Most people getting ready for a hip replacement think about the surgeon, the hospital and the weeks of rehab afterward. Very few think about their dentist. Orthopedic surgeon Dr. Michael Leighton, MD, thinks you should, and on Episode 12 of Pain 2 Power he explained why in about ninety seconds.
That was one stop in a half hour that covered the anterior and posterior approaches, why a belt line can change which operation you are a good candidate for, how hip surgery went from a week in traction to therapy the same day, and the dollar figure Medicare pays a surgeon for the whole thing. Mike guessed high. Very high.
By The First Rehabilitation Team · Reviewed by Dr. Dave Kashuba, Ph.D.
Why Dave brought in a surgeon he has worked with since 1994
Dave introduced his guest as a friend he has been working with since 1994 and one of the best in the county. Then he went straight to his standing advice about picking an orthopedic doctor. Do the research, and choose on quality and nothing else. “Don’t listen to the lady at the pool,” he said, a line Mike picked up later in the hour when he pointed out you’re not going to get Dr. Leighton’s years of training from the water cooler either.
Dr. Leighton is an orthopedic surgeon with Palm Beach Orthopedic Institute in Palm Beach Gardens. He is board certified by the American Board of Orthopaedic Surgery with a subspecialty certification in Orthopaedic Sports Medicine, and he performs both anterior and posterior hip replacement as well as robotic-arm assisted (Mako) knee replacement. You can read more about his background on his Pain 2 Power guest page.
A cup of coffee on the Duke baseball team
Dave had heard from another surgeon that Dr. Leighton played Division I baseball at Duke. Dr. Leighton was quick to play it down. “I was more like a cup of coffee on the baseball team,” he said, and he figured out early that his future was in finishing his pre-medical studies, not in baseball.
What he did keep from those years was the athlete’s view of the body. He counted the training out loud for Mike: four years of college, four years of medical school, five years of orthopedic residency, then a further year of sports medicine fellowship, where he cared for professional teams, college teams and high level athletes. Today his patients are golfing three or four times a week and playing pickleball several times a week, and he described his job as keeping that going.
The friend who played Davis Cup
The surgeon who had spilled the baseball story was Dr. Chaim Arlosoroff, M.D., the orthopedic trauma surgeon who came on a couple of weeks later to talk about e-bike injuries. Dr. Leighton gave the athletic credit right back. Chaim came from Israel, he said, was a Davis Cup player and played first singles at Duke. “He was the real deal.” Dr. Arlosoroff has his own guest page if you want that half of the story.
Infection risk is low, and most of what keeps it low happens before surgery
Dave opened the clinical part of the show by bragging on his guest’s infection record. Dr. Leighton winced. His grandmother, he said, had a word for saying something like that out loud, and it meant bad luck. He would not claim he had never had an infection in his orthopedic life.
What he would say is reassuring. “The good news is that the risk of infection in a total hip or a total knee replacement is actually quite low,” he said. He put it at less than 1 or 2% over the course of your life with the implant in place, and said the surgical team does a lot around the operation to keep it there. The bigger lever, in his telling, sits with the patient in the months before.
Here is the pre-surgery list he walked through, in the order he raised it:
- No active infection anywhere: no pneumonia, no open diabetic foot ulcers, no unhealed wounds such as one left by a skin cancer
- A visit to your dentist or periodontist to rule out an active or low grade infection in your mouth
- Off cigarettes, and off nicotine vapes too
- For diabetics, blood sugar under control, measured by hemoglobin A1C
- For heavier patients, some weight off before an elective operation
His first piece of advice on that list was plain honesty. If you have something a little weird that hasn’t been healing, tell your surgeon. That is something he does not want to go into a hip replacement without addressing.
Why your teeth matter to a new hip
This was the part that stopped Mike. We all get bacteria in the bloodstream from time to time, Dr. Leighton explained. “You brush your teeth, and you will get bacteria temporarily going through your bloodstream.” Those same bacteria can settle in a newly implanted joint. So before a joint replacement, he wants patients evaluated by their dentist or periodontist and their dental hygiene up to speed.
Mike summed up how most of us would react: “It’s not the most intuitive thing in the world to think, ‘I’ve gotta get a hip replacement. I better make sure my mouth is free from infection.’”
