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About J. Michael Watt

J. Michael Watt, MD Dr. Watt is a board-certified orthopedic surgeon who works with patients dealing with a wide range of orthopedic issues. A practicing surgeon for over 20 years, Dr. Watt specializes in sports injuries, knee and shoulder surgery, as well as anterior hip replacements.

Common Ski and Snowboard Injuries

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Shoulder Injuries

If you are a snowboarder or skiing fanatic, you know that injuries come with the territory. If you aren’t careful, you could end up with torn ligaments, sprained muscles, or broken bones.

Statistics tell us that less than 4 injuries happen for every 1,000 days of skiing or snowboarding.

Sometimes these injuries are minor and only will require home care. Other times, they can be serious, requiring you to seek medical help. This guide will help you to understand the most common snowboarding and skiing injuries.

Acromioclavicular Joint Damage

The Acromioclavicular Joint is often called the “AC joint” for short (pronounced ack-roe-my-oh-clah-vick-you-lar). This is basically a separation of the two bones that form this joint where the clavicle (collar bone) attaches to the scapula (shoulder blade). There is a ligament that attaches these two bones known as the AC ligament. The bony process that protrudes forward from the upper scapula is the acromion (pronounced ack-rome-ee-on). When these two main bones are separated, it is often referred to as a shoulder separation injury.

If you injure your AC joint skiing or snowboarding, expect to have pain at the end of your collarbone. This pain will spread throughout the shoulder at first. Eventually, the initial pain will resolve and be followed by pain over the joint itself.

Swelling will occur, too and depending on the severity of the injury, there may be a visible deformity. This will be an obvious bump where the joint has been separated. Pain will worsen with movement of the shoulder, especially when the arm is raised to or above shoulder height.

Doctors will grade AC joint injuries from one to six (1 – 6) using the Rockwood Scale which identifies injuries by amount of damage incurred. This will be based on the space between the acromion and clavicle. Grade one is just a simple sprain of the AC joint, but Grades four, five, and six involve severe conditions, and most always result in shoulder surgery.

What Should the Athlete Do?

  • Immobilize the arm and shoulder with an arm sling.
  • Start R.I.C.E. therapy.
  • Consult an Orthopedic Specialist.

What will the Orthopedic Specialist Do?

  • Use ultrasound or laser treatment.
  • Perform shoulder surgery if necessary.
  • Prescribe a special rehabilitation program to get you back moving.

Fractured Clavicle

The clavicle (or collar bone) is the bone that runs along the front side of the shoulder region and connects near the breast bone (sternum). This is one of the most common broken bones, and it occurs as a result of falling on an outstretched arm. This is one of the most common types of fractures in sporting and outdoor activities.

The bone typically fractures in the middle third region and this type of injury is very painful. Symptoms of a broken clavicle include swelling and discoloration at the site, pain of the area, a deformity that can be seen or felt, and worsening pain when elevating the arm.

What can the Athlete Do?

  • Immobilize the arm and shoulder regions.
  • Do R.I.C.E. therapy.
  • Get to an Orthopedic Specialist for evaluation and treatment.

What will the Orthopedic Specialist Do?

  • Evaluate the extent of the injury by way of X-Ray.
  • Use ultrasound or laser treatment.
  • Do shoulder surgery if the bone is displaced.

The Knee Injuries

Medial Collateral Ligament Trauma

The Medial Collateral Ligament (MCL) is a ligament that connects the inner surface of the thigh bone (femur) to the shin bone (tibia). This ligament allows the knee to resist force that may be applied from the outer surface thus preventing the inner portion of the joint from stretching under stress.

There are two parts to the inner knee ligament, the deep inner section that hooks onto the cartilage meniscus and the joint margins and a superficial band that adheres from higher up on the femur to the tibia.

An injury to the MCL occurs after there is an impact injury to the outside surface of the knee when the knee is in the bent position. The MCL will become stretched and the impact force tears the fibers. The inside portion of this ligament is prone to become injured first and this often leads to the meniscus being damaged as well. Pain in the area may not be noticed immediately after the injury.

These injuries are graded on a one to three (1 – 3) scale. A grade one tear only has less than 10% of the fibers torn. A grade two is greater than 11% but does not necessarily result in a complete tear of the ligament. A grade three is a complete rupture of the ligament, however. With a grade one tear, there may be mild tender knee on the inner aspect of the knee, but typically no swelling occurs.

