Total Hip Replacement

A hip replacement is my favorite surgery to do and I have done thousands.

The procedure removes the worn ball and socket from the Hip and puts in artificial ones. Most of my patients stand and walk the same day, go home that day or the next. The pain from the arthritis is gone immediately after the surgery and the surgical pain gets better with time.

Patients are significantly better in the long-term and are extremely happy without outcome. Running and jumping never go back on the list. National records show a little over six in ten still in place at twenty-five years. Below: who I operate on, how I do it, and where it can go wrong.

The two parts of a replaced hip. Look at how the shell sits in the socket of the pelvis and the stem sits inside the thigh bone, together reproducing the ball and socket you were born with.

What I want you to know before you decide

Hip replacement is among the most reliably satisfying operations in modern surgery, and yes-it is still an operation. An extremely small number of patients have a complication, and I am not going to tell you otherwise, because a surgeon who claims never to have had one is either not operating enough or is not being straight with you. What I can tell you is that my outcomes have been excellent in my hands.
What I will not do is sell you an approach because it is the newest one. The approach matters considerably less than whether the hip finishes in the right position, at the right length, and stable.

Here is what most Patient get wrong-

What also matters far less than most people think is the length of the incision. Skin heals side to side, not lengthwise. What really matters is what was done after cutting skin. How less invasive the procedure was after cutting the skin is what matters for minimally, invasive surgery or less invasive surgery whatever you want to call it.

Who this operation is for

The patient who gets the most from this in my hands is the one whose hip has taken something out of their life, whose examination and film agree, whose medical conditions are controlled, and who has a realistic understanding of what they are getting into. Age sits far down that list.
I replace hips for wear arthritis, for inflammatory arthritis such as rheumatoid disease, for a femoral head whose blood supply has failed (we call it avascular necrosis), for certain fractures of the femoral neck, and for hips that never formed properly, which is developmental dysplasia. That last group are usually younger, often female, and often have a leg they have known was short their entire life.
Patient having avascular necrosis of the hip are also significantly younger than patient who have degenerative hip arthritis.

Where my line sits on the grading scale-this is something I hardly care about.

Occasionally your report will probably carry a Kellgren and Lawrence grade from zero to four.

Most patients I replace a hip in are grade three or four. But I do not operate on a grade, and I want to be explicit about that. A grade four hip in somebody who is managing their life does not get replaced in my practice. A grade three hip in somebody who cannot sleep, cannot work and has exhausted the alternatives does.

Very rarely x-ray shows very minimal arthritis in the patient is significantly symptomatic for it. Those hips get replaced. These are the hips that also get advanced imaging like MRI of the Hip and the spine. If there is any suspicion about where the pain is coming from, which is extremely rare, I inject the Hip joint with a local anesthetic, and if the pain is gone, it tells me that the pain was coming from the hip and not from some other body part like this Spine.
The grade also sometimes disagrees with what I find inside the joint.

I treat patients. I do not treat radiology reports.

What has to happen before I book you

What surgery costs and how approval works

I cannot publish a dollar figure that would be true for you. What it costs depends on your insurance plan, your deductible, your out-of-pocket maximum and whether the hospital and I are in network for you, and a number on a webpage would mislead most readers.

What I can describe is the process. Nearly every insurer except Medicare requires prior authorization for a hip replacement, and nearly every one requires documentation that conservative treatment was tried and failed. In practice authorization commonly takes a few weeks once the documentation is complete, and it is slower for no reason at all and as ridiculous as this sounds. The insurance company is to blame for that delay.

For workers compensation insurance the process is different and of course, your timeline is influenced by people who are not in the room with us. What I control is the paperwork: my note is completed before you leave the examination room and transmitted the same day, including to the state board. In New York an injured worker may choose any physician authorized by that board.

Getting back to work, and what full duty means for your job

The gap between light duty and full duty is where most of the difficulty sits, and it is bigger than patients expect. Light duty usually means back at the workplace doing a restricted set of tasks. Full duty for a police officer, a firefighter, a transit worker or a tradesman means being able to do the hardest thing the job might demand on its worst day, and that standard is set by the employer rather than by me.

