Sigrid's Recovery

My Hip Injury

I love summer. Like most captives of Northern Ontario, I eagerly anticipate the end of spring so that I can dispense with my ski jacket, boots, and headband in favor of shorts, T-shirts, and running shoes. I like to sit outside on my front steps listening to the robins sing, watching the neighbors, and basking in the warmth of the sun.

I spent a lot of time sitting on my front steps during the summer of 2000 until I became aware of a nagging pain in my left hip. I've always had to be careful about sitting in certain positions for long periods of time since I fractured and dislocated my hip in an auto accident in 1981. I was visiting my parents in New Jersey when I was hit by a drunk driver and nearly killed. I sustained multiple injuries including a concussion, whiplash, a punctured and collapsed lung, several broken ribs, and a number of broken bones, such as fractures of my hip, pelvis, wrist, arm, knee, and lower leg bones. After three weeks in intensive care, I was moved to the orthopedic ward. I developed Post-Traumatic Stress Disorder and suffered from panic attacks, recurrent nightmares about car crashes, and flashbacks for many years. I was 28 years old at the time and as the band R.E.M. so succinctly put it, the accident was the end of my world, as I knew it.

Initially, my hip was set with a closed reduction, meaning that my orthopedic surgeon put my hip back into place manually after it dislodged. However, the nurses in the hospital were busy and did not always answer call bells promptly. One day I was dying for a bedpan and decided that I simply could not wait 20 minutes for a nurse to appear, so I cleverly bent down towards a small cabinet by my bed to get the pan. I was very pleased with myself until I began to experience horrific pain. Sure enough, I had dislocated my hip again by twisting my body forward. This time the solution was not so easy!

My surgeon, whom I affectionately but brazenly called "Joey," told me that in order to repair my hip, he would have to put me in K-wire traction. This involved the surgeon and his team drilling a hole straight through my already broken knee to insert a wire from one side of the knee to the other. One Saturday morning, he appeared at my bedside looking like a carpenter with a full set of nasty looking tools wrapped around his waist. I had been given a local anesthetic but it did not put a dent in the searing pain I experienced. Nor could it assuage the extreme anxiety and distress that was prompted by watching my orthopedist drill a hole through my knee. When the brutal procedure finally ended, the doctor put 25 pounds of weight at the bottom of the wire, and placed me in a position that is called Trendelenberg.

Anyone who has been in this uncomfortable position knows that Trendelenberg was probably devised by the Nazis. It required me to lie backwards in bed with my legs tilted up towards the ceiling for five long weeks. I was only allowed to sit up for meals, sponge baths, and other ablutions. Like the ghost of Jacob Marley tormented by his chains, I felt the wire inside my knee every time I switched positions. This caused great discomfort. To say that I was relieved when the wire was removed would have been a gross understatement.

I was not a very good patient. Before the accident, I had completed one and a half years towards a two-year Masters in Social Work at the University of Toronto. I was enamored with Toronto and content with my life. I enjoyed my studies and commanded a certain degree of respect as a graduate student. That ended abruptly with the accident when I found myself bedridden, in constant pain, and sleep deprived.

During the three months that I spent in the hospital, I had eleven roommates and every one of them snored! I began to desperately crave sleep, which caused tension between my doctor and me. There were no private rooms on the orthopedic floor so I requested to be moved to a medical ward. My surgeon was opposed to this; he knew that I would not receive proper care on another floor since the nurses on the orthopedic ward were specially trained to deal with my particular injuries. In retrospect, I understand that the doctor was protecting me by keeping me on orthopedics, but at the time, I was unhappy about the chronic exhaustion that resulted from my sleepless state.

My injuries had rendered me completely dependent on other people. It was frustrating and embarrassing to continually ask others for assistance. I struggled against a sense of helplessness and anger as was evidenced by insisting on getting my own bedpan, and brashly calling the surgeon by his first name.

When I was discharged from the hospital, I went to stay with my parents in order to learn to walk again. Five days a week, a private ambulance took me for intensive physiotherapy throughout the winter and spring. On a daily basis, I did a number of exercises to strengthen the quadricep and hamstring muscles in my leg. I also worked on flexing and rotating my hip joint. Eventually, I progressed to lifting weights with my injured leg and working out on a stationary bicycle.

I was non-weight bearing on crutches for six months before I graduated to a cane. A year after the accident, I was walking without any assistive devices but I had a significant degree of pain in both my left hip and knee. When I got a second opinion on my hip in 1982, the surgeon looked at my x-ray and immediately suggested that I have the joint fused. Hip fusion, otherwise known as arthrodesis, eliminates pain in the hip joint but the joint no longer has a wide range of motion. This can present problems with certain activities like getting in and out of a car and may significantly strain the back and knees. I had no such desire to restrict my movements and continued diligently with my exercise program, which eventually paid off.

