The Decision

With a referral in hand, it was time to select some surgeons for a conference and to get informed about options. But ah, the web: so much to draw from, so random in its coverage. And ah, healthcare in the US: so much technology, so many constraints and bureaucratic complications...

Luckily for me, I follow cycling and so knew of Floyd Landis and the Birmingham hip. Or at least, I knew that he had had a replacement-type procedure that was well-suited for an active person. What else did I "know"? Hip replacements were for the aged; hip replacements were common and bring many people relief. But now, despite years of hints that this was coming, I felt ill-prepared to confront some important and pressing decisions about treatments and options.

We still had HMO coverage because of our two sons: I had always joked about switching to Blue Cross when the day came for old-age repairs. Well, oops, there I was, a member of Keystone Healthplan Central, which does very much NOT include all the practices in nearby New Jersey, and all the great hospitals in Philly. So reality #1 was trying to pick a surgeon from among those available. Based on some fairly random informal advice, I visited a first doctor, intending to go for a second opinion depending on the nature of the initial visit.

This first visit did NOT go well. After an interminable wait in the reception area and then the holding cell, the surgeon breezed in, told me I had osteoarthritis, but said he doesn't do hips! I would have to make an appointment to see another doctor in the practice! Grrr. A week later, it's the same tedious waiting-room drill, then a new doctor. He gave me a cursory poke or two and then announced what he was going to do with me. Very patronizing, not supportive, no options. He dismissed resurfacing, giving no reason (like, maybe he was't trained in it?), and he just told me that I would get a conventional hip using a ceramic prosthesis.

I rocketed out of there convinced never to return, but not much closer to making an informed decision. It was obvious that resurfacing was something that would take some sleuthing, so I used the Birmingham web site to locate local doctors who did the procedure and were in the HMO system. At the time there were only two, one in Reading (too far away), and one in Easton (not perfect but ok). So off I was to see Dr. Ferrante at Orthopedic Associates of the Greater Lehigh Valley.

Here's some advice that will matter most if you live far from a major city or have a more restrictive insurance plan: if you would like hip resurfacing to be an option, you MUST search ahead, because doctors will not necessarily clue you in to every available option (obviously this will vary among physicians). Jumping ahead in this tale, on two occasions after my operation, I met relatively younger people who were seriously bummed that they had not been told about resurfacing and were now facing some of the flexibility limitations that go with conventional hip replacement, plus the longer-term issue of possibly needing revision surgery later in life. You need to have a dialog with your surgeon, because resurfacing is not for everyone, but you also need to find a doctor for whom it is at least an option.

Anyway, the visit with Dr. Ferrante was great; he gave me all the time I needed to ask questions, and was open and honest about the pros and cons of the various options (waiting-and-coping; conventional hip but with larger metal or ceramic parts; or resurfacing). The only drawback: although quite experienced in hip surgery, Dr. Ferrante had only done three Birminghams.

It took me about three days of cogitating and web-reading to make the decision. I wanted the mobility and return to athletic activity that the Birmingham hip offered, plus given my age and activity level, the ability to replace a worn part with conventional surgery is a huge plus: while many web sites talk about revision surgery as "more complicated" you have to realize that to extricate the old implant pounded into your femur (and held in place by cement or more likely bone growth) requires a lot of surgical work and messing with your femur: that was not something I would want at age 70 or 75 or 80. I was willing to live with the long-term uncertainty about metal ions, and as far as my doctor's limited number of procedures, two factors weighed in. I felt too incapacitated and in too much pain to wait nearly a year to first change insurance plans and then find a new doctor. And, I decided that I would go with Dr. Ferrante's overall experience in hip surgery, even if not in resurfacing.

If you visit website like Surface Hippy, you'll see lots of advice not to do this, and tales of woe stemming from inexperienced doctors. Well, fine, but the basic rules of math say that no one gets to 200 without going through five, and I personally find it maybe a bit off-putting to operate on the principle that some other suckers are welcome to take the risk of the early surgeries every doctor has to perform. The other thing is that if you look at the numbers, the statistics are real marginal in terms of significance, and in a multivariate context like major surgery, it is quite hard to tease out simple cause-and-effect. I'm not against experience by any means, but it's my opinion that asking some fairly technical questions and getting a context for how a surgeon works can be an important and useful way to establish your comfort level and make a decision. 

So I signed off on consent and scheduled the surgery for August 6th.