Total Hip Arthroplasty (Hip Replacement)

Why this approach — at MOS

Maryland Orthopedic Specialists' adult reconstruction program brings fellowship-trained expertise in hip replacement to Germantown and Bethesda. Our reconstruction specialist performs both anterior and posterior approach total hip arthroplasty, and the operative approach is individualized — not applied uniformly to every patient.

The anterior approach is specifically discussed with patients who ask about it or who are good candidates: those with a body habitus and anatomy that allows safe exposure without excessive soft tissue tension, those without significant prior hip surgery or deformity, and those who want the fastest possible early recovery and no hip precautions. For patients with complex anatomy, revision circumstances, or prior surgical history, the posterior approach may provide superior visualization and safety.

Implant selection follows evidence-based principles. Highly cross-linked polyethylene bearings and modern porous-coated cementless stems have demonstrated excellent long-term durability. Implant size and design are templated pre-operatively on standing X-rays to restore appropriate leg length and hip offset.

Peri-operative care follows an enhanced recovery protocol: pre-operative patient education, multi-modal pain management (minimizing narcotics), early mobilization, and coordinated discharge planning. MOS works with local physical therapy providers to ensure a seamless transition from hospital to outpatient rehabilitation.

Dr. James Gardiner, MD, a fellowship-trained adult reconstruction specialist at MOS, may also perform total hip arthroplasty for appropriate patients.

Who is a candidate?

Indications

• Severe hip osteoarthritis with bone-on-bone joint space narrowing on weight-bearing X-ray
• Avascular necrosis (osteonecrosis) of the femoral head with collapse
• Post-traumatic arthritis following prior hip fracture, dislocation, or injury
• Inflammatory arthritis (rheumatoid, psoriatic, ankylosing spondylitis) with hip joint destruction
• Hip fracture patterns in older patients where fracture repair is not appropriate
• Failed hip preservation surgery (arthroscopy) with progressive arthritis
• Significant pain, functional limitation, and reduced quality of life despite full trial of conservative care

Contraindications

• Active infection anywhere in the body (surgery must be delayed until infection is resolved)
• Significant peripheral vascular disease that impairs wound healing
• Severe cardiac or pulmonary disease that makes surgery an unreasonable risk
• Active neurological conditions that would prevent rehabilitation
• Severe obesity in combination with other risk factors (elevated complication risk; weight loss may be recommended first)
• Relative contraindication: young, highly active patients — hip replacement in patients under 50 carries a higher lifetime revision rate

Conservative Treatment First

Hip replacement is reserved for patients with documented severe arthritis and functional limitation that has not improved with non-surgical care. Before recommending surgery, the following are completed: a trial of oral NSAIDs or acetaminophen; a physical therapy program focused on hip strengthening, aquatic therapy, and activity modification; and one or more cortisone or hyaluronic acid (viscosupplementation) injections to reduce pain and assess remaining joint function.

When a patient reaches the point where pain is constant even at rest, simple activities of daily living are impaired, and injections provide only brief relief, surgery becomes appropriate. The conversation about timing is ultimately patient-driven: the goal is to improve quality of life, not to reach a specific threshold on a scale.

The procedure

What Is Total Hip Arthroplasty?

Total hip arthroplasty (hip replacement) is a surgical procedure in which a severely damaged or arthritic hip joint is replaced with prosthetic components — a metal stem in the femur, a metal or ceramic ball, and a socket liner in the acetabulum. It reliably eliminates joint pain and restores mobility when conservative measures have failed and arthritis is advanced.

The hip joint functions as a ball and socket: the rounded head of the femur rotates within the cup-shaped acetabulum. Both surfaces are covered by articular cartilage — a smooth, slick tissue that allows pain-free motion. When arthritis destroys this cartilage, the underlying bone is exposed, and every step produces painful bone-on-bone grinding. The joint swells, stiffens, and gradually loses range of motion.

Total hip replacement removes the arthritic surfaces and replaces them with durable prosthetic materials. The femoral component consists of a stem that seats inside the femoral canal and a ball at the top. The acetabular component is a metal shell that presses into the socket, lined with a smooth bearing surface (typically highly cross-linked polyethylene, ceramic, or metal). Together they recreate a smooth, stable, essentially pain-free hip joint.

Hip replacement is one of the most successful operations in modern medicine. Published patient satisfaction rates consistently exceed 90%, and modern implants are designed to last 20–30 years or more in active patients. The procedure has transformed the quality of life for millions of people with end-stage hip disease.

What Happens During Total Hip Arthroplasty?

Anesthesia Total hip arthroplasty is performed at a hospital under general anesthesia or spinal anesthesia. Spinal anesthesia numbs the lower body and is associated with reduced blood loss, lower narcotic use, and faster early recovery. The choice between general and spinal is made in collaboration with the anesthesiologist based on patient preference, medical history, and surgeon preference.

Surgical Approach: Anterior vs. Posterior

The approach to the hip determines how the surgeon reaches the joint and which muscles — if any — must be detached. This is the most commonly researched aspect of hip replacement surgery, and it is important to understand the options.

Direct Anterior Approach (DAA): The surgeon accesses the hip through an interval between the tensor fascia lata and sartorius muscles at the front of the thigh. No muscles are cut or detached from bone. Because the posterior hip muscles (external rotators, gluteus medius) remain intact, there is no need for post-operative posterior hip precautions (restrictions on crossing the leg, sitting in low chairs). Many patients experience faster early recovery, less pain in the first few weeks, and earlier mobilization with the anterior approach. A specialized surgical table may be used to control leg position during the operation. The anterior approach is technically more demanding and is best suited to patients without severe obesity, severe deformity, or prior hip surgery.

Posterior Approach: The surgeon enters from the back of the hip, releasing the short external rotator muscles to access the joint. This is a more universal approach that can accommodate a wider range of anatomy, deformity, and implant sizes. The external rotators are repaired at closure. Modern posterior approach with capsular repair and soft tissue repair has significantly reduced historical dislocation rates. Patients are asked to follow posterior hip precautions (avoid flexion past 90°, no crossing legs) for 6–12 weeks.

At MOS, our adult reconstruction specialist performs both approaches and will discuss which is appropriate for each patient's anatomy, activity goals, and overall health.

Implant Placement Regardless of approach, the core surgical steps are similar: the arthritic femoral head is removed. The acetabulum is prepared using reamers to create a precise cavity for the socket component. The socket is press-fit into the acetabulum (and often secured with screws). A trial reduction is performed to assess leg length, stability, and range of motion. The femoral canal is prepared with broaches, the appropriately sized stem is inserted, and the final components are assembled. A final stability assessment is performed before closure.

Closure and Recovery The wound is closed in layers. Patients are typically mobilized within hours of surgery. Most patients go home in 1–2 days with walker or crutches, progressing to a cane and then no assistive device over 3–6 weeks.

Recovery timeline

Frequently Asked Questions