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As a physical therapist, having done thousands of home rehabilitation treatments of total hip recipients, starting within 48 hours of discharge from their 2-day hospital stay, one thing is perfectly clear:
All total hip replacement surgeons are not equal.
This article represents the information I feel I would need to select the best total hip surgeon available to me.
How do I choose a surgeon to perform my total hip replacement surgery?
The primary data needed to select the best surgeon for my hip replacement are:
- The infection rate of the hospital.
- The infection rate of the surgeon.
- How many hip replacement surgeries has the surgeon performed over what time frame?
- Does the surgeon do anterior or posterior approach surgery?
- And a number of secondary questions.
A person contemplating undergoing a total hip replacement procedure should make every effort to choose the best surgeon.
This requires some basic information collected by the prospective patient, but also requires many questions the patient does not even know they need to consider.
Only after answering the questions above should a “recommendation” be considered, even if that recommendation comes from a healthcare provider.
Remember, recommendations are antidotal; the answers to the questions above are statistics.
Infection Rate After Total Hip Replacement:
Choosing a surgeon and hospital with the lowest infection rate can save your life!
The first thing I would do is go to the website that allows me to verify a specific hospital’s infection rate as well as the specific surgeon under consideration to perform the surgery.
One thing most prospective total hip replacement patients don’t consider is that a total hip replacement is a TEAM effort, and anyone on the team can introduce an infection pathogen.
The team consists of the surgeon, surgical MD assistants, surgical nurses, anesthesiologists, and the hospital itself.
Propublica is the official nationwide keeper of these infection statistics in the United States.
Infection is the total hip patient’s biggest nightmare.
When I first started seeing total hip replacement patients, more than 4 decades ago, a total hip replacement infection had a 50% mortality rate.
A recent article in The Journal of Arthroplasty reports that the risk of death is still high.
It reports that the one-year mortality rate for an infected total hip is 4.22%.
Comparing this statistic to the national age-adjusted risk of mortality reports a statistically significant increase for a patient that has had an infected total hip.
It gets worse with time; according to the Arthroplasty Journal, after five years, the mortality rate for a patient who has had a total hip infection is 21.12%.
I am lucky enough to have the bulk of my total hip replacement referrals done by an orthopedic surgeon who has the lowest infection rate in California.
And the hospital is at the top of the list for a low rate of infection because of the surgeon’s great pre-surgery infection control protocol.
This surgeon performs 15 to 20 hip and knee replacements three times a week.
I understand his personal best is 23 surgical procedures in one day.
Unfortunately, over the past decade, I have seen patients whose hips did become infected (none from the MD that I was speaking of above).
The protocol I saw with these unfortunate infected hip patients was to immediately start an IV drip of antibiotics, followed by surgically opening the hip again and placing antibiotic spacers in the hip.
The patient is then tethered to an IV pole, and it can take up to 6 weeks before this aggressive but necessary approach is discontinued.
In this same time frame, with the antibiotic spacers placed in the joint, the patient is now non-weight-bearing on that extremity.
That now presents the problem of how to keep the patient mobile using a walker when one hand has to control the IV pole and no weight-bearing is allowed on the surgical leg.
This is why I consider infection rates to be the first and most important piece of information needed to help a prospective total hip replacement patient choose a surgeon (and hospital) to do this surgical procedure.
How Many Total Hip Replacement Surgeries Has The Surgeon Performed Over What Time Frame?
The thing that I have seen over the many years of seeing total hip replacement patients is that the more total hips a surgeon has performed, the better the outcomes for the patient.
My personal view coincides with medical research that reaches the same conclusion in a National Institute of Health (NIH) entitled:
Does Surgical Volume Affect Outcomes Following Primary Total Hip Arthroplasty? A Systematic Review.
The second variable is the time frame in which the surgeon performed these surgical procedures.
Multiple studies of many different job skills report that it takes about 10,000 hours of engagement in any job skill for the worker to reach their maximum proficiency. That’s about 5 years at 8 hours a day.
3,000 procedures performed over 20 years (about 3 surgeries a week) do not produce the same surgical expertise as 3,000 procedures performed in 1 year (about 57 procedures a week).
It just doesn’t.
A person in a geographical location without high populations or medical schools close by will be left with the choice of a surgeon with less compact experience, but one should know the surgeon’s probable skill level before making up their mind on who and where their total hip replacement is to be done.
