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^{Chapter I. Making the Decision}

How does one arrive at the decision to commit to surgery that involves, stated bluntly, sawing off the top of one’s femur and installing a metal replacement joint? This is not an easy decision. It can be said that total hip replacement surgery (the technical term is total hip arthroplasty) is a last ditch effort after all other measures to avert pain and disability have failed. Yet, I claim that by the time it is necessary, the decision is almost made automatically. By that time, the alternative is debilitating pain and physical impairment. Nobody likes surgery, but I can tell you that I have had absolutely no regrets that I have had it. I feel as if I have a new life in front of me.

Because you are reading this, you have probably arrived at the conclusion that total hip replacement surgery might loom in your future. You will identify with some of my early experiences with pain, treatment, and, of course, denial. What I wish to stress is that, although it is a weighty decision, eliminating the pain, suffering, compromised lifestyle, and, in some cases, heightened damage to the body, are worth the inconvenience of surgery.

Prior to surgery, I had developed a very bad limp. I had let it go too far. My back developed a curvature from compensation for the bad leg. My lifestyle was severely compromised. I looked upon people who could walk normally with great envy—including people much older than I am. I was old before my time, and I was constantly in pain. Thus, the decision was easy for me, albeit a long time in the making. Let us wind the clock back about ten years, to my first symptoms.

The onset of pain

You feel a twinge of pain in your hip. It quickly goes away. A couple of months later, you feel another twinge. It might vanish quickly this time or it might stay with you for a while. Then perhaps you have a business trip and spend a day running through airports, scrunching your body into a fixed position for hours in a crowded airliner, standing in hotel and rental car check-in lines, and engaging in the myriad other body-punishing “features” of modern travel. The next day you are awash in pain from that hip. Then the pain departs for a while, and you quickly forget about it. Sometimes you are able to function completely normally without pain. Because of the insidious onset and because it is still tolerable, you probably will sum up the sporadic pain as an inevitable consequence of aging. You are in denial. The pain is a serious warning you should not ignore.

In many people, this is how the pain of degenerative osteoarthritis of the hip joint presents itself. It happened to me this way, too. I, too, denied its existence for several years.

I would say that my first bout with hip pain came about ten years ago. It was merely annoying at that point. I felt that I could work around it, and I did. I put up with the pain, writing it off as one of the dubious joys of middle age. Sometimes the pain would hibernate for a while. Of course, it always returned, generally getting worse with each bout.

Seeking medical advice

When it became clear that my pain would not be taking a leave of absence, I became more serious about exploring possible corrective measures. At first, my family doctor prescribed some mild non-steroidal anti-inflammatory drugs (NSAIDS). I believe the initial drug was ibuprofen. For a while, this kept the pain at bay. However, I wanted to learn more about the prognosis for my left hip, so I visited an Dr. S., an orthopedic surgeon who had helped me with a heel spur a few years earlier. Call him Dr. S. His X-rays confirmed degenerative osteoarthritis of the left hip. I had complained to him that driving was painful because of having to frequently operate the clutch with my left leg. He responded that I would know when it was time to stop driving a car with a manual transmission and I would know when it was time to consider more serious measures. Of course, “more serious measures” meant surgery. In the meanwhile, he changed my NSAID prescription to something he liked better than ibuprofen, and it seemed to do the job—for a while.

A year or two later, I arranged to see a rheumatologist, Dr. F. After some manipulation and evaluation, she confirmed the presence of degenerative disease of the left hip. She felt that I should manage pain via NSAIDs and lose weight. She stated that I should live with the situation as long as possible before committing to surgery. She changed my prescription to yet another NSAID, this one called Ansaid. It seemed to offer more relief from pain, but it was very hard on my stomach.

