The Operation of the Century – Why Total Hip Replacement Keeps Getting Better
Written by Dr Nick on February 23, 2026
Adolph V. Lombardi, Jr., MD, FACS
In this special edition of News You Can Use on HealthcareNOWRadio, I had the pleasure of sitting down with Adolph V. Lombardi, Jr., MD, FACS an orthopedic surgeon based in New Albany, Ohio, who has performed more than 38,000 joint replacements over nearly four decades. We explored why total hip replacement, once called the “operation of the century” by The Lancet, truly deserves that title. At its core, the procedure replaces a worn-out ball-and-socket joint with advanced materials, metal, highly cross-linked polyethylene, and ceramic that restore mobility and eliminate pain. What struck me most was how far we’ve come, from early cemented implants with limited longevity to today’s cementless designs that biologically bond to bone and may last 25 to 30 years or maybe much more.
We discussed how innovation has steadily addressed the historical weak points of hip replacement. Early challenges with cement fixation, material wear, and brittleness have largely been overcome through porous metal shells that allow bone ingrowth, antioxidant-infused polyethylene liners, and highly durable ceramic heads. Complications such as periprosthetic fracture, infection, or dislocation remain rare. Typically, around or below 1%, but like all complications, they are taken seriously. What has changed more recently is the shift toward patient optimization. For example, in the preoperative prearation we now work hard on smoking cessation, diabetes control, dental care, weight management, and even prehabilitation, all of which play a role in reducing infection and improving outcomes. Today, most patients are home within hours of surgery, mobilizing early, and benefiting from refined pain control strategies. Just as importantly, timing is now guided by symptoms and quality of life, not simply by X-ray findings or age.
Looking ahead, the field continues to evolve. We talked about robotics and AI-driven 3D modeling to optimize implant positioning and reduce instability. Most exciting is an ongoing multicenter randomized trial evaluating a “reverse hip” design, modeled after the highly successful reverse shoulder concept, to enhance stability and potentially reduce dislocation even further. Early data are promising, showing excellent fixation and minimal micromotion. What’s clear to me is that total hip replacement is already one of medicine’s great success stories, yet it refuses to stand still. Even with extraordinary outcomes today, surgeons and engineers are still refining materials, techniques, and design to make a great operation even better, and that relentless pursuit of improvement is exactly what patients deserve.
As we discussed here is a picture of the “Reverse Hip” (aka Reverse Hip Replacement System
You can find more about this and the technology at the Hip Innovation Technology website
Until next week, keep solving healthcare’s mysteries before they become your emergencies
xx
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
Listen along on HealthcareNowRadio or on SoundCloud
Raw Transcript
Nick van Terheyden
In this week’s special edition of news you can use on healthcare now radio. I sat down with Adolf Lombardi, he’s an orthopedic surgeon who practices in New Albany, Ohio, to explore an introduction to total hip technology. Adolf, thanks for joining me on the show.
Adolph Lombardi
Well, thanks for having me. It’s a pleasure to be here. I’m talking to you from New Albany, Ohio. I have been in practice in the greater Columbus area for the past 39 years. I actually started practice July of 1987, let me tell you a little bit about myself. I was educated in Philadelphia. I went to Temple University, School of Medicine. I did my orthopedic residency at Albert Einstein Medical Center in Philadelphia, and then I did two fellowships. I got very excited during my residency about joint replacement. And the reason I got excited is that those patients were happy after the operation, and you were doing something concrete to help them. You are using metal, plastic ceramics to rebuild their hip or knee joint. And so I did a fellowship here in Columbus with my mentor, Tom Mallory. At that time, he was doing quite a few of these operations. We would do anywhere from eight to 10 a day, which was unheard of at that time, we ran two hours, and I got a great education. I spent six months with him, and then I went because I didn’t think I had enough. I went to the Washington, DC area to work with a gentleman named Jerry Yang. His brother Andy Yang was a big proponent of total hips, and was one of the Guru’s actual first ones to do some of the cement less hip replacements that were now are just routine here in the United States. So I learned from Cherry how to load knees and Charlie how to do some hips. And my mentor Tom Mallory, had invited me to come back. So I’ve been back in the greater Columbus community now here in New Albany, just a suburb. And to date, ladies and gentlemen, I’ve done about 38,000 of these total joints. I specifically love total hips. And the reason I love total hips is that a journal that many orthopedic surgeons Nick don’t read, The Lancet, published an article that the this was the operation of the century, and indeed it is, when you do a total hip replacement. Let me just explain to the viewers what you’re doing is you’re taking the ball and socket. When we’re born, we have beautiful lining cartilage on the acetabular side, the socket side and the ball side, the femoral head. That cartilage gives us that freedom of motion. Unfortunately, as we age, there’s probably a mechanical a genetic component. We really don’t understand how certain people have severe arthritis, and others don’t. You know you that deteriorates, you start to get limited range of motion, you’re unable to tie your shoe, get in and out of a car, and everything is painful. And when you do a hip replacement, on the acid tabular side, you generally put in a metal shell and some type of liner. Today we’re using a highly cross link plastic, polyethylene liner. When I started, it was not the same good material, and so the failure mechanisms have changed. I’m going to go through that with you in a minute. And on the femoral side, you put a metal stem into the thigh bone, the femur.
