Elisabeth’s Story

Shortly after turning 43, I caught sight of my reflection in a big store front window, as I walked across a parking lot. I was having a “good hip day” and felt that my posture was straight, and my limp probably not noticeable. So I was stunned to see myself bent forward and tipped to one side, lurching along with a pronounced limp.

I mulled over my discovery and decided I should probably start looking for a new orthopedist. I had moved household since my last x-rays, six years before, and my orthopedist had died. In our last conversation, he had said there was nothing he could do for me till I was bad enough for a hip replacement-which at least spared me the need to consider surgery. He advised: “Do whatever you need to do, to get around.” He also found that my “good” hip showed a developmental anomaly on lateral view-a slightly peaked socket and a femoral head flattened on the backside. I was limping on that hip, at the time-fortunately, due to a flare-up that resolved in a few weeks.

Since last seeing my orthopedist, I had resorted to crutches on a few occasions and popped some ibuprofen; but I knew from experience that anti-inflammatories soon lost their effect with daily dosing. Mostly, I just put up with the feeling of rats gnawing inside my hip and kept modifying my activities.

Now, I had a scary thought: “If I consult a surgeon, I need to be ready to accept a surgical solution.” My prior experience with hip surgery was dismal-an operation at age 20 to scrape out and graft a bone cyst in my femoral head. The cyst, along with a “loose body” of cartilage jamming the joint, had developed from a disorder that started when I was 14-osteochondritis dissecans. But it was missed on x-ray, several times (MRI hadn’t been invented, yet). Both hips gave me trouble at age 14, with intermittent stabbing groin pains that made me yelp and collapse. The left got better, the right worse.

Highlights of that salvage surgery included two weeks in the hospital, 10 days in traction, five months on crutches, and a limp that continued for a year, till I found my way to a physical therapist. I also received a 12” incision, lousy post-operative pain control on widely spaced doses of morphine (which also made me itch frantically); and I developed a miserable bladder infection with three varieties of hospital-strength germs.

My hip was not “cured,” but my worst symptoms vanished for about ten years. After full recovery, I was able to walk three miles comfortably, although my hip often ached afterward. My range diminished to one mile by age 35 and kept declining.

By 43, I often thought twice about walking across the living room. I had been dealing with hip pain, to some extent, for nearly 30 years, and I was good at compensating-really good. But I was starting to feel boxed in and despondent, as my pain and limitations kept intensifying. My husband and six-year-old daughter complained about my short temper (which I conveniently dismissed as their touchiness).

Daily life taxed my endurance. I went through contortions to get dressed, use the toilet, sit at the table, and heave myself into and out of the car. I was fidgety with pain while sitting and had to lie down after being on my feet in the kitchen for 20 minutes. I could barely ride my bicycle anymore, even with the seat and handlebars raised precariously, and with a pedal extender in place to accommodate my toeing out. My husband and I kept having the same conversation, over and over: He would ask: “So, where do you want to go on vacation this year?” I would answer: “Someplace where I won’t have to walk.” And our marital intimacy was sorely affected. I decided to go ahead and consult my internist. He referred me to a local orthopedist.

I saw the orthopedist once and declined x-rays, asking instead for a prescription for physical therapy. I suppose I was stalling. He seemed to think it was a dumb idea but acquiesced, asking me to return in four months. I did so and gave what I thought was a good report: “I think the PT has helped me limp more effectively.” I was taken aback to see him scrawl “no improvement” on my chart. This time, I agreed to x-rays.

He came breezing in with them in his hand about 20 minutes later. “The good news is, your left hip is essentially unchanged,” he announced. He jammed the films into the light box and continued: “The bad news is, your right hip is significantly worse-as you can see, there is a marked deterioration since your last set of films.” My jaw dropped as I gazed at something resembling a rusted-out medieval mace. He turned around and faced me: “We can go ahead and replace this, anytime you’re ready.”

My heart jumped. I think I managed to blurt: “You’re kidding!” And suddenly I thought: “Hot damn! I can finally unload this worthless chunk of bone!” I had the presence of mind to ask how long a fake hip might last. He looked me up and down and said flatly: “Fifteen to 20 years.” I remember saying: “Wow, that’s pretty good. That’s better than I thought!”

I left elated. I got home and babbled the news to my husband. To my surprise, he was horrified and protested that, surely, I couldn’t be so badly off that I required surgery. I got mad. Then I started getting fearful.