Those roles almost always require a formal fitness for duty or functional capacity assessment, and it is carried out by an occupational medicine physician, not by me. My part is the operative record, the examination findings and a signed opinion on what is safe, and that paperwork leaves my office on the day it is asked for. Say at the first visit if there are three flights to your door, platform stairs on your commute, or a hard standard at work. With notice those are logistics. Without it they are obstacles.

Why I prefer a spinal, and the back pain myth

I prefer regional anesthesia, which for a joint replacement usually means a spinal, over a general anesthetic. The reasons are pain control that carries through the early hours, a reduction in the risk of blood clots that has been demonstrated repeatedly against general anesthesia, less nausea, and a patient who is mentally clearer afterwards and can be stood up sooner.
The anesthesiologist sedates you before placing the spinal, so in practice most patients barely register the injection itself.

There is a persistent belief that a spinal anesthetic causes back pain afterwards. There is no good evidence to show more long-term back pain after a spinal than after a general anesthetic. What I offer beyond that is my own explanation rather than a published finding, and it goes like this. A great many people coming for a hip or knee replacement have a sore back as well as a sore hip joint. The joint is shouting so loudly that the back is drowned out. We replace the joint, the joint pain stops, and what is left in the quiet is the back pain that was there all along. It gets blamed on the spinal needle.

When you wake, the leg is numb and heavy, and that feels strange. You will be asked to wiggle your toes. Once the strength returns, a therapist gets you up with a walker.

The moment most patients remember is the first time they put the foot on the floor, because that is when they notice the arthritis pain is gone. What is left is surgical pain, which is a different thing and it fades.

Front or side: which way I go into the hip. The anterior (front) approach of the posterior (side) approach.
Most of the time, I go in from the side, with you on your side and the operative hip uppermost. I moved away from doing this routinely from the front, and I would rather tell you why than leave you to work it out from the fact that I do not offer it to everyone.

Three things moved me from doing the approach in the front in most patient-and I did that once upon a time.

The first is that nerve that crosses across the incision made in the front. Injury to it does not weaken the leg, but it leaves numbness over the outer thigh. While most patients do care about it, it’s a significant finding on examination. It is also something that does not go away. And it is unpredictable. A patient once told me that he had trouble feeling the keys in his pocket that he was used to before the surgery and he actually had to put his hands in his pocket to check whether the keys were in!
For patients who get done anterior hip replacement where the incision is made from the front, their advised of this numbness.

The second is trouble with the wound at the top of the incision in a patient who carries a fold of abdomen over it.
The third is that a wide pelvis needs a longer exposure from the front than a hip, which is not wide. A wide pelvis makes it difficult for the instrumentation to reach the thigh bone from the front.

None of that makes the front approach a bad operation. It is one approach that is heavily marketed by the company that makes the table to help with the anterior approach.

The approach matters considerably less than whether the hip finishes in the right position, at the right length, and stable.

This is one of my patients who had an anterior hip replacement.

The hip replaced from the front, which is the approach discussed above. Look at how the incision sits on the front of the thigh rather than over the side of the hip. Video from my own practice, published on the Complete Orthopedics channel

How I actually do this operation- the minimally invasive posterior approach.

You are on your side with the operative hip facing the ceiling. The incision runs over the side of the hip. I tell patients it is as small as possible and as large as needed. I will not compromise the result for the length of the scar. I never promise anybody the length of the incision because the body sizes differ, the size of the bones differ, and there are so many other variables.

The large muscle over the buttock is split along the direction its fibers already run rather than cut across, because muscle split that way heals back. I go between the muscle fibers. I do not cut the muscle. Beneath it lies a group of short muscles running across the back of the hip. I tagged them with sutures because I am going to repair them at the end. The capsule is opened as a flap and preserved for the same reason.

I dislocate the hip and cut the neck of the femur at the level I planned days earlier off the x-ray, measuring from the lesser trochanter. This is one of the moments where the preoperative planning is very important.
The labrum is removed completely. That is part of the exposure and it gives me clear access to the whole rim of the socket.

Then the socket. I ream in two millimeter increments, and what I am watching and feeling for is the change when the reamer stops cutting soft gray worn bone and starts biting into firm bleeding bone. That transition is the whole thing. Ream past it and the socket is too large and the shell will not grip. Stop short and the shell is sitting on dead surface. I look directly into the socket after every pass. I also check the depth against the “teardrop” and the medial wall on the film, because those tell me how far in I am.

