"Over the past two decades the number of Americans having total hip replacements has more than doubled to more than  a year httporthoinfo.aaos.orgtopic.cfmtopica. Though most patients eventually walk again without pain or the aid of a cane recovery and rehabilitation can be rigorous painful and lengthy. The surgery is extensive As its name suggests it involves removing the joint  the damaged bone and cartilage  and replacing it with prosthetic parts made of metal plastic or ceramics. Typically surgeons enter the joint from the rear which requires cutting through muscle and cartilage. But with a relatively new procedure surgeons enter from the front and only stretch the muscles aside avoiding the cutting and minimizing pain and recovery time. According to those who use this anterior technique the benefits are substantial. Anthony Unger http medical director at the Institute of Bone and Joint Health at Sibley Memorial Hospital  http a clinical professor of orthopedic surgery at George Washington University Hospital says the anterior approach is truly minimally invasive. Unger who has done about  hip replacements over  years and has used the anterior technique for the past eight years says patients have better overall functionality can sleep on their sides and be confident the new hip wont dislocate. But as with many transitions in medical techniques some surgeons have been reluctant to change. Although agencies and hospitals dont track hip replacements by the type of procedure used Unger says that based on statistics from the American Association of Hip and Knee Surgeons only  percent of its members choose the anterior approach. Joshua Jacobs https_jacobs.cfm a vice president of the American Association of Orthopaedic Surgeons and chairman of orthopedic surgery at Rush University in Chicago says the AAOS doesnt endorse or promote one specific technique or procedure over another. Jacobs prefers the posterior approach which he says has been reliable for him. He says that while hes heard about the benefits of the anterior approach hes not aware of a randomized controlled trial comparing the posterior and anterior approach that shows a definite superiority of one over the other. Whats key is that surgeons need to do the approach theyre most comfortable with to get the best outcomes. Teetering like Chaplin A study by Unger in the Journal of Bone and Joint Surgery  httpjbjs.orgarticle.aspxarticleidin  found that with the anterior procedure there was less muscle damage and inflammation both in the immediate postoperative period and two days later than with the posterior approach. Others surgeons who prefer the anterior procedure say it preserves more of the normal anatomy which also means fewer medications and shorter hospital stays. Michael Bollinger who operates at Palm Drive Hospital in Sebastopol Calif. switched methods a few years ago.  With the anterior approach Bollinger says we can take Xrays during the operation to see if the new hip is placed correctly and adjust it when necessary. Many surgeons use a special operating table that makes this possible.  Although surgeons can also take Xrays during the posterior procedure it is much more difficult and they wait until patients are in the recovery room where Bollinger says theres not much that can be done. He explains that while the body tolerates an imperfect alignment pretty well if a new hip gets dislocated its often because its not in perfectly. The anterior approach offers other benefits.  Robert Saunders a nurse at Alta Bates Summit Medical Center in Berkeley Calif. sees about  hip replacement patients a year. He says that nurses love the anterior approach because theres less worry about dislocating the joint. With the posterior approach we have to spread patients legs apart and strap them to a pillow to keep the new joint in place. If they want to move or roll over they cant he says. Saunders says the anterior patients also have an easier time with physical therapy which can start the same day as the surgery. Those whove had the posterior procedure have a lot of pain since when they sit up theyre right on top the incision he explains. Patrick Kennelly a physical therapist with Smartherapy in Chevy Chase http says people who have the anterior procedure dont feel so weak because their hip muscles havent been cut. If theyve had the posterior procedure even if they dont consciously feel weak they tend to shift their weight onto one foot and teeter like Charlie Chaplin. Cautious surgeons Given benefits such as these why havent more surgeons switched methods Unger says that most surgeons have used the posterior approach for years have fine results and see no need to switch. Also he says they work in a very highstress highliability environment. For this reason new techniques are adapted slowly with extreme care and in some cases not at all.  Unger adds that surgeons are naturally cautious and typically wait to see results from many studies before they switch methods. Besides his study there have only been a few others. One a prospective randomized study by William Barrett an orthopedic surgeon in the Seattle area compared the two approaches in a peerreviewed paper he presented at the  annual AAOS meeting and found benefits with the anterior approach.  Another obstacle to the widespread use of the newer approach is that if established surgeons want to switch they face time and cost constraints. They must get training in classes and cadaver labs and the learning curve can be steep. Unger says his was relatively short  about  cases. Others say it took about  cases. And this creates economic issues. If youre a busy surgeon you have a volume to maintain Bollinger says and its hard to go from doing three a day to one during the learning period.  Christopher Chen a surgeon who uses the anterior approach at Alta Bates Summit adds that most doctors still use the posterior approach because its the one they were taught. And he says the majority of younger surgeons learn the older approach because established surgeons are typically the ones who staff the residency training programs and demonstrate the method they know best.  Most surgeons dont profit from choosing one approach over another Chen says. If there is a financial incentive for promoting the newer technique he says it is that more patients will want the anterior approach so that the surgeon does more surgeries and therefore collects more professional fees for that.  William Hamilton who operates at the Anderson Orthopaedic Clinic at Inova Mt. Vernon Hospital http trains young surgeons to do the anterior approach in a yearlong hip and knee replacement fellowship program. Hamilton says that during this time theyre taught both approaches. But he adds that since  of the  fellows he trained  use the anterior procedure as their primary approach in their practices. Hamilton says that a decade ago very few residencies and fellowships taught the anterior approach. Now several institutions around the country have at least one surgeon teaching it. So when students leave and begin their practices its no longer foreign to them. Hamilton who has performed  anterior procedures and strongly supports the method says that despite growing interest it will take a generation of new surgeons before use of the anterior approach is widespread.  Patients arent informed Many patients arent aware of the option. The case of Daniel Ellsberg  who in  released the Pentagon Papers a secret study about U.S. involvement in Vietnam  is instructive. His hip had been hurting for about a year and when he decided to have surgery his primarycare physician recommended a respected surgeon. Just days before the operation last July a friend told him about the anterior approach. Id never heard of it and neither my doctor nor surgeon mentioned it. I called the surgeons office learned he did the posterior procedure asked for and got a recommendation for one who performs the anterior one and my experience was amazing. The same day as the operation I walked down the hall with a walker. I was home in three days and a week later I walked one or two blocks without pain or a cane. In a month I bodysurfed at the beach says Ellsberg who is  . Margot Machol who is two decades younger and lives in Washington had both hips replaced  the first with the posterior procedure several years ago the second with the anterior procedure last October. Unger performed both surgeries.  After the first I needed pain medicine when I came home from the hospital. Also I had a long list of restrictions of what I could and couldnt do so the hip wouldnt pop out. For six weeks I had to sleep on my back couldnt cross my legs and wasnt able to drive. After the second I didnt take any pain pills once I was home slept on my side soon after the surgery had almost no rules and drove my car in two weeks. I even wanted to ski over Christmas because I felt fine Machol says. Koeppel is a writer based in Washington."