Robert Saunders, a nurse at Alta Bates Summit Medical Center in Berkeley, Calif., sees about 200 hip replacement patients a year. He says that “nurses love the anterior approach” because there’s 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 can’t,” 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 who’ve had the posterior procedure have a lot of pain, since, when they sit up, they’re right on top the incision,” he explains.
Patrick Kennelly, a physical therapist with Smartherapy in Chevy Chase, says people who have the anterior procedure “don’t feel so weak, because their hip muscles haven’t been cut. If they’ve had the posterior procedure, even if they don’t consciously feel weak, they tend to shift their weight onto one foot and teeter like [Charlie] Chaplin.”
Given benefits such as these, why haven’t 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 high-stress, high-liability 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 peer-reviewed paper he presented at the 2012 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 20 cases. Others say it took about 50 cases.
And this creates economic issues. “If you’re a busy surgeon, you have a volume to maintain,” Bollinger says, “and it’s 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 it’s 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.