Nick van Terheyden
Now, yeah, so, so, if I, if I may, I think this is fantastic, you know, excellent, sort of background. And, you know, I can’t disagree with you even slightly in terms of the operation of the century, however you want to describe it, it is absolutely revolutionary, before we get into where we’ve gotten to with the technology. I want to ask you a couple of things, because, you know, from my practice, you know, back in that era, there were a couple of things and you sort of touched on it. One was the cement, and that really became an issue in the redo because they wore down, they had about a 10 to 20 year life expectancy, and I think we’ve seen now an extension of that, but I’m not sure that we know what it is, although I refer to it as the 100 Year hip based on the wear rates that we’re seeing, what were the innovations that we got to before we started to move even more. I mean, we’ve already made some amazing progress, but those were the primary things in the early days. As I recall
Adolph Lombardi
correct when I started we were doing we had just started introducing cement list technology. My mentor had a cement list. Implant that we have reported on the actual 20 year survivorship, which was around 98% so
Nick van Terheyden
because not everybody has the same background, can you explain why cementless is so significant and why that was an important innovation.
Adolph Lombardi
Okay, so if you think about it, we use this material, polymethylthacrylate, bone cement. It is the strongest the day we put it in it then will weaken with time. And the problem was, there were certain things that were not fully understood, like how to pressurize the cement to get it to interlock into bone. Bone is a three dimensional material. The way the cement bonds the bone is not like an adhesive. It interlocks into the bone, and then the metal rod you put in there has to bond to that. Well, initially we thought that, but then we learned that, because cement is viscoelastic, meaning it moves slightly, we we designed stems that had tapers in them, yep. And then we designed them out of stainless steel. And then there came along, oh, maybe we’ll make a better chrome cobalt, because titanium is a fiasco. Yeah, right, when you put in cement, it’s a soft material, and it will rub and debride and cause significant wear. Now, at the same time, we’re having these struggles, we’re having a struggle with the plastic, because it wasn’t high quality plastic, and we were putting a metal ball against that plastic. If you put a titanium ball, that was the worst, if you ask them, we did some of those. We went then to hardening the surface of titanium, then to Chrome cobalt, and thank God. Now we’re at ceramic. And the initial ceramics were brittle. The current ceramic has a very, very indistinguishable fracture rate. I I haven’t had a fracture in 20 years, right? Ceramic head, right? But when they do her occur, they’re a fiasco. So the combination today, what we have is a combination of a beautiful ceramic. It’s actually pink in color. It’s called bilax Delta on a highly cross linked polyethylene that has an antioxidant, usually vitamin E, and a metallic shell that has a porous surface. So again, the three dimensional surface bonds to the bone. The bone will grow into it. The cement, on the other hand, was an in between. And it was a week. It was the Achilles heel. It was going
Nick van Terheyden
to be clear, no cement in that rearward facing cut that sits in the acetabulum.
Adolph Lombardi
We are very rarely you will see this in Europe, in some of, some of where you’re from, Great Britain. I understand, right?
Speaker 1
Originally, yes, yeah.