Sometimes it might make more sense to be willing to travel a couple of hours from home to have the surgery done.
Most of my patients live in the suburbs of Los Angeles, and even though they live only about 70 miles away from the hospital and surgeon of choice, it still takes them 2 hours for the trip home after surgery. Most complain about the trip home but do not seem to be slowed in the recovery process by the trip home. They are usually discharged a day or two after the surgery.
Patients that I see being discharged longer than two days post-surgery invariably had some minor complication, usually not directly related to the surgical procedure but rather to an anesthesia-related issue, and the doctors just want the patient to be monitored in the hospital for a day or two longer.
A surgeon performing total hip replacement surgeries becomes faster as their skill level improves.
In the beginning, it may take a surgeon well over an hour to perform the surgery, while the surgeon operating at their maximum proficiency usually completes the total hip surgery in under an hour.
At least that is my observation of the patients I have seen.
For the surgeon requiring 2 hours to complete the surgery, it takes 5,000 patients to reach that magical number of 10,000 hours.
At five surgical procedures a week, it will take the surgeon 20 years to reach that surgeon’s maximum skill level.
For the surgeon who can complete the surgery in 1 hour, it takes 10,000 hours to reach their maximum skill level; however, at 50 surgical procedures a week, it will take that surgeon less than 4 years to reach the top of their game.
Personally, I would be looking for a surgeon who has the most years of experience and has done as many total hip replacement procedures as I could find in my area.
Does The Surgeon Use The Anterior or Posterior Approach To Total Hip Replacement Surgery?
After seeing 40-plus years of patients receiving their total hip replacement with a technique referred to as the posterior approach, and the last decade of seeing patients receiving their total hip replacement using the anterior approach, I personally would always choose the anterior approach.
Although research reports a slight bias toward the anterior approach in the early phase of rehabilitation, in the long run, there is very little difference in outcomes.
My personal experience leaves me with a strong basis for the anterior approach.
I have seen posterior approach total hip replacements dislocate even 15 years after the surgery was performed; I have not seen any anterior approach hip replacements dislocate.
I have also had the privilege to have seen three patients who had a posterior approach done on one hip and an anterior approach done on the other hip. One is a nurse.
All three of these patients were adamant that the anterior approach was better for them.
An additional consideration is the range of motion restrictions that come with a total hip replacement.
The posterior approach to total hip replacement usually has significant restrictions that make sleeping and mobility a difficult issue for at least 6 weeks, although I am beginning to see some relaxation in those restrictions from the surgeons referring posterior approach patients for home physical therapy immediately after surgery.
The anterior approach to total hip replacements essentially has no range of motion restrictions, even the day after surgery. They are much more active because they do not need to follow mobility limitations, and they are more comfortable at night because they have a much better selection of sleep postures that are not restricted.
With the advent of the anterior approach to hip replacement and the long record of the posterior approach technique, there are now emerging techniques that are somewhere in between these two techniques, usually referred to as the “Direct Lateral” approach.
I have seen a few of these lateral approach hip replacement patients as well, but I have not yet come to a conclusion about what I think about these approaches.
Point of Interest:
Both the posterior approach and the anterior approach to total hip replacement have been around for many years. The posterior approach is an older and easier technique to master and has become the surgical approach of choice for the majority of surgeons.
The anterior approach has become popular over the past decade. Even though it is a more difficult procedure to perform, it has gained popularity in the age of the “minimally invasive” movement in surgery.
The shift to the anterior approach has been somewhat stymied because of the number of surgeons who have been performing posterior approach total hip replacement for the past 15 years of their careers and do not wish to experience the long learning curve to learn the anterior approach, especially when they have the posterior approach down and are satisfied with that approach.
Another reason for the delay in surgeons moving to the anterior approach, in my opinion, is the cost to the hospital for the special operating table surgeons need.
These operating tables are very expensive, and private hospitals often feel they can’t afford the cost based on the traffic that operating tables would generate. Without that special table, surgeons are not going to be interested in learning the anterior approach.
Personally, I would choose a surgeon and hospital that do the anterior approach for hip replacement.
A Number of Secondary Questions About Total Hip Replacement For Your Surgeon:
Does the surgeon use robotic assistance for total hip replacement surgery?
Most surgeons today use some sort of robotic assistance to plan and perform a total hip replacement.
