Naomi Rabinowitz: My Right Hip!
Almost exactly four years after my left hip THR, I am back to write the saga of my right hip replacement.
Some things about the surgery are the same:
Same hospital: Hospital for Special Surgery (HSS) May 25, 2007
Same surgeon: Douglas Padgett, MD
Same style prosthesis: Zimmer metal/ metal with "longevity" cross-linked poly liner
But there are major differences about my experience this time around.
I waited way too long to have my first surgery. By the time I scheduled the surgery I could hardly walk without pain and my leg would crumble under me or lock-up when I stood after sitting. This time I started to pursue surgical options much earlier. As soon as I saw the "handwriting on the wall" in the autumn of 2006 I began to plan my next surgery. I would say that it was at least a year earlier than the first go around, possibly two. My primary symptoms were stiffness in the joint, decreased range of motion, increased back pain, the need for daily NSAIDs and weekly massage therapy just to feel "OK".
At first I thought I would have a hip resurfacing since the FDA had just approved that procedure in May 2006. There was a lot of excitment in the press and I was under the impression that it would be beneficial to an active person like myself. I was attracted to the idea that I could get back to my yoga sooner and not have to go through the period of hip restrictions to prevent dislocation in the post-op period. One of the problems I encountered at that point, just six months after the FDA decision, was that not too many surgeons had experience with the surgery in the USA. I consulted two surgeons who did resurfacing who both agreed that I was an excellent candidate for the procedure and the time was right. The one I saw in April had actually done more than 200 resurfacing procedures by then. However I became leery as I learned more about it.
Here are some of the reasons I did not have a resurfacing:
Length of surgery - more that three hours is typical since the femur head has to be fully dissected.
Extent of surgery- the femoral head is not "just capped" it is extensively shaved quite like getting a dental crown - the underlying tissue is hugely changed, the amount of muscle dissection is extensive causing lots of local trauma with possible scarring and healing issues. Plus the sciatic nerve can be damaged (up to 5% of cases) resulting in foot drop.
There is also a chance of fracturing the femoral neck in the OR which would result in an immediate THR.
Type of prosthesis: The only available option is metal on metal - no liner. The good news touted about that is that the femoral cap can be very large. The bad news is two-fold: the cap must be cemented on which adds another factor to the risk equation and more troubling, there has been found to be shedding of metal ions into the blood in metal/metal hip couplings. While the literature on this problem to date, primarily from Europe where there is much more experience with resurfacing, does not show a link to serious illness, m/m coupling is not recommended for people with current or potential kidney problems (like people with diabetes who may develop problems in the future) and the chances for problems in the far future are unknown.
Finally, the claim is if you will need a THR in the future, you can still have one, but what about the quality of the tissue?
I have spoken with many dancers and athletes who are extremely happy with the outcome of their hip resurfacing - some of those stories are to be found on this website. And I am sure that the procedure and the prosthetic choices will improve with time. However, I found the negatives too daunting for the present.
For a lively rebuttal, please read Ruth Ziegler's story.
So at that juncture I thought, I had such a good result with my first surgery, why switch?
When I finally saw Douglas Padgett this time around to plan my next THR, we discussed resurfacing. Dr. Padgett strongly feels that resurfacing is essentially a hip replacement, but with many troubling issues. In retrospect I am sorry that the exploration of resurfacing delayed my getting surgery sooner since my hip rapidly deteriorated during those months, but I am glad that the information I gathered along the way helped me to make the right decision. In fairness too, I have to say that I had a lot of personal issues I needed to attend to before I could set aside the time for the surgery and the post-operative recovery.
Happily, while all the attention is on resurfacing, things have also progressed in the THR world. My new "Turbo Hip" (as my friend Robin Staff calls it) has a significantly bigger ball. My left ball is 28 mm, and the new one is a full 8 mm bigger at 36 mm. What that means for me is that the chances of dislocation are very small (like the resurfacing) and that the range of motion can be very large. In fact, Dr. Padgett tried to dislocate the hip in the OR and was not able to. It also means that the period of time that one is on hip precautions is reduced to ~4 weeks. The exercises post-op are much accelerated (making the number "4" with the operated leg is introduced the second week, not the fourth). Another minor but helpful development -showering without protecting the staples in the first 10 days!
