After a total hip replacement, rehabilitation must become a top priority and probably an obsession.

The surgeon can remove your old hip and give you a brand new replacement, but he cannot rehabilitate you.  No one can.  Others can instruct and guide you, but you must do this work yourself.  And you must expect much of it to be tough and painful.  The ultimate success of the operation depends on what you do in self-managing and self-motivating your rehabilitation.

They do get you started, of course.  I was helped out of bed to sit in a chair the day following surgery.  I was helped to take a couple of weak steps using a sturdy walker.  The next day I took a few more cautious steps.  I began doing simple exercises in the bed like pumping my ankles.  Any movement was considered good, except for a few that were strictly forbidden due to the risk of dislocating the new hip.  But most any movement was also painful.  I quickly learned to get new pain medication started before exercising.

In the rehabilitation hospital there was a more intensive program of physical and occupational therapy.  I was given lessons in “bathing” myself on the side of the bed, using various aids.  I was shown how to dress myself as much as I was able.  I spent hours in group classes where we learned and began to practice the exercises that would someday let me walk again.  At first all exercises were tentative and gentle, gradually increasing in effort.  The  routines were somewhat individualized to our needs and abilities.  Since I had been strong and active before surgery, I tended to be ahead of the curve.  There was camaraderie among participants in these classes.  We cheered each other on and compared notes on our surgeons and surgeries.

At home I had an excellent physical therapist who visited three times a week.  She was competent and very friendly, but tough as well.  After six or eight visits she told me she had taken me as far as she could, and I was on my own.

The tricky thing about rehab for me is to find the right balance.  I cannot count the times I have over-done it, hurt myself, and had to lay off for days.  You have to push yourself enough, but not too much.  I am always pushing too much.  My surgeon told me the most important exercise is the standing hip abduction.  You lean against a wall on your good side, and move your leg on the operated side straight out, and back, and out, etc.  As you get stronger you can add resistance using ankle weights.  I purchased an ankle weight set with individual 1-pound inserts that goes up to 20 pounds.  The surgeon had told me to work up to 10 pounds and no more.  When I got to 10 pounds I was ready to put on more, but I could not find them anywhere.  Knowing my tendencies, my wife had hidden them away and refused to reveal their whereabouts.

Your progression toward walking again is from walker to crutches, to crutch, to cane, and then to free walking.  Actually there’s a progression with the free walking also.  You linp at first and then very gradually the limp goes away.  At four months past my hip replacement, I sometimes limp just a little, but not much.  I have walked as much as a mile without stopping.  I am riding my bicycle on a training stand in the basement.  I am swimming laps.  I have six months before a backpacking trip in the high Sierras I want to do if I can, averaging about eight miles a day with a heavy pack.  I may be able to get ready for this, or I may not.  We’ll see.  I’ll let you know.

For the first two days following my hip surgery the pain was managed by the epidural which I activated with my friendly hand pump.  After this they took out the tube that injected this into my spinal fluid and I went on oral pain medications.  I recall that my surgeon had asked if I had ever taken Percocet before and my answer was no.  Percocet was what I began taking for pain and to be able to get some sleep.

Sleeping was not easy following the surgery, not only because of the pain but because I had to sleep almost motionless on my back.  One of John Updike’s books of poetry is titled “Tossing and Turning” and the title comes for a poem about his sleep habits.  My sleep has always involved tossing and turning as well.  But no such thing is allowed after a hip replacement.  Even if it were allowed, it isn’t possible with all of the tubes that connect you to things and they way you are wedged in with pillows.  It’s no fun, but the drugs do help.

But about the time I was beginning to get rid of some of the tubes, a new problem arose.  Nightmares.  Sometimes daymares.  They were unlike anything I had ever had in my life.  The dreams were vivid and would have made a great horror movie if they could have been recorded.  I became afraid of sleep or even closing my eyes because I knew that “they” would appear when I did.  “They” were killers, enemies, poisonous snakes, rapists, enemy tanks, falls from high cliffs–anything and everything terrifying and tormenting.  Often I screamed out, woke up in a sweat, and was relieved to find myself still alive and unhurt.  Then I would try my best to stay awake because I knew that to go back to sleep was to go back to “them.”