I remembered my prior surgery and my heart sank. I considered how quickly, in retrospect, those intervening twenty-three years had passed. I quailed at the prospect of a third operation after the 15-20 years the new surgeon had just predicted. I began to question the idea of having a foreign object implanted in my body. I wondered what risks the surgeon might not have told me about.

I spent the next full year obsessively researching my options and trying to reconcile my elation and terror. I found many Internet sites and read mountains of contradictory information. I read medical journals. I read about competing implant materials and designs. I read about dread complications, such as infection and dislocation. I posted daily on an Internet bulletin board and spoke to several patients on the phone.

I returned to the new surgeon, who urged me to have the surgery within the year, or risk damaging my hip socket beyond easy repair. I got a second opinion with a surgeon who denied any urgency. I got a third opinion that agreed with the second-but the third surgeon thought I should wait for ceramic bearings to get FDA approval, because of my age. I paid out of pocket to consult a fourth surgeon, who championed all-metal bearings.

I consulted my internist, who said: “You should wait. Techniques and implants improve every year. You’re too young for hip replacement.” I protested: “But it hurts all the time! How long am I supposed to wait? The surgeon said I’m ready.” He said: “Surgeons always want to operate. Just wait. Wait another year, at least.” I left his office feeling frustrated and in turmoil.

I resumed my reading. I spoke to a few more surgeons by phone and got more perplexed. A few times, I got so worked up that I awoke in the middle of the night and threw up.

Meanwhile, my hip kept getting worse. By this time, I was using crutches for most outdoor walking and taking drugs more often. My hip already had a tendency to lock up on me, but the locking became increasingly painful and hard to release.

One evening, I went to rise from the toilet, and my hip locked up with pain so excruciating that it took my breath away. My husband and daughter came running when I let out a scream, but there was nothing they could do-particularly because I barked: “Don’t touch me! Don’t talk to me!” I could neither sit back down nor straighten up.

Eventually, my husband managed to slip my new elevated toilet seat under me, as a perch. (I should have been using it, to begin with.) He had to work around me to get our daughter ready for bed, and she wailed for me the entire time. She wailed herself to sleep, because I couldn’t come tuck her in. I was still perched on the elevated toilet seat, clinging to the wall-with my pants still down, despite my husband’s gingerly attempt to pull them up for me. The way I was crouched, he couldn’t get them over my knees.

The episode went on for nearly three hours-two hours and forty-five minutes. My husband went back to his computer and paid me visits every so often. I had lots of time to think. I thought: “If I already had a fake hip, and it had dislocated, we could call 911 and get help. An orthopedist would meet us at the hospital and put my hip back in place for me. But as it is, I’m just stuck here.” I decided that even a mediocre result from hip replacement would have to be better than my current situation.

After awhile, my husband returned to check on me again. He knelt at my side and asked how I was holding up. By way of cutting the tension, I quipped: “So, do you think I should get my hip replaced?” I expected him to burst out laughing at the absurdity of the question. I almost did-except that I didn’t dare jar my hip. But he only looked more worried and said he didn’t know.

I was astonished that he still had any doubt. Suddenly, I realized I had made my decision. In my mind, I was already signing on the dotted line.

Dr. Todd Swanson was my fifth consultation-not counting four other surgeons with whom I spoke by telephone about some general concerns. I found my way to him from three converging directions-my interest in ceramic bearings, in the Zweymüller stem, and in minimally invasive surgery.

I was attracted by the long-term European record for alumina ceramic bearings, which reportedly are associated with a very low incidence of osteolytic bone loss in younger patients. I had read an interview with Dr. Karl Zweymüller and was intrigued by his design rationale for his hip stem. At the same time, my husband was passing along messages to me, from his parents and two friends in Austria: They had consulted their personal doctors on my behalf and urged me to get the Zweymüller stem. I was touched by an awkwardly phrased message from one friend, who wrote in English: “At your age, you cannot afford to make anything less than what is perfect.”

Finally, I had come across Dr. Swanson’s website and read the brief description of his surgical technique posted at that time. An incision of three to four inches and a six-week recovery seemed too good to be true. I dismissed it as a gimmick, something to attract stars in Las Vegas show biz. But I didn’t forget it.

After a lot of work, I traced the Zweymüller stem to Plus Orthopedics in San Diego and telephoned. I learned that ceramic bearings were compatible with the stem and would soon be available. A company representative gave me a short list of surgeons who used the implant. Swanson’s name rang a bell-the guy with the small-incision gimmick!

