The efficacy and success of total knee arthroplasty (TKA) in treating patients with end-stage osteoarthritis are well established. However, revision rates range from 3 to 10% at 10-year follow-up. Reasons for failure include more obvious diagnoses, such as periprosthetic fracture and periprosthetic joint infection. With some exceptions, these complications can be diagnosed and treated expediently. However, other reasons for failure, such as instability and aseptic loosening, can prove more difficult to diagnose with a standard painful TKA workup algorithm.

Flexion instability has emerged as one of the most common causes of TKA failure in recent years. However, the diagnosis can be challenging as it remains difficult to predict patients who can tolerate laxity vs those who cannot. Without obvious radiographic changes over time, subtle aseptic loosening and, in particular, cemented implants, debonding, and failure of cementless ingrowth can also be difficult to accurately diagnose radiographically, and supplemental bone scans are known to have high false-positive and false-negative rates. Revision TKA without a clear diagnosis is not recommended due to poor results.

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Throughout decades of history in total knee arthroplasty (TKA), the role of the posterior cruciate ligament (PCL) has been controversial. Some reports have shown inconsistent results with cruciate-retaining (CR) TKA. Yet other studies have found CR TKA to be advantageous over posterior-stabilized (PS) designs with respect to maintaining proprioception and knee kinematics. In the final analysis, however, a combined review of the literature has failed to show the superiority of either CR or PS TKA.

A third method that may be used to enhance posterior stability is to increase the sagittal plane conformity of the tibial polyethylene. This additional conformity may be achieved by an anterior buildup of the tibial insert. The so-called anterior-stabilized (AS) insert helps stabilize the femur during flexion and stair-climbing, potentially eliminating the need for a more traditional cam and post design.

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Refinements in surgical technique, pain management, blood conservation, and rehabilitation have resulted in quicker recovery, providing a foundation for early discharge after TJA. Evidence has demonstrated early discharge TJA to be safe and cost-saving, without increasing readmission rates.

However, discharge on the same day of surgery has been criticized as potentially hazardous, with surgeons advocating an overnight stay to observe patients for life-threatening complications and those that will trigger a readmission. But is that overnight stay actually providing clinical value? Prior efforts to decrease expenditure by eliminating unnecessary health care modalities have proven to be effective in a variety of settings. Whether TJA patients discharged on postoperative day 1 (POD 1) receive beneficial medical interventions the night of surgery, necessitating their stay in the hospital, remains unknown.

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Patient satisfaction following total knee arthroplasty (TKA) has been stagnant at around 80% without a clear understanding of the lingering 20% dissatisfaction. Satisfaction is a prominent topic in the literature, yet it remains a convoluted topic to understand. Factors reported to influence satisfaction in systematic reviews are meeting patient expectations, reduction in preoperative pain, and depression and anxiety. Other factors include medial flexion gap laxity, food received during a hospital stay, and even the use of therapy dogs.

Nonetheless, government payers have increased interest in basing surgeon reimbursement on patient satisfaction without a full understanding of the contributory factors. Therefore, it is imperative to identify the factors that influence patient satisfaction.

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I sat in a hospital boardroom early in my career. The conversation was about productivity. Specifically, about RVU targets for the surgical department. Relative Value Units, the metric hospitals use to measure how much billable work a physician generates in a given period.

The administrator running the meeting had never operated. Had never stood at a table for eight hours managing a complication. Had never had a patient look at them before anesthesia and say, “I trust you.”

He had a spreadsheet. And the spreadsheet said I was not producing enough.

I left that meeting with a clarity I have carried ever since. The system was not designed to make patients healthier. It was designed to generate units. And I was the unit generator.

That was the moment I started building something different.

The Numbers Behind the Takeover

The transformation of American medicine from a physician-led profession to a corporate employment structure has been the most consequential change in healthcare delivery over the past two decades. Most patients do not know it happened. Most physicians feel it every day but rarely say so publicly.

The American Medical Association has tracked physician practice ownership since 2012. The trend line is unambiguous.

In 2012, 60.1% of physicians worked in private practice. By 2024, that share had dropped to 42.2%. In the same period, the share of physicians working in hospital-owned practices rose from 23.4% to 34.5%, and physicians employed directly by or contracted with hospitals doubled, from 5.6% to 12.2%.

Only 35.4% of physicians had an ownership stake in their practice in 2024, down from 53.2% in 2012, and less than half the roughly 76% share estimated in the early 1980s.