Cigarettes, vaping and the A1C number
Smoking came next. Dr. Leighton said smokers have an increased risk of infection because smoking narrows the small blood vessels that carry blood to a fresh surgical wound. Dave asked the obvious follow up about vaping. The answer turned on nicotine: a nicotine-free vape isn’t really the issue, he said, because it is the narrowing of the vessels you are trying to avoid. Dave, who has been doing this a long time, admitted he had never thought of that. “I learn something new every day,” he said.
For diabetics, Dr. Leighton looks at hemoglobin A1C, a score that shows how well blood sugar has been controlled over the past few months. His line was clear. If the A1C is greater than 7.5, he said, elective surgery should not be done on that patient because of the increased risk of infection.
Anterior or posterior: what Dr. Leighton told us about the two approaches
A total hip can be done from the front of the hip (anterior) or the back (posterior). Dr. Leighton does both and said he is “more partial to a posterior approach.” He was careful about what the comparisons show when they line up like with like. A small group of anterior patients get from a chair to standing faster or better in the first two to four weeks. After six weeks, the two are the same, or are supposed to be.
| Point he raised | Anterior approach | Posterior approach |
|---|---|---|
| First two to four weeks | A small group of patients do sit to stand faster or better | No early edge on sit to stand |
| After six weeks | About the same | About the same |
| Fracture risk | Higher | Lower |
| Dislocation risk | Slightly lower | Slightly higher, though still very low |
| Wound complications in a heavier patient | Much higher | Lower |
| Who he tends to steer toward it | Thinner and younger patients can go either way | Larger patients, and patients 75 and older |
The patient who had one of each
Dr. Leighton has operated on plenty of people who had one hip done each way, and most tell him the two were about the same. One patient had both done by Dr. Leighton and liked the posterior side much better, because the recovery felt faster to him. He had chosen anterior first because his brother in another state had an anterior hip that turned out poorly, and he figured he might just have been lucky the first time around. Dave had a name for that: “The water cooler effect.”
Why the belly matters
The most practical stretch of the episode was about body size. An anterior incision sits on the front of the thigh. Picture a heavier patient sitting down with the belly resting on the front of the thigh, Dr. Leighton said. That covers the incision and keeps it moist, an environment “not really ripe for healing,” and wound complications run much higher. Mike added that the same patient may carry a higher diabetes risk, and Dr. Leighton agreed that stacks the risks.
He did not rule anyone out. A heavier patient who really wants the anterior approach can have it, he said, but he would ask them to improve their odds first. “I need you to lose 15 or 20 pounds,” he said, and pointed out that “total hip replacements, unless it’s for a fracture, are not emergency operations.” He mentioned the GLP-1 medications as one tool that works, with a side benefit: less weight on a sore hip, and on a sore knee, feels slightly better while you wait. Paul Joyce of New Life HRT covered what those drugs can cost you in muscle on our Episode 11 recap, which is worth reading alongside this.
Six weeks for bone to grow into the implant
When people ask how soon they can get back to the courts, Dr. Leighton’s general answer is about six weeks before something more rigorous like pickleball, tennis or golf. Chipping and putting can start early, whichever approach was used.
The reason is the hardware. Most modern hip components go in without cement, he explained, using what surgeons call ingrowth. The implant has a meshwork or roughened surface that bone actually grows onto and adheres to, which creates a solid fit. That takes about six weeks, “and at that point is when I kind of let people and let a little rope out and let them do a little bit more.” Cement is still used in some older patients, he said, but it is the exception now.
Mike’s reaction tied it to the people who listen to this show. In years past, he said, rigorous activity after a hip replacement would have seemed finished for good. Done properly, with the steps followed, “you’re giving people their lives back here, doctor.” Dr. Leighton agreed, and said the best patient who can walk into his office is the one whose bad hip is the only thing keeping them from being happy and active.
From a week in traction to therapy the day of surgery
Dave asked whether the old hip precautions still apply: no crossing the legs, no bending past 90 degrees, careful with rotation. He also mentioned what he teaches early on in the clinic, taking little steps to turn instead of pivoting on the new hip.
Dr. Leighton went back to John Charnley, whom he called the father of joint replacement surgery about 50 years ago. Charnley’s approach removed a piece of bone called the greater trochanter and reattached it, which required strict precautions. No flexing the hip past 90 degrees, no bending to touch your toes, no internally rotating the hip, which he likened to sitting in a chair and reaching behind you for something.
What changed
When he was training, he said, patients stayed in the hospital for a week in balanced traction with the leg up, unable to move. They did fine in the end, though many got blood clots, because the risk of clots was not understood in those days. Since then surgeons have learned it is okay to stand, put weight on the operated leg and move the hip.
