Wednesday, January 31, 2018

Paul gets a new hip!

What's new with Paul?

I haven't posted since the Oakland Marathon....which was quite a few  months ago .....and the reason is that I have been dealing with my right hip.

At the end of the Oakland marathon I noticed my right hip seemed pretty stiff. In retrospect I realized that some other feelings I was having earlier in the year (on and off) were probably due to it wearing out. I've always had a very turned out right foot, in fact I did a post about it in 2009 called "just ducky".  

In 2011 or so, my massage therapist...being very frustrated at my lack of flexibility in my right hip, suggested I get some X-rays and make sure things are ok. I did so, and the observation was: your hip is messed up and you are down to 1-2 mm of cartilage in the abnormal (right) hip. 

Being only 56, it was not going to last,  and that "I'd be back".  

It seemed congenital turnout (hip socket slightly rotated back on my pelvis at birth) was causing higher wear than normal and running was going to accelerate that, but I decided to gamble and not worry about it. 

The analogy is driving a car with a badly aligned tire that doesn't track straight wears faster. My front and back swing was not what a rotated back socket wants, and so the wear is high.

After Oakland my leg felt better for a time. but around August it really started to hurt: X-rays confirmed I was done with my wonky hip. After interviewing some orthopedic doctors at my HMO, I scheduled a hip replacement for Nov 1st.

Note: My last decent run was in early August.

Ok, let's get a THR!

Meanwhile, online I discovered that hip replacements have come a long way, and there are thousands of runners continuing to run on them, some with BOTH hips replaced. 

I decided to get a so-called THR: total hip replacement. There is also something called a 'hip resurfacing' but this is usually done on people that really want to best range of motion (e.g. rock climbers, dancers, etc). The disadvantage of the resurfacing is that eventually you need to get a THR when it wears out. 

I don't need range of motion, but the next question is 'What kind of device'? It turns out that really the primary problem with hip replacements is wear, and this concern therefore tied to how old you are, i.e. how much longer do you think you are going to live?... much do you plan to use use that new hip?

This is a big issue for people with birth defects like hip dysplasia (shallow hip socket) that can wear out at very young ages: 20s and 30's even. If they get a replacement they ideally need it to last the rest of their lives.

In the early days of THR, the devices were metal on metal bearings, these had the problem that wear was high and the metal particles from the wear built up in the soft tissues and messed them up after 10-15 years.

Then they developed ceramic coatings: they have extremely low wear  but a problem is that in an accident the ceramic coating can shatter. The shards from this are impossible to remove cleanly. 

My doctor recommended the current preferred state of the art: "COP" or Ceramic on Polyethylene. The plastic is not just any plastic: it's a highly crosslinked version that is tough as nails. The plastic has really low wear but still has some 'give' in an accident and has the huge advance of being replaceable! 

If the total high replacement operation is defined to be a "10" in degree of recovery I'm told that to replace the plastic bearing is only a "2". This is wonderful for younger people that need the THR for many decades.

What's it like to have your hip wear out?

Literally, it's a pain. Real pain. Every time you need to move the bad leg (in and out of bed, putting on a sock, getting in/out of a car) it hurts. As you get really get down to bone on bone, it hurts all the time even without being moved.

Initially, you can't sleep on your bad side, and then eventually it hurts even on your back. The doctors are willing to give you opioids so you can sleep and this is better than nothing, but the drugs really don't allow for good dream-state sleeping, and they mess with your digestion. 

It's pretty horrible, frankly.  But the good news is that after the hip replacement, all that pain is GONE. Instantly. Yes, you have the wound pain from the operation (more on that below) but the hip itself no longer hurts.

One effect of having been through this is that when I see somebody walking... I can tell if they have a worn out hip. Older folks rocking side to side as they walk are a dead giveaway. I know they are hurting and need a new hip (or sometimes two).

What does an implant look like?

Here's an X-ray of my implant. There are two main parts: the part that goes in your hip and the part that goes inside your femur. 

The latter part has a spear that goes down inside your femur and replaces the 'femoral neck' i.e. the ball you used to have with the new ceramic ball.

The metal of the 'spear' going down into the leg bone has zillions of tiny nooks and crannies in it's called 'bone loving' metal 8)

Your femur grows into this metal and fuses with it. 

The upper part of the implant is the 'cup' or 'socket', it also has the plastic bearing locked into it (not possible to see details on the X-Ray)  The back of the metal cup is also bone-loving but to keep things solid for the first few weeks after the operation it has a couple of screws.

These screws become unneeded after your body fuses with implant, but they can't be removed and aren't harmful it seems so they stay there.  You do need to be careful for the first 6 weeks after the operation to not do moves with your leg that could pull the cup part out of your hip.  (This are called 'hip restrictions') 

After that the bone should be grown in pretty well.  Before I was allowed to start running my doctor asked me to wait another 6 weeks for more bone growth (total of 12 weeks)

Note: if you are older they may cement your implant in as bone growth may take too long to happen (or never happen). If you not very active the cement will do you just fine.