I also benefited from the lessons of my previous surgery. I was very nauseous and had low blood pressure the day after my first surgery and was not able to get out of bed. I learned those symptoms were from the epidural and, in particular, the narcotic introduced through the epidural catheter. So I requested, and got, much less narcotic in the epidural. I did have low blood pressure on day one this time, but not as low, and I was able to stand and walk with the physical therapist and did not puke! I did not take any narcotics by mouth post-operatively and have managed the pain with Celebrex (NSAID) and Tylenol.
While at HSS I participated in a controlled study being conducted in centers across the country to explore options for avoiding dangerous blood clots after joint replacement surgery. The study will compare pharmaceutical control using agents like Coumadin, to mechanical compression. I was in the compression group and very begrudgingly I wore compression sleeves around my calves and a battery pack around my neck for 12 days (24/7). At the end of that time I had an ultrasound study to see if there were any clots (none were found). I was reluctant to be in the study since when I went home after the first surgery all I took was aspirin, but I am aware that at other institutions six weeks of Coumadin is customary and that requires monitoring with blood test twice a week.
My hospital course was uneventful and I went home on the fifth day using a cane. This is also different from other institutions where six weeks on crutches is required. After a few days at home I did not use the cane while indoors.
Btw, I recommend being at HSS on Memorial Day weekend since the hospital is pretty empty and I had a room for myself - and the coveted water view.
I am staying with my mother in NYC since I did not want to fly soon after surgery, I wanted to do physical therapy in NYC, be able to get regular acupuncture (thanks to Kymberly Kelly of Turning Point Acupuncture) to be able to see Dr. Padgett for my four week post-op x-ray and consultation - and my home in Colorado has a lot of stairs! Especially for the first two weeks, I think the post-THR patient needs to have someone who can help at home at least part of the day.
Today is day #19.
I have more post-operative complaints than last time around. I think because the ball is so significantly bigger and there is much more tightness in the joint. That translates into two symptoms of concern: I have more pain (manageable with Celebrex twice daily, though I do not sleep that well) and more worrisome, I experience that my legs are not the same length. In fact, the physical therapist (Jo Smith at Westside Dance PT- a wonderful practitioner!) had to put a partial lift in my shoe so that I would not walk like a peg-legged pirate! When I saw Dr. Padgett to remove the staples on day 12 he measured my legs and reassured me that they are indeed the same length and that in time the muscles, particularly the ITB ((iliotibial band), will accommodate the new, bigger prosthesis.
A few days ago I had tea with my former boyfriend who had seen me through the first surgery. He said that I had the same complaint about the leg length the first time around as well. I had no recollection of this, and I did not write about it, so I am grateful to him for reminding me.
June 13, 2007
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Quick update: I was taken off hip restrictions at 3 1/2 weeks and did not need a cane, cushion, or any special assistance to fly home to Colorado by myself. My hip is still very stiff and uncomfortable -- and the lengths still uneven. By measurement they are barely 2mm different, so time and physical therapy will make the difference.
June 23, 2007
Four months: My new hip is still pretty tight, but I am finally able to sit cross-legged if I sit on a bolster in yoga. As a result of the muscles still holding on so tightly, my legs are still not the same length yet, and my walk is a little funny. Frankly the situation does get me discouraged. However, Dr. Padgett assured me at my last visit that the leg length will ultimately be very close. My trial is being patient. I have discomfort when I am at the extreme of my range of motion and still take Celebrex, a anti-inflammatory medication. I have stopped wearing a heel lift, but if I walk for long distances I do get back pain related to the length issue.
When I returned to Colorado on week #5 I started pool therapy in the 94 degree pool in the local hospital. I also started riding the stationary bike as ordered by Dr. Padgett. I have had regular massages to help release the muscles around my hip and increase my range of motion - including massage in the water (called Watsu), which is deeply relaxing.
I have been back in yoga since the 8-week mark. By now I am able to do quite a lot of a level two Iyengar class. It is quite strange to have two hip replacements and to be figuring out how to do the asanas, particularly in this early healing time period. Actually the hardest thing to do is stand in Mountain Pose (Tadasana) with my feet together because of the leg length difference. The action of bringing my feet together causes a lot of pressure on the outside of my new hip. I am getting through the standing poses fairly well as long as I can use some props. When I do Half-Moon pose (Ardha Chandrasana) I use the support of the trestler, or I put my extended leg along the wall or the foot against the wall since I find that I don't feel very secure rotating my standing hip open for the pose. While I can only approximate any of the rotated standing poses, I can stand for a long time in tree pose and even do Extended Hand to Big Toe Pose (Utthita Hasta Padangusthasana). I can do all the inverted asanas (although I need a "help-up" in handstand) and can do the back-bending poses of Level two. All and all I am pleased with what I can do, and I feel the great benefit of my yoga practice.