I lack the words to make this sound as awful as it was, although I’ve tried.

When I finally described this to my doctor he suspected immediately what it was.  It was the Percocet.  People react to it in different ways, and these include delusions and drug-induced hallucinations.  When he took me off of Percocet and put me on another narcotic, “they” faded away.  I was reminded of the scenes in “A Beautiful Mind” where John Nash is tormented by his delusions and then the ones where they begin to recede.

Your results may vary, of course.  Percocet might be fine for you.  But do you think I would take it again, even if you gave me a year’s free supply?  No way!

I was in two hospitals with my hip replacement.  The first was where I had the surgery and stayed for several days.  The other was a rehabilitation hospital and I was there for several days as well.  Although physical and occupational therapy were begun almost immediately at the surgical hospital, these were a focus at the rehabilitation hospital.

As I had not spent a night in a hospital in about 30 years, doing so again was an interesting experience, especially given all of the current and onging focus on the American health care system.  Also I have a good friend who recently worked for AHRQ – the government agency for healthcare quality and research (http://www.ahrq.gov).  I went to the hospital with the assumption that these are dangerous places to be, and the wise patient is on her guard.

I think this assumption served me well.  To survive the hospital you must be active in your own care, not passive.  You must know about and care about what is being done to you or not being done.  You must ask questions and speak up if you need to.  You must assume that there are caregivers there who know and care about what they are doing, and others who don’t know what they are doing or care about it.

I has both kinds of those experiences.  My rooms had nicely designed whiteboards facing the bed where schedules and reminders were kept, along with the names each day and each shift of all the people whose responsibility I was.  It was a great idea and a great thing when it worked.  The trouble was that many staff did not trouble themselves to use it, and the information in some categories was days behind.  There were shifts when I never knew or met the nurse that was assigned to me.  Continuity was spotty.

There was a great variation in caregivers following or not following procedure.  There were some who never gave medication or drew blood without asking my name and birth date and checking my identifying wrist band.  There were others who asked nothing and checked nothing, even when drawing my blood.  There were times when I rang for pain medication and had it almost instantly, but three times it took over an hour and many reminders and complaints.

On the positive side I also experienced some very competent, responsive, and caring individuals.  Also on the positive side is the obvious fact that I survived the experience and emerged to continue my recovery.  The point I am making is that the patient must be an active and informed participant in this process and not a passive recipient.

My surgeon is a self-described “conservative New Englander” who uses the anterior approach to hip replacement.  I entered the hospital on Tuesday, had the operation late that day, was transferred to a rehabilitation hospital on Friday, and came home on Tuesday.  I continued with in-home nursing and physical therapy care for 2 more weeks.  Your results may vary.  I see surgeons on the Internet promising much shorter hospital stays and recovery times than mine.  Good luck with that.  As far as I’m concerned, I needed the time I took.

This is not to say that coming home from the hospital was done with any reluctance.  To finally have your own bed, your own pillow, your own food, your own pictures on the wall–everything.  It was a huge lift and milestone.  But a long road to full recovery lay ahead.

Unknown to me, of course, my hip replacement lasted three hours.  At 7:30 p.m. my very tired surgeon spoke with my wife and daughter, reported that things had gone as planned, and that they could see me shortly in the recovery area.

My memories of coming back to consciousness in that place are not pleasant ones.  My earliest consciousness was of severe pain, a crowd of people around and looking down on me, and my mental struggle to put things back together.  It had been explained in the orientation seminar that my pain would be controlled by an epidural for the first two days.  My “best friend” would be a small plunger, connected to unit that would send new pain killer down the tube inserted through my back and into my spine.  Every 15 minutes I could get a new dose by pressing the plunger.  I was advised that no one except myself was allowed to perform this operation.  I was also advised not to “get behind” on use of the pain relief, because once you got behind and in severe pain it is difficult to “catch up.”

But the crowd around me in the recovery room explained that they had taken pain relief away from me.