My family doctor, Dr. M, was an important factor in my decision making process. He supported me through times of severe frustration with the healthcare system. He also kept close tabs on my liver, which was necessary because I was taking huge doses of potentially damaging NSAIDs. The results of one such liver enzyme blood test in 1995 caused a major scare. My alkaline phosphatase was severely elevated, indicating any of several problem areas. A retest with fractions disclosed that the problem area was abnormal bone growth. This could indicate bone cancer. I went to the hospital for a bone scan after which I sweated it out for two days waiting for the results. Finally, the report came back: osteoarthritis of the left hip was the cause of the unusual bone activity. I was relieved, but somewhat concerned that the damage to my hip was accelerating.

Lifestyle changes

It was depressing to think about it, but within a year or two after the onset of pain, my arthritic hip was starting to get in the way of my normal lifestyle. On the golf course, never a place where I was happy with my performance even without hip pain, I could no longer swing the club around completely. (An important part of a golf swing is the hip turn. My hips did not turn easily.) Walking 18 holes—even with the aid of a cart—would leave me aching and ready for the “19^th hole,” where several rounds of beer would generally wash away the pain for a while. However, on the course, I was unpleasant and irascible.

Other, similar situations threatened my friendships. Walking with friends to sporting events or shopping would cause my hip joint to flare up to the point at which I could not participate in any conversations that took place. Instead, I concentrated on walking. Each step was painful. Slowing down was painful. Speeding up was painful. Stopping and starting were painful. Stepping off curbs was painful. Uneven surfaces were painful. Because every second step resulted in a sharp stab of pain, I appeared to be withdrawn and uncommunicative when I was actually concentrating on surmounting the pain. Simple things such as rising out of a chair after dining required an extreme mental effort. A few minutes before I actually stood up, I would have to start girding myself for the blast of pain I knew I would experience. While others were saying goodbye, discussing postprandial entertainment, or exchanging other amenities, I would be wincing, awash once again in pain and unable to speak for half a minute or so. When I did speak, I was irritable and belligerent. The overall assessment by many of my friends, though not openly stated, was that I was becoming a miserable, crotchety old man.

They were right, and I admit it. Pain was controlling my life. By early 1995, about seven years ago, it was clear that if I did not do something about it, I would degenerate into a reclusive cripple with no friends. To compound the problem, I was in the midst of a political conflict at the office, which did not help my mood at all. Some of the problems there related to my realization that I was becoming a slave to my pain. I had become preoccupied and indecisive. Instead of dealing with the problem directly, I was letting the pain get the better of me. Furthermore, the same irritability and bellicosity that threatened my friendships also beleaguered my professional associations.

To be blunt, I sometimes compensated for my pain by making others miserable, too. Looking back, I suppose I was trying to share my pain with friends and business associates. That was a mistake. Nobody else can feel your pain. Few others can even understand your pain. I was expecting people to make accommodations for me even as I was alienating them with my pain-inspired bad behavior. This was obviously a no-win situation.

At other times, I hid my pain well. Still, it was clear to most of my friends and some of my more observant family members that something was wrong.

Physical changes

As walking became more and more of a struggle, my exercise schedule quickly tailed off. I used to love to take long, brisk walks, but it had become far too painful to walk for exercise. Jogging was obviously out of the question. I have a Schwinn Airdyne exercise bike, which was always the easiest way for me to get an aerobic workout, rain or shine. For a while, I was able to surmount the hip pain that would sometimes flare up when using the bike. As time went on, if the pain was not debilitating during the actual workout, it would come with a vengeance the following day. After a while, I began to miss days. Thus, the backsliding began. One additional problem arose when I used the Airdyne. My left heel would bang against the frame of the bike while pedaling because of the deformity in my hip joint. The femoral head was rotated outward and pressing upward, causing my left foot to turn outward. When my heel started taking that beating, I knew that it was time to stop using the exercise bike completely.

