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It is logical that implanting the artificial joint implants with minimal collateral damage to the soft tissues and bone is desirable for quicker healing and a better outcome. The problem is that smaller incision surgery is more complicated for the surgeon and can lead to more errors if the surgeon does not have the necessary technical skills. Therefore scientific studies have sometimes shown worse outcomes for minimally invasive surgery. Many claims for quicker recovery with certain techniques are not substantiated by results. In this arena it is impossible to make general claims of superiority of any technique. Results more dependent on the individual surgeon than the specific technique. You must carefully look at an individual surgeon’s published track record to make a judgment.

When we started performing minimally invasive resurfacing, we compared our results to our previous outcome with larger surgical approaches and found them to be superior without any higher risk of complication and published this. We have used a minimally invasive posterior approach for all hip surgeries since 2005.

Most hip resurfacings in the world are performed through a large posterior approach using a 8-12 inch incision. I use a minimally invasive 4-5 inch approach.

The next most common approach is the anterolateral approach. I do not prefer this approach because it requires detachment of a portion of the abductor muscles. Sometimes these don’t heal perfectly leaving a permanent limp and this is hard to fix later. There is no scientific study to prove my opinion on this matter.

The direct anterior approach has become fashionable in total hip replacement. The claim is a lower dislocation rate and a quicker recovery. There is some evidence to support the first claim for small bearing total hip replacements, but if large metal bearings are used, the dislocation rate is almost zero through a posterior approach. The claim of faster recovery is not supported by evidence. I believe the mini posterior approach has a similar recovery rate. There is now one published paper on hip resurfacing through a direct anterior approach Dr Paul Beaule reports a 93% 10-year implant survivorship with this technique, while I report a 99% 17-year implant survivorship with the mini posterior approach. Additionally, I know several surgeons who have used this approach and I am aware of three presentations at meetings. One did not give data, the other two had a very high rate of early complications. For now I think we should stick to the proven method.

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Adequate pain management is absolutely essential to allow rapid recovery of patients after joint replacement surgery. With modern protocols, most patients have minimal pain postoperatively and can progress rapidly with learning their rehab program. They can now routinely have outpatient surgery without a hospital stay. A hospital stay is no longer required for adequate pain management.

It is best to minimize hospital time to avoid complications. A stay in the rehab unit after hospital discharge is totally unnecessary, except for selective elderly or severely debilitated patients who have no family support at home for one to two weeks. Even privately hiring a home health aide is preferable. Rehab/hospital stays expose patients to additional risks in my opinion.

A multi-modal pain management system decreases narcotic requirements and results in less pain with fewer side effects. Significant pain postoperatively is now generally only experienced by a small percentage of patients with a low pain tolerance or by patients that are already habituated or addicted to prescription narcotics before surgery.

There is a safety limit to narcotics that can be administered postoperatively. With the following multimodal pain management program, we can usually eliminate most pain postoperatively without reaching this limit.

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Multimodal Pain Management Protocol

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We begin by checking the hemoglobin well before surgery. If you are a non-local patient, you must be sure there is no delay in getting your hemoglobin level to us; otherwise you prevent us from fully implementing our protocol. Too often patients and their primary care physician don’t send this information promptly. You are responsible for making sure this happens, we cannot chase down your physician.

As soon as we have the hemoglobin level, a strategy is implemented for maximizing the preoperative level. We also recommend eliminating all bleeding agents before surgery. During the operation numerous strategies are employed to reduce blood loss. Postoperatively we have a transfusion trigger of hg =7. Using this protocol our transfusion rate is lvery low. I have not transfused any patient in over 10 years.

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Comprehensive Blood Management Protocol

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We have shown that people who are obese (BMI>29) or who have low bone density have a higher risk of early femoral failure (fractures and head collapse). Therefore all patients have a DEXA scan and a Vitamin D level checked preoperatively. also I now recommend routine hormone testing. For men both free and total testosterone; for women estrogen, progesterone and testosterone.

Uncemented components are used exclusively, Vitamin D is supplemented as needed, biological sourced (algae) calcium is recommended and special postoperative protocols are instituted based on DEXA bone density numbers and BMI.

Using these methods, risk of early femoral failure has been reduced below 0.2%. We are now also applying these protocols to stemmed total hip replacements in an effort to reduce our previous femoral fracture rate of 1.5%.

Learn more about Bone Health & Hip Resurfacing

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Bone Health Protocol for Hip Surgery

Full Bone Health Protocol

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A rapidly progressive, yet simple rehab program is made possible by minimally invasive surgery, low blood loss in surgery, good pain management and a stable implant that is unlikely to dislocate. However, some patients with weak bone conditions require a modified slowed-down version of this program to reduce their higher fracture risk.