I spent many years lobbying against drunk driving after I discovered that the man who hit me had a blood-alcohol level of .23, which was more than twice the legal limit. The driver was doing 70 miles per hour in a 30 mile per hour zone and hit me head on. At the age of 37, he had a record of driving infractions that went back 19 years. His license had been suspended and revoked a number of times and he had been caught driving without a license. My "accident" was not an accident after all; the man was a reckless driver and a self-described alcoholic. Our collision could easily have been prevented if the State had stepped in earlier to permanently revoke his driving privileges. Even after my accident, the man's license was only suspended for one year before he was able to drive again, and he was never charged with causing me bodily harm. He received the same sentence for hurting me that he would have received for running a red light.

It took time for me to forgive the man who had hit me. As a member of Remove Intoxicated Drivers, I was offered an opportunity to appear on 20/20 and to be interviewed by John Stossel. The show, entitled "It's Not My Fault," was broadcast as a Christmas special on December 26, 1985. The driver also appeared on the program along with the owner of the local restaurant bar that served him. I successfully sued both the drunk driver and the bar under the Dram Shop Law, which held third parties responsible for serving too much alcohol to drivers.

Appearing on 20/20 and on 60 Minutes in Australia allowed me to meet the drunk driver in person and to forgive him for turning my life upside down. The man was contrite, remorseful, and apologetic. He had stopped drinking immediately after the accident and thanked me for his sobriety. He told me that he started out every day of his life with a prayer for my health and recovery. The bar owner did not take any responsibility for the accident. He was indignant and felt victimized by my lawsuit against his restaurant. I understood the owner's position. I have always been ambivalent about the host liability act. How can a bartender tell who has had too much to drink in a crowded nightclub? Ordinarily, this would be difficult, but in my case, the bar that I sued was a small family restaurant that only served alcohol to ten or twelve people at a time. The man who hit me drank there frequently and the restaurant knew him. With a blood-alcohol level of .23, surely the bartender would have noticed that this regular customer was intoxicated.

By 1983, I had settled my legal disputes out of court. However, my health problems lingered on. The pain in my hip and knee had decreased to a tolerable level but the fractures had caused osteoarthritis in both joints. Before the accident, I had lived in Toronto without a car. I loved to walk and would walk four to five miles a day. I also enjoyed ice skating and sitting cross-legged on the floor. After the accident, I could not risk falling on ice nor could I rotate my hip into that yoga-like position in order to sit cross-legged. Like most people with arthritis, I began to learn the frustration of living with some degree of pain and limitation.

In addition to the soreness in my hip, I developed chondromalacia, a condition that causes damage to the kneecap and results in pain and swelling. And I had torn ligaments and cartilage in my knee, which could not be repaired surgically. I could no longer kneel since putting weight on my knee caused acute discomfort. Nonetheless, I walked well and did not have a limp. I could walk one mile a day and that was adequate for my new suburban lifestyle. For many years, the pain in my joints was manageable and did not interfere appreciably with my life, unlike the fibromyalgia and Chronic Fatigue Syndrome that resulted from the accident. Muscle pain and exhaustion became my daily companions. I was never able to return to work or to finish graduate school in Toronto, despite several attempts to do so. Over the next decade and a half, I worked as a volunteer at various women's centers, was active in politics, wrote freelance articles, and acted as a research assistant at a local university whenever my health permitted.

THE DECLINE OF THE JOINT

During the summer of 2000, my hip joint began to bother me again. At first, I thought that I had simply put the hip into a bad position by spending so much time sitting on the front steps with both knees raised higher than my hips. I began to sit on a lawn chair but this did not relieve my pain, so my doctor referred me to physiotherapy. In September, my therapist and I began working on different exercises for my hip. One involved me lying on my back and bending my left knee towards my chest in order to improve my hip flexion. After doing this exercise for about two weeks, I put my back out and was unable to walk for three or four days. At the time, I did not realize how interconnected the hip and the back were. This was the first of many episodes where my back would completely collapse on me as a result of the degenerative arthritis in my hip. After my back healed several weeks later, I timidly resumed the exercises. Within days, I was unable to stand on my left leg due to sharp, stabbing pain in my hip. It was so acute that I spent three and a half hours being investigated in the emergency room of a local hospital.

