Long ago (1988) I moved to Berkeley and started sending a monthly "newsletter" to my Boston friends. When I returned to Boston (1993), I continued the tradition for about five more years (or until I had kids). Looking back, I realize that I was actually blogging. Each newsletter contained anywhere from a few to several blog posts. Having been silent for the past decade or so, I've decided to resume these activities. Don't expect anything profound -- I tend to focus on what I find entertaining or amusing and perhaps sometimes informative. We shall see!

Tuesday, July 14, 2015

Total Hip Replacement: Surgery and the First Week

Warning: amazing bruise pictures below.

Everything went pretty much according to plan. There were a few slight hiccups -- I tested positive for Staph, so they put me on an antibiotic for five days coupled with daily Hibiclens showers. In my experience, Hibiclens is pretty standard for the three days prior to surgery, so this just meant a longer run.

Pre-Surgical Appointment

This was mostly routine, although it was my first experience with NEBH so it was kind of interesting to compare and contrast (I have now had surgeries at St. Elizabeth's, Emerson Hospital, MGH, the Brigham, and NEBH.)

NEBH was the farthest ahead electronically (or at least relative to what I'd seen other places, which was admittedly a few years old now). Every document was shown to you on paper, but you provided an electronic signature, so they had the entire file digitized, including things like your Health Care Proxy. So, no searching for random pieces of paper at future moments. Other than that, checkin was pretty typical -- sign lots of forms.

If you are "of a certain age" (over 50), then you also get the bonus ECG (they would like to make sure that you're not going to keel over during surgery). So we did that, we drew some blood, I met with physical therapy, I think we may have taken another Xray (although I am not entirely sure), and (new to me), they did nasal swabs to test for both MRSA and Staph. I don't know if this is NEBH standard for everything or something special for joint replacements. It is pretty clear that infection is a huge concern for hip replacements (e.g., from here on out, before every dental appointment, I need to get prophylactic antibiotics. Who knew?), so this might be standard everywhere; I don't know.


Then I went gallavanting off to Canada knowing that some time between 4:30 and 8:30 PM on the 6th, I would get a phone call with my surgery time. So, I'm sitting on the runway in Denver, waiting for them to close the door and my phone rings. My surgery is scheduled for 7:30 AM with a checkin time of 5:45 AM. Oh yeay; I land at 10:00 PM. My wonderful husband books a hotel room about 15 minutes away from the hospital, picks me up at the airport, and spends the night before surgery with me (isn't he a great guy?).

I show up at 5:45 expecting a pretty quiet/empty place, but au contraire -- there are already a dozen people in registration when I get there (and what time did they get there?). Checkin is reasonably efficient and then a nurse comes to get me for pre-op.

Pre-op is an interesting experience -- a (long) parade of doctors and nurses come by, introduce themselves, tell you what their role in your surgery is, and get on with their business. I'm sure I will leave out a bunch of folks, but I remember: pre-op nurse, surgical nurse, anesthesiologist, hematologist, a second anesthesiologist, and, of course, my surgeon. Everyone is pretty friendly and chipper. You get used to stating your name, date of birth, and what procedure you're having -- a lot! And, in good form, the surgeon initials the hip on which he's working. You may think this double checking is excessive, but I still remember being wheeled into the OR at MGH and seeing the board displaying RIGHT ACHILLES REPAIR. Only problem was, I had a LEFT ruptured achilles. I pointed this out pretty adamantly and they assured me they knew which side was having surgery, but let's say that the error on the sign did not instill great confidence.

I get my IV and I have to admit that I don't even remember being wheeled out of pre-op and into surgery. It seems that they must have left me under for quite some time, because I went in for surgery at 7:30 (in theory) and while I have a few vague recollections from post-op, my first real recollection was getting taken to my room right around noon. And here is the truly amazing thing: they handed me a pair of crutches and I walked, bearing weight on my brand spanking new hip from the stretcher to my bed. How totally unbelievable is that?

In-hospital Rehab

The plan was to put me on accelerated rehab so I could go home the next day instead of staying a second night. (Part of accelerated rehab is the walking to bed thing.) So they got me settled and before the afternoon was out, I had Laura, the physical therapist come by and take me for a walk. This rebah was the oddest thing I had ever experienced. While I could walk on the thing, it was still remarkably difficult to move it around and get myself into and out of bed. It's a rather different experience from any of my prior injuries.

Keith and Teagan came by that afternoon/evening to visit, which was quite nice. Mary Riendeau also came by with a bunch of balloons and a bucket of goodies. I think I was pretty cognizant that evening, but I was, in fact, on narcotics, so who knows. I asked about food and almost miraculously a tray appeared moments later -- clear liquid diet. Yuck. I drank some bouillon and called it a meal. Unfortunately, this didn't actually settle terribly well and just as Mary was leaving, so did the boullion. Oops.

The night was the first I'd spent in a hospital since Teagan was born. And I was feeling pretty great then relative to this time (even with a C-section and a terrible close). So the night was rough. I got at least one shot of dilaudid (narcotic pain killer), but it was still a pretty rough night.

I felt much better the next morning. OT showed up early (before 8) and went through my stepping into/out of a shower, getting to the bathroom, etc. She cleared me to go home! PT showed up later in the morning (after another tray of clear liquid diet and another attempt at bouillon). We mastered the stairs -- I can't tell you how much easier crutches are when you're weight bearing. With non-weight bearing, stairs are always a bit terrifying. With weight bearing, they are a piece of cake. Cleared by PT. Unfortunately, on the way back from PT I got a bit nauseous again and I experienced the return of the morning's bouillon.