In one generation, American medicine went from a profession where three quarters of physicians owned their practice to one where fewer than four in ten do. The physician went from the business owner to the employee. And with that shift, the entire incentive architecture of care changed.

What an RVU Actually Is

Most patients have never heard of a Relative Value Unit. Most physicians wish they could say the same.

The RVU system was developed in the 1980s as a mechanism for standardizing Medicare payments. Each clinical procedure and encounter is assigned a unit value based on estimated physician work, practice expense, and malpractice cost. Hospitals and health systems then set productivity targets based on RVU generation. Meet your target, you are in good standing. Miss it, the conversation with your supervisor begins.

The logic seems rational on paper. Measure what physicians do. Compensate accordingly.

The reality is something else entirely.

Current RVU-based systems strip physicians of autonomy, creativity, and deeper professional satisfaction. The pursuit of RVUs becomes a primary driver in medical decision-making.

When the metric that determines your compensation and employment security is the number of billable units you generate, the clinical question “what does this patient need?” becomes entangled with the financial question “what generates the most RVUs?” Those two questions do not always have the same answer. And in a production-driven environment, the financial question tends to win.

The patient who needs a longer appointment. The complex case that requires thinking, not doing. The conversation about prognosis that generates zero units and takes forty-five minutes. These are the things the RVU system punishes. Not because anyone designed it to punish good medicine. But because the metric does not measure good medicine. It measures throughput.

What Happens to the Physician Inside the Machine

I want to be honest about what the corporate employment model does to a physician over time, because it is something most doctors will not say publicly while they are still inside it.

It starts subtly. The EMR dashboard appears. Your productivity ranking relative to peers is visible in real time. Your RVU count is reviewed quarterly. A nurse manager begins attending your scheduling meetings. Clinical decisions that were once yours alone, what imaging to order, which patients to prioritize, how long an appointment needs to be, start requiring approval from administrators whose clinical credentials do not qualify them to make those decisions.

The language changes too. Patients become “encounters.” Appointments become “throughput.” The OR schedule becomes a “production calendar.” I watched this language arrive in hospitals where I trained and worked, and I watched what it did to the physicians around me.

The RVU model plays a significant role in the burnout crisis by incentivizing volume over quality, forcing physicians to churn through patients to meet productivity quotas. Over 50% of physicians report feeling burned out.

Burnout is the word we use because it sounds like a systems problem rather than a moral one. What I observed in those physicians was not burnout in the clinical sense. It was the progressive erosion of professional identity. The feeling, accumulated over years, that the judgment they spent a decade developing was no longer the primary variable in the room.

When physician authority erodes, patients notice, even if they cannot name what they are sensing. The appointment feels rushed. The doctor seems distracted. The plan feels formulaic. That is not a perception problem. It is an accurate reading of a clinical environment where the physician is constrained, monitored, and measured against metrics that have nothing to do with whether the patient in front of them gets better.

The Administrator Layer That Doesn’t Treat Patients

Here is what has grown as physician autonomy contracted.

Between 1975 and 2010, the number of physicians in the United States grew by 150%. In the same period, the number of healthcare administrators grew by 3,000%. That ratio has continued to shift. The people setting clinical policy, designing productivity dashboards, determining which procedures require administrative approval and which don’t, are increasingly people who have never practiced medicine.

I am not making a blanket argument against healthcare administration. Complex organizations require administrative infrastructure. Financial management, regulatory compliance, facilities coordination, these are real functions that require skilled professionals.

What I am arguing against is the inversion of authority that occurs when administrative metrics become the primary governance structure for clinical decisions. When an administrator with a spreadsheet has meaningful control over a surgeon’s clinical choices, the authority structure is wrong. Not inefficient. Wrong.

The consequences are not abstract. When patient care time is driven by administrative mandates rather than clinical judgment, negative consequences include poor quality of care and outcomes, errors, and low patient satisfaction ratings. For clinicians, the consequences include low morale, moral distress, burnout, and higher rates of staff turnover. American Speech-Language-Hearing Association

Every one of those outcomes costs money. Every one of them costs something more important than money too.

What I Built Instead

When I founded Indiana Orthopedic Institute, I made a decision that was either courageous or naive depending on who you asked at the time: physicians would lead the organization, and administrative infrastructure would serve the clinical mission, not govern it.

That meant the surgeon in the room has final authority on clinical decisions. It meant building our compensation model around outcomes and value, not RVU count. It meant creating an environment where a physician could take the time a patient needed without being penalized on a productivity dashboard for doing so.

