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THR Approaches input: Direct Anterior vs. Direct Superior with Dual Mobility cup (aka Superpath)

Hi @LaKarune ! Days ago I wrote a post here and the internet ate it:banghead: so now I'm back.

I was never a ballerina by any stretch of the imagination, but I had 20 years of classes, as a child/teen, and from 25-35. I am not built flexible. I had both legs front splits the year I turned 15, but it went away, never to return. For much of my adult life jogging was my daily exercise of choice (hello destroyed hips!), with some weight lifting, hiking, swimming, less biking after kids.

Fast forward through two anterior hips with what I will assume are off-the-shelf implants. Not sure dual mobility cups were a big thing then? Anyway, 18 months after the second, I decided I'd like to go back to ballet. Well! Just about everything except my eyelashes and fingernails begged to differ with that decision. I stumbled upon a form of exercise called Barre, here taught by a former ballerina with real choreography chops, and at a few weeks from 71 I am a Barre poster child. The classes give me joy in my body, even as I exhaust the poor muscles. The same things that felt awful (and/or hurt) in ballet can now be worked around. I took one Pilates class and caught covid but I think that would have been alright to continue with if it had been any fun. Yoga has never suited me. Did I say I have never been flexible? Anyway, I think you would be reasonable to expect that a great deal of what you do now, you could work up to after recovery. There's been a ski instructor on here, many yoga practitioners, equestrians, a couple of heavy duty fire fighters. We can make it work!

I was only given one "never do this" position. It is a very deep lunge, torso upright, most weight on rear leg, and then, turn the rear (op) leg IN. That is where my dislocate risk lies. Not something I ever considered doing intentionally. I also have never skied, only surfed once in my teens and no plans to go again, and water skiing seems attractive but not going to try. You are 10 years younger than I was at first THR and have all these proficiencies under your belt. I am very hopeful for your abilities post-recovery. Just, whatever approach and hardware you end up with, don't let anybody fool you that you can rush your body's plans for healing. It takes what it takes, which is about a year. That much is medical knowledge. Until then, follow your body's lead. If it hurts, stop! If it doesn't? Hurray!

Thank you for this encouragement. I’m having a hard time accepting ANY restrictions since I’m used to have such freedom of movement. I’ll ask about specific poses tomorrow with surgeon #3.

The rule of thumb for a year of recovery is helpful to have. I’m wondering if you have or are still experiencing any numbness in your legs since the operations? The second doctor promised irrecoverable numbness in some areas around the hip. First doc didn’t mention it so I’m curious what other Anterior recoveries have been like in terms of repair around connective tissues.
 
Caison, do you hit heavy bags with your replaced hip? I practiced Muay Thai for 15 years, and want to get back into it.

I have an anterior approach dual mobility feels very natural.

Thank,

Larry

Hey Larry — that’s lucky you were able to find a surgeon who had success with dual mobility using an Anterior approach. It sounds like your recovery is going really well. Would you feel comfortable dropping the name of the surgeon here or messaging me with it? I’d like to research his approach. The Anterior guys I’ve spoken to seem against using dual mobility and in my research to dig for a reason, it seems to be much more technically demanding and come with more risks due to a lower level of visibility and manual access to the joint during the surgical procedure. But I gleaned this from reading articles developed by surgeons for surgeons and a lot of their vocabulary is beyond my comfort level, so not entirely sure I really understand it.

Thanks again for sharing your experience.
 
@LaKarune It is good you found your way here to BoneSmart! I've been coming here for nearly 12 years now and have seen every surgical approach, technique, and implant available. And have seen excellent outcomes with all those .... and some not excellent outcomes with all of them. IMO the best predictors of good outcomes is the surgeon's experience and skills, the patient's general good health, and the patient's ability and willingness to HEAL FIRST before trying to rush back into strenuous job or activities.

My hip replacements (I was 64yo at the time) were done with a anterio-lateral approach (straight down the outside of each hip). Now I had both done at the same surgical session so my experience is different from someone getting just one hip done. Implants today are expected to last for 30+ years ... and some of the original ones lasted for 40+ years! So please don't worry too much about the longevity of implants. There are too many factors to be able to predict if YOU would need a revision any time after a hip replacement.