Adolph Lombardi
So our English colleagues will use cement, and will cement both the socket and the femoral stem. Still, to this day, to this day, there’s an ongoing controversy as we talk about some of the problems. One of the problems we’ll address right now that we can possibly have is a Periprosthetic fracture. This means you put that metal rod down into the bone, and at some point, and you know, it could be six months, it could be a year, it could be two weeks, the bone will break around the implant. Now, why is that? Well, if you look at the data, it occurs most frequently in the osteopenic elderly female, or the female who has a sub capital fracture, a femoral neck fracture, goes to the local emergency room and gets a cement list hip put in. And the argument in the United States is that our resident pool is not being trained as well as we used to in using cement, because the success of cementless has skyrocketed, and the most of what they see as a resident is cementless technology. Now there are some new versions.
Nick van Terheyden
I just want to clarify something for the listeners, because I think it’s important when, when you hear things like that, you go, gosh, you know, maybe I rethink it. But when you talk about that complication that is a rare, very infrequent complication that occurs in hip replacement, correct, correct.
Adolph Lombardi
I mean, we’re talking about 1% or so, right? Very, very small number, but we’re still working in addressing this as the orthopedic community, just having returned from a meeting abroad. You know, we had the the European versus the US kind of opinions The Europeans are going to take that osteopenic female and probably cement in a tapered stainless steel stem. And the Americans are probably going to do what we call a collared stem, so you cut the bone, you put an implant in. He has a collar that rests on the bone, and it’s felt that that collar, and there’s some finite element analysis that has been done that shows. Is it decreases the strain and decreases that incidence of periprosthetic fracture. So we are keenly aware of it. We are evaluate every patient individually, right? And decide, and we still, I still, will occasionally use the bone cement in some of those patients that I have a concern for, right?
Nick van Terheyden
So to be clear, it’s not. It is a very small subset, but it is not something that the medical community ignores, and, in fact, is focused on. And we’re going to talk about that in a little bit, before we move on from this. One of the things that, again, used to be the case, and I don’t know that everybody fully understands this was we used to hold off on putting hips in until people were those elderly osteopenic individuals. My sense of it now, with the impressive progression of that technology, is that picking the right time is much more important, because you can get a long lifespan from that device, so you want to get it in early enough, as opposed to waiting till, for instance, a fracture, which, to me, is A catastrophic incident and doesn’t improve your outcomes. Is that true? What are your feelings about timing and symptoms for patients who think about this,
Adolph Lombardi
well, I tell every patient, I don’t operate on an x ray. I operate on you, the patient. I’m listening to your symptoms, I’m assessing the limitations, I’m assessing your impression of your quality of life. And so if the number of bad days outweigh the number of good days, right, we have a great operation, and we have great implants. And as I expressed, good materials that are going to last you, I think 2530 years, one of the things that my mentor, Charlie Yang said, as I mentioned him earlier, yeah, is once you have biological fixation, once the bone grows into the implant, it doesn’t loosen. It’s the opposite of cement. It’s a it’s a living, viable interface. And what you’ll see that if that’s going to break down, is maybe that the bone shields because of the of the stiffness of the rod that you put in. But we’re not seeing much of that anymore because we have different shapes. We’re using more titanium. He was using a chrome cobalt, a very stiff material, at that time. So so I feel what I tell my young patients is, yes, maybe 2530 years down the line, you might need another operation. I think that’s going to be change of the plastic liner and a fresh new ball, right?
Nick van Terheyden
Yeah, very much. So you’ve talked a lot. I mean, let’s be clear. I think outstanding operation one that is increasingly something to consider earlier. And as you rightly say, based on the patient’s symptoms, not based on clinical X rays. You talked a little bit about complications with the Periprosthetic fracture, any other issues that people should be concerned about, or at least understand as a possible thing, and what are we doing about them?
