February 14, 2008
Healthy Talk Radio
June 03, 2007
Are you a candidate for total hip replacement?
Maybe your pain fluctuates. Perhaps you can delay or defer a total hip replacement by exercising, taking pain medications, or going to physical therapy. But chances are if you have found this page, those conservative options may not have worked out for you.
In my book, GETTING HIP: Recovery from a Total Hip Replacement, I discuss various treatments that may be effective in preventing total hip surgery, including some alternative medicine choices. I also talk about how critical it is to choose a good surgeon (up to 50% of the success of total hip replacements depends on surgical expertise), different types of implants that are available, hip resurfacing instead of total joint replacement, and how to get a second opinion if you're unhappy with the first doctor that you see. If you're already booked for joint replacement, you’ll want to know how to prepare for the operation, physically, socially and psychologically. You will also need tips on how to minimize your pain postoperatively, and how to pace yourself after surgery. Everyone has a different experience after a total hip replacement (THR). Some people have rapid recoveries whereas others take much longer. Your recovery may be entirely different from that of another person, so it's important not to compare your experience with theirs. I interviewed ten people around the world for GETTING HIP so that readers could hear about a wide variety of recoveries from the short and sweet to the more lengthy and complicated; your own recuperation may fall somewhere in between mine and the people that I spoke to.
Many doctors use traditional metal and plastic implants whereas others are experimenting with new prostheses, such as the ceramic-on-ceramic or metal-on-metal. I interviewed people with conventional implants and those with ceramic or metal implants: people who ranged in age from 43 to 73 at the time of their surgery. You may decide that the time is right for you to have your hip replaced and then have to endure the frustration of waiting for an appointment with an orthopedic surgeon, and receiving a surgical date, or being told by your family doctor that you're too young for the operation. Waiting lists are a problem for people who rely on public health care systems in Canada, the UK and Australia. Many Americans depend on HMOs, which are notorious for creating delays in all kinds of procedures, including joint replacements.
Or maybe you've already had a total hip replacement. In that case, certain lifestyle changes can go a long way towards making your prosthesis last longer. GETTING HIP devotes a full chapter to taking care of a new prosthesis so that it will last as long as possible, and a final chapter on the future of hip replacements. Many exciting advances are being made in the field of stem cells and cartilage regeneration.
HEAR ME ON THE RADIO Recently, I was on The Good Life Show with Jesse Dylan, discussing hip replacements and my own experience. The show is broadcast all over North America on Sirius Satellite Radio, has esteemed guests such as Deepak Chopra and Andrew Weil and has over four million listeners; you can hear the interview here and see a small picture of me on the way to the gym: http://www.tglshow.com/integrated.php [Can't find me? I'm the 12th person from the bottom of the page.]
BUY GETTING HIP If you'd like to save money and get an autographed copy of GETTING HIP, buy the book from me directly by clicking on the CONTACT ME button at the end of my link section. GETTING HIP is currently available for $11.60 US, not including shipping and handling(which is $3.50 within Canada and $5.00/US to the States). That's 25% less than what the book sells for on Amazon!
Just send me an e-mail to confirm pricing and I'll mail you the book. I accept PayPal, checks and money orders. If you don't want to wait for the book to be shipped, GET THE E-BOOK for $5.00/US by writing to sigridmac at sign rogers.com or by clicking on the button that says "CONTACT ME" at the bottom of my link section, on the right. E-books are delivered immediately, can be read on your screen, or can be printed out, so that you can read them in the comfort of your big chair. Do it through me or via PayPal -- it's easy.
WHY DO YOU NEED GETTING HIP?
Hip replacement surgery was not what I expected. I'd had other surgeries in my lifetime and each one required a passive convalescence. Orthopedic surgery is different; we need to be active partners. It's also critical to find out what the hip precautions are before surgery because there are certain positions that post-op patients cannot adopt for at least 4 --8 weeks. Knowing these precautions beforehand allows you to hip-proof your house, move objects up to waist level, and buy certain items like reachers and long handled shoehorns well before the operation. You also want to plan in advance because you'll be out of commission for a period of time. How will you do your shopping? Who will do your errands? What will you use for transportation during the period of time when you can't drive?
GETTING HIP addresses all of these issues and more. It talks about how to reduce your chances of becoming anemic or developing swelling in your legs following the surgery, as well as proper pain management.
TESTIMONIALS -- WHAT PEOPLE HAVE TO SAY ABOUT GETTING HIP
Linda May Bowser, webmaster of the Totally Hip Online Support Group, calls GETTING HIP "totally captivating!"
"GETTING HIP is written in such a manner that it captures your attention from page one and just won't let you go. In fact, when Sigrid sent me a personal autographed copy, my mom picked it up while my Dad and I were repairing some dining room chairs. She started reading it, and then took it home with her to finish... before I could even get a good look at it. Well, today, I made sure to get my copy back so I could read it as well. "
Ottawa Seniors declares GETTING HIP to be a "must read." Ottawa Seniors Newsletter December 2004 “Hip Replacement? If any of you or your loved ones has just or is about to go through a hip replacement, then there is a book by local author Sigrid Macdonald that is a must read. Find out the mistakes that can be made and the best tips and tricks to ensure any unnecessary suffering or problems are avoided. You can read more about Sigrid's experience and how to get the book by going to the Articles/News section of the website or by searching for "Sigrid" in our Services Directory."
