Hip Pain. Total Hip Replacement at Age 44. Protocol & Recovery.
- Patient Age: 44
- Health going into surgery: Excellent. Daily Bikram yoga practice, lift weights 1-2x a week; and ride a stationary bicycle each day. Thin. Strong upper body.
- When did pain start: 10 years ago.
- Why wait? In the 12 months leading up to surgery, pain became significantly worse and range of motion increasingly limited. Sleep was disrupted; achy pain in legs every day; walking became painful; often limped. The mental space the pain was taking up became too large, and quality of life was an issue. Pain maintenance became a challenge and very time consuming.
- Pain management in 3 months before surgery: 1 or 2 Advil each day was enough. Also took a supplement proven to help with with arthritic joint pain. Sometimes NyQuil at night to sleep "harder."
- Other forms of therapy before surgery: Chiropractic care, massage, ART (Active Release Technique) and acupuncture. Early on, chiropractic care helped with hip alignment issues, and it provided significant pain relief. Later ART helped with ongoing pain management and range of motion preservation via targeted stretches and foam rolling. Acupuncture had no effect.
- Diagnostic Process: X-rays from 6 years prior provided a base of comparison for new X-rays. New X-rays revealed significant degenerative changes and the possibility of Avascular Necrosis (AVN). An MRI was ordered as well as a CT Scan with contrast. Keep in mind that the radiologist will note everything. This does not mean it is the diagnosis, but rather the possible "set" of scenarios.
- Bottom Line: No Avascular Necrosis; torn labrums; multiple cysts. Left hip worse. Severe osteoarthritis, “hips of a 80 to 90 year old.” Part of cause was genetic, "shallow acetabulums", a cause of hip dysplasia. Total hip replacement is only curative option. Cysts are common in situations of severe arthritis. Don't panic at the initial findings.
- Surgical Plan: Replace worse hip now and the other later. "Later" ended up being 3 months later.
- Implant Materials: Ceramic head with polyethylene liner; titanium post. These were the recommended materials. Keep in mind that sometimes a different head may be chosen based on weight. This site gives you a decent rundown of the various materials. Your surgeon should be up on the latest research and have clear reasons for the recommended implant materials.
- Method: Posterior, minimally invasive, which means they did NOT cut the muscle. Recovery time is proven to be as fast or faster than the “new” anterior approach. Bottom line is that the surgeon prefers this method. In his words “he’s very good” at it. Agree. The press on the anterior approach can be misleading. Often the recovery time comparisons are NOT to the "less invasive" approach. Be careful when researching. Much information is "marketing" driven. Ask questions.
- Anesthesia: Spinal block with local anesthesia. NO general. Highly recommend this approach. There is research that suggests avoiding general anesthesia is better for your health and recovery. (The article is a MUST read if you are contemplating hip or knee surgery.) Local feels good going in (via IV), and you are awake immediately after surgery. Avoiding general means no throat tube, shivering, nausea, etc. The shot in the spine for the block is not painful. The spinal block numbing lasts 3 hours; plenty of time for surgery. The benefit of being awake fast is that you can get up and around. Yes, after surgery, expect to get up that same day. It lessens the risk of blood clots and promotes healing. An epidural takes longer to wear off versus the local and spinal combo.
- Picking the Surgeon. Do your homework. Talk to someone who is similar to you in terms of age, medical situation and activity level and who has used the surgeon. Scott T Ball was the surgeon selected, and his staff, especially his Senior Physician Assistant, Dustyn Severns, exceeded expectations with respect to knowledge and responsiveness.
- Pay Attention to the Team. Do NOT underestimate the value of the team. While the surgeon may do "the deed", keep in mind that you will have appointments and ongoing care from the Team. If you are kept waiting for an unreasonable amount of time; your calls are not returned; you have to wait days to get a reply; scheduling appointments is a challenge; questions are not answered directly...These are all symptoms to a problem. The UCSD Department of Orthopaedic Surgery gained my confidence with promptness, access and knowledge. Email was our primary form of communication, which meant very little phone tag. Phone calls are an annoyance. The UCSD team was up on research, new methods, and always straightforward with answers. After surgery, Dr. Ball was available and made sure certain things happened such as immediate physical therapy and catheter removal. Important. Your surgeon is your advocate and "power broker" in the hospital. Without this advocate, the hospital stay would have been longer, catheter left in, and little movement day of surgery...not to mention sharing a room with three others!
- Hospital: It does matter. I experienced two hospitals and there were some pretty big hiccups at one of them. BUT, again the top quality surgical team stepped in when most needed to solve problems. The hospital stay was one night and this was by choice and enough. Check in was at 7:30am and release was the next day was around 4p. The point is that with such a short “stay”, handling some “bumps” isn't too hard. More often the hospital stay is two nights; but it does not have to be.