We built it as an ASC-anchored model deliberately. The ambulatory surgery center structure, when physician-owned and physician-led, removes the hospital system’s leverage from the equation. The OR schedule is not a production calendar managed by a hospital administrator. It is a clinical tool managed by the surgeons using it.

The results are not theoretical. We grew from two people to over 100 employees and 16 surgeons in roughly three years. Physician retention is not a problem we manage. It is a strength we built. The surgeons at Indiana Orthopedic Institute are not looking for exits. They came here because they were looking for an alternative to the model I left.

That is not a recruitment pitch. It is evidence that the physician-led model is operationally viable, financially sustainable, and clinically superior to the production-target model that now dominates the industry.

What I Tell the Physicians Reading This

You became a physician because you wanted to make clinical decisions on behalf of patients. That instinct was correct. It is also the instinct the corporate employment model is systematically trained out of you.

The discomfort you feel when the dashboard contradicts your judgment is not a sign of poor organizational fit. It is a sign that your professional identity is intact. Honor it.

The path I took, building the alternative rather than complaining from inside the existing structure, is not available to every physician in every market. I understand that. The financial barriers to independent practice are real and have been deliberately constructed. Medical school debt, credentialing complexity, payer contracting leverage, hospital employment contracts with restrictive covenants, all of these are features, not bugs, of a system designed to make physician independence as difficult as possible.

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But the path exists. The ASC model exists. Physician-owned group practice exists. The regulatory environment is shifting in ways that, for the first time in decades, modestly favor independent practice over hospital employment.

The hospital system will tell you employment is security. It is. The same way a cage is security.

The patients you trained to serve need you making decisions based on what they need, not on what the spreadsheet values.

That is the incision point.

Total hip arthroplasty (THA) has conferred functional independence and improved quality of life for millions of patients in the United States and worldwide. Sadly, the operation of the century also has resulted in infection for as many as 1 (international registry data) to 2 (United States Medicare data) of every 100 patients. Absent reliable prevention measures for PJI, safe and effective treatment protocols to manage this complication have become an essential defense. Surgical treatments include irrigation and debridement (I&D) with implant retention; 1-stage exchange arthroplasty with implant removal and reimplantation in the same operative episode; and 2-stage exchange arthroplasty involving implant removal and placement of a temporary antibiotic-loaded spacer in the first surgery with a second surgery for reimplantation.

Two-stage treatment has been the gold standard in the United States, whereas 1-stage treatment is more common in Europe. The popularity of 1-stage exchange arthroplasty has been growing in the United States, with reports of comparable or better outcomes, reduced morbidity and mortality, enhanced quality of life, and cost savings. It is a concern, however, that conclusions implying the equivalence and in several cases the superiority of 1-stage treatment for PJI based on low-quality studies confounded by substantial heterogeneity in infection characteristics, patient comorbidities, bacterial profiles, details of treatment, definitions of PJI, and definitions of success are so rapidly influencing treatment decisions.

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The COVID pandemic of 2020 has emerged as a global threat to patients, health care providers, and the global economy. Owing to this particular novel and highly infectious strain of coronavirus, the rapid community spread and clinical severity of the subsequent respiratory syndrome created a substantial strain on hospitals and health care systems around the world. The rapid surge of patients presenting over a small period for emergent clinical care, admission to the hospital, and intensive care units, with many requiring mechanically assisted ventilators for respiratory support, demonstrated the potential to overwhelm health care workers, hospitals, and health care systems.

Indiana University (IU) Health is the largest health system in the state of Indiana, with 2708 total beds and over 118,000 hospital admissions annually, and is partnered with the nation’s largest medical school, Indiana University School of Medicine. Through close cooperation with our state government and examination of available epidemiological models, IU Health determined that a surge of patients affected by the novel coronavirus would encounter our health system in late March and within an anticipated peak in mid to late April. Our program made the decision to stop all elective, nonurgent hip and knee arthroplasty surgery on March 17, 2020, and based on evolving data that became clear, the ambulatory aspect of patient care also ceased immediately.

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Antibiotic-impregnated intramedullary dowels have historically been advocated and frequently used to facilitate and augment infection eradication via focused delivery of antibiotics into the intramedullary canals of the femur and tibia in periprosthetic knee infections during a 2-stage resection utilizing an antibiotic cement spacer. However, there is little literature on the use and efficacy of antibiotic-eluting intramedullary dowels in periprosthetic joint infection (PJI). There is also no published consensus recommendation on its use, as the topic was not reviewed in the recent International Consensus Meeting on PJI.