Swamy Swarma, Professional Book Reviewer, Recommends GETTING HIP
"Getting Hip is the first person account of Sigrid Macdonald, who went through a Total Hip Replacement Surgery and felt the need to share her experiences before, during and after surgery. At places poignant, at places serious and at some places humorous, the book gives a detailed account of what is involved in a Total Hip Replacement Surgery, including the decision to go in for the surgery, type of implant to be selected (given a choice) and what to expect in terms of pain, restrictions on movement and post-surgery life style etc.
"The author has referred to several books on the subject and has added her own wisdom to the subject...If you are considering a hip replacement or if you need to support a friend or relative who is contemplating such a surgery and are looking for a layperson's perspective of what is involved in a major surgical operation like Total Hip Replacement, this book is certainly recommended."
Total Hip Replacement Patient, Peter Nixon, calls GETTING HIP "the best book out there."
"I read this book 9 months after having simultaneous bilateral total hip replacements. In my opinion, it is the best book out there that documents what those in need of a total hip replacement are experiencing, from the onset of the symptoms of hip pain, to the procedure itself, and through the recovery process. I wish I had known about this book prior to my surgery, and during my recovery.
"Most helpful to me was the point that was made that there is no 'gold standard' for recovery, and that, while all patients will experience much of the same in terms of the recovery process, we will all require different amounts of time to recover."
EXCERPT I have posted the introduction and first chapter of GETTING HIP below, so you'll have a sense of what the book is about. Please drop me a note before you leave. I love hearing from other total hippers and wish you the best of success with your surgery. Thanks for visiting and stay hip!
Sigrid Macdonald
Ottawa, Ontario
INTRODUCTION
Every year, almost 400,000 North Americans undergo joint replacement surgery. Arthritic hips, knees, shoulders and occasionally, ankles are replaced with metal and plastic implants. Total hip replacements (THRs) constitute approximately half of these surgeries, allowing people who would otherwise be completely disabled by pain to resume full and active lives.
We are in the miraculous era of the Internet, the DVD, the CD player, the Cell Phone and the Palm Pilot. It is easy to take these technological advances for granted and to forget that they were all developed and made accessible within the last twenty years. Likewise, the first successful total hip replacement was not performed until the early 1960s. Fifty years ago, those who were afflicted by severe arthritis would have suffered relentless pain with no hope of effective treatment. In many instances, they would have spent the rest of their days in a wheelchair. Dr. Seth Leopold, of the Orthopedics and Sports Medicine Department at the University of Washington, considers the total hip replacement to be the most important operation developed in the 20th century, in terms of the amount of human suffering that it has relieved.
In April of 2003, I was one of 17,500 Canadians who required a total hip replacement. Many people have swift recoveries from hip surgery. The books that I read indicated that most people were able to dispense with their crutches about six to eight weeks after the operation, and that three months postoperatively, they felt relatively normal. This was not my experience nor was such a textbook recovery shared by all of the people that I interviewed.
I had a significant degree of pain and swelling in my leg that lingered for months after my THR. Although I was only 50 years old, which is young in the world of hip replacements, I needed to use a walker for more than ten weeks. I spent an additional eight weeks on a cane. Instead of feeling well three months after the surgery, my hip did not feel anywhere near normal until five or six months postoperatively. At first, I thought there was something wrong with me. I felt inadequate and worried that something had gone wrong with my operation because it took so long to regain my muscular strength, and the ability to walk again comfortably. Then I created this web site about my experience and began talking to other people who had had the surgery. I discovered that I was not alone. Not everyone had a speedy and painless recovery, although most people experienced considerably less pain than I did and regained mobility much faster; but several of those individuals required multiple joint replacements later on.
Some of my suffering was needless. I made many mistakes, which I would like to share with prospective hip patients, so that they can benefit from my errors. Unlike other surgeries, people cannot sit back, relax and let time heal the wound following hip surgery. They need to be active participants in their own rehabilitation. Information is power. If you are considering a hip replacement, the more you learn about the operation beforehand, the better off you will be.
This book is geared towards people who are wondering if they need a total hip replacement and to those who are waiting for hip surgery. It is also written for individuals who have already had their hips replaced, especially if they are under the age of 65. There is a strong likelihood that they will have to have additional hip surgery down the road since the average lifespan of an artificial joint is only 10 to 15 years.
GETTING HIP may serve as a useful tool for friends and relatives of people who are undergoing joint replacements. I offer a great deal of information about how I decided to have the surgery, what is involved in the preoperative exam, and the mechanics and history of the operation itself. In addition, I provide a detailed description of my own rehabilitation, from the time of the surgery to six months postoperatively, as well as advice on how to take care of a new artificial hip and a final chapter on the future of hip replacements.