Adolph Lombardi
Yeah, let’s talk a little bit about the number two, actually, which is actually the number one, and that’s Periprosthetic infection. And I will say you, the patient, can do some things to help prevent infection as well. I mean, no orthopedic surgeon, no surgeon at all wants to deal or is happy about infection. This is, this is the worst nightmare I face. So I want to start. There are three ways for us to approach infection. We’re never going to make it zero, but we’re going to start with Creole. With pre op, right? If you’re a smoker, stop smoking. Give me at least six weeks of smoking sensation. If you do that, you’re helping yourself and me decrease that incidence of infection. If you have poor dentition, get to the dentist, right? Get things cleaned up first. Yep. If you’re struggling with diabetes, then you need to get on the right medications. You need to get optimized. You need to get that hemoglobin a 1c down, way below seven. And you know, if you’re a little overweight, dieting is good becoming doing some pre op exercise is good so that you’re mobile. So this concept of patient optimization has come to Vogue in the past 10 years, as we’ve shifted from what I say, operating on a sick patient to operating on a healthy patient. And remember, 98% of my patients. Today are home within four hours of the operation. That’s because we’ve optimized you before the operation, and we have learned how to deal with post op pain control. And we want early ambulation. What does early ambulation do? It prevents the infamous DVT blood clot. Nobody wants a blood clot. So if we do all these things, we can minimize infection pre op. The other thing we can do is we do things such as a chlorhexidine. It’s a topical agent we use over the skin. We get, we give you, actually, that to shower with the night before we can. We can decolonize our our nasal cavities carry a lot of bacteria. We can do an iodine swab in the pre op holding area to decolonize that, prevent that so there are multiple things, or a nutrition bundle, if we need to. And then during the operation, we use a lot of irrigation saline, and we can use a dilute betadyne solution. And then obviously perioperative antibiotics. And if you’re in a high risk category, perhaps you’re a little bit overweight, we make do extended antibiotics and and then, you know. So these are the things that we tried to do, as well as making sure we have new dressings now that we apply, for example, in our heavier patients, we use dressings that are called wound vacs, a negative pressure dressing to pull the have the wound heal from deep to superficial, and any seepage that would come out in a heavier patient, that will be collected into a vacuum and discarded. So there are many things we’re trying to do to prevent infection, some of the newer things that will be available to us, I think, in the future. For example, right now, our Japanese colleagues are using implants that are coated with iodine. Now they can do that in their country. We have the FDA here, and we’re going to have to go through some hoops to get that approved. But I think once we get some good data out of Japan, we’ll probably start looking more aggressively at that with the FDA, and hopefully get that approved.
Nick van Terheyden
So So, I mean, I think it just reaffirms my experience. And to be clear, 40 years ago, this was a primary issue, because when I worked with my orthopedic surgeon and was in the it was, it was light and night and day in terms of the rigorousness and the severity of the approach to cleanliness from the orthopedic surgeon relative to others. I mean, it was, it was very clear, and for all the reasons that you described, because obviously infection in that circumstance is very challenging to deal with for the purposes of time, I want to focus a little bit on the future and some of the things that are happening. And I know that you’re working on a trial that is sort of testing out new technology. And again, I have to make this point because it’s important to me, and I think for the listeners to hear this is such an outstanding operation, you know, if you need it clearly. But for those people, this is fantastic technology. But once again, medicine doesn’t stand still, and we’re trying to improve it. What are you doing, addressing the future and thinking about, you talked about the iodine in the case of Japan, and, you know, incorporating that, what else is going on, and what are you working on?
Adolph Lombardi
All right, so we’ve talked about periprostatic fracture, Periprosthetic infection. Now we have to talk about the other thing that we dread. And the patients will come in and ask me if this is going to happen, and that is a post operative dislocation, where the ball comes out of the socket. Again, I want to make sure we emphasize these are all rare. You know, we’re talking low percentage infection is usually less than 1% very prosthetic around the same and dislocation is, is today, it’s sometimes it’s approach dependent. The big thing today is anterior approach versus posterior approach. Many of my patients are coming in saying, Adolf, you’re going to do an anterior approach. You know, of course, that’s what I’ll do. I’ve never done a posterior approach. Personally, I’ve done many lateral approaches, which is a very stable approach, helping keep that ball in place, the anterior approach also a fair amount of literature showing little that it is more stable than a posterior approach. So what? What are we doing for stability? Let’s talk about that. Let’s talk about two aspects. One is technology. Okay? Today, with the advancement of AI incorporated into robotics, we can actually get a 3d scan of your hip and model it to see where it’s going to impinge. Impinge means where it’s going to touch the bone and come out of socket. So and then decide, perhaps the exact orientation that we want to put that metallic shell in it. At that plastic liner and that stem with the ceramic ball. Now, a new implant that has hit the market is something called the reverse hip. Many of you on here may have heard of the reverse shoulder because it’s been around for a number of years, and I’ll tell you that when it came to market, there were a lot of naysayers. Interesting enough, it’s about 85% of the shoulders done today. And why is that? It is extremely stable. So if we look at the hip, there’s this reverse hip models after the reverse shoulder, we on the socket side, we’re going to put the metal shell and we’re going to put the ball in the socket on the femoral side, we’re going to put the metal rod in and the cup there. With doing that, we increase the surface area and the range of motion. If you I actually saw this in a lab six to eight years ago and told the company I was working with at the time we should look into this technology. Well, they decided not to. And then I got invited to be part of the IDE study, which is a randomized study. If you want to believe something, you have to look at a randomized study where I tell the patient, this is a device. My research assistant comes in and talks to them, signs them up, and then the day of surgery is when I find out if they’re getting a reverse hip or standard hip. That’s how you can tell if something really works. And so I’ve been privileged to do that, and I’ve enrolled over 35 patients in it. Now I have data that comes out of Canada by a doctor, tergen, RSA data. RSA is a special type of X ray data that shows us how the implant is doing. Is it moving? So when you implant these devices, we want to make sure they’re stable. And the RSA data is showing less than 0.08 millimeters of motion at two years. And now even at five years, follow up that
Nick van Terheyden
and relative to excellent, relative to existing technology, how does that rank?