What's it like to get a total hip replacement operation?

There are two methods: anterior and posterior (from the front of the leg, or the back). The anterior approach is what I had and has faster recovery (doesn't involve cutting major muscles in the butt). Some doctors have not learned the anterior approach and are still doing posterior.

My operation took about 1.5 hours: I was given a spinal to cut off pain and also a narcotic to keep me knocked out while they did their thing. Basically, I just magically woke up in recovery and realized it was over! 

After my spinal wore off they had me stand up with a walker and just see how everything felt.  The incision was covered with a super nice humongous band-aid looking thing...the cut is about 6-7" long and the upper quad of my leg was fairly swollen and numb.

I was given IV painkillers (basically Tylenol and some opioids) and this made it really easy to sleep the first night. Which is good because basically people are waking you up all the time to check on your meds...and being able to go back to sleep in 30 seconds is excellent ;)

The next day I started PT...this was learning how to use crutches...walking up and down the hall, going over a list of some exercises to do, etc. I went home later the same day.  

I ended up buying a cheap cane at Walgreens on the way home and never used the crutches, and only used the cane intermittently for a few days.

Note: Its helps if you are younger and/or you are athletic  before you get a THR. Basically  the more surplus muscle you have,  the better off you will be during the recovery. For example, you will have a hard time getting up from a toilet because your operative leg can't bend very well right away: you have to extend it out in front if you. This makes getting up hard. I was still quite strong in my other leg and could press myself up with it..I only needed a light touch on the wall to steady myself. 

Being strong you can keep to the hip restrictions more easily: e.g. if I dropped something I could just kneel down on my good leg to reach it and then press back up. (Bending over would be bad)

The first week was the roughest: I took opioids for the pain and they had all the same downsides I mentioned before, but you really need them. I was able to gradually reduce the amount of them I needed each night (didn't need them during the day) and after a week I was DONE! 

The swelling and tenderness of the stitches require some care: you have to tape plastic over them if you want to shower. Your leg will feel 'hot' to the touch for quite a few days as things get over the trauma.

I went to work (by bus) a week after the op..for only a half day and then resumed my normal schedule.

Gradually the swelling went down and after two weeks my leg was strong enough that I was given the ok to drive. (If you get the left hip done and have an automatic car you would not have any problem driving right away)

During all this time your leg is 'recalibrating' ...basically everything has changed in there and so the particular nerve firings are a bit 'off': you can move and walk but you feel a bit clumsy in your operative leg.

This gradually fades way after 12 weeks I did my first run on the treadmill and it was ok. But they do say it takes up to a year before your leg really feels totally back to being your 'original' in strength and coordination and general feeling. Obviously athletes have a big advantage here.   

PT for the total hip replacement

After the surgery I was given some PT in the hospital, and for the first couple weeks I had a couple of visits by a PT and an OT (Occupational therapist). Mostly they looked around for dangerous stuff you might hurt yourself with at home and also provided more exercises to work on. 

I started going to the gym 4-5 times a week and gradually got my cardio back on the elliptical and stationary bike. I did the self PT for a while but after I got the hip restrictions lifted I signed up for a set of 8 once-a-week calibrations with a PT at my HMO.

These sessions are immensely valuable and bring back range of motion and strength. They take about 15-20 minutes 5 days a week to do. 

How do doctors feel about running with THRs?

It's a problem for doctors: they don't really have enough study data on wear to make blanket statements. Recently, a very small number studies coming out showing very low rates of wear for runners with the latest devices. 

My doctor says that I'm old enough that even running on my implant I will not need to have the bearing replaced and he says my left (normal) hip will be fine too. I will be getting check ups every now and then and the wear can be measured off the X-ray. I can compare the wear numbers with my activity (miles of high-impact sports) over that period and see how it goes and plan based on that.

I do intend to to do more of my hard interval work on the stationary bike and ellipticals. When I couldn't run I found I could do some pretty hard workouts (cardio-wise) and not feel very sore the next day. I could also read a book, which is nice. So this should reduce the wear some.

Right now, I'm planning on still running marathons, maybe only one or two a year rather than three or four.

Where am I now?

Summary: I had my hip replacement on Nov 1 and was cleared for running 12 weeks later. I have been very slowly increasing my treadmill running, having recently done 3 miles at one go with one mile at a 9:05 m/m pace. 

I have a long way to go to get my running economy back to where it was, as well as my range of motion,  and overall endurance.

But, I'm so super happy to be back to running! 

Thank you technology... (And Dr Graw and his team) for keeping me going!

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