Hip Replacement 101

In December 2010, Diane Bradshaw, a 56-year-old attorney, reached her breaking point. “I won’t say I had a death wish, but I didn’t care if I died. I was in that much pain,” says Diane, a petite woman with a silvery bob, a wardrobe solely noir, and the manic energy of a small tsunami. Yet she was in fantastic shape, due primarily to her first career as a professional dancer. Her routine—even after entering law school at age 50—included daily gym workouts and Ashtanga Yoga, a very athletic, ambitious program. And then, suddenly, she developed severe pain in her left side, not aware that she had hip problems. “Oh, now I’ve really done it to myself,” she figured. “I’ve overstretched.’”

To make matters worse, Diane (left), a first-year associate at a boutique law firm, didn’t have health insurance. “The program at my job required paying a premium, and my husband Tom and I were just digging ourselves out of a financial hole because of the loans I’d taken out to go to law school.” But the first doctor Diane saw read her the riot act. “‘Whatever is wrong with you,” he said, “you better get insurance, and quick.’ So I signed up.”

The Bare Facts

On January 4, 2011, Diane and Tom consulted Douglas Unis, M.D. an orthopedic surgeon in the Department of Orthopaedic Surgery, Total Joint Replacement, at St. Luke’s Roosevelt Hospital (www.douglasunismd.com). She limped into his office, sobbing, “Make it go away.” An x-ray revealed the awful truth: “I had no left hip socket, and there was no cartilage between the two bones. It was bone on bone,” says Diane. “I’d never had a left hip socket, due to a congenital birth defect called dysplasia.”

Diane had somehow managed to compensate throughout her 30-year career as a dancer. But now Dr. Unis gave it to her straight. “There is no medication, no therapy, no exercise,” he said. “There is absolutely nothing in the world to remedy this situation but a total hip replacement.’”

Diane had taken tremendous energy to land her new job. Taking time off was unacceptable. But she had to face it. In quick order, Dr. Unis took charge; he made an appointment for January 10 for emergency surgery.

Diane’s case was far from typical, so she did not have the standard procedure—anterior hip replacement, in which the surgeon reaches the joint from the front of the hip. “It’s minimally invasive and the hip is much more stable, so it’s unlikely to dislocate,” Dr. Unis explained to me. “But Diane had a very deformed hip socket, which led to severe arthritis. So she had a posterior approach, because there was a chance I was going to have to do major reconstruction of the pelvis, which required a bigger incision. To be safe, I did it through the back.” (Fortunately, Diane did not need reconstructive surgery.)

The artificial hip that became part of Diane’s anatomy consisted of two materials: titanium for the socket and a socket liner of polyethylene, a high-tech plastic. “Because I’m so active, Dr. Unis put in the strongest materials he could,” Diane explains. He was right to do so: In seven months, she was out and about, pain free, at the gym twice a day, doing her beloved yoga. (Diane’s recuperation was unusually long because her case was so severe.) “Dr. Unis just warned me not to twist myself into a pretzel,” she says.

Material Matters

Hip implants come in other materials than the metal-plastic combination used in Diane‘s prosthesis. “We can also do ceramic-on-plastic or ceramic-on-ceramic,” Dr. Unis notes. “Ceramic-on-ceramic has the lowest wear rate [that is, it wears out very slowly], but the down side is there’s a 1 percent incidence of the hip squeaking as you walk.” Since that’s hardly a landslide percentage, Dr. Unis also uses ceramic implants, both for young patients and for those in their forties and fifties. “I want to give them hips with the best chance of lasting,” he says.

The one type of artificial hip that has failed at an alarming rate is the all-metal model. “I wouldn’t recommend a metal-on-metal implant for anyone,” says Steven F. Harwin, M.D., Chief of Adult Reconstructive Surgery of the Hip and Knee and Director of the Total Joint Replacement Bloodless Surgery Program at Beth Israel Medical Center (www.drharwin.com).

“The positioning of these all-metal implants is extremely critical, and surgeons aren’t capable of getting it right every time,” Dr. Harwin explains. “When they don’t, the implant generates friction and produces particles of cobalt and chromium.” These particles can enter the bloodstream and wreak havoc on the body. “There can also be a reaction of extreme hypersensitivity that generates a pseudo-tumor, and it looks like a bomb went off inside the hip.” Adds Dr. Unis, “All-metal implants are going the way of the dodo.”