Hanssen and Spangehl recommend insertions of intramedullary dowel spacers irrespective of whether the implant has a stem, based on the assumption that around one-third of infected TKAs without stems have extension of the infectious process into the medullary canals of the femur or tibia. Furthermore, they argue that antibiotic dowels, as opposed to antibiotic beads, are easier to remove at reimplantation. Their recommendation was based on the study by McPherson et al., where they found that during resection, the most common site to yield positive operative cultures was from the medullary canal.

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Two-stage treatment of periprosthetic knee infection employs either articulating or static high-dose antibiotic-eluding tibiofemoral cement spacers between resection and reimplantation, with or without antibiotic-eluding intramedullary (IM) dowels. Systematic reviews comparing articulating and static spacers do not address IM dowels but do provide general consensus that the 2 spacer types equivalently eradicate infection, although articulating designs result in improved range of motion and function following reimplantation.

After review and consideration of the available evidence, the 2018 International Consensus Meeting on Periprosthetic Joint Infection recommended the use of articulating spacers unless static spacers are indicated by severe bone loss, ligament insufficiency, or soft tissue compromise; however, the International Consensus group did not comment on the use of IM dowels to enhance treatment and facilitate the eradication of infection.

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The scale is moving. The before-and-after photos are striking. The cardiology data looks promising.

Nobody is talking about what’s disappearing along with the fat.

I operate on muscle. I have for over 20 years. When I open a joint, I see the tissue quality, the structural integrity, the mechanical reality of how a body has been treated over decades. And I am telling you: the conversation around GLP-1 drugs is missing the most important clinical variable in the entire equation.

You are not just losing weight on Ozempic. You are losing muscle. And depending on how you’re taking it, you may be losing a lot of it.

The Number Nobody Puts in the Press Release

Multiple studies on semaglutide and tirzepatide have now documented the same finding: somewhere between 25% and 40% of total weight lost on GLP-1 agonists comes from lean mass, not fat.

Read that again.

This is not speculation. The STEP 1 and SUSTAIN 8 trials, the flagship semaglutide studies published in the New England Journal of Medicine, found that 39-40% of total weight lost on the drug was lean mass. These are Novo Nordisk’s own studies. The ones used to secure FDA approval. The ones cited in every press release announcing this drug as a breakthrough.

The lean mass finding was in the data the whole time. It just wasn’t in the headline.

If you lose 50 pounds on Ozempic, somewhere between 12 and 20 of those pounds may be muscle. Not fat. Muscle.

In the orthopedic world, we have a clinical term for the condition of low muscle mass relative to body weight. We call it sarcopenia. And sarcopenia is one of the most reliable predictors of poor surgical outcomes, increased fall risk, fracture, joint degeneration, and loss of functional independence I have ever seen in practice.

We are potentially manufacturing sarcopenia at scale, celebrating it as weight loss, and calling it a healthcare breakthrough.

I have a problem with that.

What I See in the OR That Nobody Sees on a Podcast

When I perform a total knee or hip replacement on a patient with significant muscle loss, the procedure changes. The mechanical environment around the joint is different. Soft tissue tension is different. Rehabilitation trajectory is different. Outcomes are measurably worse.

I have watched patients come into my OR having lost substantial weight before surgery, believing they had optimized themselves for the procedure. Sometimes they had. But increasingly I am seeing patients who lost weight rapidly, on drugs or otherwise, and whose muscle quality tells a completely different story than their BMI does.

The scale moved. The tissue didn’t improve. In some cases it got worse.

This is not an abstraction. This is what I see with my hands.

The emerging data on bone density compounds the problem. GLP-1 receptors are expressed in bone tissue. Early research suggests semaglutide may reduce bone mineral density, particularly with rapid weight loss. The STEP trials were not designed or powered to detect fracture risk, so that signal exists in the background of the most-cited efficacy data, largely unmeasured.

We don’t know what we don’t know yet. And that should concern every clinician prescribing these drugs without a musculoskeletal assessment in the protocol.

Rapid Weight Loss Has Always Been a Red Flag. Why Did We Forget That?

This is the part that genuinely puzzles me as a physician.

For decades, the clinical consensus on weight loss was clear: slow and deliberate produces better outcomes than rapid. One to two pounds per week. Sustained behavioral change. Preservation of lean mass as a primary goal alongside fat reduction.

We built that consensus on outcomes data. We built it because rapid weight loss, whether from crash dieting, surgical procedures, or illness, consistently showed the same downstream consequences. Muscle loss. Bone density reduction. Metabolic rate suppression. Rebound weight gain that included disproportionate fat restoration.