Our therapist or trainer will teach you all the necessary exercises and give them to you in writing prior to discharge. They are very easy for phase I (first 6 weeks), basically a walking program. I DO NOT PRESCRIBE any therapist visits after discharge. At 6 weeks we progress to phase 2 of the program. At 6 months full activity including sports are allowed.

If you see me in the office at the 6-week follow-up, we teach you and give you the written protocol. If you choose remote follow-up, you will need to visit a local therapist once to learn the program. Regular therapy visits are not helpful, except in rare unusual circumstances. The exercise program is very easy to learn and follow.

However, if you have a strong desire, I will give you a therapy prescription after 6 months.

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Rapid Recovery Protocol

Phase 1 Exercises (First 6 Weeks)

Phase 2 Exercises (6 Weeks – 6 Months)

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Blood is supposed to clot in a wound to stop bleeding. But sometimes the body’s clotting mechanism overreacts and harmful clotting occurs in the major veins of the legs. This becomes dangerous if the leg clots break off and travels to the lung (pulmonary embolus). It is well-known that this sometimes occurs after major hip or knee surgery.

To prevent this, blood thinners are sometimes prescribed after surgery. But blood thinners will decrease normal desired clotting in the surgical wound and can lead to complications of excess wound drainage and infection. It can also cause life threatening bleeding from a previously silent stomach ulcer or even cause a stroke.

Blood thinners are a double-edged sword; while blood thinners prevent harmful clots, they may cause harmful bleeding complications. The level of reactivity of everyone’s clotting system varies widely, but so far, no reliable methods have been demonstrated to quantify this level of reactivity.

There continues to me enormous disagreement among experts about which level of blood thinning is best after surgery. After years of experience we have developed a protocol that results in a rate of wound infection less than 0.1% and a rate of leg clots of less than 1%.

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Blood Clot Prevention Protocol

Blood Clot Evaluation and Treatment Protocol

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Infection in joint replacement is a major problem. The infection rate varies widely among surgeons, hospitals and types of major surgeries. The national deep infection rate for joint replacement is 1-2%. Numerous factors affect this rate. Revision surgeries carry a higher rate of infection. Transfusion increases the infection rate. Patient factors such as obesity, diabetes, smoking and various immune suppression conditions or medications increase the rate of infection. Long hospital stays and rehab facility stays increase risk.

The factors influencing the rate of infection are really too numerous to elaborate on here. You can check databases to get estimates of infection rates at various hospitals, but you cannot discover the infection rate of individual surgeons. Medicare keeps data on the 3-month infection rate for hspitals. Generally smaller hospitals with less severely ill patients and outpatient surgery centers have fewer resistant bacteria floating around.

If common minor wound problems are not managed correctly deep infection can result. In the past, most surgeons believed that deep infections around implants could only be cured by removing the implant and later reimplanting another implant after the infection was cured. I have been curing many of these for years successfully without implant removal. Now there is mounting evidence from many sources that this can be successful in a high percentage of cases. If aggressive treatment fails, or if a chronic well-established infection is present, implants still need to be removed.

It is very difficult to study infection because the diagnosis and time of onset is not always clear. Therefore we arbitrarily declare that any deep infection diagnosed before 3 months is an acute perioperative infection. It is thought to be directly related to the operation, but we never know for sure. Bacteria can fall into the wound (there is actually no such thing as a truly "sterile" operation) or they can crawl into the wound that has not yet sealed postoperatively. Also, I would consider any infection that is diagnosed after 3 months in a patient who has had ongoing minor wound problems prior to 3 months as an acute perioperative type. However, these are not typically captured in the data reported to medicare. Medicare rates are therefore falsely low. Therefore when this is studied, we also sometimes consider any infection diagnosed by 1 year postoperative as acute perioperative. But these would be falsely high because some later infections after the wound has sealed uneventfully could have spread through the bloodstream from another site in the body.

The benchmark mean 3-month infection rate for hospitals is approximately 1%. There is no official surgeon specific data.  The estimated (not oficially reported to medicare) 1-year infection rate in independent studies is 2.5%. My personal 3-month infection rate in the last 10 years is 0. My 1 year rate is 0.06% (Patienteducation/latest data). These fare far below the benchmarks listed. I would argue that an individual surgeons infection rate is much more important to know than the rate in a given hospital. But most surgeons don’t even keep such data, much less publish it. In addition, the few infections that I do see are usually cured without loss of implant (Patient education/ scientific publications). Perioperative infection is a serious complication that is under the surgeons control. I have managed to drive this problem far below the reported benchmark reates, but not to zero.