With a grade two tear, there will be more pain and tenderness and some swelling over the ligament. The pain of a grade three tear is often not as bad as a grade two but this injury results in a significantly more unstable, wobbly knee. Grade three tears most always result in knee surgery.

What Should the Athlete Do?

  • Utilize the R.I.C.E. formula to the injured knee.
  • Refrain from activity.
  • Wear a knee brace for grade two and three injuries.
  • Consult an Orthopedic Specialist.

What will the Orthopedic Specialist Do?

  • Apply a cast or joint support device.
  • Use sports massage techniques.
  • Aspirate the joint to remove fluid.
  • Apply ultrasound or laser treatment.
  • Order an MRI to assess the possibility of surgical reconstruction.
  • Do knee surgery, as indicated.
  • Order a special rehabilitation program to help get you back in action.

Medial Meniscus Injuries

The Medial Meniscus (MM) is prone to many more injuries that the Lateral Meniscus. This structure is connected to the Medial Collateral Ligament (MCL) and the joint capsule. The MM is less mobile, too. Any force impacts can severely injure this structure and cause permanent damage. Tearing of the MM often requires surgical intervention.

The symptoms of a MM tear include pain on the inner surface of the knee joint, swelling of the knee at any time during the 48 hours after the injury, inability to bend the knee fully, a clicking noise with bending, and ‘locking’ or ‘giving way’ of the knee. Many who have this type of injury are unable to bear weight on the knee.

There are several types of meniscal tears. These include the longitudinal tears (ones that occur along the length of the meniscus), radial tears (those tears that occur from the edge of the cartilage inward), bucket-handle tears (like a longitudinal but occur where a portion of the meniscus becomes detached from the tibia forming a flap), and degenerative changes (making the meniscus become frayed or jagged). Most meniscal tears result in knee surgery.

What Can the Athlete Do?

  • Utilize the R.I.C.E. method.
  • Wear a knee compression support device.
  • Utilize mobility exercises to get the knee moving better.
  • Consult an Orthopedic Specialist.

What will the Orthopedic Specialist Do?

  • Check the extent of the knee injury.
  • Order an MRI scan of the injured knee.
  • Use ultrasound or laser treatment.
  • Do knee surgery if necessary.

The Wrist and Hand Injuries

Skiier’s Thumb

The most common upper extremity injury when skiing is to the thumb. The thumb has two ligaments on each side at the metacarpophalangeal (pronounced met-ah-car-poe-fah-lanj-ee-ahl) or MCP joint. The inner ulnar collateral ligament (UCL) gets damaged when a fall occurs and the skier doesn’t release the ski pole from the hand.

The pole makes a bending type stress occur to the thumb. “Skier’s Thumb”, as it is commonly called, occurs when the UCL is torn after the thumb is placed in an extreme position.

What Can the Athlete Do?

  • Immobilize the injured area.
  • Use the R.I.C.E. formula.
  • Consult an Orthopedic Specialist.

What will an Orthopedic Specialist Do?

  • Order an MRI scan to assess the damage.
  • Prescribe a rehabilitation program for you.
  • Operate on the injured area if necessary.

Wrist Fracture

Snowboarding and skiing are dangerous sports and beginners often have a higher risk of falls. Sometimes these falls damage the wrist enough that the skier or snowboarder has to have a wrist surgery. These falls result in wrist fractures, where an outstretched hand attempts to break a fall.

As a result of this, there are scaphoid and “Colles” fractures that can occur and around 100,000 of these occur each year. The schaphoid is one of the small bones called the “Carpal” area that make up the wrist.

“Colles” is the name of this type of fracture where the radius bone is injured. Signs of a fracture to this area include swelling of the wrist, pain with movement, and a visible deformity or bump. There is often tenderness in the region where the thumb and wrist connect.

What Can the Athlete Do?

  • Utilize R.I.C.E. therapy to the injured area.
  • Immobilize the injured extremity.
  • Consult an Orthopedic Specialist.

What will the Orthopedic Specialist Do?

  • Order laser treatment or ultrasound therapy.
  • Order X-ray testing and MRI scans.
  • Apply a splint or cast for support.
  • Perform wrist surgery as indicated.