Now a drug produces 15% total body weight loss in 68 weeks, and the clinical conversation has almost entirely abandoned the lean mass question. The headline metric became total weight. The nuance disappeared.

I understand why. The cardiovascular outcome data is genuinely compelling. A 20% reduction in major cardiovascular events in the SELECT trial is not a number to dismiss. But cardiovascular endpoints and musculoskeletal endpoints are not the same endpoints. A drug can reduce heart attack risk and increase fracture risk simultaneously. Both things can be true.

The question nobody seems to be asking in a clinical setting is: what is this patient’s muscle mass before we start, and what is the protocol to protect it?

The Protocol That Should Exist But Usually Doesn’t

I am not categorically against GLP-1 therapy. In specific patients, with specific risk profiles, managed carefully, the case for short-term use is legitimate.

But “managed carefully” means something specific to me. It means a baseline DEXA scan before initiation. Not a scale weight. A DEXA scan, which gives you body composition: fat mass, lean mass, bone mineral density. The actual numbers that matter.

It means resistance training as a non-negotiable co-intervention, not an optional lifestyle recommendation. The evidence on preserving lean mass during caloric restriction is unambiguous. Progressive resistance exercise is the primary tool. If a patient is on a GLP-1 and not actively building or maintaining muscle, they are losing it. Full stop.

It means protein intake calibrated to lean body mass, not general dietary guidelines. The RDA for protein (0.8g per kg of body weight) was not designed for patients losing weight rapidly on a drug that suppresses appetite and may impair muscle protein synthesis signaling.

And it means an honest conversation about the goal. If the goal is fat loss with muscle preservation, the current standard dosing protocol, designed to maximize total weight loss, may not be the right protocol for every patient.

This is where the microdosing conversation becomes clinically relevant. There is no large-scale RCT on lower-dose, slower-titration GLP-1 protocols designed specifically for lean mass preservation. That data doesn’t exist yet. But the physiological rationale is sound: slower weight loss, matched with structured resistance training and adequate protein, should produce a better body composition outcome than the maximal-dose, rapid-loss approach the STEP trials optimized for.

I want that study done. Until it is, I am paying close attention to what I see in my patients and in the emerging literature.

What I Tell Surgeons and What I Tell Patients

To surgeons: if you have patients on GLP-1 drugs heading toward a joint replacement or any major musculoskeletal procedure, add a body composition assessment to your pre-operative workup. Not weight. Composition. You need to know what you’re operating on before you’re operating on it.

The prehabilitation protocols we’ve developed at Indiana Orthopedic Institute exist precisely because we understand that the tissue quality a patient brings into the OR determines a meaningful portion of their outcome. A 50-pound weight loss that came 40% from muscle is not the same surgical preparation as a 50-pound fat loss with muscle preservation. The BMI may be identical. The mechanical reality is not.

To patients: the number on the scale is not the outcome. Body composition is the outcome. Before you start any significant weight loss protocol, including GLP-1 therapy, know your baseline lean mass. Track it. Protect it with resistance training. Eat enough protein, because your appetite suppression will work against you here.

The drug will make you lighter. That is not the same as making you stronger, more functional, or better prepared for the second half of your life.

I have seen what sarcopenic bodies look like at 65 and 75. I have seen the fractures, the falls, the failed rehabilitations, the joint replacements that don’t recover the way they should because there wasn’t enough muscle to rebuild around. That trajectory begins decades earlier, in choices and interventions that seemed beneficial at the time.

GLP-1s may be a genuine tool. The cardiovascular data says they can be. But a tool used without understanding its full mechanical consequence is just a risk you haven’t measured yet.

Measure the muscle. Then decide.

Although cemented total knee arthroplasty (TKA) is a widely successful procedure to treat many forms of arthritis, aseptic loosening remains one of the primary causes for early and late revisions. Studies and the 2017 national registries report that up to 28.7% of all revisions are due to aseptic loosening.

An evaluation of TKA failures estimated that 40% of early revisions could be avoided, in part, with optimal cement fixation. Increasing the amount of cement in the tibial and femoral bone (cement penetration) has been shown to provide a stronger bone-cement interface, which leads to increased stability and long-term survivorship of the implants.