There is also another category of infection that lies completely out of the control of the surgeon. These are late hematogenous infection (after 1 year). Infection can travel from distant sites to the artificial joint and set up shop. Fortunately these are very rare, I would estimate far less than a 1% lifetime risk. But good data is missing. Less frequently these can be cured without implant removal if the patient is diagnosed in a timely fashion and has not developed a chronic established infection. It is still a challenge.

In my opinion, deep infection of an implant is the single worst complication that a patient can suffer after joint replacement. Fortunately, in my hands, this problem has been nearly eliminated. But the rare cases where this still happens are still an immense challenge to treat.

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Infection Prevention Protocol

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I want to make sure that all of my patients are functioning well. No joint replacement operation is perfect. Complications and failures do occur. I want to know about all major complications and failures, so that I can help you and so that I can continue to learn and improve my methods for future patients. If you have a complication or failure treated elsewhere, I want to know all the details about this occurrence.

On several occasions, patients have had incorrect treatment recommended by other surgeons who are misinformed about resurfacing, therefore, please consult with me before you have another surgeon treat your resurfaced hip. My published success rate with revision of hip resurfacing is 96% at 6 years. This is almost as good as for primary surgery. In contrast, many major centers report high failure rates for these revisions (Oxford has published a 50% failure rate for adverse wear related revisions).

The best medical standard is to perform routine follow-up on all joint replacement patients. Many failure modes cause significant symptoms. But some problems are relatively silent. Due to our extensive experience we have developed surveillance protocols to discover problems early, as well as knowledge to properly diagnose the causes for problems.

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Follow-Up Protocol

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All artificial implants will wear at the moving bearing surface. A low level of any type of wear particle is usually well tolerated. Total hips also have a morse cone connector between the ball and the stem that corrodes and liberates debris. Corrosion or excessive wear  of any artificial bearing can lead to failure and may require revision surgery.

Plastic bearings

Plastic bearings release plastic particles that mostly accumulate around the local implant area and can cause bone destruction called osteolysis. These particles cannot be measured in the blood. Wear is best assessed by appearance on routine follow-up x-rays.

Ceramic bearings

Ceramic bearings exhibiting abnormal wear chiefly fail by causing loud squeaking. Soft tissue or bone reaction is rare.

Metal bearings

Metal bearings release cobalt and chromium particles that are deposited in the local tissues. They are absorbed in the blood and excreted in the urine. Wear cannot be determined from x-rays. The wear rate can be gauged very reliably from blood ion measurements.

We have learned that implant design flaws (DePuy ASR recall) and certain implant positions can cause abnormally high wear rates. High wear rates result in larger particle overload of the local tissues that causes pain and swelling. We call this an Adverse Wear Related Failure (AWRF). It is diagnosed by a triad of findings: high ion level above 15ug/L, a steep cup position (acetabular inclination angle AIA), fluid collection or inflammatory mass on MRI/CT, and extensive metal debris in the tissues (metalosis) seen at the time of revision surgery. We can screen for this problem by checking ion levels in the blood.

Extensive scientific studies of this problem have allowed us to determine safe implant positions to prevent this problem. We have had only 10 AWRF in over 7000 cases  and have not had a single case in surgeries performed since 2009. But we still advocate a monitoring protocol for early detection.

There is a period of run-in wear that lasts from 1-2 years, thereafter levels steadily decline in most patients, except those that have AWRF. Systemic harm such as cancer has been disproven in multiple studies. Neurologic signs such as neuropathy, tinnitus, hearing loss, or visual disturbances have rarely been seen with levels above 20ug/L. Heart damage has been rarely anecdotally reported at extreme levels well over 100ug/L. 80% of patients that I have measured show a normal level for patients without implants (<1.5 ug/L). 19% show a slightly higher level. Less than 1% have levels above 20ug/L; none since 2009.

Metal ion release is a double edged sword. If the levels are extremely high they can be damaging. But low levels have not been shown to be harmful. In fact, metal-on-metal resurfacing patients have a far lower all-cause mortality than matched THR patients at 10 years reported in 5 studies to date. There does seem to be something life-preserving about a metal on metal hip resurfacing when compared to a THR. But many "thought leaders" in THR refuse to acknowledge this scientific data and still try to create a climate of fear around metal bearings and ion release. In fact studies on Total Knees show higher mean cobalt levels than in metal-on-metal hip resurfacing, but this paradoxically is not at all concerning.  But when metal ion levels are high in hip resurfacing this can alert us to excess wear so that we can take action much sooner than corrosion or wear cases in standard THR where no blood markers are reliable.