Each patient is unique. An arthritic hip may be the only health issue facing some individuals whereas others, like me, may have additional medical problems. One person might have an extensive social support network, a large family or a supportive spouse, whereas another person might live alone and have very little assistance. One patient may recover quickly and effortlessly with minimal pain and another may experience a delayed recovery with quite a bit of discomfort. 55-year-old Ranny Welton of Mexico, Missouri drove himself to work one week after his hip replacement. He used a walker in the hospital, went home with a cane, and was walking without any assistive devices two weeks later! But 73-year-old Suzanne Carlos of Ottawa, Ontario spent months on a cane following her surgery. Age is not always the determining factor in recovery, either. After my surgery, the orthopedic nurses told me that sometimes patients in their eighties or nineties resume walking right away, yet someone in their forties or fifties may take much longer.
My own recovery did not occur until somewhere around the fifth or sixth month after surgery. The timetable for other people's recoveries varies. I have included interviews with ten people who have had hip surgery. Nine of these individuals had total hip replacements. One had a procedure called hip resurfacing, which results in fewer restrictions than total hip surgery, since the hip is reshaped rather than replaced. Most of the interviewees reside in the United States but two are living in Canada. One is in the United Kingdom and another is in Denmark. They range in age from 43 years old to 70 years young at the time of their THR, and most are quite satisfied with the results of their surgery.
Some people may think that the title of my book, GETTING HIP, is too facetious or lighthearted for such a serious subject. I have deliberately chosen an upbeat title because I believe that humor is an important component of the recovery process. There is nothing funny about hip replacements but I did have some amusing experiences during my rehabilitation. I have tried to laugh about these occasions and to share my comical moments, as well as my difficulties and frustrations.
I hope that this book will be read by members of the medical profession and by the staff that treat total hip patients, such as nurses, physiotherapists, occupational therapists, visiting home nurses, counselors, and home care workers. Often, in their day-to-day jobs, medical personnel are only able to spend brief amounts of time with their patients. They cannot grasp the extent to which a patient's life has been affected by the deterioration of an arthritic joint, and the difficulty that is involved in going through total hip surgery.
GETTING HIP is also directed at health care policy makers. The accident that caused my hip injury took place in New Jersey, which makes this an American story. But my surgery took place in Ontario so this is also a Canadian story. We have universal health care in Canada. When it works properly, our Medicare system is fantastic because everyone is insured. Health coverage is a right in this country, not a privilege. However our health care system is overburdened and under funded. Consequently, there are long waiting list to get in to see a specialist and even longer lists for surgery. I had to wait 18 months for my operation. This was in addition to the 18 months that it took to decide that I was going to have the joint replaced. That translated into three completely lost years for me.
The baby boomers are turning 50. As the population ages, the incidence of arthritis and the subsequent need for total hip replacements will increase. The Canadian Orthopaedic Association and the Canadian Arthritis Society have joined forces to warn the public of a "crisis in joint replacement surgery." Both organizations claim that there is not enough manpower to perform the surgeries and that people are waiting far too long. We need more orthopedic surgeons in Canada and we must learn to treat our nurses and physiotherapists with more respect and remuneration, so that these crucial medical people do not continue to emigrate south of the border. Surgeons need better access to operating rooms. We need more hospital beds so that orthopedists have a place to put their patients once they have scheduled operations. New advances in joint surgery are exciting, but they will be of limited usefulness if the Canadian national health care system cannot make this routine operation available to people in a timely fashion.
Waiting lists may not be an issue for Americans but insurance coverage is often a problem. 43 million Americans lack health insurance, according to CNN's medical authority, Dr. Sanjay Gupta. The uninsured tend to receive catastrophic care in the emergency room. They are less likely to receive preventative treatment. Medicaid, Medicare and Health Maintenance Organizations cover millions of other Americans. HMOs are notorious for creating delays in the approval of medical procedures, including hip replacement surgeries. Chris Warner is the owner of Panther Enterprises, a physician recruiting service in Long Beach, California. He says, “The morass of government programs and private insurance plans is bewildering, extremely convoluted, complex and very expensive: some say at a cost of two hundred billion dollars a year. Physician's offices are rampant with cascades of forms, paper, regulations, codes, manuals, phone calls, hair wringing and teeth gnashing as a direct result of this third party oversight, due to spending constraints by individuals and employers. As a result the basic fabric of our health care system is in grave jeopardy." Thus, Americans, Canadians and Britons, who also have a public health care system, all experience some type of frustration with access to joint replacement surgery.
Lastly, this book may be of interest to the dedicated people who campaign against drunk driving. I needed hip surgery before I turned 50 because I fractured and dislocated the joint at the age of 28 when I was hit and badly injured by a drunk driver. My hip became arthritic, eventually wore out and needed to be replaced. For many years, I was a member of Mothers against Drunk Driving and Remove Intoxicated Drivers. I appeared on three television shows about drunk driving including 20/20, 60 Minutes in Australia, and a Manhattan cable TV show entitled “Alcohol Abuse.” According to Mothers against Drunk Driving, in 2002, 17,419 people were killed in the U.S. in crashes involving alcohol, representing 41 percent of the 42,815 people killed in all traffic accidents. Fortunately, lobbying efforts have paid off and alcohol-related fatalities have decreased significantly since my accident in 1981. Injuries have also declined but still number about 500,000 each year in the United States alone. Even one serious injury can alter a person’s life forever.