The first step in the robotic assist is the software input of the imaging for the joint that is going to be replaced. This software sets the metrics for the surgery, then during surgery helps guide the surgeon’s work by monitoring how closely the surgeon is to the surgical plan and provides the physician with feedback.
The robotic arm provides positional information to the surgeon but never controls the robotic arm; the surgeon is always 100% in control. Only the surgeon can determine if the surgical plan needs alteration once the joint is exposed to their eyesight. The surgeon can alter the surgical plan at any point during the surgical procedure as they deem necessary.
The surgeon who sends me the bulk of my home physical therapy patients after joint replacement uses the Mako robotic-arm-assisted technology.
I’m very impressed with his patient outcomes.
How will the surgeon close the total hip replacement surgical site?
I see three ways surgeons close the total hip surgical site:
- Biological glue
Staples is my least favorite way.
Staples are exactly what they sound like. Staples are chunks of metal whose ends are driven through the skin on both sides of the surgical wound, and the ends are curled over to hold the skin together, much like a paper stapler. They are placed about ½ inch apart from top to bottom of the surgical site.
While they are cheap and easy to use, the staples have some drawbacks, in my opinion.
I always caution my patients with staples to be cautious when using a cold pack coming out of a freezer.
While these gel-filled packs are a great, inexpensive method to employ cold therapy pain interventions, they do come out of the freezer at about zero degrees Fahrenheit, and the staples are metal. Extra padding is needed, in my opinion, to prevent the metal staples from frost-biting the surrounding soft tissue. I view this as a potential infection risk.
Additionally, I do not like the open puncture wound caused by the staple. While the staples are in place, I feel there is an entryway for pathogens to enter the body. There is still that metal piece that does not allow the body to completely heal the puncture wound until after the staple is removed.
The staples also pull on their anchor points at the end of the range of motion, causing pain. This is more of a problem for my total knee replacement patients than for my total hip replacement patients.
Stitches are better than staples, in my opinion; the puncture holes for the stitches are much smaller and they are not metal; therefore, pain intervention with freezer-cold gel packs is far less concerning for me.
My patients with stitches tend to complain about “pulling on the stitches” when they are doing activities of daily living. Once again, I hear more “pulling on the stitches” complaints from my total knee patients than my total hip patients.
Biological glue would be my choice if I were having a hip replaced.
No staples, no stitches, just some support tape strips known as steristrips.
The surgeon I previously mentioned with the lowest infection rate in all of California (and, I think, in the nation) uses biological glue and strei-strips to close his total hip surgeries.
Now here is the impressive part: he removes the surgical bandage on the 7th day, counting surgery day as day one.
All the patients I see from surgeons using staples or stitches keep their patient’s surgical site covered with bandages for between 2 and 4 weeks. Could it be because of the opportunity for the staple or stitch puncture holes to be a point of entry for pathogens that could cause infection?
I think yes.
How long will I be in surgery for a total hip replacement?
This question is really asking two questions:
- How long is it from the time I’m put to sleep until the time I wake up?
- How long from the time you first cut my skin until it is surgically closed?
How Long Asleep?
Being under anesthesia is hard on the body’s systems, such as the heart, lungs, kidneys, etc.
That is the anesthesiologist’s primary job: adjusting the amount of anesthesia based on the patient’s vital signs so that the patient does not crash and die on the operating table. They walk that fine line while trying to give the patient enough anesthesia to keep the patient asleep during the procedure
It will take at least 24 hours for that anesthesia to wash out of the body.
The longer a patient is under anesthesia, the longer the patient is in an “awkward” body positioning required during surgery. This awkward position puts some soft tissue under stress, much like leaning against a wall with an open hand places stress on the soft tissues of the wrist.
The longer a patient is under anesthesia, the more stress these tissues will experience, and the more they will be sore and achy after the surgery.
Just the fact that a patient will be lying in one position on a reasonably hard surface, much like lying on a carpeted floor, can produce some residual pain once the patient is removed from that position.
Imagine lying on the floor for an hour. Most people will adjust their posture to relieve the pressure points before the hour is up.
Compare that to what it would be like to lie on the floor in the same position for two hours.
There will be a difference.
Additionally, the operated leg is placed in distraction during the surgery to help separate the head of the humerus from the socket. There is well-documented evidence that this distraction can cause post-surgical pain, so the longer the hip is in distraction, the greater the risk it will cause post-surgical pain.