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Metal Ion Testing Protocol

The preferred method for performing most joint replacement operations is in the outpatient setting.

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We have pioneered outpatient joint replacement surgery at Midlands Orthopaedics and Neurosurgery. We began in 2012, as one of the first groups in the country, and have performed thousands of joint replacements of all kinds in the last 10 years. We have now perfected this to the point that most of my joint replacements are done as outpatient procedures. Some less complex revision surgeries are now also done as outpatients.

Local patients go home several hours after the operation and follow up with me in the office 1 week later. Out-of-area patients go to a hotel instead where I see them the next morning before they begin their drive home. Patients flying home are advised to spend a second night in the hotel before flying. Only patients with more complex operations, certain serious comorbidities, or those with uncooperative insurance plans are still done at the hospital.

Most patients who have had one procedure done at the hospital and another as an outpatient much prefer the latter. The outpatient approach is safe, convenient, friendly, less costly, and avoids exposure to hospital infections. One requirement to qualify for outpatient surgery is to bring a capable and responsible caretaker (family or close friend at least 18 years of age) with you.

When I trained in Orthopedics at Johns Hopkins over 30 years ago, it was routine to keep patients in the hospital for 2 weeks and then send them to a skilled nursing center for another 2 weeks. Now we perform the surgery outpatient, with the patient going home several hours after surgery. Usually, patients are off narcotics and can drive in 3-5 days and return to office work in 1-2 weeks. Most of the country is following our lead and the process has accelerated during the COVID pandemic. What has led to this development? There are numerous factors, both traditional, clinical, and economic that are responsible.

The three most common reasons that joint replacement patients have traditionally required a hospital stay are: managing blood loss, controlling pain, and monitoring those with major medical comorbidities. In the first 20 years of my private practice, I gradually improved the process of joint replacement to the point where we were only routinely keeping patients one night in the hospital. For years none of them required transfusions even after bilateral surgery and pain control was so good that few needed anything but oral medication.

Our Group owns a surgical center where we had been performing outpatient orthopedic surgery of all types very safely and cost-effectively for years. In 2012, we made an agreement with one of our major insurers to begin moving joint replacement and spine surgery to our center. Over time we have continued to gradually expand the indications for outpatient surgery and have compiled an excellent safety and patient satisfaction record. We now control the entire patient experience and no longer need to depend on an inefficient and overpriced hospital partner to implement changes.

I have not had to transfuse a primary joint replacement patient in over ten years. Improved minimally invasive surgical techniques, careful preoperative preparation, tissue sealers, tranexamic acid, platelet concentrate with thrombin, irrigation with epinephrine solution, and selective use of cell savers have all contributed to eliminating the need for transfusion. Only a few years ago the national transfusion rate for joint replacement was in excess of 30%. Mine has been zero for over 10 years.

Pain management has also dramatically improved in the last 2 decades. Multimodal pain management starting preemptively with a combination of maximum dose Tylenol, anti-inflammatory meds, ice therapy, platelet concentrate, long-acting local anesthetic injections, and oral slow and fast-release oral narcotics has totally changed the surgical experience for patients. Using short-acting blocks (spinal, lumbar plexus, or femoral-sciatic) that wear off quickly after the surgery means patients usually do not experience much pain in the process. While the block is wearing off in the recovery room the nurse slowly dials in any required narcotic. With an anesthetic block, this transition out of surgery is usually quite smooth and is the last time injectable narcotics are required. Patients are able to walk out of the surgery center and ride home very comfortably after several hours. Narcotics are usually only required for 3-5 days for hips and 2-3 weeks for knees. Patients with certain comorbidities can sometimes be accommodated with an additional overnight observation period in our center. If the comorbidities are too severe, the surgery must still be done in the hospital.

Infection is one of the worst complications to arise from a joint replacement. Despite our best efforts, no operation is truly sterile. Some bacteria enter the wound during every surgery. Usually, the human immune system can eradicate these and prevent infection. If an artificial implant is present, it is harder for the immune system to do its job.Then, after the surgery, it is a race for the skin to totally seal and prevent bacteria on the skin from entering and creating an infection. An infection that develops by one of these two methods is called a perioperative infection because there is no way of knowing exactly how the bugs got in. Hospitals and surgery centers are required to report to the government any joint replacement infections that develop by three months postop. This captures many perioperative infections, but really a year is needed to be sure.

