I need a new what?

An informational page by Warren Montgomery

Please note -- the information here is not intended as medical advice.  You should always follow the instructions from trained medical professionals who know your case.

During 2009 and 2010 I went through the pain of a worn out hip joint, several treatments with varying effectiveness, and ultimately a replacement.  Now in rehab following replacement there are some things I didn't find in any of the quick guides to the procedure that I consulted before going down this route and wish I had known in advance so as to better plan my recovery.  This short note describes some of the key challenges and hopefully will be of some use to others considering the procedure.

You need a new hip -- but you are too young.

These days we are constantly given messages that we don't get enough excercise and that you can never get too much.  Even with exercise though Americans aren't getting any lighter, and the combination of lots of exercise bearing lots of weight on your joints takes its toll.  In late 2008 I began to experience some pain in my left hip.  I was no stranger to joint problems, having had more than my share of strains and sprains and even arthroscopic surgery to deal with a cartiledge tear in a knee.  No big deal I thought as I went to tell my doctor at my next checkup in early 2009.  He took an X-ray and sent me to an orthopoedist saying he thought it was arthritis but I should let the expert determine that.  The orthopedist took one look, winced, and said "You need a new hip, but you are too young."  I was just short of 58 at the time and indeed, hip replacement to me always called to mind someone near 80 walking poorly with a cane -- not me.  His advice was to try to get by for a while because the implants don't last forever and replacing a bad one is much more difficult than replacing your natural hip.  I went away and continued my normal activities -- lots of golf walking and carrying a bag, but the condition got steadily worse and I developed a signficant limp.  I just couldn't walk normally up hill or even on a side hill with with my left side higher.  I couldn't swing my left leg in and out of a car without helping it along a bit.  Meanwhile Tom Watson, only a year or two older than I was, nearly won the British Open on a new hip.  Maybe I wasn't really too young after all.  I went back to my regular doctor for a routine visit and he suggested some anti-anflamitory drugs.  That might have helped a bit, but not a whole lot.  Things got worse and worse as 2009 wore on, and I decided to get a second opinion, this time checking around for the best surgeon in town.  He told me the same thing, but that I wasn't necessarily too young because most of the longeivity records for implants comes from those used 20 years ago, and they are a lot better now.  Good to know, but I still wanted to wait a bit.  We tried Cortisone, which he said probably wouldn't help much but might by me some time.   It helped a bit for a while, and I limped into 2010

2010 was another year full of walking golf and various other athletic pursuits. The pain caught up with me as I went, at first making it impossible for me to walk 36 holes, then driving me to stop carrying the bag even for 18.  I'd tow a pull cart, which wasn't a lot easier, but at least put no more weight on the faulty joint.    By late 2010 I was usually only managing 9 holes on my feet before putting my bag on a riding cart, and I was miserable.  In addition, I dreaded walking in crowded public areas because I'd wobble as I walked and couldn't stay out of the way, and more limber folks would rush around me, causing me to get off balance trying to avoid them.  My golfing freinds didn't want to play with me any more -- watching me struggle was just too painful (more painful it seemed to them than it was to me, as my gyrations mainly managed to avoid too much pain on the course.)  I was ready for surgery.

Getting ready.

There's a bunch of things that they will tell you if you decide to have surgery, and a lot of other information out there.  I knew to expect to have  about 6 weeks of limited activity with some limits to the range of motion while I progressed from a walker to a cane to normal walking.  I knew there would be a period I couldn't drive, and a longer period I couldn't get on an airplane.  In prepration I did several things that I think worked out well:
  1. If you can, plan surgery for a time when it won't be a problem not to travel, and when it won't be inconvenient for a spouse or a roommate to give you a lot of help.  Not being able to drive is a big limitation in suburbia.
  2. Do all the periodic household chores you can so they won't need doing for 6 weeks after surgery.  This is especially true of anything that requires climbing or getting on the floor, both of which will be difficult for a while.  My timing was pretty good here in getting all the fall chores done.
  3. Keep up whatever exercise you can.  This one nobody told me, but it just makes sense.  Rehab addresses two problems: a) the damage done by the surgery itself, and b) the atrophy of muscles caused by years of favoring that side.  The latter is likely to be a big issue for a lot of people who had limited mobility before surgery.
  4. Get your house in order for rehab.  We didn't do as well here.  While we knew what the general mobility issues would be, we didn't know how to translate that into specifics, and how much they effect you will depend on your house and your body shape.  We were in good shape with the house layout (one floor, no stairs and plenty of room to maneuver), but hadn't realized that my body was a bit unusual in dimensions which made the mobility restricitions more difficult to cope with.

