Wednesday, August 29, 2007

Day 23 - Plateau and the Song of the Open Road

Just a little more than three weeks after surgery, I'm now able to walk for fair bit without any support from a crutch. But after PT or a more active day scuttling around, I get tired and a little sore, which reverts me to a rolling, limping gait. Also, now that I'm more active and not on any anti-inflammatories, my right hip is making itself known (the silver lining of which is that I can compare and see how much better the new hip feels). Overall I feel like I'm on a small plateau, doing ok but still with considerable rehab to do.

The other thing is that it's just gorgeous riding weather, and I miss the bike. I realize that one great thing about the bike is that it makes you more aware of details like the weather: the temperature, wind, and rain all matter a lot, but not if you just blob around in your car. So I'm eager to get back, because I've just been blobbing around in my car for too long.

Sunday, August 26, 2007

Oh, Right, About the Pain

Sorry to get so caught up in all the details of surgery that I omitted one important report: what about the pain that I was trying to defeat in the first place?

Well, it's gone! I guess because there is still some stiffness and soreness in my left leg, I haven't been paying attention to this important point. In fact, I've already forgotten what the arthritic pain was like. The only small reminder are some complaints from my right hip, which will probably need work one day before too long.

Thinking about it, it really is astounding. 20 days ago I was limping and wincing, and as most hip sufferers will know, the referred pain - up and down the leg, in my knee, in my groin - was frustrating, widespread, and random. I was getting concerned that my limp was aggravating my knee, such that after surgery, I would have a great hip but a rotten knee and thus no net progress. Not so. All those pains have vanished.

Saturday, August 25, 2007

Day 19: Progress! Stairs and Bike!

Yesterday evening and this morning saw two big advances. First, I found myself able to walk UP stairs leg over leg, with only minor assistance from a railing. That doubles my ascending speed(!), and means my quadriceps muscle must be coming around.

And this morning, I got myself onto my wind trainer and rode for 20 minutes. I actually raised my heart rate! And sweated! A whole 3.5 miles!! Not exactly like riding a century, but I see a way forward back to fitness. Woo hoo!

Of course, I was careful to have a little platform to help mount the bike, and I alerted my sons to check on me should I fall and not be able to get back up. I'd been worried that twisting out of the clipless pedals might be hard, but it wasn't a problem. I did feel a little winded and dizzy at higher spin rates when I was down in the drops, so that will take some work. But overall, great to finally get some exercise.

Day 11: Freedom to Drive: Outpatient Life

On August 17th, 11 days after surgery, I visited the surgeon's office and got the great news that a new X-ray showed everything looks good. The implant looks like a mushroom: I can't wait to deal with TSA at U.S. airports. As my left hip was involved, I was given the green light to drive (one of our cars, the Prius, is an automatic, so the left leg just has to cope with the parking-brake pedal).

Free to drive, I switched over to outpatient physical therapy, planning to go about 3 times per week. It's good to get some exercise and begin to push the leg with concrete goals like cycling and stair-climbing in mind. By about the 22nd, I was mostly getting around using just one crutch for a little support. On the 22nd, at PT I actually rode an exercise bike for about 2 miles worth of spinning.

Here's a timeline of how things progressed for me:

Day 0 - surgery; up in recliner
Day 1 - cathether out, first PT session, walking with some weight-bearing and two crutches; quadriceps stiff
Day 2 - PT twice, antibiotic IV done; some swelling in leg
Day 3 - discharged to home
Day 4 to 6 - quadriceps sore; swelling in leg; evening fever and some depression; just occasional Tylenol and one nightime Vicodin for pain. Took short crutch-assisted walks in neighborhood (maybe 500' total),
Day 7 to 9 - more energy, more flexiblity
Day 11 - visit doctor, ok to drive
Day 13 - maximum likelihood of blood-clot problems is two weeks after surgery; so far so good
Day 13 to 15 - start outpatient PT; participate in off-campus retreat for new program I am running
Day 16 - go back to work for a half-day; able to walk down stairs leg-over-leg
Day 17 - full day at work, several meetings
Day 18 - start this blog, discover that I can walk up stairs, ride 20 minutes on wind trainer (low resistance spin).
Day 19 - basically off all pain meds, including Tylenol. Am just taking 325 mg of Aspirin twice a day as pain killer. Back on wind trainer again, and am walking shorter distance around house without any crutches.