The shell goes in one millimeter larger than the last reamer so that it grips. I open up the “mouth” of the cup to decrease the risk of the cup fracturing. After placement of the cup, I add a screw for additional stability. Then the liner.

For position, my key landmark is the “transverse acetabular ligament”, the band that runs across the bottom of the socket and is continuous with the labrum. Lining the face of the shell up against it sets the version reliably, patient by patient, rather than against an average. I check the back edge of the shell which is typically at the two o’clock position, and I check on the film how much of the shell sits out over the lateral wall of the socket, which matters particularly in a dysplastic hip where there is less bone covering it.

Then the femur. I open the canal and broach it in increasing sizes. Here I am listening as well as feeling the bone. Each strike of the mallet on a broach that is still advancing gives a dull sound. When the broach stops moving and the pitch rises and rings, it is seated. That change in sound is what tells me the stem will be stable. This is important detail to decrease the risk of breaking the thigh bone.

Then trial components go in, the hip goes back, and I test it. I take the leg through a full physiological range of movement, including the positions in which a hip dislocates, and I watch what happens. I lay the legs together and compare lengths against the other side. If it is loose, short or long, I change the neck length or the broach size and I test it again.

I then bend the knee after putting in the trial components to look at the tension in the muscles. If the tension is too much, I recheck everything till it is perfect.

I do not leave the operating room till everything is perfect. I have never once left an operating room thinking that something would probably be fine later. It is never fine. I have to be hundred percent comfortable with everything before walking out.

The real components go in and then I repair. The short muscles and the capsule flap are sewn back to bone through drill holes, using a straight needle that my scrub team loaded with suture before the incision was made, so that nobody is threading a needle while the hip is open. Skin to skin, a straightforward primary hip takes me about an hour.

Part of my hip instrument tray, laid out before the incision. Look at the broaches in ascending sizes, the canal finder, the acetabular reamer and the retractors: everything that can be assembled before I start is assembled before I start.
A photograph from my own operating room. Identifying information and the embedded file data have been removed.

Where a surgeon can get this wrong

A surgeon can go wrong at numerous places. I am mentioning only a few here. Cup position is the first place. If the shell goes in too vertical, the load concentrates on the rim of the liner and the polyethylene wears faster than it should. If the version is wrong, the hip is at higher risk of dislocating and of “impinging”. Neither error announces itself on the day. They announce themselves years later, which is exactly why I use a landmark that belongs to the patient rather than an average angle.

The second place is seating the stem in a femur whose bone is soft. Push a broach into osteoporotic bone with force and the femur can split. The warning is a change in feel before there is any change in appearance, with the broach advancing more easily than it should. When I feel that, I stop and look, and if the bone is that soft I change what I am doing.

The third is leg length. This is why I do preoperative planning and intraoperative checks

Surprises in the Surgery-there are none

There is never an instance where there is a surprise interoperative. I do thorough preoperative planning.

The x-ray is two dimensional while the hip is three dimensional. That’s why we take two views of the Hip on x-ray.
The x-ray cannot clearly determine the quality of the bone-whether it’s soft or good quality and that’s an interoperative assessment.

How much to broach. How much to ream. How much to cut the bone. What sizes to use. These are interoperative decisions, combined with preoperative planning.

I always insist on having a Implant representative who is extremely familiar with my steps so that there is no delay in opening. The implants are assembling the instruments at the backend.

Very rarely during a complex revision case, I may ask for something which is not in the operating room and the nurse has to get it. It could be additional bone graft or a different kind of “burr” based on an intraoperative decision.

What I put in, and the bearing surfaces that lost

For primary hips I currently use a Zimmer M/L Taper stem, the standard cementless version rather than the modular-neck variant, and a G7 acetabular shell. For the bearing I use a ceramic head on a highly cross-linked polyethylene liner.

I am not a consultant for Zimmer or any other implant company. I use the implants that I feel are best for my patients.
I’m also not paid by any hospital and I choose the facility which I feel is best for my patient. There are some facilities that do not give enough surgical assistance. Some facilities that do not allow me to use the implants that I want to use in my patients. I’m not employed by anybody and I have the Freedom to choose the facility and Implant that I love for the best successful outcome of the surgeries that I do electively.

