My new hip
As proven by Floyd Landis in the 2006 Tour de France a bum hip does not necessarily prevent one from participating competitively in cycling. Far from suggesting he and I are in the same league, we do have one thing in common: we both have a unilateral post traumatic hip problem . In 1968 I dislocated my right hip and fractured part of the femoral head. I spent about 3 months in full body cast and subsequent traction. As opposed to Floyd Landis I was fortunate enough not to develop avascular necrosis of the hip. Avoiding running and walking whenever feasible, I kept myself in shape with long distance swimming and scuba diving. I was able to lead a pretty active life including skiing, horse polo and fox hunting with rather minimal symptoms. I started cycling in 1992, which actually helped the mobility of my hip joint. The many Furnace Creek 508's and Solo RAAM 1996 and 1997 did not aggravate my symptoms. I had to make some adjustments in handlebar height, aero-bar position and cleat position. Speedplay pedals offered me the range of motion to " toe out" while pedaling. In 1998 I even finished the Western States100 mile Tevis Cup, which required a great deal of running to "save" one's horse. While training for two man team RAAM 2001 I started to develop the occasional right groin pain , which I attributed to over training. During RAAM 2001 my right thigh muscles and hip would get very sore and stiff when off the bike. Again erroneously I did not attribute this directly to worsening arthritis. Initially unnoticeable by me, I developed a limp. This gradually got worse, but cycling continued to offer some relief. In 2004 I could not walk very far, but still finished the Furnace Creek 508. My wife and I started Argentine Tango in 2005 which certainly did not do my hip any good. In 2006 , to try to alleviate neck problems, I changed to riding recumbent tricycles. Retrospectively, the increased hip flexion inherent in riding a recumbent aggravated my symptoms. Finally climbing Onion Valley Road and Townes Pass ( 8200 ft of elevation gain in 24 miles ) in one day proved to be the proverbial straw. Changing to the ICE Mini tricycle with its lower bottom bracket allowed me to continue to stay in shape without worsening my condition. Regardless towards the latter part of 2006 I could hardly walk and even required the occasional use of crutches, which brings me to the next chapter.
Xray and MRI demonstrating osteoarthritis with severe joint space narrowing and cyst formation right hip
Search for the "right" hip and surgeon
For years I knew that sooner or later, I was going to need an artificial hip joint. I was hoping to postpone that dreaded procedure well into my sixties allowing this technology to advance further. Currently the useful life of an artificial joint has dramatically lengthened but is still finite. I dealt with this issue by " sticking my head in the sand". I never researched the various developments even though, being a radiologist, all the literature was readily available to me and I was in frequent contact with many orthopedic surgeons. So much for being prepared! The rapid decline of my condition hit me like the proverbial " ton of bricks."
Googling total hip replacement ad nauseam, it became clear that the only viable options for me personally were either the ceramic on ceramic or the "big head" metal on metal joints. For the various pro and cons I will refer to links I found most informative. Working my way through the literature and having the benefit of discussing this with several excellent orthopedic surgeons one thing was crystal clear: no matter what the choice of implant, the surgeon with his skill and experience would the single most important factor in the functionality and longevity of the joint. I consulted several surgeons specializing in hip replacements, talked to numerous patients and decided on Dr. Brad Penenberg. In my mind he clearly stood head and shoulders above all the other orthopedists in Los Angeles area in his dedication to and development of the least invasive way to perform a total hip replacement with most soft tissue preservation and faster return of function. Dr Penenberg suggested the metal on metal big femoral head ( BFH )prosthesis from Wright Medical Technology, similar to the prosthesis he used for Jimmy Connors, the tennis champion.
Surgery was scheduled for January 9th at Cedars Sinai Medical Center, second case of the day. The days leading up to the surgery were spend agonizing about ceramic versus metal joint replacement. Ceramic on ceramic demonstrating the least wear but much smaller femoral head (28-32mm ), potentially smaller range of motion, small risk of fracture of the ceramic with subsequent difficult revision and ? more difficulty in avoiding leg length discrepancy. Metal on metal offering a potentially more balanced and stable joint with no risk for dislocation or fracture. Unfortunately the serum levels of chromium and cobalt are markedly elevated with this joint. So far this has not resulted in statistically significant changes in cancer rates. The numbers however are relatively small and the implantation times are less than 20 years. As far as I know there currently does not exist a tumor registry for patients with these implants, so who really knows? After turning myself into a complete nervous wreck, I finally decided to go with the opinion of my chosen expert and take my chances with the metal on metal joint.