I posted the list of surgeons on an Internet bulletin board. As it happened, a patient from Las Vegas posted a reply and announced her intent to make an appointment. A few weeks later, she reported back and raved about Dr. Swanson-his patience with her many questions, his thoughtful and detailed answers, his gentle approach and good humor. I decided to write to him and found, to my delight, that he also answered his own e-mail.

Meanwhile, the patient in Las Vegas booked surgery with Dr. Swanson. She sent me a digital film clip of herself at three weeks post-op. She was zooming around her house with just a cane, only a trace of a limp remaining. Suddenly, my husband was sold on the idea. We huddled in front of my computer and played the clip over and over, amazed.

I booked a flight for my family. We trooped into the examining room together. Collectively, we tested Dr. Swanson’s patience and quizzed him on his knowledge of competing implants, experience with his minimally invasive technique (500 patients, at that time), experience with all-ceramic bearings (50 patients, as I recall), experience with revision hips (since my hip already had surgical scarring), and ability to guess children’s ages (his only low score-he pegged my petite daughter at two years younger).

We flew back to California the same day. Shortly afterward, I booked my surgery date, got off the phone, and did a little dance of joy like a lame chicken, flapping around my living room. Ever since then, my stock answer to patients who ask me: “How do you know when it’s time for hip replacement?” is: “When booking surgery on a sunny Friday afternoon seems like a fun thing to do.”

In my perception, my surgery took about two seconds. One second, the anesthesiologist was chatting with me; the next, a large warm hand was holding my limp cold one, and a voice was booming: “Elisabeth? This is Dr. Swanson. Your surgery went beautifully!”

Many times during my recovery, I recalled the words of a patient who had reassured me: “Look, hip replacement is not that bad. I’ve had dental work that was worse.” Having had two difficult wisdom tooth extractions and couple of root canals, I agree. My recovery went like clockwork, despite my weepiness on my third post-op day. My pain control was superb-nothing like what I’d been dreading based on my first surgery. My hip extension was already better on my second post-op day than it had been for ten years.

I was ecstatic. I flew home alone at one week post-op and followed my precautions to the letter. I wore my surgical stockings, did my exercises, took increasingly long walks, rested in bed, and ate red meat and green veggies as prescribed (kindly supplied by my husband). By three weeks, I no longer needed even a cane indoors. By six weeks, I was using a cane outdoors only for walks of more than half a mile. I abandoned the cane two weeks later, when I was walking up to a mile at a time.

Learning how to walk smoothly again took many months and lots of physical therapy. The hardest thing was learning how to stand straight, and what that should feel like. The first time I got the hang of using good posture, I burst out laughing to feel how pleasant it was. Within the hour, I had forgotten how to achieve it. My therapist taught me again.

Now, I can walk as far as my biologic hip permits-up to four miles. I can squat and sit “Indian style” on the floor. I ride my bike with pleasure and sometimes bike my daughter home from school on our tandem. She used to beg to bike more often, and I felt guilty; now she pouts that she wants to ride in the car, and I laugh at her. When she’s not annoyed at me for being her slave driver, she admits I’m nicer since my hip replacement. My husband agrees (sometimes).

My only lingering problem since my hip replacement has been hip flexor pain and weakness, along the path of my prior surgical scarring. Symptoms have included sharp groin pain with sneezing or hard coughing and a poor ability to lift my knee. Flexor strengthening exercises helped a bit, to a point-then seemed to make the problem worse.

At 1.5 years post-op, my follow-up surgeon in California diagnosed chronic psoas tendonitis and prescribed physical therapy with an emphasis on abductor strengthening and stretching and avoidance of flexor strengthening. My therapist found that my butt was so tight from years of limited motion that my hip was being pulled into external rotation, stressing the psoas tendon. I started a regimen of specific stretches (which were remarkably unpleasant, at first), along with side-lying leg lifts and “bridging” exercises to strengthen my abdomen and lower back.

As of this writing, exactly one week before my second post-op anniversary, my hip is better than ever. I’ve been merrily sneezing without pain (I’ve got allergies), my ability to walk on rough terrain and sand is vastly improved, and I can lift my knee enough to climb stairs and hills without hitching my pelvis. My fake hip behaved beautifully on a recent family vacation-better than my natural hip, and better than my feet, which got tired. I walked miles. I kept feeling surges of gratitude to Dr. Swanson and my therapist.

In preparing for this vacation, I retrieved an old packing list from my last vacation before hip replacement. It included the item “gimp sticks,” meaning my forearm crutches. I felt a huge smile spread across my face, as I picked up a pen and crossed it out.

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