Other changes in my physical stature and my gait began insidiously, but steadily grew worse with the passage of time. I was compensating for my bad leg by swaying when I walked. I could not carry a cup of coffee from the kitchen to my favorite chair without spilling a sizeable amount of coffee into the saucer or onto the floor. The worse the pain became, the more violently I would sway. Even with a cane, I had a Walter Brennan gait.

What is worse, I developed scoliosis (curvature of the spine) due to compensating for the bad leg in this exaggeratedly swaying manner. I first noticed this when zipping up my trousers. The top of the zipper would always point an inch to the left of my belly button. My belt buckle did not align with the buttons of my shirt. If I moved it to try to align it, the whole thing looked crooked. My thoracic vertebrae were going right while my lumbar vertebrae were going left. Subsequently, X-rays and an MRI confirmed this. I was like an old, swayback horse, ready for the glue factory!

I would be remiss if I did not mention that physical pain has an insidiously depressing effect on mental activities. After years and years of suffering chronic pain, you might not be consciously feeling the pain. You have “tuned it out.” Yet inside your brain, the act of tuning out is still a distraction. Thus, pain is at once fatiguing and mentally distracting. For this reason, my capacity for work involving concentration decreased remarkably during the lengthy crescendo of my hip pain. Increasingly at work I would subconsciously choose “no-brainer” tasks instead of complex problems, ignoring the tougher ones until my head cleared. It never did. My powers of concentration succumbed to limitations imposed by the pain. This effect was something I never thought about until after the surgery, when I felt the gradual return of my ability to concentrate. Although it might sound strange to couch it this way, absence of pain gave me one less major thing to “think about.” Had I known how serious this effect was, I might have pressed the surgery issue much earlier for that reason alone.

Let me now leap forward to my initial consultation with the surgeon I would eventually select to perform the operation, Dr. G. He remarked that I probably had such a relatively high degree of resistance to pain that I did not know the extent to which the pain was affecting me. Had I remained unconvinced that I needed the hip replacement because of the deterioration of my lifestyle, he could have graphically demonstrated the effects of the pain by administering local anesthetic in the left hip joint, which would block the pain there for an hour or so. It was his conjecture that being free from the pain of a hip that was as far gone as mine would convince me that the surgery was greatly preferable to suffering in silence. I told him that it was not necessary, that I had resolved to have the surgery. Looking back, had I taken him up on the anesthetic, I might have asked him to operate on me immediately after the effects wore off!

Conservative measures

Because surgery is a big deal with inherent risks and lofty expenses, doctors and insurance companies tend to recommend it only when all other measures have failed. The term conservative measures encompasses drug therapy, physical therapy, massage therapy, use of herbs and supplements, and alternative medicine—anything short of surgery. Unless it is an emergency, there is little chance that a scrupulous surgeon will commit to a total hip replacement operation unless the patient has employed at least some of these conservative measures. I describe a few of them below.

NSAIDS

Non-steroidal anti-inflammatory drugs (NSAIDs) are likely to be your first course of conservative treatment. As I mentioned above, this was the first form of therapy for my hip pain. NSAIDs are available in over-the-counter and prescription varieties. There are approximately sixteen such drugs. Examples of over-the-counter formulations are Advil (ibuprofen), Alleve (naproxen), and Orudis KT (ketoprofen). There are many prescription strength NSAIDs, which are either merely increased dosages of NSAIDs available over the counter or higher potency formulations that are not available over the counter. NSAIDs exist in both brand name and generic varieties.