What I wished I knew and should have done.

Basically what I wished I knew was how to translate tthe motion limits  into specifics of how I would need to adapt.  You will be told over and over again the basic restrictions after hip surgery:  Don't bend that hip past 90 degrees, don't cross that leg over the other one, and don't turn that leg inwards.  Unfortunately that doesn't tell you immediately what activities become hard, and it's not always easy to work out.  To do that I suggest beffore surgery you sit down someplace where you can get your lower legs 90 degrees to the floor and your upper legs roughly parallel to it and measure from the floor to the bottom of your leg.  That distance determines how easy it will be to sit down, get up, and use the bathroom.  If you have relatively short legs, this won't be much of an issue, but if you have "basketball player legs", even if you aren't that tall overall, it's going to be more challenging.  Here are some specific issues:

Your furniture

Start by measuring the height of the pieces of furniture you use.  Anything that's less than your floor to bottom of leg measurement will be tough to use after surgery.  The reason is obvious.  You can't sit down or get up with your back straight and keep that joint less than 90 degrees.  While you can finesse this a bit by leaning back and getting up and down on your "good" leg, it's not going to be as comfortable for you.  You may be able to adapt furniture by adding pillows or putting legs on blocks, but be careful because pillows tend to flatten and blocks can easily become unstable.  Raising a chair may create other problems, like the fact that a table you use it with is now too low to use without bending forward (and more than 90 degrees.)  You need a plan for what pieces of furniture you will use during your first few weeks of recovery and make sure that is adequate.  While you are at it, practice getting up and down on those pieces without going past 90 degrees.  I found that actually 90 degrees wasn't as limiting as I thought (i.e. I could usually get up and down normally without violating that limit, but on a low seat you have to do it by sticking your "bad" leg out, leaning back, and going up and down on your "good" leg.  If your good leg isn't strong enough, build it up until it is.

The bathroom. 

Bathrooms deserve some special attention because you will need to use the facilities after surgery and can't easily bypass that.  Information given you will talk about raised seats, grab bars, and other accessibility features, but there are a couple of specifics that will determine exactly what kinds of adaptations you really need.

Clothing/Dressing

Here's another area where you might have surprises.  The 90 degreee rule means you won't be able to get at the lower part of your operated leg or foot.  that means trouble pulling on socks, getting into and out of pants, putting on and taking off shoes, and especially tieing shoes.  They will probably give you a simple kit of tools for most of this stuff, if not it's readily available:
The one thing these tools won't solve is tieing shoes.  For that you need a live in partner, or shoes that don't need to be tied.  I suggest you have at least one pair of the latter good for all uses.  (low rise shoes are much easier than boots here).  You can also get elastic laces which allow you to slip shoes on or off without untieing, but these are a bit tricky -- if tight enough they constrict the shoe so much you can't easily get it on and too lose and the shoes slip on you.  You may also be able to get casual shoes on and off with a shoehorn without fully untieing them.  Again, practice it if you can. 