Personally I prefer a surgeon who is conservative in what they promise rather than one who promises the moon. My surgeon just promised I'd walk without pain- and he kept that promise! And when he officially discharged me from his active practice he said the only life time restriction I had was "NO bungie jumping". Any thing else I wanted to do was fine with him!

Best of everything to you! And do keep us informed of what you decide .... we do love to help!

This is really encouraging. I don’t have any desire to bungee jump so I could live with that being my one and only restriction.

I agree that a surgeon should be able to balance the reality of how major this surgery is with a desire to instill confidence in patients. Still looking for that balance out here in LA. The first surgeon sort of blew off my more detailed questions and the second one made me wonder if it was even worth the risk.

It sounds like you’re really happy with your recovery. 12 years is quite a testimony. Did your doc explain why he preferred anterio-lateral vs direct anterior, by any chance?
 
Hey Allie!! His outcomes are so good that I haven’t crossed him off my list despite that and several other responses to my questions.

How are you doing in your recovery so far? Do you have a recovery thread I should follow? Curious about where you were @ physically right before your surgery vs how far you’ve come in the first four weeks, if you care to share. ☺️

Hey Allie, how are you doing in your recovery today? I’m gonna try to find your recovery thread… just wanted to check in.

Meeting with a third Anterior surgeon in the morning so definitely still strongly considering the approach you picked. Hope you’re feeling like healing is happening for you. I know it’s not always as fast or as straight a line as we hope for, but want to send you positive energy towards your recovery, as it was so relatively recent.
 
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Hi @LaKarune ! Days ago I wrote a post here and the internet ate it:banghead: so now I'm back.

I was never a ballerina by any stretch of the imagination, but I had 20 years of classes, as a child/teen, and from 25-35. I am not built flexible. I had both legs front splits the year I turned 15, but it went away, never to return. For much of my adult life jogging was my daily exercise of choice (hello destroyed hips!), with some weight lifting, hiking, swimming, less biking after kids.

Fast forward through two anterior hips with what I will assume are off-the-shelf implants. Not sure dual mobility cups were a big thing then? Anyway, 18 months after the second, I decided I'd like to go back to ballet. Well! Just about everything except my eyelashes and fingernails begged to differ with that decision. I stumbled upon a form of exercise called Barre, here taught by a former ballerina with real choreography chops, and at a few weeks from 71 I am a Barre poster child. The classes give me joy in my body, even as I exhaust the poor muscles. The same things that felt awful (and/or hurt) in ballet can now be worked around. I took one Pilates class and caught covid but I think that would have been alright to continue with if it had been any fun. Yoga has never suited me. Did I say I have never been flexible? Anyway, I think you would be reasonable to expect that a great deal of what you do now, you could work up to after recovery. There's been a ski instructor on here, many yoga practitioners, equestrians, a couple of heavy duty fire fighters. We can make it work!

I was only given one "never do this" position. It is a very deep lunge, torso upright, most weight on rear leg, and then, turn the rear (op) leg IN. That is where my dislocate risk lies. Not something I ever considered doing intentionally. I also have never skied, only surfed once in my teens and no plans to go again, and water skiing seems attractive but not going to try. You are 10 years younger than I was at first THR and have all these proficiencies under your belt. I am very hopeful for your abilities post-recovery. Just, whatever approach and hardware you end up with, don't let anybody fool you that you can rush your body's plans for healing. It takes what it takes, which is about a year. That much is medical knowledge. Until then, follow your body's lead. If it hurts, stop! If it doesn't? Hurray!

Thank you for this encouragement. I’m having a hard time accepting ANY restrictions since I’m used to have such freedom of movement. I’ll ask about specific poses tomorrow with surgeon #3.

The rule of thumb for a year of recovery is helpful to have. I’m wondering if you have or are still experiencing any numbness in your legs since the operations? The second doctor promised irrecoverable numbness in some areas around the hip. First doc didn’t mention it so I’m curious what other Anterior recoveries have been like in terms of repair around connective tissues.
Hey @LaKarune in a word, yes. I was never (that I recall) warned of it, but numb patches not directly over the incisions but out to the side and a bit below still exist. I don't even notice them, and it is only skin-deep. Allergy shots (1/2" needle) still hurt lol. I have a similar numb patch under my hysterectomy incision. That was 1989, and nothing bad has ever come of it, so I'm not concerned.