Then things got bad: they decided to give me reglan for the nausea. Unfortunately the reglan started giving me the shakes -- so bad that my muscles started clenching and I was in agony. In what seemed like forever, they tried some adavan to help relieve the shakes. Eventually I calmed down, but within a couple of hours, I felt the shakes starting to come back on again. I alerted the nursing staff, but it seemed like it took forever for anyone to do anything -- this time they tried demerol. Finally the shaking stopped and didn't come back.

But this ended up torpedoing any chance I had of going home that day. I would have been OK with the nausea if we could have skipped everything else!

Keith came by that evening to visit again, and we planned to get me out of there as early as possible the next day. I had one more PT session that evening, walking further, doing stairs again, etc. Hemotology signed off on my status. The surgeon came by and he seemed happy.

So, on day two post-op, I had one last PT session, another visit from the surgeon, another hemotology checkout, and then got myself cleaned up and dressed and went through the endless pile of paperwork. I think we finally got out of the hospital around 11:30 AM. The PT was completley accurate that the day right after surgery was the worst and that the second day after was considerably better. It may be that staying in the hospital both days was really all for the good.

Home Rehab

Part of the discharge process includes setting me up with both home nursing service and home PT. It seems that the home healthcare service spent a large part of Thursday trying to reach me, but they kept calling my cell, and I wasn't really paying attention to it (I also don't get great cell reception in the house). It turns out that I was going to be getting weekly visits from a nurse and PT three times a week for awhile and then twice after.

This bout of rehab has been rather different from anything else I've experienced. On one hand, I can walk -- I'm pretty much fully weight bearing and just using the crutches to make sure I'm balanced and I take fairly normal strides. Put another way, the goal is to make sure I don't develop any bad walking habits. So that is quite amazing. But then there are stupid little motions (sliding my right leg off to the side) that are exhausting and painful. The exercises I'm supposed to do seem so trivial, but man do they knock it out of me!

I took my last dose of narcotics just after midnight Thursday night and stopped all painkillers at that point. I hate how the narcotics make me feel, and the tylenol doesn't seem to do anything.

Friday was one of those days of sitting around, napping, not eating much, changing positions, napping, etc. Both the nurse and physical theraphist came by around two and checked me out to make sure all was going well. Immediately after I had to do a qualifying exam via Skype. I was pretty good for the first hour, but could feel the fatigue setting in by the remaining half hour; after I just crashed for a couple hours of napping. I think the combination of 1) not feeling like eating much, 2) still recovering from surgery, and 3) the exertion required to move around was combining to make me extremely tired.

That night as I went to bed, Teagan commented on my bruising. It is all in the back of my leg, so I couldn't see it, but I decided to start photographing the progression of the bruising. We didn't save the Friday night pictures, but the Sunday night pictures looked like this:
Wow. I had no idea.

Saturday and Sunday were much of the same -- moving around, sitting around, icing, getting stiff, walking around, napping, etc. While the pain isn't too bad, I would also say that I'm pretty much constantly uncomfortable. At the same time, I can feel that things get just a touch easier each day. Another physical therapist came over on Sunday, and she pushed me through all my exercises and reminded me to get a few real walks in each day. So, I decided that I would make sure I did three sets of each of the three types of exercises I had and take three walks. Although my walks were slow, I was able to do a 5 minute walk, an 8 minute walk and a 12 minute walk. That felt pretty satisfying.

Unfortunately, the laying down exercises were so extraordinarily painful and difficult (the PT assured me that they'd be a lot easier if I were still doing painkillers) that they left me kind of whimpering by the time I went to bed (honest).

I decided to take it much easier on Sunday -- only a couple of sets of exercise and one 15 minute walk. But I did get a lot of work done around the house -- mostly paying bills. This ended up exhausting me in new and different ways! My back was really, really sore -- essentially, my hip flexors are super tight and this puts strain on the back. Stretching the hip flexors is the most painful thing I have to do, with abduction a close second.

Monday wrapped up my last day in the first week of surgery -- I managed to stay awake all day, until about 5:00, including a few sets of exercises and a 15 minute walk. My appetite had pretty much returned to normal (although I have no sweet tooth, which is OK with me). I'm trying to eat as much iron-rich food as possible in an effort to combat the fatique. In other situations, I've found it pretty effective.

So my week one summary would be something like this

  • Walking is remarkably easy.
  • Tightness in the hip flexor is the single biggest problem leading to stiffness and an unnatural gait.
  • The muscles that got damaged in the surgery (hip abductors, in particular) are the most troubling in terms of what I can do. My guess is that this would not be the case for the anterior approach -- something I haven't discussed. The traditional hip replacement takes place from the rear buttock. There is a new approach that comes through the front. In theory, it's supposed to preserve more muscles. My experience is that the anterior is more common on the west coast; on the east coast, every surgeon I spoke with was much more comfortable with the posterior approach, particularly because it provides better visibility. The tradeoffs are nicely summarized here. In theory, the anterior approach leads to faster recovery, but the numbers I see and what I expect don't fully support this and to the best of my knowledge there are no conclusive studies.
  • I was bathing independently by day 5; day 4 was mostly independent. That said, we have a walkin shower with a built-in seat, which makes things easy. I have an extra chair next to it that mostly gets used for getting out of the shower, put also provides some leverage to keep that right buttock off the toilet.
  • Appetite has pretty much returned to normal by day 6.
  • By day 7 I was reasonably functional in terms of phone calls, conversations, balancing my checkbook, paying bills, etc.
  • The bruising is really quite amazing.


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