Late-2011 Update

Time flies. While I still at times am aware of having two mended hips (hey, I fly at least every few months), lots of days go by where I don't even think about it. In 2010 I rode the most miles ever on my road bike (4750), and I rode two centuries with my son; 2011 will be similar. I also have done some pretty strenuous fieldwork, camping, and hiking in Yosemite and Mongolia. I do get phantom twinges every so often that can be briefly worrying but they always disappear quickly; kind of a scar-tissue feel in most cases. Really my biggest issue at the moment is re-discovering that my knees aren't so hot either. I follow the news about metal ions and resurfacing, and I'm just glad to have Birmingham implants (the full Australian report is pretty reassuring in that regard).

Moving on to too-much information territory, the surgical scar from 2007 is really faint, and the 2009 double scar is getting better, although I'm not planning on a retirement that involves modeling thongs (for which the world is grateful). So, so far, so good. Even if the implants fall out tomorrow, I already feel like it's been worth it.

On surgeon error and slipped cups

On the very useful and comprehensive Surface Hippy web site, there have been recent posts about slipped cups becoming a more common problem in hip resurfacing, with this problem being strictly surgeon error. Since in my academic research analysis of error is something I think about a lot, I feel the need to add a comment because of the way technical and everyday uses of the word "error" can cause confusion.

Nothing is definite and exact: all measurements and procedures will have error. Good engineering is about using the latest technology to construct something such that the error tolerances are way outside our day-to-day experience. So error is part of life in this world. Used in this way, 'error' is a value-neutral term.

If you think about all that's involved in a process like setting an acetabular cup (drilling, shaping, pounding, testing, bone quality....), some "error" is quite possible and can be expected. Experienced people will have lower error rates, but the complexity of the process and of the human body means that this rate can never be completely zero. To say it again: this rate can never be zero.

If I gave you 100 nails, and I just told you to pound them into a board, I bet you would get most of them into place, but I also bet you'd blow a few of your attempts at this very simple procedure: you'd make a few errors. A skilled person would make fewer mistakes. Anyone would in general make more mistakes if they were tired, rushed, or momentarily distracted, and fewer mistakes if they were really focused and practiced. All these are shades of gray between degrees of error.

My concern is that when people hear "surgeon error" they will tend to make the leap towards thinking "malpractice" or "incompetence" or "neglect" when they should just be hearing the value-neutral word, error. Clearly, if a surgeon has a complication rate way outside the norm, something might be up (assuming that the issue is in the operating room and not in patient selection, and that the numbers are high enough to be statistically valid). You really have to watch out for the latter - low to moderate-n statistics involving random error are really prone to runs and streaks: look at baseball as an example: with enough players randomly batting 250, a few players are always going to have a hitting streak going.

All surgeons go through training, and if hip resurfacing is to spread and help lots of people live better lives, lots of those people will be seeing surgeons who have done relatively fewer procedures. Instead, should they all, every one of them, go visit the handful of superstars who have done many hundreds of operations?

The tough thing for the prospective resurfacing patient is that you can't easily tell if you're surgeon is just riding an unlucky or a lucky streak, or if they are truly inept (or gifted). That is where high numbers do tend to help out. But you have to keep things in perspective, and beware of the human tendency to seek out zero risk - I'm sorry: but you cannot have that, because it does not exist. I think some realism and perspective is important, and at a time when you are already under stress and making lots of decisions, feeling pressed to hook up with a superstar might not be the most helpful thing, all other things considered.

I'm sure others might disagree.

Mending and on track...

Finding myself superstitious after the travails this hip has given me, I've been laying low, not wanting to jinx my recovery. But at this point, I've decided to emerge from my hideaway to give this report. 

My doctor has cleared me for full activity, provided I listen to my body and avoid extremes. I've ridden my road bike four times over the past 10 days, discovering mostly that I am now fat, slow, and out of shape. I also hiked up Mt. Cardigan in New Hampshire, about a 3 mile roundtrip hike with about 1000 feet of climbing on a moderately rough trial. Given all that and how I felt, I also stopped outpatient physical therapy this week, figuring that activity like I was doing plus some exercises at home would be fine, and save me some time and the healthcare system some money.

So, 75 days after the revision surgery to fix the slipped cup, things look good. I still get a little sore if I push it on the bike, or briskly mow the lawn (it's about 3.5 miles of walking on uneven terrain behind our wee little Neuton electric mower). But flexibility is good for the new hip and mostly there are lingering tugs and pains in me butt.

One tip - About two weeks ago, feeling sore after a session with the lawn, I popped one of my diclofenac anti-inflammatories that I had been using before surgery. Just one long-release pill. Wow! It just took away the soreness, and I felt great. I asked my doctor and he said it would be fine to do this on occasion, understanding that by the six-month point pain relief should not be necessary. So, if for some reason like me you have been going cold turkey on meds but you're feeling sore, try an Aleve or something like that. You might be surprised at the improvement.