I think you can search this recovery forum by single words or phrases- -I know that numb patch thing has been discussed here and there.

And PS I didn't "pick my approach". I picked my surgeon based on recommendations from three unconnected medical persons over a period of close to a year, I think. I actually did not know anything about my hip pain, which had been getting worse for several years, until my PCP told me I should look into THR! The OS was known for anterior. I got what he had to give. Shortly after my first hip, he got a write-up someplace for having completed 10,000 (yep 10K) anterior hips. He was a good 10years younger than me, if not 20. He also had the rock-bottom lowest complication rate of anybody within 100 miles, according to a third-party "dot o r g" website that I can't remember the name of. Aha! Found it! Propublica is the name to search. You can (or could) look up hospitals, surgeons, surgery type by name or area.

I was not one to overthink my surgery. I'd had a necessary hysterectomy at 37, between my two (adopted) kids, and knew the beauty of having something that absolutely does not function as advertised-- and causes constant pain-- removed from my body, life, radar, and general outlook on life. So getting the hips done was a no-brainer, as was a more recent hernia repair. And in all three cases I went into it knowing I'd be better off when done. Attitude has a lot more to do with surgical success than some give it credit for.
 
If you Google
Surgical approaches for primary elective hip replacement NICE ( National Institute for Clinical Excellence) you will get a 156 page report looking at all the evidence for different approaches. Pages 31-33 summarise the committee 's view and weigh up the evidence. They finally say there is no definite evidence that one approach is better!
I did a lot of this reading when I was considering hip surgery although currently (fingers crossed) - my hip is better post having my knee done and my leg straightened......
 
The rule of thumb for a year of recovery is helpful to have. I’m wondering if you have or are still experiencing any numbness in your legs since the operations? The second doctor promised irrecoverable numbness in some areas around the hip. First doc didn’t mention it so I’m curious what other Anterior recoveries have been like in terms of repair around connective tissues.
I do have a numb patch on my outer thigh. But it does not affect leg strength or movement.

The arthritis pain was agonizing so I will live w numbness forever if I have to.

Numbess is not pain.
 
@LaKarune When I went to my regular doctor about my hip pain at first he didn't think it was as bad as I said it was but he ordered x-rays of both hips. He called me personally the next morning and apologized! And said he was immediately sending off referral to orthopedic surgeon (I have HMO insurance so referral was to surgeon my doc said he'd want to do his hip if he ever needed that). When I went in for the first appointment with the surgeon he came into the office and said "Ms M I've reviewed the x-rays and your medical records and the only thing I can offer you is hip replacement. And I recommend you do both at once". Color me shocked! At the time I was only experiencing the right hip as painful and dysfunctional. But x-rays showed left hip was also bone-on-bone and right hip had already fused (ball part of the femur was growing into my pelvis so did not move at all).

The surgeon had excellent credential though was not of the "warm and fuzzy" persuasion. Initially he got a bit backed up when I asked questions but we sorted that out when I told him I had worked for the HMO for a long time and was a well educated patient. Once that was established he was more willing to answer my questions. While he did not go into detail about why he used one approach over any other ( that IMO is the surgeon's choice and what ever he/she is trained to do) he did say incisions would be down the out side of each hip. Following the surgery I found those to be quite easy to deal with - easy to apply ice, they did not get "bent" or laid upon, were easy to tend to dressings, and for me they healed well and now are just very thin while lines.

The reasons he gave for doing a bilateral replacement (both hips in same surgical session) were - In his opinion less risk, one surgery, one session of anesthesia, one hospital stay and one recovery. Plus he said doing both at once I'd be able to return to a normal gait faster and would be less likely to have any trouble with leg length differential. I must say for me all that was true and YES I am very happy with my hips. These days I rarely think of them .... until I log in here :heehee:
 
Hi @LaKarune ! Days ago I wrote a post here and the internet ate it:banghead: so now I'm back.

I was never a ballerina by any stretch of the imagination, but I had 20 years of classes, as a child/teen, and from 25-35. I am not built flexible. I had both legs front splits the year I turned 15, but it went away, never to return. For much of my adult life jogging was my daily exercise of choice (hello destroyed hips!), with some weight lifting, hiking, swimming, less biking after kids.