Day 3: Home from the Hospital

We have a two-story house, and it turned out to be no problem to live on the second floor. I was able to crutch up stairs without problems, and since the renovated bathroom, the bed, and our best easy-chair recliner were up there, this way I could withdraw and rest. Descending for meals and visits by the therapist and nurse made for some variety.

I set up a recliner next to my bed, and gathered together some pillows, a big mug of icewater (you'll be thirsty for quite a while), reading material, cell phone and cordless phone, and my laptop (we have wireless, which is a great boon). This made for a pretty comfortable base with lots of options. Bless the recliner - it was home sweet home for a while.

I grew to hate the phone, because inevitably I would forget to schlep along the handset, and as I was expecting calls related to nursing visits and such, I could not ignore the wretched thing. So if you hate cold-calls by solicitors anyway, wait until you have to wrench yourself out of a chair, hobble to find the phone, and then enjoy a recorded message from some dufous...

You will probably have arrangements made for a visiting nurse and physical therapist. It's nice to be able to talk over your condition with someone, and to start work on mobility and strength. My therapist made a very good point about not rushing things: form, balance, posture, and gait are important. If you were limping before the operation, it may have been a long time since you've walked normally, and the goal of the operation is a restoration of full activities, not merely a return to gimphood. I know different people will heal at different rates, but I wonder if some of the miracle reports about people walking unaided after a week need to be asterisked: are they walking smoothly, or limping and gimping around?

A few things to know about:

First, it is very easy to feel lightheaded when you pop up out of a recliner, especially if you get into the shower and have nice warm humid vapors around. Make sure you have a place to sit or someone to help you, certainly the first time or two. Note that this is true in the hospital as well: be careful about trips to the bathroom, etc. You really don't want an uncontrolled fall onto your new hip.

Also, apparently it is common to experience post-operative temperatures in the evening, and you might find yourself with minor chills, sore skin, lower energy, or whatever symptoms you show when you run a temperature (we're talking numbers between 99 to 100 F, not the higher values that might indicate an infection and the need to contact your doctor).

Sleeping sucks. Until you get loose enough to roll over onto your stomach you're kind of stuck sleeping on your back or non-operative side, and for me that is a position that turns my brain on, not off. A pillow between the legs is not required for Birmingham people, but helped me when I tried sleeping on my side. Even once you can sleep in any position, I found that there was just enough tightness or discomfort that I would only sleep in blocks of 90 minutes or so, with lots of twisting and turning, which did not help my wife sleep. For a few days I reverted to taking a Vicodin at bedtime, but then I saw the recent news story about ramapant abuse and I decided to stop. If you can at all help it, do NOT nap during the day.

Finally, I felt - and apparently this is not uncommon - quite despondent and depressed for one or two evenings once I was back at home. I still felt sore, and incapacitated, and just miserable and sorry for myself and sorry to be causing such a fuss for everyone. This feeling passed as my energy returned and things healed up. So if you feel this way, tell people, but don't worry: the feeling is likely to pass.

Surgery and the Hospital Stay

On the day of your operation, you will probably be asked to get up at an unearthly hour, take an antiseptic shower, and report to the hospital for admission and preparation. This is one time that you do not need to worry about lack of sleep, I promise you.

I chose to avoid a final decision on anesthesia until meeting with the surgeon on the morning of the operation. Everyone was 50-50 about using a general versus a spinal. I decided that I had no interest in seeing the operation, even if my memory would get wiped. And, as it turned out, if the surgery takes extra time, like mine did, then a general is the better choice. You'll have to make your own decision based on your condition and the advice for your doctors.