Shoes raise another issue.  When they replace a hip they make that leg just a little longer than it was before.  Not much -- 1/4 inch or less. This is partly because before surgery you wore out the cartiledge on that side and lost about that amount of effective leg length, but mainly because they want to insure that your muscles will hold the joint tight enough that it won't dislocate.  That extra length may or may not be real noticeable to you.  (I suspect it depends in part on the shape of your other hip -- if it's "normal", the extra length will just balance you, but if it's worn down as well it will make you a little unbalanced).  You may find that to balance more naturally you need to add a little height to your other leg by putting an insert in the shoe.  Since I was already using heel/arch supports in my shoes due to past bouts with Plantar Fasciaitis, this wasn't a problem for me -- I just used the inserts on my "good" leg only (which probably not coincidentally also was the one I had the heel/arch problems on most often in the first place, with my left side worn out I was working the right side harder).  If you don't have something like this, try buying some cheap arch supports to try it with.  Your doctor may send you for custom orthotics to help here too, and that's likely to be a better fit, but it will also be a lot more expensive and you will probably want several sets to cover various pairs of shoes.

The other key clothing need is loose fitting pants.  This is no problem for some, but when I approached surgery I had nothing elastic.  A last minute sale purchase by my wife gave me something to come home from the hospital in that I lived in for some time.  The issue here is not only the incision itself, which will protrude and rub on tighter pants, but that after surgery your legs will swell (some or a lot) after exercise and you need room to expand.

More than anything, look at where you store your clothing.  Things you can't reach (because they are in under-bed chests or bottom drawers) might as well not be there for a while at least so make sure the stuff you will actually use is accessible.

Your car.

First of all -- you did remember to get any required maintenance done and fill it with gas before surgery right?  Hard to find a full service station anywhere but New Jersey and Oregon these days, and while you should be able to fill it yourself if you have to why make things hard.  (Less of a problem if your spouse/partner is used to doing this, but in many households one person does most of the gas buying and the spouse may not  be anxious to learn).

You will be a passenger for a while, so make sure the passenger side is accessible (i.e. get rid of all the accumulated junk in the car.)  The "floor to leg" measurement is very likely too low to sit easily so you will need some maneuvering.  What works for most is putting the seat back and reclined, then standing on your "good" leg with the operated leg extended duck your head into the car and sit lying back, then swing your feet in bending the knees.  If I can do it in a Honda Accord I expect most people will be able to handle this, though right after surgery you may not be able to bend enough.  Having a solid handle above the passenger seat also helps (most newer cars have this), but you need to determine the best places to grab.  Practicing this maneuver helps.  One special concern -- make sure your driver is very careful closing doors.  Early on you will have a cane or walker to be stowed by your driver in the back seat, and it's tempting just to shut the door while you are still adjusting where you sit.  The danger is that the post dividing the front and back doors is a very convenient grab point and a dangerous place for fingers when you shut the door!

A big issue with the car is where you park it.  After surgery  the doctor can give you a form for a temporary "handicapped" sticker to let you use those spaces.  I didn't think I would need that because I was walking pretty well within 2 days, but I had neglected one issue -- you need room on the passenger side to execute the "duck and slide" maneuver, so my wife went back for the sticker.  Have your driver park places where nobody can park on the passenger side and there is room for this.  Curbs can be a real challenge.  Basically if the car is against a curb on the passenger side, the curb height reduces your clearnace in "duck and slide", so avoid them if you possibly can.  Garages are also a challenge, because you probably can't open the door wide.  You may need help getting the car in/out of the garage even after you recover a bit if it's very tight, or you might just be able to move enough stuff stored in the garage to give youself a little extra room to get in on the drivers side.

Healing

Getting out of the hospital is only the start of what's a fairly long process.  To put those replacement parts in there the surgeon cut through a lot of muscle, removed some bone, and moved all those pieces around, then sewed it all together to patch you up. Recovering from all of that damage can take a long time.  They will tell you about 6 weeks, but it varies, and in particular with all that disturbance your leg will probably swell up a bit, and you will almost certainly have some pain, both things that could go on a long time.