The parts named above, shown on a model. Look at the ceramic head sitting inside the polyethylene liner, and the porous coating on the stem, which is the surface bone grows into. A teaching model fitted with the implant components, photographed for this practice.

That bearing choice is deliberate, and the alternatives lost for reasons worth stating.

The head size is chosen to give stability without the shell overhanging. A larger head is harder to dislocate, which is why I favor it where the socket allows.

The outer surface of an acetabular shell. Look at the rough porous coating, which is the surface bone grows into, the holes that take a screw where I need extra fixation, and the grooves inside that lock the liner.

Where the robot sits in my hip practice

I use robotic assistance when there is a reason to, and not by default.

A robotic system executes a plan built from a scan and from points a human registers on the bone during the operation. If those inputs are off, the machine delivers an inaccurate plan very precisely, and it delivers it with a number on the screen that makes everybody in the room more confident. Poor input, poor output. Garbage in garbage out!

Where it earns its place is a hip whose landmarks are missing or misleading: a socket deformed by childhood hip disease, a previously operated hip, a case where judging anatomy will be unusually difficult etc.

What it has not been shown to do is make the average hip replacement last longer or feel better-at least not clinically proven with long-term studies as yet. It does place components inside a target range more consistently, which is real. But an operation planned properly off the films, reamed under direct vision, referenced to the patient’s own transverse acetabular ligament and tested through a full range before anything is committed is already accurate.

I have written about this at greater length on my robotic hip replacement page. Baba.

How I handle your pain

A spinal anesthetic wherever possible, local anesthetic placed around the joint before I close, and a combination of medications afterwards so that we are not relying on any single drug. Acetaminophen and an anti-inflammatory around the clock in patients who can take them, with a stronger tablet available for the first stretch.

My aim is to have you off strong pain medication within about two weeks. Patients who were taking significant doses beforehand take longer, which is why I want that addressed before the operation.

Two practical points that cause more misery than anything technical. Make sure the pain prescription is filled and physically in your hand before you leave the hospital, because strong pain medication cannot simply be telephoned in: it has to be checked against the state prescription monitoring program first. And take a dose before you get into the car, whether you are going home or to a rehabilitation facility, because a facility may need an hour or two to admit you and approve your medications and I do not want you spending that hour in pain.

The risks, stated honestly

I would like to be able to tell you there are no complications. I cannot. What I do is sit down with every patient and name them.

Infection is the one I take most seriously, because it is the one that turns a good operation into a hard year. I have not had a deep infection so far. I did have a superficial infection once that was addressed immediately.

One hip replacement patient of mine developed an infection. I washed the hip out and exchanged the liner, and in the long term that patient did very well with that single procedure. When something goes wrong, the response has to be immediate.

Injury to the blood vessels and nerves around the hip is genuinely rare, and I name it anyway, because a risk you were not told about is worse than one you were. I have never had one.
The realistic worst outcome is a deep infection requiring the implant to be removed, a period with an antibiotic spacer, and a second reconstruction. It is uncommon, and it is the reason for every precaution on this page: the blood sugar threshold, the dental rule, the three months after an injection, and the insistence on a properly staffed room.

How I prevent a clot reaching the lung

I gave a lecture on “Thromboprophylaxis after joint replacement” in 2009 and my position has not changed much since, so let me set out the reasoning rather than just the prescription.

The thing that kills people after joint replacement is not a clot in the calf. It is a clot that travels to the lung. Those are different targets, and a great deal of the guidance written on this subject is built around preventing clots in the calf, which is an endpoint I do not think matters as much as it is treated.

Before the surgery, I evaluate the risk of developing blood clots. A discontinue medications that cause increased risk of blood clots. Multimodal prophylaxis includes decreasing the increased risk of coagulation, decreasing the injury to the vessels and decreasing the risk of stasis.

So I use a multimodal approach rather than relying on a drug to do all the work. Regional anesthesia rather than general wherever possible, which by itself is associated with a substantial reduction in venous thromboembolism compared with general anesthesia. Getting you standing and walking the same day. Ankle pumping exercises, which measurably increase the flow of blood in the femoral vein. Compression. And aspirin.