If you've ever had surgery of an kind, you'll know that one minute your wheeling along in a cart on the way to the OR, and then suddenly you're groggy and on your back in a different place. My surgery (on Monday 6 August) took over two hours because the surgeon needed to work a little harder due to my hip dysplasia.

I had been told that Birmingham patients do PT on the day of their operation. Well, sort of. It consisted of being moved out of bed to a recliner, maybe 1 meter in distance. I almost passed out on this long journey. Impressively though, my surgery ended at 10 am, and by 2 pm I was in the recliner, awake. My family visited and watched while I picked at my dinner (I had ordered the meatloaf selection as comfort food, but my appetite was beyond comfort, certainly any comfort that meatloaf could offer).

When I awoke, I had a urinary catheter, an IV for pain med, antibiotics and fluids, and a dressing on the incision but no surgical drain. The wound was closed internally by dissolvable stitches and externally by steristrips (compared to other Frankensteinian sutures I've had, the closure was gorgeous and tight; too bad this is not the most photogenic and oft-displayed part of me!). The catether came out the next morning (no real pain), the dressing got changed daily (no real pain), and I did PT morning and afternoon starting Tuesday afternoon (no real pain). Constantly asked about pain on the 1-10 scale (WTF is a 10 supposed to be: slowly being crushed by a truck??), I never went beyond about a 4, thanks partly to the opiates, including morphine over the first two days. Probably the most pain I had were brief sharp tugs in the area of the incision; these diminished over time as the wound healed and the sutures adjusted.

By the way, there are various ways a surgeon can access the hip, but if your view of the hip is of the hands-on-your-hips variety, you may be surprised to find your incision is on your ass as much as anywhere else! Hip surgery = ass surgery.

One thing to be prepared for is an unpleasant norm for post-operative, opiate-filled life: constipation. They give you some palliative stuff, but really, in my experience from years spent traveling in remote areas and using various "stomach" remedies, once an opiate gets into you, your intestines just go on holiday, extended holiday. What made my life worse was the toilet extender they had perched around the hospital toilet. I am not a huge guy, but sitting in there pinned my legs together in such a way that even if something was maybe gonna happen, nothing was gonna happen. I had to get home to find relief. If you're lucky, this will not be your experience. Moving on...

The biggest post-operative issue I had and am still getting over is the trauma to my quadriceps. If you have the right constitution, find one of the detailed surgical videos posted on the web and watch the Birmingham operation. You'll see that fairly early in the procedure, Igor the Assistant gets the word to dislocate the hip, and this involves a rotation of the leg that ain't natural. Your leg is twisted in a weird way, the femur is exiting the incision and I assume pressing up against connective tissue and muscle, and you are unconscious and not in a position to say 'ouch -- I'm cramping'. That goes on for like two hours. So I found that while I could bear weight on my hip, and right from the start could walk on my left leg with a walker or crutches, my quad was shot, and any attempt to raise it, say in a straight leg raise, let alone climb a stair, was hopeless. I don't know if this is just something that happened to me, or is common to hip operations, but I was a bit surprised. I thought that all the pain and trouble would relate to the incision and the cut tissue there, but that has not been the case.

I was discharged on Thursday (Day 3) and was able to crutch to our car (a Prius, with nice high seats), comfortably get in, and escape to home.

Run-up to Surgery

Your experience in the run-up to surgery and during the procedure itself will vary enormously. So again, I'm just reporting my path.

If you've never had major in-patient surgery, you'll be impressed by the numbers of steps involved: scheduling tests, arranging referrals, and meeting with individuals. You'll need your personal physician's clearance for surgery, including an EKG; you may want to donate blood to yourself (autologous transfusion); you'll need a chest x-ray (inexplicably, a separate referral needed); you'll confer with the anesthesiologist; and you'll likely get involved in a pre-surgical information program. Plus, you'll be advised to buy some necessities to make life easier when you get home.

"Joint Camp" at Easton Hospital is a nice idea: you meet your approximate cohort of victims and you get a briefing and a chance to ask questions. Although if you're reading this blog, you'll probably have done lots of web research, it's still nice to talk to the supervisor for your care, and the physical therapst who you'll be working with. Also, this Jointworks Program has rallied all participating doctors to use similar protocols, simplifying andf streamlining care: this is good, because confusion in a hospital is bad.