The incision itself will heal over in a 10 days or so and they will take out the top layer of sutures or staples, but there is a lot more going on underneath as the muscles heal up.  One thing that you need to be very aware of is the potential for infection.  You do not want to get any bacteria into the joint itself.  This requires serious intervention to eliminate, and as my surgeon put it -- there are no real good outcomes when that happens.  They will give you some precautions (e.g. no dental work or othe surgery for 3 months, and after that you take an antibiotic before anything like that to knock out the bacteria), and tell you to monitor the incision, since the incision site is one of the easier routes for bacteria to get in.  Pay real close attention to that and call if it's not healing properly or seems infected.  It's not fun if they have to open it up and put you through another course of antibiotics, but by catching it early you avoid the even less fun prospect of having to cure a serious infection in the joint.  Above all keep that area clean and avoid things that will irritate it until everthing is solidly healed.  You may also want to make some wardwrobe adjustments while it heals.  If the seams on underwear or pants fall on the incision you may want to try another type, at least for a while, and you probably want to avoid carrying anything in pockets in that area just to avoid sources of friction against the scar. 

Rehab

Everyone will tell you this, but it really needs to sink in -- your new hip is only as good as the muscles that move it, and they are only as good as the condition you put them into.  Rehab is how you do that.  You can rehab in several ways:
Doing your "homework" is easier if you have a live in partner to help.  Make sure he or she goes to the rehab clinic with you (probably will since you can't drive yet) to get the routine down pat.  A partner is very helpful not just for "spotting" (standing ready to keep you from getting into bad positions), but also counting and timing, leaving you to focus on doing the work.  What you will most likely need in terms of equipment is mainly just a flat surface you can get onto and lie on and pillows.  The bed works fine for most (particularly if you have a firm matress, but you probably need a plastic sheet to put over it because some exercises involve sliding your feet and that's not easy on normal bedding.  Pillows for your head are fine, but you will also need something stiff enough to raise your leg or your knees about  9 inches.  The foam wedge they will likely use on you to keep your feet apart after surgery works here but the shape isn't ideal. 

You may need other equipment in time (e.g. squeeze balls, weights, elastic cords), but don't worry too much, the rehab people can get that stuff for you.)

Walker?  Cane?

Coming out of surgery they will put you in a walker.  Don't let the image of the little old lady in the grocery store get to you, it's solid support and will let you go a lot farther than you can on your own, which helps a lot.  Going home from the hospital you will need your own.  You can buy one from the hospital but you can also buy your own independently.  Which is better financially depends on your insurance.  This stuff isn't cheap (around $200) but it's useful.  After a week or two you will be ready for less support and can use a cane.  Again you can buy this in advance, or you can decide just to skip this stage (with permission from your doctor and/or therapist) and use the walker until you can manage without support.  How fast this happens probably depends on how you were walking before surgery.  In my case I was walking pretty well, and 10 days after surgery decided to try to let my wife carry the walker the rest of the way on our exercise walk, and having no particular difficulty I never went back to it.  If you were using a support before surgery it will probably take a lot longer to get off one afterwards.

With both a walker and a cane, you will likely learn new hazards in your house.  After a short time you will likely want to push your walker continuously and try to walk more or less normally.  This is fine, but walkers catch on everything:  Thresholds, edges of carpeting, stuff left on the floor, etc.  Keep the floor clear and make sure you have walker width alleys to reach everything you need.

Getting out.

If things are healing well there's no reason you can't start going to stores, work, or social occasions a week or so after leaving the hospital.  Again, seating is likely to be your big challenge -- you won't want to stand the whole time, and will need a "high" seat with room to maneuver your legs a bit getting up and down.  If you are going to a party it might be worth making the host aware of the potential issues.  We found that telephone directories or other thick books can be used to boost you a bit in a low chair, and given warning a host can try to keep a chair open for you.  Theaters and auditoriums are another challenge.  Attending a couple of concerts locally, I was lucky to know that the venue had 2 rows which were extra wide and planned to sit there.  Guess what --  Older people with mobility issues know this too and often a big part of the audience at certain kinds of concerts (e.g. Classical, Jazz, christmas music, etc.)  Get there early to make sure you can get a seat.