Rarely infection can still spread to the joint at any time in your life from an infection elsewhere in the body through the bloodstream. Infections that occur after 1 year are late infections; they are NOT perioperative. They are not caused by the operation itself and are not under the control of the surgeon. Fortunately, they are rare. I estimate a lifetime risk for late infections is well below 1%.

We focus on the 3-month and 1-year perioperative infection rate because the surgeon has control of this. The 3-month perioperative infection rate at our center is well below 1%. My personal 3-month rate in the last 10 years is zero. You can find 3-month but not 1-year online data for any hospital but not by surgeon. From scientific studies, we estimate that the national benchmark 1-year infection rate is approximately 2.5% and growing. Hospitals and surgery centers don’t collect this data. My personal 1-year rate for the last 10 years has been 0.06%. One factor that allows me to have a 1-year infection rate 25 times lower than the national benchmark is the fact that this surgery is performed mostly at a surgery center (where I have ownership control) and not a hospital where sick patients bring in lots of bacteria.

The cost of doing joint replacement at a surgeon-owned outpatient center is lower in our center and across the country. Hospitals all across the country have spent the last two decades consolidating into huge hospital groups that own most doctors’ practices. This process has been accelerated by the Obamacare rules. Hospitals have largely been successful in creating near-monopoly positions in most markets and have used this leverage to dramatically raise prices.

At the same time, government rules (certificate of need, CON) make it nearly impossible for anyone to build a new independent hospital to challenge the hospital monopoly. But the advancements that have allowed us to transition major operations to an outpatient center have allowed independent (not hospital-owned) surgeon groups like ours to challenge this hospital stranglehold.

As this trend accelerates, we hope that more surgeons are lured out of hospital employment and start their own outpatient programs. Also because of CON rules it is difficult but not impossible to build new outpatient centers. But, as surgeon-owned outpatient centers proliferate, the cost of surgery will go down while the quality rises as we have shown in our center. The free market in medicine has been severely distorted by crony capitalism driven by government regulation and hospital consolidation. All aspects of the medical system need to be reformed to promote transparency and competition. Hospitals and their employed surgeons at major medical centers have fought this development, but the value proposition for the patient and their insurer is too strong. This new model is growing rapidly. We are proud to be one of the first groups in the country to pioneer this approach.

The CON has recently been abolished in SC! This means that surgeons no longer face any restrictions in building and expanding outpatient surgery centers. But unfortunately we are still restricted in building hospitals by the Obamacare legislation. Non-physicians can now build hospitals, but doctors cannot. This rule was inserted into the Obamacare legislation at the request of the hospital association so they would not have to face competition. Currently, hospitals can own doctors but doctors cannot own hospitals. We urgently need both models to coexist and compete so that the patient will be able to benefit from the best price/quality proposition. We assert that hospitals run by professional administrators offer poor quality and high prices. As soon as this anticompetitive Obamacare rule is recinded, we will build an orthopedic hospital and take our competition with the overpriced monopoly hospital systems to the next level.

Insurance contracting is complex and byzantine. But I will give an example using approximate numbers. The total cost for joint replacement at our center is $28,000 with one major insurer. This insurer posts on its website that the cost at the three major hospitals in the Columbia metro area is $35,000, $45,000, and $60,000. There are other hospitals in the country where the cost can be as high as $100,000. Discovering the actual cost and comparing hospitals in advance of your surgery is very difficult, despite executive orders from both Presidents Trump and Biden requiring hospitals to post this information. Most hospitals flagrantly violate this law, and the government has not instituted meaningful penalties to force them to comply.

We urgently need the federal government to do its job to enforce the recent executive order for price transparency so that all patients can make cost comparisons in advance. Transparency is critical to restoring a damaged free market system; transparency would allow patients to drive quality up and prices down.

Costs for joint replacement vary widely and are difficult to compare. Unfortunately insurance companies have forced us into such complex contracts that quoting a price is almost impossible.

I can give you a rough estimate of costs. An episode of care cost for joint replacement is the total amount paid to all providers for the service over a 120-day period.

An episode of care cost for joint replacement is the total amount paid to all providers for the service over a 120-day period.

For Government plans, this is about $12,000.

For Blue Cross at Providence Hospital NE (the hospital where I operate), this is $35,000.

For outpatient surgery at our surgery center, this is $28,000.

At the other two major hospital systems in our metro area it is: $45,000 at Palmetto Health and $65,000 at Lexington Medical (from the Blue Cross website).

At some hospitals in this country, the cost is over $100,000. Depending on your insurance contract, you will pay some portion of this.

For more information, please see the section on Fees and Insurance.