Fast forward through two anterior hips with what I will assume are off-the-shelf implants. Not sure dual mobility cups were a big thing then? Anyway, 18 months after the second, I decided I'd like to go back to ballet. Well! Just about everything except my eyelashes and fingernails begged to differ with that decision. I stumbled upon a form of exercise called Barre, here taught by a former ballerina with real choreography chops, and at a few weeks from 71 I am a Barre poster child. The classes give me joy in my body, even as I exhaust the poor muscles. The same things that felt awful (and/or hurt) in ballet can now be worked around. I took one Pilates class and caught covid but I think that would have been alright to continue with if it had been any fun. Yoga has never suited me. Did I say I have never been flexible? Anyway, I think you would be reasonable to expect that a great deal of what you do now, you could work up to after recovery. There's been a ski instructor on here, many yoga practitioners, equestrians, a couple of heavy duty fire fighters. We can make it work!

I was only given one "never do this" position. It is a very deep lunge, torso upright, most weight on rear leg, and then, turn the rear (op) leg IN. That is where my dislocate risk lies. Not something I ever considered doing intentionally. I also have never skied, only surfed once in my teens and no plans to go again, and water skiing seems attractive but not going to try. You are 10 years younger than I was at first THR and have all these proficiencies under your belt. I am very hopeful for your abilities post-recovery. Just, whatever approach and hardware you end up with, don't let anybody fool you that you can rush your body's plans for healing. It takes what it takes, which is about a year. That much is medical knowledge. Until then, follow your body's lead. If it hurts, stop! If it doesn't? Hurray!

Thank you for this encouragement. I’m having a hard time accepting ANY restrictions since I’m used to have such freedom of movement. I’ll ask about specific poses tomorrow with surgeon #3.

The rule of thumb for a year of recovery is helpful to have. I’m wondering if you have or are still experiencing any numbness in your legs since the operations? The second doctor promised irrecoverable numbness in some areas around the hip. First doc didn’t mention it so I’m curious what other Anterior recoveries have been like in terms of repair around connective tissues.
Hey @LaKarune in a word, yes. I was never (that I recall) warned of it, but numb patches not directly over the incisions but out to the side and a bit below still exist. I don't even notice them, and it is only skin-deep. Allergy shots (1/2" needle) still hurt lol. I have a similar numb patch under my hysterectomy incision. That was 1989, and nothing bad has ever come of it, so I'm not concerned.

I think you can search this recovery forum by single words or phrases- -I know that numb patch thing has been discussed here and there.

And PS I didn't "pick my approach". I picked my surgeon based on recommendations from three unconnected medical persons over a period of close to a year, I think. I actually did not know anything about my hip pain, which had been getting worse for several years, until my PCP told me I should look into THR! The OS was known for anterior. I got what he had to give. Shortly after my first hip, he got a write-up someplace for having completed 10,000 (yep 10K) anterior hips. He was a good 10years younger than me, if not 20. He also had the rock-bottom lowest complication rate of anybody within 100 miles, according to a third-party "dot o r g" website that I can't remember the name of. Aha! Found it! Propublica is the name to search. You can (or could) look up hospitals, surgeons, surgery type by name or area.

I was not one to overthink my surgery. I'd had a necessary hysterectomy at 37, between my two (adopted) kids, and knew the beauty of having something that absolutely does not function as advertised-- and causes constant pain-- removed from my body, life, radar, and general outlook on life. So getting the hips done was a no-brainer, as was a more recent hernia repair. And in all three cases I went into it knowing I'd be better off when done. Attitude has a lot more to do with surgical success than some give it credit for.

I super appreciate your honesty. And I totally hear you on picking the surgeon with the cleanest record. Unfortunately in my case that’s the doc who gave me the spooky scaries. Hoping to unwind from that experience but there’s a part of my nervous system that I’m worried won’t be able to come online around him. You mention attitude as a factor for successful recovery and that’s similar to what I mean… I’d like the tangibles and intangibles to all be on board as I move forward.
 
@LaKarune When I went to my regular doctor about my hip pain at first he didn't think it was as bad as I said it was but he ordered x-rays of both hips. He called me personally the next morning and apologized! And said he was immediately sending off referral to orthopedic surgeon (I have HMO insurance so referral was to surgeon my doc said he'd want to do his hip if he ever needed that). When I went in for the first appointment with the surgeon he came into the office and said "Ms M I've reviewed the x-rays and your medical records and the only thing I can offer you is hip replacement. And I recommend you do both at once". Color me shocked! At the time I was only experiencing the right hip as painful and dysfunctional. But x-rays showed left hip was also bone-on-bone and right hip had already fused (ball part of the femur was growing into my pelvis so did not move at all).