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Clinical and surgical care principles underlying modern, evidence-based care and coordination for early discharge total joint arthroplasty (TJA), also known as fast track, rapid recovery, or enhanced recovery from surgery, have led to an increased prevalence of short-stay and same-day discharge for appropriate patients. Acute postoperative urinary retention (POUR) is a significant barrier to same-day and early discharge TJA as it can result in pathologic bladder distention and injury, urinary tract infection (with possible hematogenous periprosthetic infection), and catheterization-related complications.

The incidence of acute POUR following TJA has been documented to range from 0% to 75%, varying based on the perioperative practices of TJA programs; characteristics of study populations; and definitions, measurement, and treatment methods for acute urinary retention. The incidence of POUR in fast-track TJA has been reported in recent years and is surprisingly high. Bjerregaard et al reported a 40% incidence in a prospective study of 1062 elective primary total hip arthroplasties(THAs) and total knee arthroplasties (TKAs) performed in highly established fast-track programs. Scholten et al reported a 31.3% incidence in 307 TJAs performed in another established fast-track center.

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Over the last approximately 15 years, rapid recovery protocols focused on multidisciplinary care coordination, standardized perioperative protocols, and careful discharge planning have created a natural evolution from the inpatient to outpatient setting for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Recently, this evolution was inadvertently accelerated as a result of confusion stemming from the removal of TKA from the inpatient-only list for Medicare patients by the Centers for Medicare and Medicaid Services Outpatient Prospective Payment System 2018 rule.

Combining the two-midnight rule and the removal of TKA from the inpatient-only list without defining justifying criteria for length of stay has inadvertently caused hospitals and payers to treat all Medicare TKA patients as outpatients, despite the intent of the Centers for Medicare and Medicaid Services that most Medicare TKA procedures would remain inpatient procedures.

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Over the past decade and a half, there has been increasing interest in performing primary hip and knee replacement in the outpatient setting. Rapid recovery protocols have helped with a natural evolution of this procedure from the inpatient to the outpatient setting.

Interest in outpatient arthroplasty has also been fueled by financial considerations, including the ability to control costs within the episode of care, the potential for surgeon ownership in ambulatory surgery centers, and the ability for a surgeon to control his or her operating room and surgical care environment more easily in an ambulatory surgery center.

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Historically, long-term success in total hip arthroplasty (THA) has been limited by implant loosening and late failure caused by osteolysis at the bone-implant interface due to third-body wear particles of conventional polyethylene. The historical critical threshold for osteolysis in conventional polyethylene is approximately 0.1 mm/y. Over the past 2 decades, advancements in polyethylene cross-linking and sterilization methods have made it possible to irradiate and remelt highly cross-linked polyethylene (HXLPE), which has shown improved tribological properties in biomechanical testing compared to conventional polyethylene, along with encouraging early and mid-term clinical results.

Recently, a sequential annealing process for HXLPE has been introduced with promising tribological and early clinical results compared to irradiated and remelted HXLPE. Few studies to date have reported the effects of femoral head material, femoral head size, and implant position on wear, creep, and head penetration rates for this sequentially annealed HXLPE. We set out to investigate the true mid-term wear rates of this specific material.

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Pneumatic tourniquets are commonly used in total knee arthroplasty (TKA) to reduce intraoperative blood loss, enhance operative visualization, provide a cleaner field for cement penetration and fixation, and increase operative efficiency. However, the use of tourniquets during TKA has been a subject of debate in the scientific literature due to the risks and benefits associated with their use.

While pooled analyses consistently show less intraoperative blood loss with a tourniquet, they also point to a greater likelihood of thrombotic events, wound problems, and minor complications. Furthermore, several studies have demonstrated that tourniquets result in greater pain in the immediate postoperative period after TKA, with some studies additionally noting an increase in analgesic consumption.

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There are multiple causes of recurrent dislocation after total hip arthroplasty (THA), including component malposition, extraprosthetic impingement, polyethylene wear, abductor muscle incompetence, altered neurologic or proprioception about the hip from neurologic disease or spinal disease, and, less commonly, adverse local tissue reaction from metal hypersensitivity or infection. Successful treatment of recurrent instability after THA requires an adequate assessment of the potential causal factors, an identification of the etiology, and a treatment approach targeting the specific etiology of the instability.

A detailed workup of the THA patient with recurrent instability is mandatory. As with all medical and surgical evaluations, a detailed history and physical examination are essential and must include the nature and direction of the instability. If the dislocation is an isolated event in the early postoperative period, within 3 months of surgery, with implants that are well-positioned, the patient can expect a reasonable chance of closed reduction, rendering the hip stable without further surgical intervention. Studies show a success rate of 67-81% for closed reduction of an early dislocation after a THA. Conversely, if more than once dislocation has occurred remote from the original surgery, the chance of closed reduction rendering the hip stable without further surgery is less likely.