Ankle and Knee Sprains

Twisting and turning down the slope can put a bit of a strain on your ankles and knees. Ankles get sprained when they are extended past the point they should be. Knees are devised to only bend in one direction and they are easily sprained when forced in an unnatural position.

Sprains are common among those who engage in sporting activities like skateboarding, snowboarding, and skiing and usually are nothing serious. If you suffer a sprain, you can expect pain, swelling, bruising, and a decrease in range of motion of the knee or ankle.

R.I.C.E.

The main formula for treating sprains is R.I.C.E. This stands for Rest, Ice, Compress, and Elevate.

  • R: Rest. You should stop the activity as soon as it starts to hurt. Stay off the knee or ankle for a while and see if it gets better. If the discomfort stops after a brief rest, gently rotate and flex the area to see if there is any remaining discomfort. If not, then you are good to go. If it still hurts, it’s time to I.C.E. it, so read on.
  • I: Ice. Do NOT apply it directly onto the skin! Instead, apply an ice pack wrapped in cloth for 20 minutes on the sprained knee or ankle. Ice is essential for minor turns and twists that don’t stop hurting after a brief rest period. For serious sprains, you should apply ice to your sprain immediately, pronto, or stat! Even if you are going to seek medical attention, you should ice the area down anyway. Apply an ice pack or just use a can of soda from the frig or a bag of frozen peas. Some people put ice in a Ziplock bag and cover it with a towel. Whatever works for you.
  • C: Compression. This simply means you need to wrap your sprained ankle or knee with an ACE bandage. Be sure to wrap it firmly but not too tightly. The pressure encourages the stray fluid that is at the sprain to get back into the vessels where it belongs and circulate back to the heart. Do this for even minor strains to reduce the chance of swelling and support the injured area. Apply the ice on top of the bandage.
  • E: Elevate. Simply raise the injured area above the heart right away. You should also do this at night. The purpose of this is so gravity will help drain the excess fluid from the tissues.

Frostbite and Hypothermia

Everybody has heard of Jack Frost. He’s that happy cold-weather fellow who likes to nip at your fingers, nose, and toes. If you feel that ‘pins and needles’ feeling, that’s your sign to get to a warm area. When frostbite occurs, your skin will be bright pink and then turn red and swollen at first. Serious frostbite makes the areas turn bluish-gray.

When hypothermia occurs, you will shiver and your heart beat and breathing will speed up as your body temperature goes down. You may feel clumsy, confused, and feel really sleepy. Both of these conditions are serious and you should seek medical help if they occur.

If your fingers, nose, or toes are turning bluish-gray, red, or dark pink from frostbite, get help immediately. Don’t use the frostbitten part of your body and don’t rub the skin. Warm up the area with warm water (not hot) and avoid heating lamps or campfires. Cover the chilled area if possible, and put your hands or fingers in your armpits for warmth. Remove any wet clothing and get to a warm place.


Sunburn

The sun’s rays are the hottest from 10 am to 4 pm. If you are out during this time, you are more likely to burn. If you do get sunburned, expect discomfort and pain, redness, swelling, and even blistering. A minor burn will make the skin be tender to touch. A more serious burn will involve blistering. If you have lots of blistering on your body, you will need to seek help immediately.

The main objective is to cool down the skin and limit the extent and discomfort of the burn. Take a shower with cool water or use aloe vera cooling gel on your skin. Drink plenty of fluids, too. Sunburns are dehydrating as they draw water from the body. If your skin is burned, you will need to stay out of the sun for a couple of days to let it heal.


Prevention of Skiing and Snowboarding Injuries

It is easier to prevent than to treat, so take this advice seriously and do what you can in the way of prevention. Here are some handy tips:

  • Warm it up. Before starting a sports activity, jog in place, walk briskly, and stretch to warm up your muscles. Get into the sport gradually over a few minutes, giving your muscles a chance to get a good supply of blood.
  • Cool it. Cool down afterwards by stretching or light walking to keep the muscles from shortening and trapping the by-products of exercise (lactic acid) in the tissue and resulting in stiffness.
  • Cover up. For hypothermia and frostbite prevention, wear a hat, dress in layers, wear long underwear, and use a water-resistant coat and gloves. Another tip is to do buddy checks with a friend. Drink warm fluids before going out for your ski or snowboarding activity.
  • Lather up. For sunburn prevention, use sunscreen with an SPF of at least 15. It is important to remember to put this on top of your head and in your part line if you aren’t wearing a hat.
  • Dress up. For sunburn prevention, wear large shaded goggles or glasses and appropriate gear. Keep your head covered, as your part line and scalp is sensitive.