All that stress probably lowered my immune system enough for me to come down with a nasty flu the days preceding the scheduled surgery. To make matters worse there were severe Santa Ana conditions with strong winds and very dry air. Dr Penenberg's physician assistant recommended to show up for surgery anyway unless my condition worsened. I kept myself NPO untill about 4am at which time I threw in the towel. Fever up to 101.9, splitting headache and very sore throat. My wife called the OR to cancel the surgery and I grabbed the Tylenol and water bottle. Did I feel like I whimped out! Getting even sicker later in the day I finally realized that there was no way they would have gone ahead with a total hip replacement.
Fortunately Dr Penenberg was able to reschedule for the next week, same day, same time. Guess what? More time for second thoughts and concerns about postoperative leg length discrepancy. Because of development of pelvic tilt I already had an apparent longer leg on the right. Now I got worried again. If he would make the joint slightly loose i.e. shorten the prosthesis or whatever, would I end up with a shorter leg on the right after the pelvic tilt resolves? Or alternatively if he makes the legs equal and the tilt does not resolve would I keep my longer right leg with further aggravation of my bad back? I hope for Dr Penenberg's sake that not all his patients second guess and ruminate like me.
January 16th ,Tuesday at 7 am the Pop family gets to the OR waiting area. Little did my wife and kids know they would spend the next 12 hours in that room. At about 10:30 I get my spinal anesthesia and next I know I wake up in the recovery room at about 1 pm. Numb from the waist down and unable to even move my toes. Pretty weird. The recovery room appears way overcrowded. Apparently there are not enough empty floor beds to accommodate the busy surgery schedule. I don't care but it is driving my family crazy. Linda is allowed to see me for a few minutes. Finally at about 5:30 pm they transport me to the floor. I am very glad to see Linda, Melissa and Michael. I am starving and dying for a Starbuck's Frappucino but only some juice and gel for me. Later that night they get me up using a walker with full weight bearing. The next day physical therapy starts, It is remarkable how "easy" walking (assisted) is relative to lifting my leg, moving it in all directions, getting up, sitting, etc. Must have lost some blood during the surgery, my hemoglobin had dropped from 14.1 to 11,6. Thursday morning I am all set to go home. Get my PT instructions and 11 day supply of Fragmin ( low molecular weight heparin to prevent deep venous thrombosis ) and we are off, back home to Malibu. I am still shell shocked and in a daze that I actually have this artificial joint instead of my good old arthritic hip. Now the hard part starts, to get back in shape and trying to get a full range of motion.
My new "metal on metal" hip, 52 mm head
It feels like a full time job: trying to walk as correctly as I can with a cane to assist, doing the various exercises, rest and start over again. Each afternoon I inject myself subcutaneous with a dose of Fragmin, I hate it! I am taking Celebrex 200 mg PO/ daily for the next month. On Saturday I walk much better, receive a visit of the home health physical therapist and get instructions for more exercises. My right leg length is about the same as preoperatively. Hopefully I can get rid of that pelvic tilt. Thursday I get my first outpatient physical therapy at Malibu Rehabilitation Center. More exercises , including leg abduction against gravity and most difficult of all straight leg raising while supine. The latter I just can not perform without some assistance, incidentally this was difficult for me prior to surgery as well. I am trying to avoid sitting for even a relatively short time. It just makes it that much harder to move around afterwards. Like I said getting back to normal is a full time job.
January 30th Its now two weeks after surgery. I walk much better, but have no endurance. After 5 minutes I need my cane to prevent a slight limp. Range of motion is better, but I still have a long way to go Standing straight legs feel now about equal. Hurrah! Got the approval from PT to ride my recumbent on rollers. I have been riding it 10 minutes twice a day in a low gear. It's amazing that I can get in and out of that low seat without problems.
February 1st Just got back from my first follow up visit with Dr Penenberg and his assistant Anna. The bandages were removed, incision looked good. Xray OK. Both surgeon and patient are happy. Anna gives me a few more exercises to improve range of motion. Dr Penenberg advises against the leg lifts, to let the tissues heal and avoid the risk of trochanteric bursitis. I am glad I asked. I will concentrate on the range of motion exercises. Driving is OK as long as I feel that I can do this safely.
February 6th Went back to work for 1/2 days starting Tuesday, three weeks after surgery. Amazing really to be able to do that so soon after surgery. Walking is OK for about 5-10 minutes. My leg however stiffens and gets sore very quickly. Four hours of film reading is all I can manage. On top of that I developed tingling in my left hand secondary to the cervical scoliosis and foraminal stenosis and probably aggravated by the position of my neck during surgery. Even riding my tricycle on rollers is making it worse. Rather depressing. All that results in very little sleep. Thursday I developed some hip pain walking especially starting off and getting out of a chair, making it even more exhausting to work in the morning. Will take it a bit easier and cancelled the physical therapy Friday. Hopefully my next entry will be more positive.