How Long Surgically Open?
The longer the surgical site is open, the greater the chance an infectious pathogen has to embed itself deep into the open hip joint, and the more likely the patient will suffer hip surgical distraction pain.
How many people will be in the operating suite during my total hip replacement surgery?
The more people in the operating suite, the greater the chance for an infection or distraction.
However, there is a trade-off.
Surgeons doing multiple surgeries daily are more likely to have additional people in the operating room at the time of the surgery.
The more in demand the surgeon is, the more people they will need to help him complete the surgeries.
A lot of busy surgeons do not step to the operating table until the patient is prepped and ready to be surgically opened up.
It is not uncommon for a busy surgeon to assign the closure of the surgical site to a different doctor (or two).
I once had an anesthesiologist patient after a total knee replacement point out that there were apparently two different doctors who had done the closing on his knee.
One surgeon closed the upper half and the other the lower half. There was an obvious difference in skill level.
The anesthesiologist patient quipped “This doctor is going to be a plastic surgeon, the other one is going to be an orthopedic surgeon”. I laughed. I could clearly see the difference in stitching skills.
And if the surgeon is operating in a teaching hospital there is a good chance there will be student observers, some may be students that are in the ancillary professions, such as a physical therapist. The first total hip surgical procedure I observed was in 1974 and it took over 3 hours, it was a revision of a prior total hip that had failed.
How long will I be in the hospital after total hip replacement?
With the advent of new hospital rules from Medicare, doctors are being pushed to get the total hip replacement out of the hospital as quickly as possible.
Many total hip replacement patients are released the day after surgery.
I’m not opposed to discharge as soon as possible.
Hospitals are not a safe place to be.
In fact, patients so frequently “catch” something in the hospital that they did not have before entering the hospital that there is a name for that process.
It’s called “nosocomial”, meaning I caught this disease/infection while I was in the hospital.
Remember this: Hospitals have really good drugs and it takes about 24 hours after surgery for the body to clear most of the anesthesia.
A very common scenario I see is a patient discharged from the hospital the day after surgery and feeling really great.
But when I see them a day or two after the discharge their pain levels are much greater than at discharge from the hospital.
The patients I see discharged from the hospital the same day as surgery with a pain pump have a much tougher time with the pain than those that were in the hospital at least overnight.
And I see a significant number of pain pumps that do not work or are accidentally pulled out.
Today’s total hip replacement hospital discharge time has shrunken greatly from the time that I first saw hip replacement patients. Back in the old days, the patient would have been in the hospital for two weeks; but then again childbirth was not a “one day after hospital discharge” either.
Does the surgeon have a home exercise protocol for immediately after a total hip replacement surgery?
Orthopedic surgeons who have exceptional outcomes surround themselves with a support team of ancillary professionals including home nursing, physical therapy, and occupational therapy.
They have also thought about what home exercises the patient can do safely, after all, they are the one who knows exactly where they cut and what exercises would put stress on that surgical cut.
There has been a long-standing basic home exercise protocol for the posterior approach hip replacement. These exercises are safe, but not optimized for the specific surgical approach technique the surgeon is using.
With the advent of the anterior approach to hip replacement, home exercise is allowed to be more aggressive and promotes an earlier decrease in pain and increase in function.
I see total hip patients from several different surgeons.
The best surgeons have a set of home exercises as a baseline program that allows me to add and subtract as needed to reach the rehabilitation goals I have set for that specific patient.
As a physical therapist with many years of experience, I know which exercises are appropriate for both the anterior and posterior approaches, but most importantly I know which exercises are inappropriate and could injure the patient.
For those doctors who do not provide me, as a physical therapist, an exercise protocol that meets with their approval, I have to devise the program myself.
When presented with such a scenario I must search the patient’s chart to determine what surgical approach was used for this total hip replacement.
Surprisingly, even some of the good surgeons do not identify what surgical approach they used.
And this is just for the surgeons using either an anterior or posterior approach.
Throw in the approaches known as “lateral approach”, and the variations of range of motion and exercise restrictions, without specific exercise protocols approved by the surgeon, or at least the documentation of what surgical approach was used, the therapist can’t optimize the exercise program for that specific patient.
The only safe and prudent thing to do is to use a tried and true safe home exercise program, the posterior approach exercise program, which may not be the best exercise program for the patient.
But above all else, Do No Harm!
