A new lease on life

Two weeks ago I underwent surgery to replace both of my hip joints. I’d been having trouble since the summer of 2012, when running became painful and I found that I couldn’t mount my bicycle by swinging my leg over the seat. These were signs of what would be diagnosed, in April 2015, as moderate-to-severe osteoarthritis. It could have been diagnosed two years earlier, when I presented symptoms I identified as a groin pull and pain in my quads. But I was still able to be very active then and, after a round of physical therapy, regained much of the range of motion I’d lost the year before. Deep down I knew something was really wrong but I convinced my doctor and physical therapist that it was all muscular, that I’d be able to work through it, and that there was no need for an x-ray.

In reality the disease was progressing, and although I returned to cycling, hiking, and running, things never felt right. There were other signs. During my final season of firewood stacking, in the summer of 2013, I found myself sitting on a bench pitching logs. Around the same time I tried working at a standing desk but quickly abandoned that experiment. Stretching didn’t help because it couldn’t. Cartilage was eroding, bone spurs were deforming the balls of my femurs.

After our move to California last year, the signs became impossible to ignore. Halfway through a 12-mile hike at Point Reyes I had to admit I was in real trouble. I went to see Luann’s physical therapist, he leveled with me, and I just about took the poor guy’s head off. Being active is incredibly important to me, I’ve always feared loss of mobility, and I catastrophized the situation.

Conventional wisdom has been that you want to postpone surgery as long as possible. That would mean years of increasing pain and loss of function. I visited the surgeon who would ultimately fix me, Briant Smith, and learned two vital facts. First, the hardware has improved so much that there’s less incentive to delay surgery in order to avoid a repeat. Second, the anterior direct method is massively superior to earlier methods.

Direct anterior hip replacement is a minimally invasive surgical technique. This approach involves a 3 to 4 inch incision on the front of the hip that allows the joint to be replaced by moving muscles aside along their natural tissue planes, without detaching any tendons. This approach often results in quicker recovery, less pain, and more normal function after hip replacement. Because the tendons aren’t detached from the hip during direct anterior hip replacement, hip precautions are typically not necessary. This allows patients to return to normal daily activities shortly after surgery with a reduced risk of dislocation.

At that point I didn’t know when this would happen. Years? Months? Dr. Smith said: “When you can’t take it anymore, we’ll fix it.” A month later I was in San Francisco for a week-long series of events. The first morning I walked two miles, a distance that had been well within my tolerance until then, and was incapacitated. I hobbled through the week, unable to sleep, and pinged Dr. Smith. “Sometimes the progression is linear,” he said, “and sometimes you fall off a cliff.”

On my next visit we discussed tactics. Most bilateral hip replacements are done serially, so you’ve got one relatively good leg to stand on during recovery. In my case, both joints were about equally bad. Should I replace both at once? My primary doc didn’t recommend that. And Dr. Smith didn’t exactly recommend it either. But he let me know that it’s doable. “It’s a big wallop,” he said, and a slower recovery, but people in my cohort — athletic, mid-to-late fifties (I’m 58) — are having successful outcomes, and it’s great to get it over with in one go.

So I signed up for the twofer, and then had a few months to wait, research the topic, and talk to veterans of the bilateral procedure. People were reporting almost unbelievably good outcomes. One fellow I met told me that his post-surgical pain was so minor that he’d needed nothing stronger than Tylenol to control it.

And that’s exactly how it went for me. An hour after surgery I walked from the hospital bed to a recliner, using a walker for safety more than for support. The next day I walked 500 feet, not because I was pushing myself but because the physical therapist invited me to and was confident that I could do it safely. The day after that I walked 1000 feet, navigated some steps in the PT gym to ensure I’d be OK entering our house, and went home.

It really was a big wallop, and the energy that’s gone into healing hasn’t left much for higher-order brain function. I’m sleeping a lot, and only gradually getting up to speed with my work. But I’m gaining mobility, strength, and flexibility every day. I used the walker for a week, then graduated to hiking poles — again, more for security than for support. And despite having major carpentry work done to both sides of my skeleton — hammers, saws, dremels — the pain has been minimal, and I too have needed nothing stronger than Tylenol. It’s reasonable to expect that I’ll be hiking and cycling in a month or so, and doing those things pain-free for the first time in years. My range of motion is already better along some axes than it was two weeks ago, and should continue to improve. There’s residual numbness in the skin over my quads, and some puffiness around the incisions, but these effects are normal and should resolve. (No staples or stitches, if you were wondering, they use superglue now.)

What accounts for this astonishingly good outcome? It seems to be a combination of factors. Hip repair has always been more straightforward than knee or shoulder repair, and with the anterior direct method it’s radically better than it was. That’s a recent development, my surgeon only began using the technique five years ago. But the physical therapist and occupational therapist in the hospital told me that they’ve only been seeing outcomes like mine for about two years.

What changed? There’s some fancy gear involved. The Hana table, for example, enables precise positioning, but it’s been around for longer than two years. Maturation of surgical technique is clearly a key factor. When I asked Dr. Smith about this, he said: “Speed matters.” It only took three hours to upgrade both of my hips. I was reminded of Atul Gawande’s 2007 New Yorker story The Checklist, a precursor to The Checklist Manifesto. Part of that story follows a team in Austria that had tried unsuccessfully to resuscitate people who drowned or were buried in avalanches, then managed to save one person, and soon afterward several more.

One step went right after another. And, because of the speed with which they did it, she had a chance.

Another key factor, I suspect, is that surgeons are seeing more patients like me: active people in their fifties who want to stay active, and who are realizing that surgery — this one in particular — need not be postponed.

It’s still not a walk in the park. I’m moving slowly, and there’s a long road ahead. But two weeks ago, every step I took made things worse. Now every step I take makes things better. It’s miraculous, and I could not be more grateful. For most of human history my condition meant a lifetime of diminishing mobility and increasing pain that medicine could do nothing to help. Within my lifetime a fix became possible. In just the last two years it’s gotten incredibly good. I’m well aware that there’s plenty that can’t be fixed at all, never mind fixed so well. I know I’m a lucky guy to be here in 2015 and, crucially, to have health insurance. But I also think Dr. Smith is a lucky guy. Being able to improve lives in the way he has improved mine, day in and day out, has to be an amazing joy and privilege.