Trial and Error

Hip replacement surgery has come a long way since the days when it was considered dangerous and painful. According to Dr. Harwin, who cites industry standards, there are approximately 1,300,000 hip replacements performed globally each year. About 90 percent of patients return home or to a rehab center after two or three days; within four weeks most patients can drive and travel; and six weeks after an operation most patients are fully recovered, although they still might experience some pain, swelling, and stiffness. The operation is even safe for patients in their nineties. “Mortality is considerably less than 1/10 of 1 percent, and I have operated successfully on patients in their 90s  and 3 who were over 100,” says Dr. Harwin.

As upbeat as those numbers are, complications can sometimes arise. Consider the case of Betty Mosedale (left), a 79-year-old retired teacher in New York City. Betty, a gracious and graceful woman with a swanlike neck and a grey pouf of hair, has seen the inside of an operating room more times than she cares to remember over the past decade.

In the fall of 1999, Betty began having pain in her right hip when going up stairs, and some discomfort walking. A cortisone injection didn’t help, but physical therapy was effective. A year later, however, Betty’s pain became worse at night, and she couldn’t sleep. Her orthopedist prescribed painkillers and stretching, to no avail.

Over that winter, Betty had x-rays, an MRI, and nerve conduction tests. She saw two orthopedic surgeons; both assured her that she didn’t need a hip replacement. One doctor recommended prolotherapy—a way of managing pain through the injection of substances like dextrose and Lidocaine. Still, Betty got no relief. That summer, her pain was so bad that her doctor put her on morphine.

Finally, on November 5, 2001, Betty had her hip replaced. She envisioned a pleasant recovery, the kind Dr. Harwin describes for a typical patient. “Generally, people start walking in the hospital. They get out of bed the day after surgery, and most go home on the second or third day. Going to a rehab center is not necessary, because, in the first 6 weeks, you’re basically sitting, standing, walking, getting up from the bed and toilet, and doing a range of motion exercises.” In the hospital, case managers arrange for a visiting nurse and a physical therapist to go to your home for the first few weeks.

After that, notes Dr. Harwin, “I want people to get out and get back to normal as soon as possible. At 6 weeks, we start doing muscle strengthening exercises in physical therapy.” PT continues for a few months. “The average recovery time is 3 to 4 weeks,” Dr. Harwin sums up.

Repeat Performance

Alas, Betty had no such snappy, happy scenario: “Recovery from the first surgery was never complete. I still had trouble climbing stairs, and pain would wake me up as often as 17 times a night. Plus I couldn’t do all of the prescribed exercises.”

Amazingly, Betty endured this condition for four years. “Then my doctor suggested he might be able to improve the situation with minor surgery. Twice I turned this idea down, because it conflicted with my family time in Minnesota.” Ultimately, on January 8, 2007, Betty had a second operation. This time, her surgeon removed a large bone spur and reattached some muscles and ligaments that had become disconnected. Why did they detach? “The doctor explained that the staples that had been used in 2001 were feeble, and that the new staples were much better.”

Yet, in the 10 months following this procedure, Betty’s nights became a torment once again. She found her way to another doctor, who said that her right bursa was inflamed and gave her a second cortisone shot. It didn’t help, and a third surgery followed on February 14, 2008. This time, her right bursa was removed, along with two sutures that had come undone. The doctor said the bursa would probably grow back, and it did.

Finally, Betty’s time on the torture rack seemed at an end. “Things went along pretty well,” she says matter-of-factly, “until I started having problems with my left hip. I had an operation to replace that hip on October 4, 2010.” By then Betty’s husband, John, had died, so she was sent to Burke Rehabilitation Center in White Plains for 10 days to recuperate. “That was fabulous,” she recalls. “I went for physical therapy twice a day, and it was rigorous.”

Betty has bounced back from her long ordeal with remarkable cheer. “In fact, I was feeling so good last February that I decided to take a Tai Chi course,” she says with a laugh. As for her favorite form of exercise, walking, she is indeed covering a lot of ground. In November, as if to underline the great strides she has made, Betty went on a lengthy walk—with Occupy Wall Street protesters.