February 14th Four weeks after surgery. Working 1/2 days. Walking much better. Sometimes I even forget to carry my cane. Early in the morning and during the night I still need it when my muscles are very stiff and sore. The new onset of hip pain resolved. The tingling in my left arm and hand continues to bother me. For the last two days I have been taking 200mg Celebrex twice rather than once a day in the hope to cool down the nerve irritation. Muscle soreness and restless feet are less. The last two nights I was able to sleep off and on without Vicodin. Abduction of my right hip is nearly equal to the left. Still have some problem bringing my thigh to my chest and putting on my right sock. Continue to work on the flexion contraction.. Been riding the trike on rollers in low gear 30 minutes twice daily. Today rode the Mini for 15 minutes on the parking lot.
February 21st Still working 1/2 days. This interferes with my range of motion exercises. So be it. In between reading films I try to do some exercises in the chair as well as getting up and try to start walking without " cheating " when putting weight on my right leg. My neck is still bothering me, but I am sleeping better. Started riding my trike in very low gear on Encinal Cyn. This weekend I was able to climb Encinal to the top in 1hr and 13 minutes. Before the surgery this would take just over 49 minutes. This week I switched to the Catrike 700, which is easier on my neck. Today I rode for 16 miles on PCH north of Ventura County line. I am trying to improve my walk using the mirrors in our dance studio and even practice some Tango steps. This is helping me to improve my balance. I am very glad I went with Dr Penenberg as my surgeon. Reviewing some of the postoperative instructions following the more conventional hip replacement, I would have barely made it out of crutches and would still be following hip dislocation precautions.
March 13th Eight weeks post surgery! Last week we extended my working hours to about 3/4 days. I am now back to essentially full time, while allowing some time for physical therapy. Because of difficulty scheduling I am down to physical therapy once a week. I am back to riding Encinal Cyn daily. Still taking it somewhat easy, my fastest time is about 53 minutes. Yesterday I took the longest ride so far : 2 hours and 16 minutes, Encinal Cyn to the top of Yerba Buena Rd via Little Sycamore Cyn Rd with 2400 feet of climbing. I am walking more, mostly along the beach. The longest so far just over an hour from my house to Trancas Starbucks and back. The walking wears me out much quicker than cycling. Still impossible for me to stand straight on my right leg without " cheating " by bending to my right. Range of motion better. Trying to practice Tango each night, hopefully that will help with my balance. Twenty minutes is about all I can take. Went to the Tango Room last Saturday but that was pushing it, we did not dance all that much. Overall the hip is doing well. The paresthesias in my left arm and hand however are driving me crazy! Its hard to find a comfortable sleeping position. Keeping my fingers crossed. Next week I will have my follow up visit with Dr Penenberg and I will be back on the call schedule.
March 21st Nine weeks. Checkup visit with Dr Penenberg. Last week I walked 3 miles each day for the last five days. In addition I had to walk quite a bit in the hospital and I am back doing procedures wearing a lead apron. Subsequently I developed a dull ache in the front of my thigh, especially while standing on my right leg. Dr Penenberg advised me to take it easier. It's only two months after the surgery. Ride the bike instead. I am allowed to start gaining strength in the abductor muscles, specifically the gluteus medius. So far so good. I am now at the stage that the improvement is far more gradual. Rather frustrating!
April 3rd Twelve weeks. Walking less, cycling more. Back to work fulltime. In physical therapy we found out the pain in my thigh originates from the distal aspect of one of the adductor muscles rather than from the quad muscles. Very painful on deep massage! Rather unusual. Unfortunately there is no good stretch for this particular muscle. The idea is to massage it myself, which turns out to be nearly impossible at work. Tango is on the back burner now. Will start again next week.
May 16th Four months. Checkup visit with Dr Penenberg. Still impossible to get up and start walking without an initial limp. Dr. Penenberg does not appear to be too concerned. I have to admit I went to physical therapy only once in the last two months and I am slacking off doing the various exercises. Taking time out for this, while working fulltime, seems impossible. Tango still on the back burner. Worried about all the clicking in my left knee with leg straightening , especially while getting out of my chair. Determined to do "VMO" strengthening exercises.
June 14th Five months. Still a challenge to walk without an initial limp. Standing straight on my right leg without balancing against the wall or furniture is still not possible. Walking quite a bit in my work. Have to force myself to do the exercises. Just back from a three day trip climbing some of the steep climbs from Lone Pine, Big Pine and Bishop. Unconsciously I am still somewhat favor my right leg pedaling my trike, making me less strong as compared to last year. But no pain at all afterwards. What a difference!