I will see Dr. Padgett in a couple of weeks and will update this page then.
September 19, 2007
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One Year Anniversary RTHR:
It was been much harder to adjust to this hip than my first one in 2003.
My biggest issue with my new THR from the start is that my legs seem uneven. In the early months after my surgery, when I stood with my legs together, I would be standing on my new hip leg exclusively and my other leg did not reach the floor. Dr. Padgett measured my legs and assured me that they were nearly even. However, functionally that was not my experience. My gait was very odd and I habitually stood in a lopsided manner - with my weight on the shorter side and longer leg extended.
I conscientiously did my PT exercises, massage, chiropractic, acupuncture and regular Iyengar yoga and I improved slowly, but not dramatically. At six months I no longer needed to take any anti-inflammatory medication for my hip discomfort. I was able to stand with my feet together with both feet on the ground, but I felt tremendous pressure on the outside on my new hip. I did all my yoga with my legs hip-width apart. My gait was such that I avoided walking when at all possible. Additionally, I grew a painful keloid scar at the surgery site and had to have it injected with steroids. I was quite discouraged.
At the eighth month point I consulted the famed dance physical therapist, Marika Molnar in NYC. I was faced with the dilemma as to whether I would always have legs that were uneven -- and that it was time to get lifts in my shoes and get on with my life, or whether some further real progress could still be made.
Marika was very reassuring, noting some pelvic rotation that certainly contributed to my sense that my legs were more uneven than they actually were. In addition, since I had also had a serious abdominal surgery 5 months after my THR, she felt that I might have some internal pelvic issues, (adhesions, etc.) that were impacting my hip function. She did some visceral manipulation work and suggested a recovery plan going forward that included pursuing more visceral manipulation back home in Colorado, followed by some serious deep tissue work, and finally gait re-training.
Marika also made the wise comment that any progress is progress - and I appreciated her pointing that out since my disappointment with not having the outcome I wanted, in the time-frame I expected, had certainly soured my outlook.
So back home these last few months I have had a series of visceral manipulation work with Monica Chase, PT, followed currently with weekly deep tissue massage with Louise Sexton, CMT, and gait re-training with Norman Allard, DO. Norman has noted that my pelvis still has rotation and has taught me how to use pelvic wedges to block myself daily. I think this blocking has been very helpful, along with some spinal mobilizing exercises that he has recommended that are Feldenkrais-based.
I am not wearing a lift in my shoe. I am still improving and I am optimistic that the therapies I am pursuing now are the last piece in a full recovery.
On the good side, I have more range of motion with my new right hip - easily getting my leg above 90 degrees, and it is much more stable. My left hip has good range of motion, but not as high an extension. The problem with the older hip is that it has a smaller ball that "clunks" and moves alarmingly in the socket if I do too deep a forward bend over the legs. Currently this happens at least once a week. I try to counteract the displacement by being very cautious doing these movements and consciously engage the muscles that support the hip joint before, during and after the bend. It was primarily because of this play in the prosthesis that Dr. Padgett chose the bigger ball for my second hip. We are both concerned that the abnormal motion of the ball slipping in the socket could lead to quicker deterioration.
I do Iyengar yoga regularly and lately have begun teaching yoga at the Iyengar Yoga Center in Boulder under the supervision on my major teacher, Laura Allard. I am very open about my hip surgeries and hope to be a power of example to students working with disabilities. That said, no one can tell that I have had hip replacements and are amazed when they find out.
Written May 25, 2008 Longmont, CO
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UPDATE May 17, 2011 Longmont, CO
Just a short note to say that, much to my surprise, I continue to improve. A patient of mine who is a physical therapist noted some stiffness in my gait and suggested I do some dry needling (trigger point stimulation) to get some of my hip muscles to fire better. I went to see her and she did the needling (not pleasant!) and also re-initiated my doing some strengthening exercises, like the clam-shell, that I had been neglecting. I was able to notice improvement after just a few weeks, especially in my ability not to shift off my standing leg in yoga poses like tree pose.
I have recently updated the yoga page to talk about my facility in yoga practice. The short of it is that I can do a lot.
Click here to visit the Yoga page (03/11)
Click here to read My Left Hip. (07/03)
Click here to read my follow up report at one year post-surgery. (07/04)
Click here to read my follow up report at two years post-surgery. (07/05)
Click here to read my follow up report at three years post-surgery. (06/06)
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