One downside is that for the moment and for the next few years, resurfaced hips are still a novelty, and in orientations, in the hospital, in PT, and elsewhere, people give you conventional info and treat you overly conservatively. That's not dangerous, but it does leave you feeling a little underinformed and confused about YOU can and cannot do. The only solution for this is knowledge, and being a squeaky wheel.

Some pieces of advice about the immediate run-up:

I would delay buying the recommended "hip kit" until you see how you're doing and how home care is going. A hip kit is usually a sponge-on-a-stick for washing the lower half of your body, a sock-donner, and a grabber claw. The claw is fun and my sons and I enjoyed clawing things (think "Toy Story"), but so far I have only used it once when I dropped my glasses behind an easy chair, and was home alone. I could bend enough to wash all but my lower left leg, and hell, water was good enough for it, so my sponge-on-stick stayed unused. As for socks, it was summer and I wasn't going anywhere fancy, so a sock device wasn't critical. That said, it can be a little tricky and uncomfortable to get a sock on for the first 3 weeks, but not worth the device, at least for me.

You will probably be urged to use a walker in your recovery (you will be happy to use one at the hospital). I was too vain to be attached to such a device long-run, plus I wanted the greater mobility of crutches, so that's what I opted for. I had my wife bring the crutches to the hospital so that I could work and practice with them during physical therapy.

Either before surgery or while at the hospital you will be helped with arrangements for getting some sort of toilet-seat extender. These devices vary greatly. Without getting into the details, some of these suck, for a variety of reasons. I would wait and see how you are doing at the hospital: if you get resurfacing done, you might not need a higher toilet. In my case, we had happened to renovate our bathrooms recently, and given that everyone in the family was grown and no one is getting younger, we installed ADA-grade toilets that are a bit higher (I think 17 inches). This turned out to be more than fine for me, so I didn't bother bringing in any extra appliances. We also have a shower with only a small tread to step over (i.e., not a tub), and the shower has a separate hand-held unit, so that worked out well, too.

Finally, even though you might begin to feel like you are obsessively hogging attention with all your hip talk and endless blah blah blah about surgery, talk to people about your concerns and fears. I really began to feel spooked: (1) there is some finite chance of dying in all surgery (even if the hip-surgery odds are probably skewed by the traditionally older clientele); (2) even though you need the surgery, it still feels elective, so you are bringing down all these hassles on your family and on yourself, by choice; (3) the outcome is not 100% certain; and (4) somehow compared to past outpatient knee jobs and minor repairs, this surgery felt to me like some kind of life threshold, a gateway to old age and never-ending strings of medical procedures (if you're getting resurfacing done, most members of your cohort are going to be older than you). These are natural reactions and concerns, and your best way of dealing with them is to talk them out.

Once you wake up on the day of surgery, you're heading down the ski jump so things will go fast, and the only elegant way out is forward....

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.

The Backstory

Let's set the stage for this hip story. This will be a longish post, intended to let you compare yourself to my case to see if anything jives. If you're more interested in the surgery and the aftermath, you might want to skip this too-much-information report!

I'm a 51, male, and a college professor. To counteract the sedentary lifestyle, I try to road bike 4000 miles a year, which between travel and meetings, and the darker winter months here in eastern Pennsylvania, is about all I can manage if I include trainer mileage and can throw in some longer summer rides. I love cycling, and given the state of my knees (and hips), it's the perfect exercise. I've never raced, but I try to average 15 to 17 mph on the hilly rides around here, which I'm proud of even if it's a snail's pace for really good riders. All the riding allows for robust eating and the chance to work out the tensions that accumulate at work (even professors bear their crosses...). I'm 5'10", and seasonally fluctuate in weight between about 202 and 212 pounds with a fat content of about 25% (at least according to a Tanita scale in standard mode). (I told you this post would be boring!). The other reason I try to keep active is that for quite some time now my research has involved field work in the Himalaya and Tibet (see www.ees.lehigh.edu/groups/corners), and even in teaching we lead field trips, so being fit is important professionally as well as personally.

