean cup inclination. The more consistent potential value of these systems appears to lie in improving positioning precision and reducing outliers, particularly in technically demanding cases. Imageless navigation may represent a pragmatic compromise, offering improved accuracy with less operative-time and radiation burden than CT-based systems. Adequately powered, pre-registered randomized controlled trials are needed to establish the true clinical benefit of these technologies in improving patient outcomes and reducing dislocation rates.