The surgeon had excellent credential though was not of the "warm and fuzzy" persuasion. Initially he got a bit backed up when I asked questions but we sorted that out when I told him I had worked for the HMO for a long time and was a well educated patient. Once that was established he was more willing to answer my questions. While he did not go into detail about why he used one approach over any other ( that IMO is the surgeon's choice and what ever he/she is trained to do) he did say incisions would be down the out side of each hip. Following the surgery I found those to be quite easy to deal with - easy to apply ice, they did not get "bent" or laid upon, were easy to tend to dressings, and for me they healed well and now are just very thin while lines.

The reasons he gave for doing a bilateral replacement (both hips in same surgical session) were - In his opinion less risk, one surgery, one session of anesthesia, one hospital stay and one recovery. Plus he said doing both at once I'd be able to return to a normal gait faster and would be less likely to have any trouble with leg length differential. I must say for me all that was true and YES I am very happy with my hips. These days I rarely think of them .... until I log in here :heehee:

Wow, so it’s not just my surgeons who get A WAY when I ask questions… for some reason it helps to hear that you had a similar experience and were able to persevere.

What a gift to have a general doc who was such an advocate for you once he realized you were right about how bad it was. The bone fusion - woah. I’d been wondering what happens when people just wait and wait. The left hip that had fused — you weren’t experiencing pain? Was it quite stiff/ immobile but asymptomatic otherwise? Apparently I have some arthritis in the other hip but no signs of fusion, no pain, good mobility. The two surgeons so far have both said no operations until it’s symptomatic. It’s also not dysplastic like my left hip. But part of me wonders how long I’ve got before that one will need surgery.
 
@LaKarune It was the right hip that was fused ... left one was bone-on-bone but not yet fused. I'd know the right one was bad for a while but what really made me scurry to my regular doc was going in for a routine GYN appointment (not with my regular doc) and having the nurse practitioner have difficulty getting the exam done because the hip would not -ahem- assume the position (if you know what I mean). Yes I was in a lot of pain -- slept on my couch for over a year before the surgery because it hurt too much to climb the stairs to my bedroom. I was rather in denial for a long time about how bad it really was ... and rather apprehensive at the thought of having surgery!


Fusion happens when the ball part gets so warped and rough that body says "wow that's broken. Gotta fix that" and grows new bone to "fix" the problem ... but bone growth attaches ball to pelvis so it's not really a fix .... just makes the problem worse. And for some folks if left too long the hip can collapse -- which is extremely painful and an emergency situation.
 
@LaKarune a few years older than you and had direct superior posterior, no restrictions. I did not have computer assisted SuperPATH. I have a small 4 inch scar. 8 weeks post Ops. No dual mobility, just a standard ceramic/polyethylene cup combo that has worked well for many over the years.

I chose direct superior as it was tissue sparing, just like Anterior. Also supposedly it’s really hard to dislocate hip after this approach. Also surgeon has great view of playing field and (supposedly) more precise cup placement for accurate leg length. Now, the counter to this is that if cup placement is computer assisted apparently solves for that for either posterior or anterior. Honestly, all that says, who knows!

Anyway…Three things I’ve learned here from lots of reading here…

Regardless of age:

1) all recoveries unique
2) skill of surgeon #1 consideration versus approach
3) what you bring into surgery (ROM/strength) is where you start coming out.

My main issue is the last one and need a few more months of rehab before I can enjoy higher level preop activities.

Anyway all things considered happy with result but on my result/approach but like folks here saying think either one works well.
 
@LaKarune a few years older than you and had direct superior posterior, no restrictions. I did not have computer assisted SuperPATH. I have a small 4 inch scar. 8 weeks post Ops. No dual mobility, just a standard ceramic/polyethylene cup combo that has worked well for many over the years.

I chose direct superior as it was tissue sparing, just like Anterior. Also supposedly it’s really hard to dislocate hip after this approach. Also surgeon has great view of playing field and (supposedly) more precise cup placement for accurate leg length. Now, the counter to this is that if cup placement is computer assisted apparently solves for that for either posterior or anterior. Honestly, all that says, who knows!