The doctor examined my x-ray and exclaimed, "Looks like you need a hip replacement!" "No way!" I replied. I was convinced that he was wrong. My hip had served me well for almost 20 years. Even though I was told at the time of the accident that I would need to have the joint replaced eventually, I did not believe that the time had come. I was 47 years old. I was too young for a hip replacement! The joint had only started to bother me within the last few months and I thought that it had been sprained by the physiotherapy exercises. I was certain that it would recover.

Despite the severe deterioration evident on the x-ray of my hip taken in the hospital, and the fact that I could hardly bear any weight at all on my leg, I refused to accept the fact that I needed the hip replaced. As the saying goes, "Denial is more than a river in Egypt!" Disbelief and denial were my first reactions to the diagnosis and I held on to them for at least a year after the episode in the emergency room. The average life span of an artificial hip is only 10 to 15 years. I was afraid that if I had the procedure done in my forties, I would need to have at least two more joint replacements during my lifetime. However, I accepted the hospital’s painkillers and had them refer me to a rheumatologist and a surgeon, despite my skepticism about the diagnosis.

The appointment with the rheumatologist was arranged quickly. I saw her within five or six days of my emergency room visit. She concurred with the emergency room doctor that the joint needed to be replaced. I was given a prescription for Celebrex, an anti-inflammatory drug, which made me sick to my stomach. We had to bypass the first line of treatment with the NSAIDs (nonsteroidal anti-inflammatory drugs) like aspirin or Advil because reliance on the latter had given me fourth degree ulcers.

Initially, I dealt with the hip pain by being as inactive as I could. The less I moved, the less my hip hurt. I started doing all of my cooking sitting down on a chair. I would drag a chair from the kitchen table over to the stove or to the refrigerator, using it as my own portable wheelchair, because I could not stand up to cook for even five minutes. When I went out with my friends, I would have them drop me right at the door of a restaurant, so that I would only have to limp in on my cane for 20 to 30 feet. I would sit in the car outside of the grocery store, feeling guilty and useless while my mother or my friends did my shopping.

CONSULTING WITH THE FIRST SURGEON

I braced myself for a similar diagnosis from the orthopedic surgeon, whom I was finally able to see that November. The doctor surprised me. He was loquacious, which was unusual for a surgeon. He spent at least 30 to 40 minutes talking to me and asked me all kinds of questions. He then began to describe a doom and gloom scenario; he told lurid tales about everything that could go wrong during the hip surgery. I could get a blood clot that could travel to my lungs or my brain, and provoke a stroke or kill me. The new hip could dislocate. I could get an infection that would necessitate re-operating, with a chance that my hip joint would be so damaged that I would have to spend the rest of my life in a nursing home, confined to a wheelchair. I could have a heart attack on the operating table or the surgeon might accidentally break my leg during surgery. I found this conversation to be unduly frightening, and decided to research the likelihood of any of these events actually occurring to me.

POSSIBLE SURGICAL COMPLICATIONS

According to the American Academy of Orthopaedic Surgeons, more than 170,000 total hip replacements are performed each year in the United States. In the United Kingdom, patients receive more than 50,000 artificial hips annually. The Canadian Orthopaedic Foundation states that more than 37,500 hip and knee replacements are undertaken in Canada each year and the number is rising annually due to an aging population. Almost half of those are total hip replacements (THRs) and most of them are required as a result of advanced osteoarthritis, says Dr. Robert Bourne, professor of orthopedic surgery at the University of Western Ontario. Bourne is the director of the Canadian Joint Replacement Registry (CJRR,) a project set up in the summer of 2000 to monitor and track the number of hip and knee replacements in Canada. "About 2.5 percent of the entire population or 1 in 40 Canadians will have a hip or knee replacement at some point,” Bourne claims.

Worldwide, approximately 500,000 hip replacements, also known as arthroplasties, are conducted every year. For the most part, joint replacements are very successful and dramatically improve the quality of life for the recipients. Like any major surgery, there are risks. There is a risk of blood clot or infection following a total hip replacement but every precaution is taken to reduce the incidence of these complications. Patients are given large doses of intravenous antibiotics to prevent infection, operating rooms are especially designed to filter out bacteria, and sterile techniques are employed. If the prospective hip patient has any kind of infection, from bacteria in the urinary tract to the common cold, the surgery will not be performed. Most sources agree that the chance of contracting an infection following total hip replacement is somewhere around 1 percent.

