This surgeon dropped hip replacement precautions entirely

William Leone, MD, changed the way he performs total hip replacements after decades of doing them another way.

It was not because the operation was failing. Total hip replacement was already producing excellent results in his practice. But Dr. Leone, orthopedic surgeon and head of the Leone Center for Orthopedic Care at Holy Cross Health Fort Lauderdale (Fla.), saw room to improve two persistent concerns: postoperative instability and restoring leg length.

In 2020, that led him to begin using the SPAIRE technique, spare piriformis and internus, repair externus, a variation of the posterior approach that preserves most of the short external rotator muscles surrounding the hip rather than releasing and repairing them.

Years later, Dr. Leone sees the clearest difference early in recovery. He no longer gives patients traditional hip precautions, and he said many return to activity quickly.

He is more cautious about what SPAIRE means years later.

“I don’t know if in the long run there’s a difference,” Dr. Leone told Becker’s. “But I definitely see a difference early on.”

That distinction has shaped how he thinks about improving an operation that already sets a high bar.

What changed when the muscles stayed intact

During a conventional posterior hip replacement, surgeons typically release short external rotator muscles to access the joint and repair them afterward. SPAIRE preserves most of those structures, with the obturator externus released to create access.

Dr. Leone sees two advantages. Preserving the muscles provides additional resistance against posterior dislocation, he said. He also believes the intact structures act as a restraint against inadvertently lengthening the leg during reconstruction.

The most immediate change has been in his postoperative protocol. Patients undergoing a posterior hip replacement may traditionally be instructed to avoid certain positions while tissues heal. Dr. Leone no longer gives those restrictions to his SPAIRE patients.

“As soon as they leave the operating room, I don’t limit them in any way,” he said. “I say immediately, just go do what you’re comfortable doing.”

What Dr. Leone cannot separate is how much of the early recovery he observes comes from preserving those structures and how much comes from giving patients the confidence to move without restrictions.

“It’s probably a combination of both,” he said.

Learning a new approach after decades in the OR

The concept appealed to Dr. Leone immediately.

 Performing it did not come as automatically. When he began using SPAIRE in 2020, he had already spent decades performing joint replacements. He watched videos of the technique and then worked through the learning curve of operating while preserving anatomy he had previously released.

“It was a new concept to me,” he said. “I watched a couple of videos online, but I was so enamored with the idea.”

Now, he said, the technique has become routine. He often sees patients return at two weeks without their canes. Some do not return for their six-week appointments because, he said, they have already returned to their lives.

But SPAIRE did not evolve in isolation. Dr. Leone has refined the broader hip replacement process alongside it, incorporating regional or spinal anesthesia, multimodal pain management and robotic technology to assist with component positioning and reconstruction.

That makes him reluctant to attribute the recovery he sees to any single change. “You add it all up, and the sum is a lot greater than the parts,” he said.

‘It’s the person doing the surgery’

That perspective complicates one of the most persistent debates in hip replacement: which surgical approach is best.

Dr. Leone has a clear preference in his own hands. He calls SPAIRE combined with a mini-posterior approach the “best of both worlds.” But when asked what the debate over anterior versus posterior approaches gets wrong, his answer was immediate.

“I’m telling you this with 100% confidence,” he said. “It’s the person doing the surgery.”

Dr. Leone does not believe the name of an approach determines the result. A surgeon with extensive experience using an anterior approach can produce excellent results through that technique, he said, just as an experienced posterior surgeon can through a posterior approach.

SPAIRE itself underscores his point. “Most surgeons probably can’t do the SPAIRE approach because it’s a little harder unless you’re really taught,” he said. “But it’s about who does the procedure.”

For Dr. Leone, experience shows up in details that are difficult to capture in the name of an approach: how a surgeon handles tissue, reconstructs anatomy and responds when an operation does not unfold exactly as expected.

 “Experience comes from stepping in buckets and saying, ‘I’m not doing that again,’” he said.

The long-term question remains

Dr. Leone is confident about what has changed in his practice since adopting SPAIRE. He no longer prescribes traditional hip precautions. He believes preserving the posterior structures makes it easier to recreate normal anatomy without lengthening the leg. And he sees patients returning to their lives quickly after surgery.

What he does not yet know is whether those differences translate into a superior hip replacement years later. He has patients whose hips he replaced using earlier techniques 15 or 20 years ago who return because the other hip needs surgery while the original replacement is still doing well.

Asked what would have to be true for SPAIRE to prove itself a meaningful long-term advance rather than another way of performing an already successful operation, Dr. Leone resisted making a prediction.

“I don’t know if in 10 years it will,” he said. “I don’t know whether the curves cross.”

For now, his case for the technique is more specific.

“What’s absolutely different is no precautions,” he said, adding that he also sees less tendency to lengthen the leg.

That restraint may be as revealing as his enthusiasm for the technique.

After decades of performing hip replacements, Dr. Leone’s standard for innovation is not simply whether surgeons can devise another way to perform the operation. It is whether a change can make recovery easier without sacrificing the results that made hip replacement so successful in the first place.

Friday, September 25th, 2026