Winter Sports Injury Prevention

According to the United States Consumer Product Safety Commission, more than 440,000 people were treated in 2010 for winter sports-related injuries. These injuries were related to snow skiing, snowboarding, sledding, tobogganing, and ice skating.

What are some common winter sports injuries?

Injuries that are associated with winter sports include sprains, strains, fractures, and dislocations. Most of these injuries are easily prevented if sports participants adequately prepare by keeping in good physical condition, stopping when they are in pain or fatigued, or by staying alert.

Knee injuries that occur include tears to the anterior cruciate ligament and the meniscus. Also, head injuries are common serious winter sports injuries.

What are some prevention measures?

There are several things you can do to prevent injury during your favorite winter activities.

  • Maintain fitness. You should be in good physical condition to participate in winter sporting activities. If you are out of shape, start on a ski run that is not challenging.
  • Warm up. You need to warm up thoroughly before participating. Cold unstretched muscles, tendons, and ligaments are susceptible to injury. Warm up with running in place or doing jumping jacks for around 5 minutes.
  • Hydrate yourself. Mild dehydration can affect your endurance and physical ability. Be sure to drink plenty of water before and after winter sporting activities.
  • Ensure a safe environment. Be sure you stay on known marked trails and avoid avalanche areas. Pay close attention to rocks and ice patches. Ask about upcoming storms and severe drops in temperature.
  • Take a buddy. Do not participate in winter sports alone.
  • Know the safety rules. Be sure you understand and follow all rules of the ski resort or winter sports arena.
  • Layer up. Wear several layers of loose, light, water- and wind-resistant clothing for protection. This will allow you to accommodate your body’s changing temperature.
  • Wear proper footwear. Make sure your shoes keep your feet warm and dry, as well as provide adequate ankle support.
  • Seek shelter when necessary. Get out of the cold when you are experiencing signs of hypothermia or frostbite.

Knee Injuries on the Job

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Driving down Interstate 5 through the Pacific Northwest, you see a lot of logging trucks pass you by.

Loggers and truck drivers do a lot of heavy lifting and/or climbing, but so do other professions, like nurses, construction workers, doctors or even chefs who walk long distances while lifting items they may need on the job.

You may not think of these jobs as a place where a knee injury might occur, but in fact, occasionally injure a person.

A knee injury might not be apparent at first, but over time, may become swollen and painful. The knee injury now becomes an impediment, and you are unable to lift things because your stance is unstable.

Think about the last time you wobbled a little because your knee gave out and developed a nagging pain soon after. Did you do anything to alleviate the pain you felt in your knee?

Common Knee Injuries

Meniscus Injuries: Meniscus tears can cause intense pain and instability in the knee depending on the severity of the tear. Clients with tears to the meniscus describe a sensation of their knee “giving out” or “coming out from under them” while walking or climbing stairs.

The knee will most likely swell in order to protect itself, which can be intensely painful and can limit movement. Although physical therapy, anti-inflammatory medication and cortisone injections can help reduce symptoms, an orthopedic doctor will often recommend arthroscopic surgery to repair the tear.

Ligament Injuries: Injuries to the cruciate ligaments – such as the anterior cruciate ligament (ACL), medial collateral ligament (MCL) and posterior cruciate ligament (PCL) – are sometimes referred to as sprains, but they can be much more complicated than simple muscle strains. These injuries can require months of treatment to recover, and some cruciate ligament injuries — e.g., anterior cruciate ligament (ACL) tears – may require reconstructive surgery.

Chondromalacia: Chondromalacia is a disorder caused by softening of the articular cartilage of the kneecap. It can be caused by traumatic injury or overuse or repetitive motion on the job. Signs and symptoms of chondromalacia include dull, achy pain in the front of the knee, increased pain when walking up or down stairs, pain in the knee when kneeling or squatting, knee pain after sitting for long periods of time, a grating or grinding sensation when you extend your knee and knee stiffness.

To diagnose the problem, an OSS physician may require you to attempt simple knee exercises or recommend X-rays or other imaging tests such as an MRI or CT scan. Treatment options include rest, pain relievers or physical therapy. In rare cases, arthroscopic or realignment surgery may be options.