Adolph Lombardi
So it’s, it’s equivalent, and, if not better, it’s right, existing, the anything you put in is going to move slightly, slightly, 0.2 millimeters. Is the cut off? Right?
Nick van Terheyden
0.08 so, right. So it’s a 10th or a 100th even of what we’ve seen in other instances, which is still normal, but you know, much less
Adolph Lombardi
so, but the more the key feature of this is, once you put it in, you can take that hip through a range of motion, and it doesn’t dislocate. And you know, we have seen this in the lab. We have seen it in the or so. I have been expanding my indications and enrolling more patients, the studies going on at multiple centers in the United States. I do think this is going to bring an added technology to our armor atarium, something that will really help us, perhaps eliminate this problem. And the patients that are at significant risk are the spinal pelvic fuse type patients, the ones that have had massive spine surgery, all the way down to the pelvis. They don’t flex their pelvis like one who’s not so that stiff spine needs an extra stability. Now are other constructs that are used to help this one called dual mobility, which is a double motion cup, but it’s not without dislocation either.
Nick van Terheyden
So so just to summarize, there’s an ongoing trial that is looking at, and I’m going to use the term you used a reverse hip, which we’ll put in in the details, in the notes for this, and maybe we can get some diagrams to actually show what this means, because I’m even confused, because it’s difficult to sort of picture without, you know, actual images. And the trial is currently undergoing. You have multiple centers. You’re one of the centers. People can reach out, find out about it. Obviously, with multi centers. They don’t have to travel to Ohio, so there’s an opportunity to sign up. And the primary endpoint, am I right in understanding this is a reduction in instability, or the potential for instability in the future, is that this
Adolph Lombardi
is what we’re after? Yeah, we’re after a very stable construct, and we’re getting it with this device, and we know that it gets the fixation, because that was what was most criticized, you know, is, are you going to be, you know, those forces that are generated, are they going to make that move or and it’s not happening. It the RSA data is concrete. And. My clinical data so far, patients are very, very happy. I can’t tell the difference between my standard and my reverse hip patients. Neither can. Can they so, but it’s so. I have a lot of confidence in this device, and would suggest that if you’re have any concerns, look into it. Right?
Nick van Terheyden
All right. Unfortunately, as we do each and every week, we’ve run out of time. Fascinating subject, I think anybody that knows me knows this is, you know, very personal to me. Individually. I’ve had the benefit of this technology and a big advocate for hips, hips replacement, you know. And obviously the innovation that we’re bringing to bear and addressing, albeit a minority of cases that have challenges with complications, which, let’s be clear, that’s the case across the whole of medicine, irrespective of what we’re looking at. We are always dealing with challenges, but they’ve been reduced to extraordinarily low numbers. And even today, we continue to advance, and there is an opportunity. So for those of you that are interested, you can learn more about this at hip innovation technology.com which is where details of that particular innovation, the trial that’s ongoing. And Dr Lombardi, it just remains for me to thank you, Dr Lombardi, for joining me on the show, sharing all of the details, all of the excitement, quite frankly, with this operation, the opportunity for people and explaining the details so that everyone can understand. Adolf, thanks for joining me today. Thank you, Dr Nick, you.