Finally, I hope that I can convey my sense of awe for the science of joint replacement and my gratitude that I was born at a time when such impressive technology could relieve my suffering.
October 16, 2006
Chapter 1 of Getting Hip
My Hip Injury
I love summer. Like most captives of Northern Ontario, I eagerly anticipate the end of spring so that I can dispense with my ski jacket, boots, and headband in favor of shorts, T-shirts, and running shoes. I like to sit outside on my front steps listening to the robins sing, watching the neighbors, and basking in the warmth of the sun.
I spent a lot of time sitting on my front steps during the summer of 2000 until I became aware of a nagging pain in my left hip. I've always had to be careful about sitting in certain positions for long periods of time since I fractured and dislocated my hip in an auto accident in 1981. I was visiting my parents in New Jersey when I was hit by a drunk driver and nearly killed. I sustained multiple injuries including a concussion, whiplash, a punctured and collapsed lung, several broken ribs, and a number of broken bones, such as fractures of my hip, pelvis, wrist, arm, knee, and lower leg bones. After three weeks in intensive care, I was moved to the orthopedic ward. I developed Post-Traumatic Stress Disorder and suffered from panic attacks, recurrent nightmares about car crashes, and flashbacks for many years. I was 28 years old at the time and as the band R.E.M. so succinctly put it, the accident was the end of my world, as I knew it.
Initially, my hip was set with a closed reduction, meaning that my orthopedic surgeon put my hip back into place manually after it dislodged. However, the nurses in the hospital were busy and did not always answer call bells promptly. One day I was dying for a bedpan and decided that I simply could not wait 20 minutes for a nurse to appear, so I cleverly bent down towards a small cabinet by my bed to get the pan. I was very pleased with myself until I began to experience horrific pain. Sure enough, I had dislocated my hip again by twisting my body forward. This time the solution was not so easy!
My surgeon, whom I affectionately but brazenly called "Joey," told me that in order to repair my hip, he would have to put me in K-wire traction. This involved the surgeon and his team drilling a hole straight through my already broken knee to insert a wire from one side of the knee to the other. One Saturday morning, he appeared at my bedside looking like a carpenter with a full set of nasty looking tools wrapped around his waist. I had been given a local anesthetic but it did not put a dent in the searing pain I experienced. Nor could it assuage the extreme anxiety and distress that was prompted by watching my orthopedist drill a hole through my knee. When the brutal procedure finally ended, the doctor put 25 pounds of weight at the bottom of the wire, and placed me in a position that is called Trendelenberg.
Anyone who has been in this uncomfortable position knows that Trendelenberg was probably devised by the Nazis. It required me to lie backwards in bed with my legs tilted up towards the ceiling for five long weeks. I was only allowed to sit up for meals, sponge baths, and other ablutions. Like the ghost of Jacob Marley tormented by his chains, I felt the wire inside my knee every time I switched positions. This caused great discomfort. To say that I was relieved when the wire was removed would have been a gross understatement.
I was not a very good patient. Before the accident, I had completed one and a half years towards a two-year Masters in Social Work at the University of Toronto. I was enamored with Toronto and content with my life. I enjoyed my studies and commanded a certain degree of respect as a graduate student. That ended abruptly with the accident when I found myself bedridden, in constant pain, and sleep deprived.
During the three months that I spent in the hospital, I had eleven roommates and every one of them snored! I began to desperately crave sleep, which caused tension between my doctor and me. There were no private rooms on the orthopedic floor so I requested to be moved to a medical ward. My surgeon was opposed to this; he knew that I would not receive proper care on another floor since the nurses on the orthopedic ward were specially trained to deal with my particular injuries. In retrospect, I understand that the doctor was protecting me by keeping me on orthopedics, but at the time, I was unhappy about the chronic exhaustion that resulted from my sleepless state.
My injuries had rendered me completely dependent on other people. It was frustrating and embarrassing to continually ask others for assistance. I struggled against a sense of helplessness and anger as was evidenced by insisting on getting my own bedpan, and brashly calling the surgeon by his first name.
When I was discharged from the hospital, I went to stay with my parents in order to learn to walk again. Five days a week, a private ambulance took me for intensive physiotherapy throughout the winter and spring. On a daily basis, I did a number of exercises to strengthen the quadricep and hamstring muscles in my leg. I also worked on flexing and rotating my hip joint. Eventually, I progressed to lifting weights with my injured leg and working out on a stationary bicycle.
I was non-weight bearing on crutches for six months before I graduated to a cane. A year after the accident, I was walking without any assistive devices but I had a significant degree of pain in both my left hip and knee. When I got a second opinion on my hip in 1982, the surgeon looked at my x-ray and immediately suggested that I have the joint fused. Hip fusion, otherwise known as arthrodesis, eliminates pain in the hip joint but the joint no longer has a wide range of motion. This can present problems with certain activities like getting in and out of a car and may significantly strain the back and knees. I had no such desire to restrict my movements and continued diligently with my exercise program, which eventually paid off.