According to Dr. Watt, “Knee problems and injuries may be job-related or not. Sometimes it is obvious and sometimes not obvious and this may be part of the initial evaluation. I have extensive experience on all types of knee problems and injuries and would love to help anyone with a knee problem to try and regain a healthy knee.”

Dr. Watt is a board-certified orthopedic surgeon here at OSS who works with patients dealing with a wide range of orthopedic issues. Dr. Watt carefully weighs conservative and aggressive methods of treatment to devise a plan tailored to the specific needs of the individual. This personalized approach creates excellent outcomes, with patients working as close partners in the treatment process.

Shoulder Ligament Injuries

Things tend to wear out and break at the moving parts. It’s just one of those principles of engineering that we cannot shake. It is one of the reasons that we see so many people with shoulder injuries.

The shoulder is the most mobile joint in the body and we ask it to do a lot for us. Every day, we reach forward, overhead and behind the back, sometimes repetitively or with heavy loads.

Other times, the shoulder absorbs more force than it should as we use the arm to break a fall in sports. This activity can lead to either traumatic or repetitive use injury. Today, we will focus on those injuries specific to the ligaments of the shoulder complex.

Ligaments hold one bone to another bone and limit the amount of motion available in the joint. This prevents excess movement or motion in directions not intended for a particular joint.

The tighter the ligaments are, the less motion available. Because the shoulder is a highly mobile joint, the ligaments must be loose to allow motion in all directions. This creates some inherent instability in the joint, and an avenue to potential injury.

Anterior Ligament Sprain/Dislocation

This injury usually occurs when we raise the arm overhead or out to the side and apply a force, such as with retrieving a heavy object from an overhead shelf. If the load is too great, then the ligaments in the front of the shoulder become overloaded and can tear, causing a sprain. If the ligaments tear enough, then the bones can separate and cause a dislocated shoulder.

Dislocations should get immediate medical attention in the emergency room. Treatment involves applying traction to the joint, which allows the shoulder to return to its normal position and then a period of immobilization to allow the ligaments to heal.

Unfortunately, the ligaments do not heal quite as tightly as they once were. The shoulder becomes increasingly unstable, disposing it to another dislocation. Conservative treatment following a dislocation involves strengthening of the rotator cuff, a group of four muscles that provide additional stability to the shoulder.

As you move your arm through space, the rotator cuff sucks the head of the arm bone, medically termed the humerus, into the socket. After a dislocation, it is even more important to keep the rotator cuff working properly. You may be referred to a physical therapist, who can provide instruction in the proper exercises.

Should the shoulder continue to dislocate, surgical intervention may be required. This entails tightening the shoulder capsule by “pulling up the slack” in the loose ligaments and stitching them back in place. This surgery is highly successful at stopping future dislocations, but there is a period of immobilization and rehabilitation for several weeks following the surgery.

Shoulder Separation

This is a common traumatic injury caused by falling on an outstretched hand. With this injury, the force of landing on the hand is transmitted through the shoulder, causing a tear in the ligament that holds the collarbone in place. The result is a dislocation of the joint where the collarbone meets the shoulder blade, located at the bony area on top of the shoulder.

This joint is called your acromioclavicular, or AC joint, and because this is the pivot point where the shoulder blade rotates, an injury here can cause significant loss of function in the arm, especially in the overhead range of motion.

Minor sprains in the ligament may heal, but active individuals who have difficulty or pain with arm use may need to undergo surgical correction, as conservative treatment usually will not restore proper mechanics and movement patterns.

Surgery involves harvesting a tendon from elsewhere in the body and using is as a replacement for the broken ligament. This effectively anchors the collarbone back in its correct position.

Frozen Shoulder

Medically termed adhesive capsulitis, this condition may be a result of injury to the shoulder, but just as often occurs without any type of trauma. It is an inflammation of the shoulder joint capsule, which contains the shoulder ligaments.

As the capsule becomes inflamed and thickened, the shoulder becomes painful and loses significant mobility. Frozen shoulder may persist from several months to a year or longer and usually follows a predictable pattern of presentation that includes three stages.