For most of my patients aspirin is the only blood thinner I use. Stronger anticoagulation goes to patients whose risk is genuinely higher, and to patients who were already taking a blood thinner before they came to me. That is what risk stratification means in practice: the drug is matched to the patient rather than issued to everybody.

I want to be straight with you about where this sits in the wider debate, because it is not unanimous. Large randomized trials have found aspirin non-inferior to strong anticoagulants. Those are published figures across many surgeons, not mine. Potent anticoagulants cause bleeding, and bleeding after a joint replacement means hematoma, wound drainage and a higher chance of infection.

That is precisely why I stratify rather than apply one rule to everybody, and why I customize the treatment for every patient rather than a protocol I hand out.

Why I do not routinely scan your legs afterwards

I do not order routine ultrasound scans of the legs after surgery in patients who have no symptoms. This is not me cutting a corner. There are strong recommendations against routine postoperative duplex ultrasound screening after elective hip or knee replacement, and I agree with it.

The reason is that scanning everybody finds clots in the calf that were never going to cause harm, and then somebody feels obliged to treat them with a drug that carries a real bleeding risk. You have been exposed to the harm of the treatment without the benefit.

If you develop symptoms, that is completely different and we scan you.

The small number of patients in whom I place a filter

In a very small number of patients whose risk of a clot reaching the lung is extreme, I arrange for a filter to be placed in the large vein of the abdomen before surgery, so that a clot travelling up from the leg is caught mechanically before it reaches the lung.

You should know that this is not routine practice and it is not supported by a guideline. Filters carry their own problems, including clotting, migration, and difficulty removing them later. Most patients at high risk are managed with anticoagulation instead, and that is what I do for the great majority.

My reasoning for using one in that small group is specific: it is for the patient whose thrombotic risk is very high and who, for a separate reason, cannot be safely anticoagulated. In that particular situation I would rather accept the known problems of a filter than leave a person with no protection at all. If that is being considered for you, I will explain why in your case, and you should feel free to seek another opinion on it.

If this hip ever fails

A hip replacement can fail, and being told what that looks like in advance is more useful than being protected from the idea.

The earliest signs are worth knowing in your own words. Pain in the groin that comes back after a period of being genuinely comfortable. Pain in the thigh that is worst for the first few steps and then eases. A new limp. A sense that the leg length has changed. Any of those means come back and be assessed rather than wait it out, because loosening and wear are far easier to deal with when they are found on a film than when they are found because the hip has become painful.
A revision is a bigger undertaking than the first operation. The exposure is larger, taking a well-fixed component out without destroying the bone around it is the real skill, and missing bone has to be made up with augments, graft or a longer stem that grips healthy bone further down. Recovery is longer, often roughly twice as long, and weight bearing may be restricted for a period, which never happens after a first-time hip.

And the honest answer on results: a revision usually leaves a patient much better than they were, but generally not as good as a well-functioning first-time hip in the same person. I say that before a revision rather than afterwards.

What this operation will not do

It will not give you the hip you had at twenty. An artificial joint has no capacity to repair itself, which is the single most important thing to understand about living with one.

Some patients find they have trouble tying their shoes afterwards, and a small number never get that back completely.

Impact activity is off the list permanently. Not because I want to restrict you, but because running and jumping shorten the life of the implant. Being active is the entire point of the operation and I want you active. Golf, swimming, cycling, doubles tennis, skiing for experienced skiers, riding for experienced riders: those I support. Running does not go back on the list.

On how long it lasts: the published registry figures are as above, over six in ten still in place at twenty-five years. What makes one fail early is impact and abuse, wear, and infection. What makes one last is a well-positioned socket, a patient who stays active without pounding it, and dental hygiene taken seriously for life.

A television segment on how long a hip replacement lasts, which is the question this section answers. Look at what is said about the patient’s own activity, because that is the part you control. Television interview, CBS2 New York, October 2021. Two minutes and twenty-nine seconds.

Antibiotics before dental work

I ask my patients to take an antibiotic before any dental procedure that works on the gums or breaks the lining of the mouth, and to continue for life. This differs from some guidelines that routine prophylaxis after two years of surgery may not reduce the risk. That option rests on low-quality studies in my opinion, and the guideline itself notes that they did not separate out higher-risk patients among other issues. My reasoning, and the counter-argument stated fairly, are set out in full on my hip replacement recovery page, because the reasoning matters more than the instruction.
Bottom line is, I want my patients to be on antibiotic prophylaxis after hip replacement surgery for the rest of their lives.