The big problem in stores is likely just to be the crowds.  Keep in mind it's good practice, but you may get a little intimidated, especially if you were limited before surgery and had to work to stay out of the way.

Getting back to Normal

All of this becomes less and less of a problem over time.  Depending on your condition and what kind of artificial joint they put in you will probably be able to get back to being able to bend far enough to touch your feet and get into and out of most furniture.  In fact you may find yourself having been too well trained to avoid bending your hip that you are too conservative.  Check with your surgeon on what's appropriate and start slowly, but do take advantage of all the motion the new joint will give you to get back to a more normal lifestyle.  One thing to find out is just how careful you need to be about the mobility restrictions.  In my case I was told that my joint would allow more or less normal movement with no more possibility of dislocation than a natural hip.  The only thing I need to be careful of is extreme bends with pressure on the joint.  that's good -- I can tie shoes, use low seats, and do everything else more or less normally (though I still don't cross my legs.) 

Walk a lot, and take every opportunity to exercise your new joint going up and down stairs (i.e. don't revert to stepping up only with your other leg.  I found I was much more capable walking, playing golf, climbing stairs, and just about anything else within 3 months of surgery, though I still felt some stiffness and muscle soreness for long after that.

Airline travel is another adventure.  With an artificial joint you won't get through a metal detector without setting it off.  The doctor can give you a card explaining your condition, but they will still need to scan you.  The newer X-ray scanners in some airports are actually a boon to anyone with a joint replacement because they can see it and usually won't require any special screening, but if not, expect to get stopped and get a full pat down whether or not you have an explanation.  It's no big deal really, it just takes an extra 5 minutes at the checkpoint. 

Travel can present some other challenges if you still have restrictions on bending your hip -- low seats, awkward seating on public transport, unfamiliar cars, etc.  If you are concerned, consider booking a "Handicapped Accessible" room -- most places will let you do this for no charge or stipulation.  Such rooms usually have higher toilets wider doorways, and extra places to grip, useful if you are feeling at all dubious about your ability to navigate in a strange room. 

Mostly though expect to return to your normal activities and feel better at them than you have in years.  When I first spoke to the physical therapist planning my rehab he asked me what my goal was.  Thinking a little I said I wanted to be able to play 36 holes of golf walking and carrying a bag (10-12 miles of walking), something I had done regularly before experiencing trouble.  He said that would be no problem.  I was of course dubious, but after finishing rehab and asking my doctor I've gone back to walking and carrying and 4 months after surgery can already easily walk 18, something I hadn't been able to do in almost a year.  At about 5 months, I played my first 36 hole day.  It wore me out and made me remember all the other joints that were failing, but no pain or problems with the replacement, and once I get the muscles built up I predict it won't even leave me sore the next day.

In the year since my surgery, I probably played about 200 rounds of golf, mostly walking.  I hiked mountain trails in several western states, flew a dozen times, and stayed in dozens of hotels.  I can now move normally and have no problems with low seats or cars.  (Check with your surgeon before going past 90 degrees, but in my case they told me my joint would support normal motion, and as near as I can tell it gives me at least as large a range of motion as my original hip).  I can still sometimes tell that there's somthing different about the left hip (a little stiffness), and I still have a scar that is can be irritated if I wear something that rubs on that side, but otherwise I'm better than new.  About the only time I worry at all about my joint is approaching a security checkpoint.  Again, the newer X-ray based units work great for this if that's an option, but many airports don't have then and when they do they are frequently out of service.  At US airports if you can't use the X-ray you get a pat down, not awful, but awkward, and once I was asked to go into a private screening area and strip to my underwear (probably the inexperience of the screener rather than anything about me).  Curiously I had no real problems in Europe, where in 2011 at least they were still using wands to scan those who failed the metal detector and had no real concern about me. 

Postscript -- hip 2.