Anyway…Three things I’ve learned here from lots of reading here…

Regardless of age:

1) all recoveries unique
2) skill of surgeon #1 consideration versus approach
3) what you bring into surgery (ROM/strength) is where you start coming out.

My main issue is the last one and need a few more months of rehab before I can enjoy higher level preop activities.

Anyway all things considered happy with result but on my result/approach but like folks here saying think either one works well.

Thank you for sharing this! It sounds like you are well on your way to your best case recovery. I appreciate that you share my desire to research and really understand what each approach offers and potentially what their downsides might be.

Today I’m choosing to honor how lucky I am to be in a position where 1) I have options and 2) Have some of the best surgeons in the US (Los Angeles) in my pool of possibilities and 3) that BoneSmart exists for such heartfelt and experienced support for all of us and 4) that my hip is responding well to Celebrex and PT, which will hopefully allow me to prehab my way to a best case recovery once the surgery is done (speaking directly to your last point).

What a journey. Thank you all of you for being here as I embark on mine.
 
@LaKarune Forgot to mention...do some work to find a good PT that understands hip/spine, and ideally has some soft tissue/massage training BEFORE the big day and schedule post op... Otherwise you sort of just get whoever is around the hoop... if you research this topic, PT can make a huge difference in a great, sensible recovery versus less favorable outcome with setbacks (IMHO)
 
@LaKarune Forgot to mention...do some work to find a good PT that understands hip/spine, and ideally has some soft tissue/massage training BEFORE the big day and schedule post op... Otherwise you sort of just get whoever is around the hoop... if you research this topic, PT can make a huge difference in a great, sensible recovery versus less favorable outcome with setbacks (IMHO)
Thank you. I have an amazing PT (with a doctorate; legit legit) who I've been 'prehabbing' with, and working with her has been instrumental in giving me more stability and strength and decreasing my pain while I figure out this surgery. She's been an incredible champion for me and I'll definitely work with her after surgery too. She doesn't do the in-home rehab though -- my understanding is that the surgical office will give me that referral for the acute at-home PT for the first 6 weeks. Since they are a joint replacement specialist orthopedics practice, I'd assumed I'd just get someone great. Are you thinking that's a dice roll? Can I get ahead of that?
 
Hi all— I want to share that I found my guy today and I cannot overstate how relieved I am. This was my third surgeon consult, who I thought was another Anterior guy, but it turns out he does a MAKO assisted “mini posterior” with an approach that enters through the bony part of the side hip— and he uses dual mobility bearings on nearly all his patients. This was the last method I researched and I honestly didn’t think there was anyone in my area who used it, so I didn’t think it was an option for me— but in my research it started to sound like the right approach for me. I am so relieved to have found my surgeon. AND— he is personable, patiently answered all of my questions, and even complimented me on my thorough research. Nervous system regulation: check. I scheduled for his earliest avail— 4/20 (in Los Angeles that’s a special date, lol). I feel like a huge weight has lifted off me today. I’ll add my name to the April list here. (Though could be sooner… I'm on his cancellation list as well.) Thanks again for all your excellent advice and for sharing your journeys and I look forward to sharing mine once I’m through it!
 
@LaKarune, that is wonderful news! I felt such relief after I had chosen my surgeon and set the surgery date, so I completely understand your relief.
Can you please post here with which hip is to be replaced?
Then on of the moderators will make your signature with both the surgery date and the hip involved.
Again, Congratulations! You were very thorough in making your decision. :yes:
 
@LaKarune, that is wonderful news! I felt such relief after I had chosen my surgeon and set the surgery date, so I completely understand your relief.
Can you please post here with which hip is to be replaced?
Then on of the moderators will make your signature with both the surgery date and the hip involved.
Again, Congratulations! You were very thorough in making your decision. :yes:

Yes, it’s my left hip. Thanks again!
 
@LaKarune I wouldn't worry about in home PT choice. Generally, they are coming over to tell you how to go up and down stairs with crutches, pull the water tight bandage off after two weeks etc. The PT they give is pretty garden variety, ankle pumps etc.. Think you'll be all set. Also sounds like you'll be getting a Mako/Stryker dual mobility. Very cool... I have a boring Depuy lol
 
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