What I say when patients ask me these

How many of these have you done? I have been doing hip and knee replacement and revision since 1997 and I have done thousands. Ask any surgeon this and be wary of evasion.

Have you ever had complications after the surgery you performed?
Yes. I do some complex revision procedures that carry a very high risk-like a revision surgery-fixing surgeries of other surgeons. The patient is aware of the increased risks prior to the surgery.
A surgeon who says otherwise is either not operating enough or is not telling you the truth. What I can tell you is that when something happens we are on it immediately. One patient thanked me afterwards for how her complication was handled, and said a complication could have happened anywhere but that it being attended to and fixed immediately was the difference.

Why I may not operate at the hospital that you prefer.
Because I am not employed by a hospital, I take my patients to hospitals where I know I will get the room, the staffing and the implants I have asked for. Some hospitals will not permit certain implants and I find that hard to justify. Some will not provide adequate assistance in the operating room, which I find unacceptable.
I was once asked by an administrator why I needed more assistance than the hospital’s own orthopedic surgeon. My answer was that he does not have a choice and I do.

Will it last my life?
For an older patient, very often. For a younger patient it is a real consideration and I say so. The published figures across national registries suggest over six in ten hip replacements are still in place at twenty-five years, and the lifetime risk of needing a revision is highest in men operated when they are young. Those are published figures, not mine. The worst results are in active patients who abuse the joint.

Would you replace the Hip of your relatives and friends?
Yes. I have replaced my own mother’s hip.

Should I get a second opinion?
Yes, always, and I say so before any surgery. Patients come to me for second and third opinions constantly. You should explore your options before choosing a surgeon.

What I arranged for my own mother

I have replaced my own mother’s hip, so this is not hypothetical.
For a family member-and I would treat no patient any differently-I would want it replaced through a minimally invasive posterior approach, with the patient on their side, without a traction table, planned carefully off the films days beforehand, with a ceramic head on highly cross-linked polyethylene, referenced to their own transverse acetabular ligament, and the leg lengths compared directly before anything was committed.
And I would want them told the truth about the complications beforehand, out loud, sitting down, rather than handed a form.

What I count as a good result

A patient who is completely free of pain. The x-ray is secondary, although in practice the two usually travel together. I treat patients rather than x-rays.

The target is that you stop planning your day around the hip and stop thinking about where you are parking. If you come back at a year and talk to me about a holiday instead of about your hip, that is the operation having worked.

Hips I have replaced, before and after

These are films from my own patients, from case studies published individually on this website. What I look at on each is the same: the position of the shell in the socket, the seating of the stem in the femur, and how the two sides compare.

Postoperative x-ray showing the front and frog-leg side views of the right hip, published on this site as Primary Total Hip Arthroplasty in an 84-year-old female for Hip Arthritis. Look at the shell seated in the socket and the stem running down the centre of the femur.
An x-ray from one of my own patients. Identifying information and the embedded file data have been removed.

Postoperative x-ray showing the front and side views, published on this site as Left Total Hip Replacement in an 82-year-old male. Look at how the two sides compare.

Preoperative x-ray showing the frog-leg side and front views of the left hip, published on this site as Left Total Hip Replacement in a 77-year-old female with Hip Arthritis. Look at how little space is left between the two bones before anything was done.
An x-ray from one of my own patients. Identifying information and the embedded file data have been removed.

Preoperative x-ray of the pelvis, front view, and the frog-leg side view of the right hip, published on this site as Right Total Hip Replacement in a 75-year-old female. Look at the difference between the two hips.
An x-ray from one of my own patients. Identifying information and the embedded file data have been removed.

Preoperative x-ray of the pelvis, front view, and the side view of the left hip, published on this site as Left Hip Total Replacement in a 54-year-old female with Hip Arthritis. Look at the age on this one, because it is the group in which how long the implant lasts matters most.

Preoperative x-ray showing the front view of the pelvis with both hip joints, published on this site as Right Hip Coxa Plana Management in a 56-year-old male by Total Hip Replacement. Look at the shape of the ball on the affected side.
An x-ray from one of my own patients. Identifying information and the embedded file data have been removed.