I could not have this relief because my blood pressure had fallen so low.  I think they said it was something like sixty over forty.  I remember being angry at this crowd because they seemed so casual and unconcerned about these breach of the promised “pain management.”  They were talking back and forth across my bed of pain about matters I had no interest in, but I do remember finally hearing one of them ask if there wasn’t something they could do to get my blood pressure raised so I could use the epidural.  I remember observing that no one around my bed seemed to have an answer to this question.

About this time my wife and daughter appeared and insisted that I was in great pain and someone must know what to do about it.  My wife asked to speak with whoever was in charge of this place.

Someone was finally found and something was finally done.  I remember hearing the frequent announcements of my blood pressure readings and being groggily conscious that improvements had taken place.  I am probably way off due to the pain-blur of memory on this, but perhaps around 70 over 50 they finally rolled the unit back beside me and gave me the plunger.

The struggle of life was easier after that.  I drifted in and out of consciousness.  It was 10 p.m. when I arrived in my hospital room with my new hip.

My wife slept in the room with me that night.  If you would call it sleep.

The thing about major surgery is that you place yourself in the hands of others, most of them strangers, and become totally helpless.  I remember saying to the anesthesia guy that I had three requests: put me out before the surgery starts, keep me out while it goes on, and be sure to wake me up afterward.  For those used to being in control of themselves and the circumstances around them, this is a humbling and possibly instructive experience.  For those of us lacking battlefield type bravery, it is also frightening.

My orthopaedic team provided an advance seminar to help us prepare.  I reported (pushed in a wheelchair by my attending wife) along with several others also scheduled for hip and knee replacements.  For two hours we were told and shown what to expect.  Much was made of how our pain would be managed and how we must become active and begin physical therapy almost immediately.  The discussion and demonstrations were certainly informative, but they were also like pre-living the experience.  My wife and I continued to discuss and go over every point until late that night, and my sleep became a rehearsal.

The three main risks of hip replacement surgery are blood clots, dislocation, and infection.  Blood thinner is taken orally to reduce the risk of blood clots.  In my case I stayed on the blood thinner for 6 weeks, starting the evening before surgery.  Blood is drawn and analyzed several times a week in order to maintain the correct amount.

Since the hip must be dislocated in order to perform the surgery, the muscles and ligaments that hold the hip in place are weakened, and the replacement is at risk of dislocation following the surgery.  The risk decreases as time goes on and the supporting structure becomes strong again.  But that process goes on for perhaps two years, so you have many precautions to observe in the beginning.  The seminar provided all these warnings.

The risk of infection is two-fold.  Infections can be introduced during the surgery itself, or they can travel to the new hip appliance afterward by moving through the blood stream from other body sites.  This was of special concern to me since the foot attached to my bad hip has been infection-prone in the past.  Infection of the artificial hip is a catastrophic event.  Once infected, the appliance cannot be treated with drugs and must be removed from the body.  You may spend weeks in the hospital receiving antibiotics intravenously.  And it may be a long time before they can give you another hip to start all over with.

In the late 1970′s I got to observe open heart surgery from inside an operating room.  I stood on a low stool right behind one of the surgeons.  Like them, I wore a gauze covering over my nose and mouth.  That was for infection prevention in those days.  Today, for my surgery at least, the team wore space suits that cover them completely and air-tightly.  The air they breath comes in through a pipe and the air they exhale goes out the same way.  After one surgery, an hour is spent purging the operating room of every trace and leaving it spotless and pure for the next procedure.  Not that I ever saw these things, of course, because, like I said, you do place yourself in the hands of others.

Actually I did see my operation, in a way.  After I came home for the hospitals I found a video of anterior hip replacement surgery and watched it from start to finish.  If you’d care to watch, you can find it here:

http://www.orlive.com/prohealthcare/videos/anterior-hip-replacement-surgery

I reported to the hospital at some early hour, having abstained from food or drink since midnight.  My surgeon met and told me that he had three hip replacements to perform that day and mine would be last, perhaps soon after lunchtime.  His intern later revised the estimate to around 2:30 as things were running late.  It was actually about 4:30 when things were ready for me.  The last thing I remember was entering the cold, brightly lit, gleaming room with all the panels, gauges, cabinets, and tools laid out and ready.