I spent many years lobbying against drunk driving after I discovered that the man who hit me had a blood-alcohol level of .23, which was more than twice the legal limit. The driver was doing 70 miles per hour in a 30 mile per hour zone and hit me head on. At the age of 37, he had a record of driving infractions that went back 19 years. His license had been suspended and revoked a number of times and he had been caught driving without a license. My "accident" was not an accident after all; the man was a reckless driver and a self-described alcoholic. Our collision could easily have been prevented if the State had stepped in earlier to permanently revoke his driving privileges. Even after my accident, the man's license was only suspended for one year before he was able to drive again, and he was never charged with causing me bodily harm. He received the same sentence for hurting me that he would have received for running a red light.
It took time for me to forgive the man who had hit me. As a member of Remove Intoxicated Drivers, I was offered an opportunity to appear on 20/20 and to be interviewed by John Stossel. The show, entitled "It's Not My Fault," was broadcast as a Christmas special on December 26, 1985. The driver also appeared on the program along with the owner of the local restaurant bar that served him. I successfully sued both the drunk driver and the bar under the Dram Shop Law, which held third parties responsible for serving too much alcohol to drivers.
Appearing on 20/20 and on 60 Minutes in Australia allowed me to meet the drunk driver in person and to forgive him for turning my life upside down. The man was contrite, remorseful, and apologetic. He had stopped drinking immediately after the accident and thanked me for his sobriety. He told me that he started out every day of his life with a prayer for my health and recovery. The bar owner did not take any responsibility for the accident. He was indignant and felt victimized by my lawsuit against his restaurant. I understood the owner's position. I have always been ambivalent about the host liability act. How can a bartender tell who has had too much to drink in a crowded nightclub? Ordinarily, this would be difficult, but in my case, the bar that I sued was a small family restaurant that only served alcohol to ten or twelve people at a time. The man who hit me drank there frequently and the restaurant knew him. With a blood-alcohol level of .23, surely the bartender would have noticed that this regular customer was intoxicated.
By 1983, I had settled my legal disputes out of court. However, my health problems lingered on. The pain in my hip and knee had decreased to a tolerable level but the fractures had caused osteoarthritis in both joints. Before the accident, I had lived in Toronto without a car. I loved to walk and would walk four to five miles a day. I also enjoyed ice skating and sitting cross-legged on the floor. After the accident, I could not risk falling on ice nor could I rotate my hip into that yoga-like position in order to sit cross-legged. Like most people with arthritis, I began to learn the frustration of living with some degree of pain and limitation.
In addition to the soreness in my hip, I developed chondromalacia, a condition that causes damage to the kneecap and results in pain and swelling. And I had torn ligaments and cartilage in my knee, which could not be repaired surgically. I could no longer kneel since putting weight on my knee caused acute discomfort. Nonetheless, I walked well and did not have a limp. I could walk one mile a day and that was adequate for my new suburban lifestyle. For many years, the pain in my joints was manageable and did not interfere appreciably with my life, unlike the fibromyalgia and Chronic Fatigue Syndrome that resulted from the accident. Muscle pain and exhaustion became my daily companions. I was never able to return to work or to finish graduate school in Toronto, despite several attempts to do so. Over the next decade and a half, I worked as a volunteer at various women's centers, was active in politics, wrote freelance articles, and acted as a research assistant at a local university whenever my health permitted.
THE DECLINE OF THE JOINT
During the summer of 2000, my hip joint began to bother me again. At first, I thought that I had simply put the hip into a bad position by spending so much time sitting on the front steps with both knees raised higher than my hips. I began to sit on a lawn chair but this did not relieve my pain, so my doctor referred me to physiotherapy. In September, my therapist and I began working on different exercises for my hip. One involved me lying on my back and bending my left knee towards my chest in order to improve my hip flexion. After doing this exercise for about two weeks, I put my back out and was unable to walk for three or four days. At the time, I did not realize how interconnected the hip and the back were. This was the first of many episodes where my back would completely collapse on me as a result of the degenerative arthritis in my hip. After my back healed several weeks later, I timidly resumed the exercises. Within days, I was unable to stand on my left leg due to sharp, stabbing pain in my hip. It was so acute that I spent three and a half hours being investigated in the emergency room of a local hospital.
The doctor examined my x-ray and exclaimed, "Looks like you need a hip replacement!" "No way!" I replied. I was convinced that he was wrong. My hip had served me well for almost 20 years. Even though I was told at the time of the accident that I would need to have the joint replaced eventually, I did not believe that the time had come. I was 47 years old. I was too young for a hip replacement! The joint had only started to bother me within the last few months and I thought that it had been sprained by the physiotherapy exercises. I was certain that it would recover.