  1. The acute stage is marked by sharp pain in the shoulder throughout the range of motion, but especially with reaching overhead and out to the side. Shoulder mobility becomes limited.
  2. During the frozen stage, acute pain starts to subside, but mobility of the shoulder continues to be limited.
  3. The final phase is the thawing phase, where the joint mobility of the shoulder begins to improve, and functional use returns.

Although frozen shoulder can afflict a wide range of people, there are certain risk factors that may dispose someone to getting this condition including diabetes, cardiac disease, and hypo or hyperthyroid issues. Treatment is usually non surgical, as the condition usually gets better with time.

During the acute and frozen phases, anti-inflammatory medications may be prescribed, as well as a steroid injection directly into the joint capsule, which significantly limits the degree of inflammation.

Physical therapy may be ordered in order to learn some gentle mobility exercises, followed by more aggressive stretching and mobilization of the shoulder as the condition progresses into the thawing phase.

Switching to Anterior Approach for THR

I initially looked at switching to the anterior approach (going into the hip from the front rather than the side or back of the hip) because the PAs (physician assistants), nurses, and physical therapists in my hospital all told me that they felt that the patients who had anterior approaches were having significantly less pain and were able to rehabilitate faster.

I have a partner who was one of the first people in the Seattle area to do anterior approach THR and the hospital staff could watch the difference in how the patients recovered after their surgery.

Anterior Approach

Finally one day I asked our head PA how she would want her total hip done and she said definitely by the anterior approach. At that point I knew I had to learn more about it and whether it was reasonable for a surgeon that has always done THR through a posterior approach to change to a dramatically different technique and still be confident that my patients would benefit.

I first observed the technique in the operating room and then studied the anatomy of the anterior approach. The first obvious benefit is that the approach to the hip from the front is anatomically easy and does not involve cutting any major structures to get to the hip. You simply spread the interval between two muscles and you are down onto the hip capsule.

When you go in from the back you have to divide the gluteus maximus (butt) muscle and split part of the ilio-tibial band on the side of the hip and then cut several small tendons off the back of the hip.

The thing that stops a lot of surgeons from doing this approach is that it is so different from what they are used to. The other thing that stops them is the special technique that is necessary to place the stem into the femur (upper thigh bone). When you approach the hip from the back, it is fairly easy to place the stem of the implant into the femur.

From the anterior approach most surgeons use a special table called a fracture table that allows you to position the leg in a very specific way. In my case, all of the operating room staff and my assistants were used to doing this approach and that made my job a lot easier.

Once I decided that I wanted to learn this technique, I went to a lab where you can practice on cadavers. I was surprised at how easy the approach was and how well I could get good exposure of the socket and the femur to do the surgery. Once I had the exposure, the actual placement of the implants was exactly what I had been doing from the posterior approach.

I have now been doing all of my hips using the anterior approach, and although the first few that I did made me a little anxious, after about 10 hips I knew that I would never go back. For me to switch, I had to feel that it was an advantage to my patients and that I could do as good or better job implanting the components. I have definitely found both to be true.

I have found that my patients have less pain and are ready to leave the hospital sooner. After an anterior hip there are no hip position precautions like there are after a posterior approach. This means no pillows between the legs and you can bend over as far as you want.

My patients who have had one hip done through the posterior approach and one through the anterior approach tell me that not having to follow specific hip position precautions is one of the biggest positive differences that they noticed and they feel that it helped them recovery more quickly.

From my standpoint as a surgeon, I love the approach because I don’t have to cut any major structures to get to the hip, and also when it is done through the anterior approach it is easy to use fluoroscopy (real time x-ray) to check the position of the hip components while you are putting them in. This allows the cup position to be optimal and allows the surgeon to check the leg length to be sure it is the same as the other leg.

I am very happy that I was pushed to learn this new approach to THR. Total hip replacement surgery is one of the most rewarding surgeries that we do. No matter how it is done, as long as it is done well, patients have wonderful results. This is exactly why many surgeons don’t feel the need to change. They are doing an operation with excellent results and they don’t want to take a chance on having problems while learning a new way of doing it.

Fortunately for me, I was able to see a good surgeon and support staff doing this procedure and it convinced me to change.

My last thoughts for anyone reading this who is contemplating having their hip replaced is to know that the most important thing for a successful hip replacement is having a good surgeon and a hospital that does hip replacement surgery routinely. I do think the anterior approach has advantages over the posterior approach for both the patient and the surgeon and that’s why I switched.