Thinking about what it’s like when you find out you need a hip replacement made me decide to write up some advice based on my experience.
This is pretty daunting, especially if you’ve never had major surgery before. The first step is to find a good surgeon you have confidence in. I was lucky enough to have a great sports medicine doc that referred me to my surgeon, and one meeting with the surgeon made me totally confident I had found the right person. I actually had an appointment with a different surgeon for a second opinion which I cancelled because I had such a good feeling about Dr. Abidi . Other people I know have found good surgeons through word of mouth. Absolutely by far the most important piece of advice is to good surgeon you have confidence in and have a good rapport with, and follow his or her advice. There are a some options about the surgery I’m about to discuss. If you’ve already found a good surgeon I’d almost recommend not reading them because I don’t want to introduce any doubt. But if you are just starting out looking for a surgeon I think it helps to know the options.
There are actually 3 options with hip surgery. The first is whether to go with hip resurfacing or hip replacement. In both approaches the damaged socket of the hip joint gets lined with an artificial component. In resurfacing, the ball, also known as the femoral head, it trimmed and then resurfaced with a smooth metal cover. In replacement, the femoral head is removed, and an implant is inserted in the thighbone. The replacement ball of the joint is part of the implant. There can also be a lining placed between the ball and socket.
The pros and cons of resurfacing vs replacement are discussed in the link above. In my surgeon’s opinion, resurfacing is better suited for somewhat lighter candidates. At about 175 pounds (79.5 kg), he felt I was not a good candidate. He did say that while he does not do the resurfacing procedure himself, he had a good surgeon he could refer me to if I wanted to check that option. But he said that, in his experience, that other surgeon would usually send people of my size back for the replacement. That was in 2012, I don’t know if the state of the art has changed since then.
So resurfacing vs replacement is the first choice. If you are going with replacement, the second choice is whether the surgeon does the procedure via an anterior (front of the leg) incision or posterior.
The posterior approach is performed by the majority of surgeons, but a significant number of surgeons now does the anterior approach. There is actually two other approaches called the lateral and antero-lateral approaches that I am not familiar with, all are described in this link.
The posterior approach dates back to the 1940s . The anterior approach actually dates back to 1947 (developed by Dr. Robert Judet in France, who developed a special table, the Judet table, required for this procedure). It was rarely used outside France until its use was pioneered in the US by Dr. Joel Matta in the 1996, and it has been gradually catching on as an alternative since then.
The posterior approach has the disadvantage that it involves cutting through some leg muscles, leading to a longer rehab time while they heal. In the anterior approach, access to the hip joint is between two of the muscles in the front of the leg (the sartorius and tensor fasciae latae). These muscles do not need to be cut, although they can get bruised in the procedure, so rehab can be shorter compared to the posterior approach. The disadvantage of the anterior approach is that there are more blood vessels and nerves in the front of the leg than the back, so many surgeons consider it higher risk. The anterior approach also requires a special operating table and an experienced surgeon. An additional advantage sometimes mentioned for the anterior approach is that dislocation of the replacement joint is less likely. However, the Wikipedia link above states that dislocation rates are now low for both approaches with the latest insert designs.
There are less movement restrictions after surgery, at least in the short term, for the anterior approach than the posterior (for example, with the anterior approach there is no restriction on crossing your legs). One final difference is that with the anterior approach there is more likelihood of nerve pain or numbness in the front of the leg in the first few weeks post-op, which my surgeon warned me about but told me it is temporary until the nerves heal. He prescribed the drug Neurontin (Gabapentin) in the first few weeks to address this. I did not experience any pain but did have some minor numbness, which went away after a couple of months. Both approaches, as far as I know, have just as good of a long-term outcome.
My surgeon, Dr. Abidi, uses the anterior approach. He has done thousands of the anterior procedures without problems, is well aware of the risks, and knows how to avoid them. After discussing the pros and cons, he convinced me that was this was the way to go for me, and the outcome was superb for both surgeries. I must admit that I have noticed that my rehab both times was quicker and less painful than for friends who had the posterior approach done.