Despite the severe deterioration evident on the x-ray of my hip taken in the hospital, and the fact that I could hardly bear any weight at all on my leg, I refused to accept the fact that I needed the hip replaced. As the saying goes, "Denial is more than a river in Egypt!" Disbelief and denial were my first reactions to the diagnosis and I held on to them for at least a year after the episode in the emergency room. The average life span of an artificial hip is only 10 to 15 years. I was afraid that if I had the procedure done in my forties, I would need to have at least two more joint replacements during my lifetime. However, I accepted the hospital’s painkillers and had them refer me to a rheumatologist and a surgeon, despite my skepticism about the diagnosis.
The appointment with the rheumatologist was arranged quickly. I saw her within five or six days of my emergency room visit. She concurred with the emergency room doctor that the joint needed to be replaced. I was given a prescription for Celebrex, an anti-inflammatory drug, which made me sick to my stomach. We had to bypass the first line of treatment with the NSAIDs (nonsteroidal anti-inflammatory drugs) like aspirin or Advil because reliance on the latter had given me fourth degree ulcers.
Initially, I dealt with the hip pain by being as inactive as I could. The less I moved, the less my hip hurt. I started doing all of my cooking sitting down on a chair. I would drag a chair from the kitchen table over to the stove or to the refrigerator, using it as my own portable wheelchair, because I could not stand up to cook for even five minutes. When I went out with my friends, I would have them drop me right at the door of a restaurant, so that I would only have to limp in on my cane for 20 to 30 feet. I would sit in the car outside of the grocery store, feeling guilty and useless while my mother or my friends did my shopping.
CONSULTING WITH THE FIRST SURGEON
I braced myself for a similar diagnosis from the orthopedic surgeon, whom I was finally able to see that November. The doctor surprised me. He was loquacious, which was unusual for a surgeon. He spent at least 30 to 40 minutes talking to me and asked me all kinds of questions. He then began to describe a doom and gloom scenario; he told lurid tales about everything that could go wrong during the hip surgery. I could get a blood clot that could travel to my lungs or my brain, and provoke a stroke or kill me. The new hip could dislocate. I could get an infection that would necessitate re-operating, with a chance that my hip joint would be so damaged that I would have to spend the rest of my life in a nursing home, confined to a wheelchair. I could have a heart attack on the operating table or the surgeon might accidentally break my leg during surgery. I found this conversation to be unduly frightening, and decided to research the likelihood of any of these events actually occurring to me.
POSSIBLE SURGICAL COMPLICATIONS
According to the American Academy of Orthopaedic Surgeons, more than 170,000 total hip replacements are performed each year in the United States. In the United Kingdom, patients receive more than 50,000 artificial hips annually. The Canadian Orthopaedic Foundation states that more than 37,500 hip and knee replacements are undertaken in Canada each year and the number is rising annually due to an aging population. Almost half of those are total hip replacements (THRs) and most of them are required as a result of advanced osteoarthritis, says Dr. Robert Bourne, professor of orthopedic surgery at the University of Western Ontario. Bourne is the director of the Canadian Joint Replacement Registry (CJRR,) a project set up in the summer of 2000 to monitor and track the number of hip and knee replacements in Canada. "About 2.5 percent of the entire population or 1 in 40 Canadians will have a hip or knee replacement at some point,” Bourne claims.
Worldwide, approximately 500,000 hip replacements, also known as arthroplasties, are conducted every year. For the most part, joint replacements are very successful and dramatically improve the quality of life for the recipients. Like any major surgery, there are risks. There is a risk of blood clot or infection following a total hip replacement but every precaution is taken to reduce the incidence of these complications. Patients are given large doses of intravenous antibiotics to prevent infection, operating rooms are especially designed to filter out bacteria, and sterile techniques are employed. If the prospective hip patient has any kind of infection, from bacteria in the urinary tract to the common cold, the surgery will not be performed. Most sources agree that the chance of contracting an infection following total hip replacement is somewhere around 1 percent.
Deep vein thrombosis (DVT) is the most common cardiovascular complication following a hip replacement. This is when blood clots form in the deep veins of the legs. The American Academy of Orthopaedic Surgeons states that 80 percent of orthopedic surgical patients would be likely to develop DVT, and 10 percent would be likely to develop a pulmonary embolism if preventive treatment were not provided. Preventive treatment consists of providing postoperative patients with anticoagulants and anti-embolism stockings, called TEDs. Even with these prophylactic measures, deep vein thrombosis and subsequent pulmonary embolism remain the most common cause for emergency readmission and death following joint replacement, the American Academy notes.
Certain people are at greater risk of developing a thrombosis. People who smoke, are overweight, are on estrogen or who have had a history of previous DVTs are more likely to develop a blood clot following hip surgery. Other people are genetically predisposed towards blood clots. Studies show that the use of a spinal rather than a general anesthesia may reduce the likelihood of a DVT by up to 50 percent.
3.6 percent of patients will experience a potentially fatal pulmonary embolism, according to Dr. Richard Villar, British orthopedic surgeon, and author of the book Hip Replacement: a Patient's Guide to Surgery and Recovery. That is why Coumadin, an anticoagulant, is routinely given to patients along with shots of heparin to make their blood thinner. Many doctors require hip patients to wear TED stockings, which reduce swelling. They are encouraged to get up within 24 to 48 hours of the surgery to get their circulation moving in order to avoid a blood clot.