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I have a question I cannot stop asking.

The United States spent $14,885 per person on healthcare in 2024. Switzerland, the second highest spender in the world, spent $9,963. The average among wealthy peer nations was $7,371.

We spent double what our peers spend. And according to KFF and the Peterson Center’s most recent analysis, the average life expectancy in those comparable countries is 82.7 years. In the United States, it is 79.0.

We are spending twice as much to die three and a half years sooner.

I am an orthopedic surgeon. I am also an engineer. And I can tell you with certainty: when a system consumes double the inputs and produces inferior outputs, the problem is not under-funding. The problem is the system itself.

The Numbers That Should End the Debate

Let me stack the data because it needs to be seen together, not scattered across separate news cycles.

The U.S. ranks 33rd out of 38 OECD countries in average life expectancy. The obesity rate in the U.S. is 43%, compared to an OECD average of 26%. The U.S. opioid mortality rate is 223 per 1 million people, against an OECD average of 30 per 1 million. U.S. healthcare spending as a percentage of GDP is 16.6%, against an OECD average of 9.2%.

Read those numbers in sequence. We are spending 80% more of our economic output on healthcare than the average wealthy nation. We have the highest obesity rate in the developed world. We have the highest opioid death rate. And we rank 33rd out of 38 in how long our citizens actually live.

This is not a healthcare financing story. This is not an insurance access story. Those are real problems, and I write about them directly. But they do not explain this gap. Countries with universal coverage and lower administrative overhead still do not have a 43% obesity rate. The gap between American health outcomes and peer nation outcomes is too large and too consistent to be explained by billing complexity or prior authorization.

The sickness is upstream of the healthcare system. It is being manufactured before patients ever see a physician.

55% of American Calories Come From Ultra-Processed Food

I want to be precise about what I mean by upstream, because this is where the argument gets dismissed as wellness content rather than clinical reality.

The CDC released results from the National Health and Nutrition Examination Survey covering 2021 through 2023. The finding: among Americans aged one and older, an average of 55% of total calories came from ultra-processed foods. Among children aged 18 and younger, the figure was 61.9%.

More than half of the caloric intake of the average American, including the children, comes from products specifically engineered to override satiety signaling, maximize palatability, and drive repeat consumption. The NIH randomized controlled trial published in Cell Metabolism demonstrated this mechanism directly: subjects eating ultra-processed food consumed 500 more calories per day than those eating whole food, without reporting higher hunger at baseline.

The downstream consequence of that caloric architecture, sustained over decades, is exactly the disease burden we are now spending $5.3 trillion annually trying to manage.

A 2024 umbrella review published in The BMJ, covering 45 meta-analyses and nearly 10 million people, found that greater exposure to ultra-processed foods was directly associated with a 21% higher risk of all-cause mortality, a 66% higher risk of heart disease mortality, and a 40% higher risk of type 2 diabetes.

Those are not small associations. Those are the chronic disease profile of the United States, summarized in a single study.

What I See at the Operating Table

After 10,000+ joint replacements, I can tell you something specific about the American disease burden that does not show up cleanly in life expectancy statistics.

I see it in tissue quality. I see it in the inflammatory state of joints in patients who are 55 years old but whose biological tissue architecture presents like someone 20 years older. I see it in the comorbidity list that now accompanies the average joint replacement candidate: type 2 diabetes, hypertension, obesity, metabolic syndrome. Conditions that were once exceptions are now the baseline.

The patients I operated on 15 years ago, as a group, were less metabolically compromised than the patients I operate on today. Same procedures. Meaningfully different physiological starting points.

The surgical implications are real and measurable. Higher infection rates in patients with uncontrolled diabetes. More complex soft tissue management in severely obese patients. Longer recovery trajectories in patients with significant sarcopenia. More post-operative complications across the board.

I am not describing a moral failure of individual patients. I am describing the clinical consequence of a food environment that has been systematically engineered to produce metabolic disease, combined with a healthcare system that treats the disease while leaving the engineering untouched.

The Plan Nobody in Power Will Actually Name

I want to be direct about what a real plan would require, because the political conversation keeps generating frameworks that deliberately avoid the hard parts.