So he does not routinely put people in those restrictions now. Early on he still asks patients to avoid bringing the knee to the chest and the other most provocative positions. The goal is to get motion back gradually over the first few weeks while the wound heals. When Dave asked if that means patients can reach down for their shoes and socks, he said yes.
He liked where the field has landed. “What’s going on now in 2026 is an appropriate level of fear,” he said. The surgeon names the moves to avoid, and he said the physical therapists tend to add a few more cautionary tales of their own, which he is fine with because patients need to feel comfortable doing the activities. We have written more about those early weeks in our hip impingement article and on our post-surgical rehabilitation page. Either way, your surgeon’s protocol is the one that counts.
Why he keeps most patients overnight
The operation can be done as an outpatient, Dr. Leighton said, but he generally keeps people in the hospital one night. His reasoning was about the first night home. If you go home the same day, you are looking at your partner and saying, “You’re gonna be my nurse overnight.” If chest tightness or a bad headache shows up at 2 in the morning, neither of you is comfortable. In the hospital there is nursing staff, and patients get physical therapy the day of surgery and again the next day before going home. Dave noted that he sees more and more patients arriving at the clinic for outpatient therapy right after surgery.
Prehab, Medicare visits, and where we come in
Dave asked about prehab, the therapy some surgeons order before an operation to tune a patient up. Dr. Leighton’s answer was that he does not prescribe it for everyone. He saves it for people who have been away from activity and are deconditioned, who need some aerobic work and whatever motion they can get back in the low back, the other hip and the knees. Two of our surgeon guests compare notes on that question in our partial versus total knee replacement article.
His reason was practical. A Medicare patient with hip arthritis, he pointed out to Dave, only gets so many tickets, and prehab visits count against the same yearly therapy benefit as the rehab after surgery. Dave explained that First Rehabilitation is a Medicare-certified Comprehensive Outpatient Rehabilitation Facility (CORF), and said that gives his patients more room to continue care when they hurt themselves or re-hurt themselves. How the Medicare therapy thresholds work in 2026 is laid out in plain terms in our Medicare guide, and the front desk checks your coverage before your first visit.
Thirty years of shared patients
Mike asked whether any of this comes from the mailman. Dr. Leighton said no, and then talked about Dave. Dave has taken care of his patients for 30 years, he said, and it is not a case of putting someone on a bicycle in the corner and leaving them to pedal. “He really does spend time with his patients, and does a great job.”
That is how our physical therapy program is meant to run for hip patients. Before surgery, the work is mobility, glute strength and walking mechanics, as described on our hip pain page. After it, we follow the surgeon’s protocol, starting with motion. If you want a feel for the movements, Dave walks through several on our hip exercise page, and our physical therapy FAQ covers referrals and what a visit looks like.
The $1,162 question
The show was wrapping up when Dr. Leighton asked for one more plug. He wanted listeners to know how a surgeon is paid for what he called the single best operation in orthopedics.
He set up the scenario: a healthy 66 year old Medicare patient, the operation, the hospital visits, and 90 days of care after surgery, all covered by one payment. Then he asked Mike to guess. Mike, who said he can’t even guess ages or weights, went with 136,214. The real answer: “$1,162, okay?”
He added that this was before what he described as a recent July announcement of a further 3 to 5% cut. Rent doesn’t go down, employees don’t ask for less money, and the cost of running an office keeps climbing, he said. His view was that Medicare is great at covering what patients need, and does not pay surgeons a fair number for a total hip. Mike called it a powerful note and a discussion for down the line, and Dave said he hopes to have Dr. Leighton back.
Before that, Dave had slipped in the joke of the week, about a boy who comes home from biology class with a question about evolution. The punch line belongs to his mom, and it’s best heard in Dave’s delivery.
Hear the whole conversation
Dr. Leighton practices in Palm Beach Gardens, and on air Mike gave his office line as 561-727-1318. If you live near his office, our page for Palm Beach Gardens patients explains how therapy with us works from there.
Listen to the full episode on the Pain 2 Power podcast page, watch it in our video library, and catch the show live Saturdays at 8:30 AM on 100.3 Legends Radio. If hip pain is starting to decide how often you play, or a hip replacement is on your calendar and you want to go in prepared, call us at 561-624-4263 or request an evaluation.
This article is general information, not medical advice. Every situation is different, so please consult a qualified professional about yours.