As I said, great orthopedic surgeons have thought this through further than just surgical technique, giving the patient the most optimal options for fast and complete rehabilitation.
Does the surgeon request home physical therapy after a total hip replacement surgery?
I see a trend in total hip surgery toward less and less physical therapy after the surgery.
I personally think this is a mistake.
On rare occasions, I see a patient after total hip surgery that does not warrant home physical therapy, but that is very rare.
This trend toward less physical therapy is twofold:
- Insurance companies are pressuring surgeons to decrease therapy visits.
- Therapists are focusing on billable procedure codes and time frames rather than patient needs.
In my experience, I would say the average number of times a total hip patient needs to see a home physical therapist is three times a week immediately after surgery.
On this schedule, I’m usually able to teach my total hip patients a good progressive home exercise program that they can demonstrate correctly, and walk a ¼ mile without a walker or cane, in about 5 to 7 visits.
I then recommend the patient go to outpatient physical therapy for a couple more weeks for instructions of more aggressive exercises. They are not ready for aggressive exercises in the first two weeks after surgery.
I’m seeing some surgeons now sending total hip patients directly to outpatient physical therapy after surgery.
That is because they do not understand the insurance rules and they are potentially robbing the patient of their insurance benefits.
Under Medicare, home physical therapy is covered under part A, the hospitalization part of the insurance, and has a 60-day window of coverage, much more than a total hip patient needs.
Outpatient physical therapy is covered under part B of Medicare. It has a limitation that will cover about 10 outpatient visits.
When the surgeon sends the total hip patient directly to outpatient therapy, the outpatient physical therapist will need to start therapy exactly where the home therapist starts, and in about 5 to 7 visits the patient will be ready to start the more aggressive physical therapy program generally associated with outpatient therapy.
The problem now is that the patient only has 3-5 outpatient visits left under insurance coverage, so the surgeon has robbed the patient of 50% to 70% of their outpatient benefits.
I feel sure most orthopedic surgeons simply do not understand this concept.
How long before the bandage will be removed after a total hip replacement surgery?
The physician that refers the bulk of my home health physical therapy patients after a total knee or total hip removes the surgical bandage on the 7th day, counting surgery as day one, leaving the surgical site uncovered and steristrips in place.
He has the lowest infection rate in California now for several years in a row.
Other of my referring doctors leave the bandage on as long as 3 to 4 weeks post-surgery.
The bandage is there to protect the surgical wound from exposure to pathogens that might enter the wound, so this time frame is dependent on how long there is open access to the surgical site by a pathogen.
With biological glue, the entry points are all well sealed. With stitches or staples, there is still an entry point for the pathogen through the puncture holes being partially open because of the pulling on stitches/staples with just everyday movement.
Will the bandage be changed and who will do it after a total hip replacement surgery?
The criteria for changing the bandage is usually:
- Is there staining on the bandage?
- Is the water-resistant seal of the bandage still intact?
Staining on the bandage is the first sign that a total hip patient is doing too much and needs to decrease their activity level.
Minor staining, such as a spot the size of a pencil eraser is not usually a reason to change the bandage, but anything bigger needs to be brought to the attention of the doctor for their consideration.
Surgical wounds closed with staples or stitches are much more likely to show minor stains caused but the staple/stitch as it pulls on the puncture site with just everyday normal activity.
Water Resistant Seal:
Total hip surgical sites are covered with a bandage that is encased in clear transparent tape on all sides, sealing the surgical wound from pathogens and minor water contact. It is important to maintain that seal.
The water-resistant bandage I see used most commonly is the Tegaderm-like bandage known as a Mepilex/Optifoam bandage. I have seen these bandages hold up for more than 3 weeks without being changed.
Who Will Change The Bandage?
This question is entirely physician preference.
For my doctor with a very low infection rate, the answer is:
A registered nurse is sent from the home health care agency to the patient’s home and the nurse changes the bandage using near-sterile techniques.
Some surgeons will have the patient come into their office to change the dressing using near-sterile techniques.
The downside to this approach is the necessity for the patient to go to the surgeon’s office. Not a problem if the surgeon is 10 minutes from the patient’s home but quite a consideration if the patient has chosen a surgeon an hour or two away from their home.
Still, other surgeons elect to send the patient home with extra bandages and expect them to change the bandages themselves.