Another important tip specifically for men is to not schedule the surgery so that it only gives your wife 8 days’ notice and it interferes with her hair coloring appointment. You lose a lot of points over that! I’m still hearing about it 7 years later. It’s amazing what a nice nurse she was during rehab under the circumstances 🙂 . In my defense, the doc had an opening that soon, perhaps because of a cancellation, and with the importance of the event I wanted to get it over with rather than dilly-dally. Seriously, I do highly recommend the no dilly-dallying part, rather than having this hanging over you for months.
Fitness Going Into Surgery- Prehab
The next important point is to do everything you can to be as fit as possible going into the surgery, which some refer to as “prehab”. There are statistics showing a higher likelihood of good outcomes for those who a physically fit undergoing surgery. This can be a challenge because the reason you are getting the surgery is you have a bum hip, which probably makes walking painful. But there are other hip-sparing activities you can do, like rowing, swimming, or biking. In my case it was biking, even towards the end when I was limping pretty badly I could bike pain free. I had a hip that was on the verge of freezing up but it could still flex normally, at least enough for a pedal stroke. It was only a problem “extending”.
When you’re standing up straight your hip is in the neutral (also called “anatomical”) position, with 0 degrees of flexion or extension. When you walk, the rear leg has to extend to the back. In my case the hip could not do this and it torqued my back with each step. But biking was not a problem so I kept that up to the end. I was also heavily into outrigger canoeing with a local canoe club at the time. Getting close to the time of my surgery it was kind of ludicrous how I’d limp down to the canoe and get in, but then I could paddle just fine.
So I highly recommend finding the equivalent for yourself, something like rowing, swimming, or biking that you can do pain free to keep your fitness up going into surgery.
State of mind
Your state of mind before surgery is crucial and is more in control than you think. In his book Timeless Healing, Dr Herbert Benson gives statistics on the contribution of positive mindset to good surgical outcomes. He laments the fact that one of the last things you have to do before surgery is sign forms that you’re aware of the risks, however small, of various dire outcomes (including death). It is of course totally necessary from a legal standpoint that you are giving informed consent. But it is unfortunate if you dwell on these negative possibilities and let it cause you to enter surgery without an optimistic mindset.
Here is my number one tip: you have put yourself in a good surgeon’s hands so trust that it will go well. Do not focus on anything negative like the slight possibility of things going wrong in the surgery. Instead, focus on how great the outcome will be, and how much better you’ll feel in a few weeks after some rehab.
Positive thinking is something you can train yourself in, as Deana Kastor relates in her book Let Your Mind Run. Working diligently on this took her running career to an elite level, and helped her worked through injuries and other setbacks. It’s also helpful to read inspirational stories like hers to stay in an upbeat mood. There are also recordings for positive thinking you can listen to.
Attend the Pre-surgical Orientation
Most hospitals offer pre-surgical orientations that help you get acquainted with what to expect during and immediately after the surgery, and answer a lot of FAQs. Because my first hip was scheduled on such short notice we were not able to attend. My wife was freaking out about a lot of unknown details. Does he need to go into rehab, or can I take care of him at home? But we have stairs! What about the handicapped placard? Fortunately, there was an absolutely wonderful woman, Kathy, working at Dominican Hospital in Santa Cruz (whose joint replacement facility is called “motion by the ocean” 🙂 ). Kathy was a patient advocate, and took Karen by the hand and guided her through everything. I sincerely hope you find someone like her to deal with.
Nevertheless, it was nice for the second hip that we had more time and were able to attend the orientation. We didn’t need it as much because we were “old pros” at that point, but we saw in retrospect how much less in the dark we would have been for the first surgery if we had been able to go to the orientation.
