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fashion or were descriptive in nature were coded as expert opinion publications. Citation density, defined as number of citations per year, was also recorded for each article. Results The primary search query yielded a total of 2046 results. The top 264 most cited results were reviewed to determine the top 50 publications on the subject of DAA hip arthroplasty (Fig. 1). The top 50 publications included articles published between the years of 1980 and 2017, with a median publication year of 2011. 47 of the 50 articles were published since the year 2000, and 39 of the articles were published since 2009 (Fig. 2). The year with the most publications was 2009, which included 10 of the top 50 articles. Analysis of the number of total citations per year revealed that 2018 had the most with 680. This was followed by the years 2017 and 2016 with 607 and 563 citations, respectively. The total number of citations attributed to the top 50 articles was 3,521, with an average of 86.3 total citations per year between 1980 and 2019. The total number of citations for each paper ranged from 31 to 253 citations at the time of data collection, with an average number of 70.4 citations per paper. The citation density, or the average number of citations per year since the date of publication, was also analyzed for each of the top 50 articles (Table 1). Fleischman et al. (43.0 citations/year), Barrett et al. (20.3 citations/year), and Matta et al. (18.1 citations/year) were the top 3 articles by citation density. The oldest article, Light et al., ranked the 13th in total citations (80) and 48th in citation density (2.1 citations/year). Examination of the selected articles by study design revealed that cohort studies were the most common, composing 22 of the 50 publications. Cohort study design was followed in frequency by descriptive studies (9), case series (7), and randomized controlled trials (5) (Table 2). Level of evidence is closely related to study design. Analysis of level of evidence among the top 50 most cited publications revealed level III studies to be the most prevalent with 15 papers (Fig. 3). This was followed by level IV studies (11), level I studies (5), and level II studies (7). There were no level V studies included in this analysis. The level of evidence was not applicable to 13 articles because they were classified as expert opinion. Table 1 (continued ) Rank Article No. of citations (citation density) Level of evidence Martin CT, Pugely AJ, Gao Y, Clark CR. A comparison of hospital length of stay and short-term morbidity between the anterior and the posterior approaches to total hip arthroplasty. J Arthroplasty. 2013; 28(5):849-54. 33 De geest T, Vansintjan P, De loore G. Direct anterior total hip arthroplasty: complications and early outcome in a series of 300 cases. Acta Orthop Belg. 2013; 79(2):166-73. 46 (4.6) IV 34 Bender B, Nogler M, Hozack WJ. Direct anterior approach for total hip arthroplasty. Orthop Clin North Am. 2009; 40(3):321-8. 46 (7.7) NA 35 Klausmeier V, Lugade V, Jewett BA, Collis DK, Chou LS. Is there faster recovery with an anterior or anterolateral THA? A pilot study. Clin Orthop Relat Res. 2010; 468(2):533-41. 45 (4.5) II 36 Barton C, Kim PR. Complications of the direct anterior approach for total hip arthroplasty. Orthop Clin North Am. 2009; 40(3):371-5. 45 (5) NA 37 Fleischman AN, Rothman RH, Parvizi J. Femoral Nerve Palsy Following Total Hip Arthroplasty: Incidence and Course of Recovery. J Arthroplasty. 2018; 33(4):1194-1199. 43 (43) III 38 Restrepo C, Mortazavi SM, Brothers J, Parvizi J, Rothman RH. Hip dislocation: are hip precautions necessary in anterior approaches?. Clin Orthop Relat Res. 2011; 469(2):417-22. 43 (4.8) IV 39 Lugade V, Wu A, Jewett B, Collis D, Chou LS. Gait asymmetry following an anterior and anterolateral approach to total hip arthroplasty. Clin Biomech (Bristol, Avon). 2010; 25(7):675-80. 43 (5.4) II 40 Rathod PA, Bhalla S, Deshmukh AJ, Rodriguez JA. Does fluoroscopy with anterior hip arthroplasty decrease acetabular cup variability compared with a nonguided posterior approach?. Clin Orthop Relat Res. 2014; 472(6):1877-85. 42 (8.4) III 41 Chechik O, Khashan M, Lador R, Salai M, Amar E. Surgical approach and prosthesis fixation in hip arthroplasty world wide. Arch Orthop Trauma Surg. 2013; 133(11):1595-600. 41 (6.8) NA 42 Keggi KJ, Huo MH, Zatorski LE. Anterior approach to total hip replacement: surgical technique and clinical results of our first one thousand cases using non-cemented prostheses. Yale J Biol Med. 1993; 66(3):243-56. 41 (1.6) NA 43 Maffiuletti NA, Impellizzeri FM, Widler K, et al. Spatiotemporal parameters of gait after total hip replacement: anterior vs posterior approach. Orthop Clin North Am. 2009; 40(3):407-15. 40 (4) IV 44 Hallert O, Li Y, Brismar H, Lindgren U. The direct anterior approach: initial experience of a minimally invasive technique for total hip arthroplasty. J Orthop Surg Res. 2012; 7:17. 39 (5.6) IV 45 Judet J, Judet H. [Anterior approach in total hip arthroplasty]. Presse Med. 1985; 14(18):1031-3. 38 (1.1) NA 46 Sheth D, Cafri G, Inacio MC, Paxton EW, Namba RS. Anterior and Anterolateral Approaches for THA Are Associated With Lower Dislocation Risk Without Higher Revision Risk. Clin Orthop Relat Res. 2015; 473(11):3401-8. 35 (2.7) III 47 Nogler M, Krismer M, Hozack WJ, Merritt P, Rachbauer F, Mayr E. A double offset broach handle for preparation of the femoral cavity in minimally
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