Villar states that the risk of death from a total hip replacement or THR is about 1 percent, but the development of these complications depends on many factors, such as age, general state of health, and surgical expertise. If patients are over the age of 80, Villar claims that up to 20 percent of them will experience some form of postoperative problems. The risk of developing complications also rises significantly during hip replacement revisions. Problems are less likely to occur during the primary hip replacement.
Another potential risk of the total hip replacement is that one leg may be longer than the other following surgery. This happened to Ryle Miller, a retired engineer from Vermont, who had both a hip and a knee replaced. He was able to correct this unfortunate problem by building up the soles of his shoes. The book Hip and Knee Replacement: a Patient’s Guide was co-authored by Miller and his orthopedic surgeon, Geoffrey McCullen. Miller was a veteran who was traveling through Europe in 1971 when his knee went out on him. At the age of 48, he was diagnosed with rheumatoid arthritis and went through a grueling series of gold shots and treatment with cortisone pills. Miller attained dramatic but short-lived relief with this regimen. After he discontinued the gold shots, his old symptoms of fatigue, painful muscles, and morning stiffness returned. He struggled with these until 1987 when he twisted his left knee snowshoeing. Miller then tried injections of cortisone, oral anti-inflammatories, and a knee brace. He even had a knee arthroscopy to prevent the need for joint replacement, to no avail.
An arthroscopy is a way of looking inside the knee or hip joint via fiber optics to assess the status of the joint. Sometimes, pieces of tissue, bone or bits of cartilage and ligaments can be repaired via arthroscopy. But it is not a valuable technique for treating severe arthritis because of the extensive joint deterioration involved. Miller did not find relief from pain until he received a total knee replacement in March of 1989. He felt reasonably well afterwards until he was diagnosed with Parkinson's disease. Parkinson's interfered with Miller’s balance and made him unsteady on his feet; he took a fall while working in his backyard. He fell 30 feet, broke his pelvis and injured his hip, necessitating a total hip replacement and a 17-day stay in the hospital. Miller had more than his share of joint replacements, which is not uncommon for someone whose joints have been damaged by rheumatoid arthritis.
In terms of my own hip dilemma, I knew that the surgeon I saw had to protect himself legally. He would not have wanted me to sue him if I developed an infection or a blood clot, and had not been forewarned. I am sure that he was a good doctor but I did not feel reassured by his manner. Since I was already opposed to the operation, the surgeon's alarmism strengthened my fear and denial. Although he did offer to operate on me, he did so reluctantly. It was clear that he wanted me to spend several more years on painkillers and a cane before I considered a THR.
PREVENTING HIP SURGERY
That was fine with me. About six weeks after my trip to the emergency room, the screaming pain began to abate and I became a bit more mobile. I began to read everything I could on ways to prevent hip surgery. I had already tried physiotherapy, ice packs, moist heat, aspirin cream, ultrasound, glucosamine and chondroitin sulfate and Celebrex. Carrying additional weight is a strain on an arthritic joint. Luckily, I am on the slim side so I did not have to lose weight to take pressure off the injured joint. I had been living in shock absorbing running shoes for some time, which reduced the impact of walking on the hip joint. And I had severely curtailed my weight bearing activities, such as walking, climbing stairs, and standing for any length of time. I decided to forego massage, chiropractic, homeopathy, and acupuncture because they were too expensive and had not worked for me in the past. Lastly, my arthritis was much too advanced for an arthroscopy.
Instead, I started swimming twice a week and following the program set out by Dr. Robert Klapper and Lynda Huey in their excellent book Heal your Hips: How to Prevent Hip Surgery — and What to Do if You Need It. This instructive manual advocates a program of specific exercises to strengthen and restore mobility to the hip joint. The exercises are to be done ten minutes per day on land and ten minutes per day in the swimming pool. Klapper warns against repeated use of cortisone shots, which can damage the joint. This is an informative and sensible book that may work well for people whose joints have not deteriorated significantly. All of my hopes for the aquatic cure vanished one day when I got stuck at the pool because I could no longer get my socks and shoes back on after swimming. I had no choice but to ask the woman next to me for help. I began to understand why James Dean said, "Live fast, die young, and leave a good-looking corpse." Yes, and preferably one whose joints functioned! If this was middle age, I needed to investigate cryogenics.
The pool episode left me feeling discouraged but it helped to break my cycle of denial. There was no doubt in my mind after the incident that I was going to need the joint replaced. The question became when I would have it done and with whom. Although I had booked surgery with the first surgeon I saw, I decided that I would not be comfortable with him operating on me, so I cancelled my surgical date and began to look for another orthopod.
GETTING A SECOND OPINION
Specialists are busy people. They do not have vast amounts of time to spend with patients. However, I wanted to find a doctor who would provide me with a reasonable amount of time, answer my questions, and alleviate my concerns about the effect of the surgery on my other health problems. I am a consumer of medicine and have every right to shop around for a good doctor.