Surgery and Hospital Stay
I also hope you are taken care of by people as wonderful as the staff I experienced at Dominican. Please don’t forget to show your appreciation. The highlight of my stay was when I overheard some nurses discussing their assignment for the next shift, and one of them sad sadly “no, I don’t get Mr. King”. It felt good that I was the patient they wanted to have rather than one of the crabby ones. I know people can be uncomfortable and in pain after surgery but don’t take it out on the staff. As a friend of mine who’s a fellow recipient of a heart valve replacement told me after his surgery “you know Rich, if you’re cool with the nurses, they’re cool with you!”
During your stay, you may be given some instructions on bed exercises, and you’ll be working with a physical therapist. I recommend doing the exercises and anything the PT tells you diligently. It will help you bounce back more quickly.
Pain management is a big issue for some, I was lucky and had very little and required nothing but Tylenol. If you do have more pain and have to take narcotic meds, it’s important to avoid staying on them for too long for possible dependence reasons. Mindfulness based stress reduction has been shown to be very helpful for pain relief and there is a video about it available at this link. There are also pain relief cds available at Amazon. Techniques like these may relieve pain enough to require less pain relievers. Or hopefully you’ll have the same experience I did.
You’ll probably go home with some instructions from your hospital or surgeon which include home exercises. I still have my big fat notebook “Total Joint Care” they sent me home with from Dominican. These exercises are not necessarily fun, and 30 reps or so may make your muscles burn. I get it, they can be quite literally, a pain in the ass.
But they are vital and I again urge you to do them diligently. During the long period while your arthritis progresses and your walking is degraded, a lot of strength can be lost in muscles like the glutes and hip abductors. These exercises are to get that strength back so you regain a proper gait. The nice shiny new hip joint will not get you walking properly on its own if the muscles around it are not up to the job. If you read elsewhere on this site you’ll see I’m into doing fun physical activities. I don’t particularly enjoy calisthenics in general. But this is a short term exception where you take the exercise “pill” and will be glad you did later. Even better than at home exercises is if you get referred to a good PT. Hopefully a drill sergeant, as some tough love is good motivation to get you strong again.
I’m harping on this because my surgeon told me lots of people don’t bother doing their rehab exercises and never get a proper gait back. Also, a couple of months after my surgery, I was back 100% to all my activities, and was walking just fine. I met a woman who had had the same anterior hip replacement that I had a year previously. And she was noticeably limping. She said the surgery had gone just fine with no complications, but sheepishly admitted she had not done her exercises.
In addition to the PT exercises, it will probably be recommended that you start walking, a little bit at first and ramping up the amount a little each day. My surgeon was quite happy on follow-up a month later when he found out I was walking an hour a day and he confirmed for himself that my gait was just fine.
Unfortunately the same cannot be said for the rehab from my second hip. For that one, I got cocky after a few weeks and decided to start taking the stairs two at a time with a 40 lb. weight vest to make my legs stronger. I managed to partially tear my achilles tendon, and when I saw my surgeon for the next follow-up he said gruffly “You’re limping. Why are you limping?”. We had just looked at the follow up xray and the hip looked fine, so he knew that wasn’t it. When I blushingly told him I had a sore achilles and how I think it would happened he shook his said and said “Don’t do that anymore”. He then examined the achilles and could feel the partial tear, so put me in a boot which I needed for a couple of months. So I guess the moral of this one is to rehab enthusiastically but don’t overdo.
If you weren’t active previously, getting to where you can walk a significant amount each day is a great start. After years of getting by with an overly stiff hip, walking has felt delightful to me ever since the replacement. If you’d like to push it harder, you can pretty much do whatever you like as long as it’s low impact (at least that’s what my doc says). Coming up with some sort of challenge to point towards and train for after you are 100% is helpful to motivate some people during rehab. An adventure like a long bike ride or hike, climbing a demanding mountain nearby, or whatever intrigues you. It is inspiring if it is something you would not have dreamed of doing in the days of your bad hip.