Postoperative x-ray of the pelvis showing the front and side views, published on this site as Total Hip Replacement in a 65-year-old Male with Avascular Necrosis of the Left Hip. Look at the position of the shell in the socket.
An x-ray from one of my own patients. Identifying information and the embedded file data have been removed.

Some of my case studies

Rather than summarize my hip results in general terms, here are the individual operations, each with its own films.
Each is published for the decision it illustrates rather than as an endorsement, and nobody in them is identifiable.

• Complex hip replacement for Hip Dysplasia Femoral shortening osteotomy with hip replacement in a 49 year old male
• Complex hip replacement – Hip replacement with prior hardware in position in a 71 year old female
• Left Hip Core Decompression with Stem Cell Injection in a 45-year-old male with Avascular Necrosis (AVN) of the Hip
• Left Hip Total Replacement in a 54 year old female with Hip Arthritis
• Left Total Hip Replacement in a 50-year-old female with Avascular Necrosis of the Left Hip
• Left Total Hip Replacement in a 55-year-old male with Avascular Necrosis (AVN) of the Left Hip
• Left Total Hip Replacement in a 74-year-old Male
• Left Total Hip Replacement in a 77-year-old female with Hip Arthritis
• Left Total Hip Replacement in an 82-year-old male
• Management of Avascular Necrosis of the Left Hip in a 40-year-old Male
• Management of Avascular Necrosis of the Left Hip with Total Hip Replacement in a 25-year-old Male with Prior Core Decompression Surgery
• Management of Left Hip Avascular Necrosis with Total Hip Replacement in a 60-year-old male
• Primary Total Hip Arthroplasty in an 84-year-old female for Hip Arthritis
• Primary Total Hip Arthroplasty in an 84-year-old female with Hip Arthritis
• Right Hip Coxa Plana Management in a 56-year-old male by Total Hip Replacement
• Right Total Hip Arthroplasty in a 45 year-old patient
• Right Total Hip Arthroplasty – 74 year old male
• Right Total Hip Replacement and Left Hip Core Decompression in a 38-year-old male with Avascular Necrosis (AVN) of both the Hip Joints
• Right Total Hip Replacement in a 75-year-old female
• Total Hip Replacement in a 52-year-old male with Avascular Necrosis (AVN) of the Left Hip with prior Hip Dislocation
• Total Hip Replacement in a 65-year-old Male with Avascular Necrosis of the Left Hip

The surgeon performing your hip replacement

I am Nakul Karkare, and I have been performing total hip replacement since 1997. I perform the entire operation myself, assisted by an orthopedic surgeon and physician assistants. I do not scrub out partway through a hip and hand it over.

My training at the Hospital for Special Surgery gave me exposure to essentially every implant system then in use. What that left me with is not a brand preference but the habit of knowing what each system does well.

What the implant companies pay me, which is nothing

No implant company pays me anything. I have no consulting arrangement, no royalty and no ownership interest with the makers of the stem, the shell or the bearing named on this page. That matters here more than on most pages, because this page names specific products.

What governs how I run a hip replacement

The way I run a hip replacement is decided long before the day. Planning happens several days ahead off your films. On the morning, everything is confirmed in the room before I come to meet you: implants open, instruments assembled, the reamer size I expect already on the table, the suture already threaded onto the needle.

That preparation is most of the reason a primary hip takes me about an hour, and increased operative time is infection risk. It is unglamorous but necessary.

Inside the operation, the decisions that matter are the position of the shell, the seating of the stem and the length of the leg, and all three are settled with trial components in before anything is committed. I have never once left an operating room thinking something would probably be all right.

And I do not compromise on the room. Two implant representatives know my steps. If neither is available, the case is canceled.

This page describes my own practice and judgment. It is not medical advice for your situation. Please see a physician about your own condition.

Why choose Dr. Karkare?

As a top joint replacement specialist in New York City, Dr. Karkare has extensive experience in anterior hip replacements, ensuring patients have the broadest array of safe and effective treatment options to relieve hip pain and other symptoms.

Before any procedure is performed, Dr. Karkare performs an in-depth evaluation of each patient to determine if an anterior approach could be a good choice or if another approach might be preferred.

This enables every patient to make an informed, educated decision so they can feel confident in their care every step of the way.

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