128 patients scheduled for total hip arthroplasty were randomized to surgery performed through either a direct anterior approach or posterolateral approach. Patients were assessed for operative outcomes, pain scores at 24, 48, and 72 hours, markers of muscle damage and inflammation over the first 4 postoperative days, and functional outcome and gait parameters at 3 and 6 months postoperatively. Results demonstrated significantly longer operative times and greater intraoperative blood loss with the direct anterior approach, but also significantly lower postoperative pain, lower markers of muscle damage and inflammation, and higher functional scores at 3 months postoperatively when compared to the posterolateral approach.