When I was young, I was full of admiration for physicians. My late father was a medical doctor. Those were the days of Marcus Welby, M.D. and Ben Casey. Doctors were held in such high regard that they were seen as almost mythical creatures. There is an old joke about a Jewish mother whose son was elected President of the United States. A friend turned to the woman during the inaugural ceremony and said, "Oh, but you must be so proud!" The mother replied, "Yes, but you should see his brother. He’s a doctor!"
Nowadays, doctors are not necessarily held in high esteem. In my 23 years as a career patient since the car accident, I have dealt with dozens of doctors and have seen an abundance of their shortcomings. Many were abrupt, arrogant, and presumptuous. Others were well intentioned but quick to jump to diagnostic conclusions without taking a proper history. They did not listen well. Specialists, in particular, were notorious for their haste and lack of empathy.
A 2002 study conducted by Fuschia Sirois and Mary Gick of Carleton University in Ottawa, Ontario examined the beliefs and motivations of patients who sought out alternative medicine practitioners. Sirois and Gick concluded that the individuals who were most likely to choose an alternative or complementary practitioner were people who had multiple health problems, greater awareness of health behaviors and predictably, dissatisfaction with conventional medicine. Unpublished findings from the same study indicated that many patients who abandoned traditional medicine complained that their doctors had failed to take the time to listen to them. In order to make a proper diagnosis, it is crucial for doctors to hear their patients. Some participants in this research project compared their medical visits to being on "a conveyor belt," or to being moved through the office "like cattle," an experience that I can certainly relate to.
Most of the doctors that I saw during the 1980s and 1990s did not spend enough time with me. As a result, they misdiagnosed my problems. Physicians routinely dismissed my multiplicity of physical complaints as nothing more than depression. I believe that there is a bias against patients with chronic health problems. Often, the size of my medical file alone would lead a doctor to conclude that I was a hypochondriac. In addition, although I do not see sexism lurking behind every dark corner, I do suspect that my health problems would have been treated more seriously if I had been male.
In fact, a study from the Toronto Rehab Center indicates that women in high socioeconomic brackets have less access to joint replacement surgery than do men of a similar income bracket. Toronto Rehab is an organization that specializes in rehabilitating people who have had joint replacements. This research, published by Dr. Gillian Hawker and co-developed by Dr. Jack Williams, revealed that people communicate differently with their doctors according to their gender. Women are the greatest consumers of health care. The 8th annual ACNielsen study of consumer health-related attitudes and behavior found that women are more likely than men to visit a doctor, consult with a pharmacist, and take vitamins and/or minerals. Men, on the other hand, are more likely to "tough it out" when they experience medical symptoms. Women are more verbal about their bodily ailments whereas men are apt to be more stoical. If women complain more often than men do, doctors may perceive women's health problems as being less serious than men's physical challenges.
It took many years for me to assemble a team of doctors whom I felt were bright, compassionate and on target with my health. Now I have a group of physicians whom I like, admire, and respect. My family doctor is a kindhearted and intelligent soul, who always takes the time to listen to me and to be thorough. I wanted to find an orthopedic surgeon with similar qualities. Having a hip replacement is not like having a gallbladder removed. I will remain in close contact with my surgeon for some time and will continue to see him or her many years after the operation. I wanted someone who was highly skilled and would give me the facts about the operation without terrifying me.
A friend of my mother's had just had her hip replaced by a prominent surgeon at a local hospital. I called her and asked a number of questions about her doctor. I spoke to other people who had had hip replacements and asked how they felt about their surgeons. I decided to book an appointment with the surgeon who had operated on my mother's friend to see if I liked him. A doctor at my neighborhood clinic made the referral and I waited several months for a consultation.
The doctor was bright, warm and had a twinkle in his Irish eyes. After viewing my x-rays, he immediately agreed to do a THR and apologized for the length of his waiting list, which was 12 months long. He informed me of all of the potential risks of the surgery but unlike the earlier surgeon, this man did not overwhelm me. He assured me that the procedure was routine and generally successful — some studies estimate that the probability of patient satisfaction following a primary total hip replacement is as high as 90 percent — and he did not seem to have a problem operating on someone who was under the age of 50. I was impressed with his reputation and his bedside manner. The surgeon had performed numerous hip replacements and had a specially designated orthopedic floor in his hospital, as well as a short-term rehabilitation unit. I felt comfortable with him and knew that I could work with him.
During our interview, I told the surgeon how much my hip was affecting my daily activities and my mood. I added that hip pain and restrictions on my range of motion in the joint were preventing me from having intercourse. The surgeon seemed surprised by this and assured me that most of his patients were able to maintain a reasonable sex life. I was hard-pressed to imagine just who these gymnasts could be. Were these the same little people in his waiting room who could not walk a city block, were bent over their walkers and canes, and were popping Advils just to get through the day? Was there a Kama Sutra that I had yet to discover for the arthritically challenged? Sex was only one of many activities that were no longer possible for me as my hip continued to deteriorate. Walking, standing, bending, and lying down were all extremely painful. Shopping, cooking and doing laundry were very difficult; recreational pursuits were impossible. The more pain that I experienced, the more I limited my activities, which resulted in boredom and depression.