When I first saw the orthopedist in 2009, he said my right hip was bad too, so it wasn't unexpected when I started to experience some stiffness and a bit of pain on the right side in 2013.  It wasn't a big deal, but I could feel it.  Then in late fall, after a cold round of golf on a difficult course to walk, It was worse, and 2 days later after flying to Denver I could hardly walk -- in fact I couldn't stand for long, even putting no weight on the right side.  When I got to the orthopedist 2 weeks later it was a little better, but not normal.  He told me the hip was worse than before, but still nowhere near as bad as the left had been when he first saw it and suggested my acute problem was probably a carteledge tear that would fade over time.  He said it would probably still respond to Cortizone.  I decided to wait on that until golf season next year.

I did stop carrying a golf bag and eventually got my own pull cart but continued to walk as much as I could in 2014.  At first I could go 36, with some pain, but quickly dropped back to at most 18 walking in a day, and by late summer was down to 9 at a time.   I tried the Cortisone just before two volunteer weeks in which I was scheduled to do a lot of walking.  It was great -- for 3 days.  Oops -- that was supposed to last 3 months.  By the last day of my assignment as a walking scorer for the BMW championship I limped so bad that my committee chair shadowed me on  the last 9 to be ready to take over if I couldn't finish.  I finished, and immediately called in saying it was time to replace the right side.

Second time around. 

Since my first hip surgery, my surgeon had organized a "best practices program at the local hospital.  It involves a pre-surgery class for the patient plus an in-hospital rehab program that starts the day of your surgery, as well as the adoption of many new practices in their work and your preperation.  The result has been shorter hospitalization, faster recovery, and fewer complications.  I followed the program, and knew coming out of recovery it made a difference.   My post surgical recovery was a lot better this time, probably reflecting a difference in anethesia (last time I was sick and on a liquid diet for a day, not so this time).  My leg was less swollen, and when they got me up on the second day I fullfilled the walking requirement for release before I ever got to the rehab class.  Rehab in hospital went well and I went home the same day, only one overnight in the Hospiatal vs 3 the last time.  Trust me, the fewer days you spend in the Hospital, the better.  It's not that they aren't wonderfully attentive, but you will sleep better at home, and every doctor will tell you you are better off with your own germs than someone else's.

I did rehab at the same place as last time, and even was evaluated by the same therapist.  This time I was clearly more capable than last.  I progressed rapidly in exercises and reps for the first week.  For one thing, I could immediately raise my operated leg, something that took 6-8 weeks to accomplish last time.  One thing I'm sure helped was pushing myself all I could to keep usiing all the muscles in the bad leg, something I didn't do last year.  It hurts, but gettin back to normal more quickly is well worth the pain.  All wasn't smooth though -- after a week something snapped and I had extreme pain trying to raise the leg.  Some rest and muscle massage therapy cured that one.  As before I lost the walker in about 10 days, and was walking miles in 3-4 weeks.  At 3-1/2 weeks though, after a 2 mile walk, I fell.  I droped face down on my knees and hands after tripping on a twig or pine cone on the sidewalk less than 100 yards from home.  Nothing seemed broken, and indeed it wasn't, but it was a reminder to remain vigilant. 

No infections this time.  Maybe my change in underwear to "boxer briefs", which extended below the incision helped, or maybe all the washing in anticeptic cleaner helped as well, but I healed normally.  After 6 weeks I graduated from rehab, though continued daily at-home exercises.  I rapidly passed onther milestones -- getting up and down from our lowest furniture, driving, getting up and down from the floor easily, etc.  Now, at about 2 months out I'm certainly better than I was for the past year, and in shape to know I'll be able to fullfill my planned assignments as a walking scorer for the US Open and Senior Open in 4 months, as well as have a normal year of activities.  The new program clearly lead to more rapid recovery, and I'm sure less risk of complications.  I know dozens of people now with at least one joint replacement, and feel lucky to have had an excellent surgeon, hospital, and rehab program to speed my own recovery.



Warren Montgomery (wamontgomery@ieee.org)