The anesthesia guy put a small rubber cup thing over my nose and mouth.  He said to take five breaths and I would be asleep.  I began to count.  I think it was actually six or seven.

A lot led up to my complete hip replacement on September 29, 2009.  Thinking back on my decision process, I now know it was an evolution directed by my deteriorating condition.  It was a long journey from a time where I thought I might need and benefit from surgery to one where no other choice was possible.  I’ll explain as best I can.  I want to illustrate my advice in this matter: “Don’t ask for a new hip unless you really need one.”  As much as some people might lead you to believe, hip replacement is no small deal.  It represents a major life event and a large commitment by yourself and those around you.
I have a dear friend in California who leads an annual backpacking trip in the high Sierras.  In 2007, we were talking and I became interested in joining this trek. Bob and I had been active in Boy Scouts together in our home town and he had kept up with backpacking but I had not.  I decided this would be a great thing to do and committed to join the group in the summer of 2008.  I researched the latest in lightweight, high tech gear and ran up large bills at REI.  At one point, I had a tent set up in the living room and all my gear strewn around and being pondered and organized.  I practiced packing and unpacking, pitching and taking down the tent, using the stove, the water purifier, the food dehydrator I bought, and other such preparations.

When spring came, I knew I must get in hiking condition.  I began to take long walks of up to 7-8 miles.  Then I began to hike with my backpack and loads up to 25-30 pounds.  Sometimes on these hikes, things went well.  But increasingly I began to have occasions when my right hip did not act right and was painful both during and after the hiking.  I took more and more Aleve, thinking this was just arthritis and all I needed to do was tough it out.  But toughing it out was not to work.  I remember one 4 mile hike around a local lake with a loaded pack when I wondered if I could make it back home.  My right hip felt like it might “go out” at any time.  Bitterly disappointed, I finally called my friend and withdrew from the trek.

That fall I sought medical help and advice.  I will make this brief, but I saw several doctors, had X-rays, CAT scans, MRIs, steroid injections, and an assortment of prescriptions for anti-inflamatory drugs. My condition came and went, and always when it “went” I believed that now I was surely getting better and the prescriptions were working.  One doctor offered surgery but without much conviction.  I was busy at work and kept putting off any action.  I even entertained some notion that I might improve and try the 2009 summer hike.  But there was no way.  The distance I could walk became shorter and shorter, as my pain became more and more pervasive.  Pain was especially prominent when I lay in bed and tried to sleep.  I began taking drugs for pain as well as arthritic inflamation, just to get a night’s sleep.

In July 2009 I went to see a new surgeon my California friend’s doctor had recommended.  I took it from him that I would need a hip replacement sometime.  But he could not predict when that time would be or when it had arrived.  He explained what I could do but stopped short of telling me what I should do.  He gave me a complete picture of what the surgery and rehabilitation involved and answered my long list of questions.  I drove away assuming that I would eventually have this operation and with this man as my surgeon.  But when?

My condition deteriorated rapidly after this visit.  I had to give up riding my bicycle 12 miles and back to work, and started needing a cane to assist me with walking.  My hip was unable to lift my leg in and out of the car, and often onto the bed.  I had to grab my pants and lift the leg by hand.  Fearful grinding noises issued from the hip joint.  I kept working but never got a good night’s sleep.

A month later I made the call and asked for a new hip as soon as possible.  But due to my surgeon’s loaded schedule, the operation had to wait for many weeks.  I lived the life of a crippled man by day and a sleepless sufferer by night.  My doctor who is “not a fan of narcotics for arthritis pain relief” was forced by my begging to give me stronger and stronger ones.  I started working from home and taking sick leave while counting the days until my appointment in the operating room.

I want to show you an X-ray of my hips just before the surgery.  This is from the front, so my good left hip is on the right, and my bad right hip is on the left.

You don’t need to be a radiologist to see the difference.

The “works” of your hip is a ball in a socket.  My left hip still has a nice one.  The right hip shows bone grinding against bone and surrounded by a nasty-looking arthritic mess.  On September 29th that would get replaced.