As I recently learned, I have mild dysplasia in both hips and considerable osteoarthritis, partly as a result of the dysplasia. The angle of my femoral neck is also quite shallow. Before my hips became the main focus of my joint discomfort, I was more worried about my gimpy knees, which are missing some ligaments due to untreated ultimate-frisbee accidents in grad school and in retrospect, too much jogging and running (leaping down trails in the Presidential range; humping out heavy packs of rock samples, all the dumb things we do when young...). Interestingly, I've been told by my doctor that the state of your knees is pretty much your fault, but for the state of your hips you can blame Fate.



It's hard to know when the hip pain began. Probably about 7 to 8 years ago I started noticing stiffness in my groin and my thigh after a hard day trekking. Also, standing or shuffling about, like at art museums or during poster sessions at professional meetings, really started to hurt to the point where I was starting to avoid such events. But biking did not cause pain, leading to awkward explanations about why I could happily ride 50 tough miles, but would start whimpering if threatened with a visit to MOMA.

About three years ago, a sampling trek in Tibet went wrong: we thought a route might gradually head up a glacial valley, but instead went straight up a vegetated cliff. It was a desperate few hours, requiring big lunging steps and unforgiving foot placement, and by the time we got up and then back down, I literally could not walk due to the sharp hip pain. When I returned to the US I saw my GP, and she diagnosed osteoarthritis. She put me on two forms of Diclofenac (Voltaran and Cataflam). It was a miracle: little pain, much improved range of motion, and I could ride my bike or play 18 holes of golf walking and carrying my clubs.

Time passed, and gradually the NSAIDs weren't working as well. Walking a round of golf was a crap shoot in terms of pain, I was avoiding museum-type standing, and meanwhile I was wondering about the long-term wisdom of eating the Diclofenac twice a day. In late 2006, at the end of the bike season I noticed that at the end of longer rides I was feeling very sore, and I was backing off agressive attacks on rises and hills. When the 2007 season started, the soreness was still there, but worse.

Then in May 2007 I went to a conference in Hong Kong, and it was nearly a disaster. Getting off the long flight, I could hardly get through immigration, and the daily walk to the conference and the standing around were just crushingly painful. When I arrived back at O'Hare, I honestly thought I would have to declare a medical incident and ask for a wheelchair to get to passport control. In the weeks that followed I could only walk with a painful and obvious limp. When I tried to ride, anything more than 10 miles left me very sore, and I couldn't push any power through my left side. The pathetic finale on June 18th was an attempted 15-mile ride where I got caught in a thunderstorm just as my hip gave out: I bailed, and crept home in a downpour, trying to spin granny gear long enough to get home.

I revisited my GP, who had me go for X-rays, and after seeing them, said she was sorry, but really the only thing to do was to see an orthopedic surgeon.

Welcome and Background

I'm starting this blog 19 days after enjoying Birmingham hip resurfacing. My goal is to record my experience with this procedure. This includes my decision to go ahead, my concerns and questions, and finally my still-ongoing journey through the procedure and its aftermath. This will be an intensely boring and uninteresting story for most people - except those aching souls who find themselves with a sore hip and the dawning realization that they need to do something about it.

I'm targeting active, athletic middle-aged types who are finding it a little hard to believe that they are facing a major operation, and who are trying to navigate the piles of material on the web, which amounts to a tangle of dated material, excerpts from technical medical studies, and mostly, information for more elderly people who are looking at conventional hip replacement (but see the surface hippy site as an exception!).

It's important to realize that I'm not a medical doctor: I have a Ph.D. in tectonics and geochemistry, and this just makes me dangerous, not an authority on medicine and orthopedics! It's likely that other people have reported things better, and it's nearly certain that your hip and your condition will leave you facing details that will add up to a different experience. So please, treat this as one person's story, n = 1.