- Get Moving: I was up and using the bathroom within hours after surgery. The same day of surgery I practiced stairs with a Physical Therapist. Moving promotes healing and lessens the risk of a blood clot. A walker was used while in the hospital.
- Insurance: Get it sorted out ahead of time. The surgeon selected was out-of-network while the hospital was in-network. This combination under a HealthNet PPO meant TWO deductibles and TWO out-of-pocket maximums to satisfy. While this situation is not ideal, I felt very strongly about the choice of surgeon. Looking back, I would not do it differently.
- Assistance: A walker was used while in the hospital. At home, after the first replacement, a cane was enough. Stairs were not a problem. While I used a hospital-issued "granny cane", companies like Top & Derby make stylish ones (see image left)!! For the second surgery, crutches were necessary for two weeks, because of a hairline fracture that occurred during surgery. The crutches were a safety precaution and I used them religiously for 2 weeks.
- Challenges: Sitting on the toilet and getting in/out of bed were the most challenging. (Accept the raised toilet seat. Most hospitals provide them. It helps.) These challenges lost their intensity after 2 weeks. In terms of the cane/crutches, there was some negotiation with respect to the duration of using the crutches. Two weeks and then a check-in was our agreement. Typically the first check up after hip replacement surgery is 4 weeks. (This 2-week check-in speaks to the flexibility of the surgical team.) After the first surgery, I saw a doctor after 2 weeks to get approval to return to Bikram Yoga. It was important to ensure that the surgical incision was healing as expected. Precautions were taken for all activities. (Bikram Yoga is not a "flowing" practice and is easily modified for safety.)
- Activity Level: Within 2-3 days after both surgeries, i was on a stationary bicycle. The resistance was minimal and the time spent in the saddle short (10 minutes building to 30 minutes by the end of week 1). Despite long naps and lots of "horizontal time", I was still on my feet a lot (more than recommended). Even with crutches, I was likely on my feet 6+ hours a day. Ankle swelling was the result.
- Recovery Pain: Pain is expected and each day it will be different. Pain thresholds are individual and the amount of drugs taken will dictate how much pain is felt. After 2 weeks, the pain decreases and by 4 weeks it's a whole new game.
- Drug Regimen: Understanding exactly what is being prescribed, and why, is important and will help you take control of the recovery process. For example: I was prescribed: Celebrex, Oxycontin, Oxycodone, and Xralto. Celebrex is not covered by my insurance plan, but is one of the only anti-inflammatories that is safe with a blood thinner (Xralto). I decided to skip it. The blood thinner is important to prevent clotting and is a non-negotiable. The narcotics are helpful, but the amount prescribed was extreme. For example, 60 tablets of Oxycontin were prescribed with a recommended dosage of one tablet every 12 hours. So that is a month's supply. I only needed ONE week’s supply…14 tablets. However, insurance coverage is per drug name ($70+ co-pay for the drug whether 5 tablets for 50). The same method applies to the quicker acting Oxycodone. My objective was to get off the narcotics and rely solely on Tylenol as soon as possible.
- Getting Off the Drugs: I stopped the daytime Oxy 3 days after surgery and nighttime Oxy, about 7-10 days after surgery. By week 2, I was taking the blood thinner (Xralto) and Tylenol only.
- Driving: Getting off of the narcotics is a prerequisite to driving. I was driving within one week post both surgeries. However, I limited my range significantly for the right side. Getting in and out of a car will be a challenge for the first two weeks. Expect leg cramping. Even sitting in a normal "office" chair was a challenge in terms of comfort. Give it a solid month.
- The “tipping point” is when the new hip feels better than the old. 4-5 weeks
- Notice mobility improvement at 4-5 weeks
- After both surgeries, massage helped loosen everything up. I had massages at 2 weeks post surgery. Using a foam roller is also helpful to loosen the IT band.
- Started PT about 1 month post surgery. Do it. And do the exercises at home. Just do it. There is only upside.
- 8 weeks: Hips are not on the mind. Mentally, it is a night/day difference. Leg "crampies" going away.
- If both hips are bad, you will start to itch for another replacement at about 8 weeks. Because the light at the end of the pain tunnel shines brightly.
- 12 weeks: Strength and endurance are greatly improved. Range of motion now only limited in groin area. Balance on one leg still not as good as before. Thoughts about hips and pain...pretty much ZERO.
A HAPPY ENDING
Hip replacements are known to be less complicated than knee replacements and the success rate higher. I am thankful that my "issue" could be corrected. At almost 3 months post second surgery, it's a whole new world. My range of motion is now better than before surgery and I have no pain. I walk better; I can finally kick a soccer ball; and do so many other things that had required modification or Advil. One of the best parts about being pain free is that I am not thinking about the pain and spending the time managing it. It is truly freeing.