With the exception of two new drugs I will get to shortly, all of the NSAIDS have potentially serious side effects involving the stomach, liver, and kidneys. Taking large doses of these drugs over time can cause serious damage, including life threatening internal bleeding. In all cases, you should take them with food and a doctor should monitor you carefully at regular intervals. The two new drugs I mentioned earlier, which are supposedly easier on the stomach, are called COX-2 Inhibitors. At present, these are Celebrex and Vioxx. Perhaps because of the reduced side effects, they have gained considerable popularity among arthritis patients. However—and take this as completely subjective, anecdotal, layman’s testimony—I found that for me they provided significantly less pain relief than other NSAIDs I had taken. To be fair, please note that these two drugs were introduced late in the course of my hip degeneration, when the pain was severe. At an earlier point, they might have been more effective.*

My progression through the NSAIDs over a seven-year course had included ibuprofen, Nalfon, Relafen, Ansaid (which was very hard on my stomach and might have been the cause of some hair loss), ketoprofen, Naprosyn, Celebrex, Vioxx, and Voltaren. The last of the NSAIDS I tried and stayed on for the two or three years before surgery was a 1200 mg daily dose of Daypro. At the end, in the several months prior to surgery, nothing short of morphine would have helped.

Supplements

The FDA does not control food supplements as closely as it controls drugs. While manufacturers must nevertheless be careful with frivolous claims, the public can purchase these products  without prescriptions and can use or abuse them as if they were food, rather than drugs. Manufacturers can provide anecdotal evidence of the effectiveness of the products and consumers who are convinced by the hype can use the supplements to their hearts’ content. A huge dietary supplement industry has burgeoned in the past twenty years, as is evidenced by the growing number of “health food stores” appearing in shopping areas. Because of the size of the markets involved, it is not surprising that two major targets for such supplements are weight-loss and arthritis.

I am not saying that supplements are always bad or a waste of consumers’ money. In fact, I have tried glucosamine/chondroitin and MSM. I have friends who swear by them. For me, the jury is out. I have seen no evidence of cartilage regeneration in my X-rays since taking glucosamine/chondroitin. I do not know whether it relieved any of my pain, either. The pain was all but overwhelming at the end. A small amount of relief would have been barely noticeable.

The best thing I can say about these supplements is that, like chicken soup, they might not provide a cure, but they couldn’t hurt. However, be careful to keep up to date with current findings about food supplements you are contemplating taking. In recent years, many have been pulled from the market after harmful side effects were discovered. Moreover, it is essential that you apprise your doctor of any supplements you are taking.

Physical Therapy

It is of great benefit to keep those joints moving, active, and the surrounding muscles, tendons, and ligaments strong and healthy. Any amount of exercise is quite helpful. After a while, however, you will find that your exercise capabilities have decreased. The pain is the culprit here. Keep at it as long as you can, though. Even when surgery is inevitable, keeping those muscles strong will be beneficial in speeding your recovery.

“You’ll know when it’s time.”

You have cycled through the NSAIDS, you have tried some physical therapy, you have seen orthopedists and rheumatologists, you have taken huge doses of glucosamine/chondroitin or MSM, maybe even tried bee stings or some of the other radical alternatives, but that hip pain seems to be getting worse and worse. In my case, it was bad enough to keep me awake at night. No position in bed was comfortable. The pain gnawed away at me night and day, day and night, ad nauseum. This was the point at which the there was only one clear solution path.

The words of that first orthopedic surgeon, Dr. S, echoed in my pain-beleaguered brain: “You’ll know when it’s time.” For me, it was time.

Of course, fate intervened. I had left my heartburn producing university job, becoming a self-employed consultant. In 1998-99, I landed a large consulting assignment that entailed commuting between Florida and California over a 15-month period. This project was rewarding both professionally and financially, but it nearly finished off my hip. When the project wound down and I returned to Florida full-time, my first order of business was to begin seriously pursuing surgery. As it turned out, it would take a year to get things going on the right track. After a false start or two, I was successful in finding the right surgeon. I shall describe that search in Chapter III. Finally, in October 2000, I made the commitment to myself to arrange for the total hip replacement surgery.

In the next chapter, I will present brief synopses of books I had read for background on total hip replacements. I found them very helpful and informative. Read them if you have the time and the wherewithal. I urge you to get all the information you can. Forewarned is forearmed!

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Copyright © 2001, 2002, Benjamin I. Goldfarb
All Rights Reserved