I have to say, I’ve been in a lot of patients’ homes and some give me concern about infection even without changing the bandage, especially some less tidy patients with multiple pets.
I think many surgeons have no idea of the patient’s living conditions, they only see the clean well-groomed person sitting in front of them.
What post-surgical medications will I be prescribed after a total hip replacement surgery?
- Blood thinners
- Pain killers
Blood thinners, along with compression hose and ankle pump exercises are the Triade protocol to prevent blood clots in the leg.
Dislodged blood clots end up in the heart (heart attack), brain (stroke), or lung (pulmonary embolism).
None individually has a good prognosis and a patient could experience all three!
The longest blood thinner in use is an injectable that the patient or caregiver injects into the abdomen daily for about two weeks. These blood thinners require blood sample monitoring a couple of times a week and the injectable dose is adjusted accordingly.
The upside of these thinners is that if there is a problem, the thinner can be adjusted immediately.
The downside is the daily injection requirement and the need to monitor the vitamin K intake found in green leafy vegetables.
More recently, oral blood thinners have come to market, which requires no bloodwork monitoring.
The downside is these oral medications, once in the system, have no mechanism of physician intervention should the medication itself cause a problem, the patient just has to “ride it out” until the body clears the medication.
The pain medications prescribed after surgery are usually two opioids, one more mild opioid such as tramadol to control moderate pain, and a stronger opioid such as Norco to be used intermittently when the patient is in severe pain.
The mild opioid is used time-contingent, meaning it is taken on a prescribed time frame regardless of the pain level. It takes regularity to get the blood levels up high enough to be the most effective.
The stronger opioid is used on a pain-contingent basis, meaning it is only used when the patient’s pain becomes severe, usually 7/10 or greater. Once the pain has returned to moderate (below 7/10), the stronger opioid is discontinued until needed.
Most of the patients I see were issued these medications at discharge from the hospital, and they were instructed on how to use them at that time. Unfortunately, those patients are already in a pain medication “fog” and don’t really grasp how they are to use the medications.
Better to ask this question before surgery while the head is still clear.
Final Thoughts On Opioids:
- Opioids are a necrotic, and like any narcotic one must take more and more over time to get the same result.
- I do see total hip patients after surgery who had been taking opioids for some time before the surgery in an attempt to forestall the surgery.
These patients do not get the same relief as patients who have not been taking opioids before surgery.
- It would be a good idea to discuss this with the surgeon before the surgery so they can better tailor your medication protocol after surgery.
- Opioids are a controlled substance and as such many pharmacies require a handwritten original of a doctor’s prescription before they will fill the prescription. Faxes or phone calls from the surgeon may not be honored.
Will the surgeon be the one to order refills of pain medications or will it be my family MD after a total hip replacement surgery?
Some surgeons prefer to be in control of the patient after total knee or hip replacement surgery until they see the patient at the post-surgical follow-up, usually at about 3 weeks post-surgery.
Other surgeons feel once the surgery is completed, their job is completed and they prefer any pain medication (or any other medications) be monitored and prescribed by the patient’s family doctor.
Either way is fine in my opinion, however, the patient should know in advance who they need to contact if they need additional refills of prescription medications.
I have seen far too many patients twho are unclear on this topic and are only a day or two away from being out of pain meds they still depend on for pain control before they take action.
They call the surgeon’s busy office only to receive a call back in a day or two telling them they need to contact their family MD.
If this scenario happens on a Friday, and the patient is out of pain meds, good luck with getting a handwritten prescription on a Friday evening from the family doctor.
They could be in for a rough weekend.
I’m sure there are other questions that can be asked of the surgeon, but with this information, I feel I could make the decision on which surgeon I would prefer to do my total hip surgery.
With the right surgeon and a good support team, you should be up, functional, and able to walk without a walker or cane for about a ¼ mile, and pain levels at 3/10 or less without opioids at the three-week post-surgery mark. At least that is my experience seeing patients from a surgeon I would use personally.
At that point, the patient will be stable enough to start a more aggressive outpatient physical therapy program with enough coverage under Medicare Part B to complete full rehabilitation in physical therapy.
Read my other articles about Total Hip Replacement
Good luck with your total hip replacement surgery.
Paying It Forward
Perhaps you are approaching or already retired and wondering how you could earn extra money in retirement.
One option would be to do as I am doing.
Read my article How To Generate Retirement Income: Cash In On Your Knowledge.
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