I guess the only other thing to report is my blimping up by a few pounds. The scale provides the undeniable evidence of the net change (as do my riding jerseys) but I don't feel like I changed my eating habits. But about two weeks post surgery, with my weight having been stable, suddenly I just started the enblimpification. It's probably some depressingly simple thermodynamics that are the explanation (one extra cookie per day....), but the explanation I prefer is that the surgery has caused me to become photosynthetic, such that the spring weather has caused me to leaf out. Right. So now it's time for discipline and ramping up the riding miles.

Proof of two-hip status

Here's what things are looking like in x-ray:

More metal for the metal detectors. But still not quite a Terminator.

Where hip #2 is at.

Having two surgeries for one hip, along with the associated ups and downs, has been draining. It knocked hell out of my master plan for dealing with the work I do at the university. My entire psychology is different: whereas for my left hip, everything was great, improving, progress, this time I've ended up more negative and really cautious and worried and tentative (hence the long delay in posting anything about this surgery). 

At this point, I think I've turned the corner, and within the noise, I'm at the point where many patients would normally be. Whether by chance or due to the extra trauma, I've been experiencing a syndrome that many but not all hip patients face (whether they are conventional or Birmingham); it's the get-up-and-go problem, where you experience sharp groin pain when you stand and try and take your first step; this clears up within a moment or two, but is an annoyance in terms of mobility. I also experience more of this pain after therapy, and I am way behind on the ability to do straight leg raises: it's still hard to get the leg started at all, let alone without pain, though once I start doing the raises, it's no problem to keep doing them or even restart the exercise. But, I am just about walking pretty well without a cane and can do a mile or more with really no pain or fatigue. I'm spinning up my speeds on the bike trainer towards 17 mph, and I've gone as long as 50 minutes. 

Here's a summary of the events and sequence since surgery.

Day 1: Initial right-hip resurfacing surgery on 23 February.

Day 4: back home

Days 7-9: lots of discomfort, sense that something is wrong with joint

Day 12: Visit surgeon; get news that another surgery is needed to replace slipped cup

Day 13 (Day 1): Second surgery, 7 March. New cup with screws inserted.

Day 22 (Day 10): Hold graduate seminar home; using crutches to get around

Day 25 (Day 13): staples out, no infection, implant looks good

Day 27 (Day 15): Use cane for some walking, mix with crutches

Day 29 (Day 17): Back to work full time, lots of stair climbing descending

Day 31 (Day (19): First outpatient therapy

Day 34 (Day 22): First ride on indoor trainer: ~20 minutes, 5 miles (15.1 mph)

Day 48 (Day 36): Indoor trainer, 12 miles, 45 minutes, 16 mph

Day 50 (Day 38): Walking longer distances, basically not needing cane; still need cane a bit after therapy or after sitting for longer periods. Can sleep in any position without any real discomfort. Stretching at therapy starting to feel good rather than painful.

What's the deal with two surgeries in succession?

You might wonder what the outcome was to have two surgeries in such quick succession. Well, remembering the fundamental equation, that hip surgery = ass surgery, it is an insult to your ass, because the incision is re-used, and partly healed muscle and tissue is cut... Ouch. Dr. Ferrante closed this new incision with staples, rather than sutures and steri-strips (which he had used for the initial one).

The biggest concern is infection, with rates apparently reaching 10%, because of the greater difficulty of sterilizing the area plus the plain reality of re-exposing traumatized tissue to the environment. I did have a bit more tenderness, and a day or two extra of mild evening temperatures, but so far it looks like I'm ok. 

Other than that, the two surgeries have left me in a slightly curious hybrid state, as there was some healing from the first surgery that I retained and that wasn't reset by the second operation. So for that reason and because each hip and each surgery can be different anyway, it's a little hard to index my progress this time against progress after the surgery I had two years ago on my left hip. All in all, the net is that I'm a little more sore and weak this time, probably reflecting the additional trauma. 

Surgery 2b: groundhog day

The second surgery got off to a wobbly start in that I was told to report too early, to the wrong place, in a hospital that does not do or handle surgeries like this on the weekend. But we found a helpful person who connected us with people who were in fact looking for me. I was back in the same room that I had just left 10 days before ( it is not good when the staff remembers you!).

The surgery was short and sweet (I had a general this time, no stinking spinal (see earlier post)). The original cup was hand-loose, and although some extra cutting was needed to insure that the replacement with screws went in for sure, things went well and I was out in about 40 minutes. I woke up feeling great, and relieved that I was back in one piece with the Birmingham hip intact. I was able to head home after two days, given that this surgery was not quite as major.

We never really had an explanation for how the cup could have popped out so quickly. There was no recorded fall or incident that I had. True, my leg was numb for too long after surgery, but I didn't try walking on it or anything. Dr. Ferrante said that is went in well and firm. ALl I can figure is that the press fit was just barely ok, and it popped out under a fairly minor nudge in normal use. There's no point in blame for anyone because there is no evidence of anything particular happening, and the repair worked out. 

But... if you feel lots of sudden shifts and motion in the days post surgery, don't wait: see you surgeon. I would have saved myself a bunch of wasted recovery days if I had reported the systems and asked for an examination and x-ray.