A real plan would acknowledge that 55% of American calories coming from ultra-processed food is a policy failure, not a personal choice failure. The GRAS loophole allows food manufacturers to self-certify the safety of additives without independent FDA review. SNAP, the federal nutrition assistance program serving 42 million Americans, allows billions in federal spending to flow to products with no meaningful nutritional value. School nutrition standards, rolled back repeatedly under food industry lobbying pressure, govern what 30 million children eat during their developmental years.

These are not natural market outcomes. They are policy decisions. And they can be changed by policy decisions.

The MAHA commission’s report named ultra-processed food as a primary driver of the chronic disease crisis. That is the correct diagnosis. The question is whether the named diagnosis produces structural intervention or remains a talking point while the food industry’s lobbying apparatus ensures the underlying policy architecture stays intact.

I am watching. So far, the diagnosis has not produced the treatment.

A real plan would also require the healthcare system to stop being financially dependent on chronic disease management. The current system profits from treating obesity, diabetes, hypertension, and their downstream consequences. It does not profit from preventing them. That misalignment is not an accident, and it will not be corrected by adding more chronic disease management programs to a system whose incentives run in the opposite direction.

What the Engineering Lens Tells You

I trained as an engineer before I trained as a surgeon. The engineering perspective on this problem is unambiguous.

A system that spends double the input cost to produce inferior output has one of two problems: a process failure or a design failure. Process failures are fixable with optimization. Design failures require redesign.

The American healthcare system is not failing because of a process failure. Physicians are working harder than ever. Hospitals are adding capacity. Insurance companies are processing claims. The machine is running.

The design is wrong.

The design treats disease management as the primary product and prevention as an optional service. The design funds research into pharmaceutical interventions while dramatically underfunding food environment research and policy. The design allows the entities most responsible for the chronic disease burden, the food industry and the pharmaceutical industry, to be among the most influential voices in the policy rooms where solutions are theoretically being developed.

At Indiana Orthopedic Institute, I built the organization around a different design premise: patient-centered care, clinical research, and innovation working in alignment, with the physician’s judgment at the center. It is a small-scale proof of concept. The macro problem requires macro redesign.

But the redesign starts with a decision to stop calling this a healthcare problem and start calling it what it actually is: a food system problem with healthcare consequences we are billing at $14,885 per person per year.

What Has to Change

To the patients reading this: the system is not going to fix this for you. Understanding that 55% of American calories are ultra-processed is not a wellness insight. It is a survival fact. The data on what that food architecture does to your metabolic health, your inflammatory state, your long-term mortality risk, is not ambiguous anymore.

To the physicians and healthcare leaders: stop accepting the premise that chronic disease is the natural condition of an aging American population. It is not natural. It is manufactured. And our clinical protocols need to reflect that the patient’s food environment is as relevant to their surgical or medical outcome as their imaging or their labs.

To the policymakers: the OECD data is public. The mechanism is documented. The policy levers are identified. Every year this redesign is delayed is another year of 33rd place life expectancy, $14,885 per capita, and a 43% obesity rate in the wealthiest country in human history.

That is not a healthcare crisis. That is a choice. And it is being made, repeatedly, by people with financial interests in keeping the design exactly as it is.

Infection following total knee arthroplasty (TKA) remains one of the most dreaded and difficult complications to treat. The overall incidence of infection in the literature ranges between 0.5% and 2% for primary TKAs and 2% and 4% for revision TKAs. While successful eradication of periprosthetic joint infection (PJI) has been reported in the range of 85%-95%, the mortality associated with PJI is high.

Disruption of the extensor mechanism is an infrequent but catastrophic complication following TKA. Repair or reconstruction of the extensor mechanism disruption (EMD) is technically challenging. A recent longitudinal study of patients treated with extensor mechanism reconstruction (EMR) using allograft demonstrated 69% of knees retained the allograft at a mean follow-up of 68 months. However, the reoperation rate was high at 58%, with the most common reason for reoperation being the development of PJI at 26%.

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Facing pressure to reduce length of stay and costs after total knee arthroplasty (TKA), many centers have begun to offer the procedure to select patients as an outpatient. While outpatient total joint arthroplasty has become more popular among patients and health care providers, concerns exist about an increase in complications from discharging patients home from the hospital too soon.

Private insurers have begun reimbursing hospitals and ambulatory surgical centers for outpatient TKA, but it remains on the Centers for Medicare and Medicaid Services (CMS) Inpatient Only (IPO) List. The IPO List was created in 2000 to identify surgical procedures that should be performed exclusively in an inpatient hospital setting. CMS has solicited public comments for the 2017 Proposed Rule to consider removing TKA from the list to offer patients and surgeons the option to perform TKA as an outpatient.

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