Deep vein thrombosis (DVT) is the most common cardiovascular complication following a hip replacement. This is when blood clots form in the deep veins of the legs. The American Academy of Orthopaedic Surgeons states that 80 percent of orthopedic surgical patients would be likely to develop DVT, and 10 percent would be likely to develop a pulmonary embolism if preventive treatment were not provided. Preventive treatment consists of providing postoperative patients with anticoagulants and anti-embolism stockings, called TEDs. Even with these prophylactic measures, deep vein thrombosis and subsequent pulmonary embolism remain the most common cause for emergency readmission and death following joint replacement, the American Academy notes.

Certain people are at greater risk of developing a thrombosis. People who smoke, are overweight, are on estrogen or who have had a history of previous DVTs are more likely to develop a blood clot following hip surgery. Other people are genetically predisposed towards blood clots. Studies show that the use of a spinal rather than a general anesthesia may reduce the likelihood of a DVT by up to 50 percent.

3.6 percent of patients will experience a potentially fatal pulmonary embolism, according to Dr. Richard Villar, British orthopedic surgeon, and author of the book Hip Replacement: a Patient's Guide to Surgery and Recovery. That is why Coumadin, an anticoagulant, is routinely given to patients along with shots of heparin to make their blood thinner. Many doctors require hip patients to wear TED stockings, which reduce swelling. They are encouraged to get up within 24 to 48 hours of the surgery to get their circulation moving in order to avoid a blood clot.

Villar states that the risk of death from a total hip replacement or THR is about 1 percent, but the development of these complications depends on many factors, such as age, general state of health, and surgical expertise. If patients are over the age of 80, Villar claims that up to 20 percent of them will experience some form of postoperative problems. The risk of developing complications also rises significantly during hip replacement revisions. Problems are less likely to occur during the primary hip replacement.

Another potential risk of the total hip replacement is that one leg may be longer than the other following surgery. This happened to Ryle Miller, a retired engineer from Vermont, who had both a hip and a knee replaced. He was able to correct this unfortunate problem by building up the soles of his shoes. The book Hip and Knee Replacement: a Patient’s Guide was co-authored by Miller and his orthopedic surgeon, Geoffrey McCullen. Miller was a veteran who was traveling through Europe in 1971 when his knee went out on him. At the age of 48, he was diagnosed with rheumatoid arthritis and went through a grueling series of gold shots and treatment with cortisone pills. Miller attained dramatic but short-lived relief with this regimen. After he discontinued the gold shots, his old symptoms of fatigue, painful muscles, and morning stiffness returned. He struggled with these until 1987 when he twisted his left knee snowshoeing. Miller then tried injections of cortisone, oral anti-inflammatories, and a knee brace. He even had a knee arthroscopy to prevent the need for joint replacement, to no avail.

An arthroscopy is a way of looking inside the knee or hip joint via fiber optics to assess the status of the joint. Sometimes, pieces of tissue, bone or bits of cartilage and ligaments can be repaired via arthroscopy. But it is not a valuable technique for treating severe arthritis because of the extensive joint deterioration involved. Miller did not find relief from pain until he received a total knee replacement in March of 1989. He felt reasonably well afterwards until he was diagnosed with Parkinson's disease. Parkinson's interfered with Miller’s balance and made him unsteady on his feet; he took a fall while working in his backyard. He fell 30 feet, broke his pelvis and injured his hip, necessitating a total hip replacement and a 17-day stay in the hospital. Miller had more than his share of joint replacements, which is not uncommon for someone whose joints have been damaged by rheumatoid arthritis.

In terms of my own hip dilemma, I knew that the surgeon I saw had to protect himself legally. He would not have wanted me to sue him if I developed an infection or a blood clot, and had not been forewarned. I am sure that he was a good doctor but I did not feel reassured by his manner. Since I was already opposed to the operation, the surgeon's alarmism strengthened my fear and denial. Although he did offer to operate on me, he did so reluctantly. It was clear that he wanted me to spend several more years on painkillers and a cane before I considered a THR.

PREVENTING HIP SURGERY

That was fine with me. About six weeks after my trip to the emergency room, the screaming pain began to abate and I became a bit more mobile. I began to read everything I could on ways to prevent hip surgery. I had already tried physiotherapy, ice packs, moist heat, aspirin cream, ultrasound, glucosamine and chondroitin sulfate and Celebrex. Carrying additional weight is a strain on an arthritic joint. Luckily, I am on the slim side so I did not have to lose weight to take pressure off the injured joint. I had been living in shock absorbing running shoes for some time, which reduced the impact of walking on the hip joint. And I had severely curtailed my weight bearing activities, such as walking, climbing stairs, and standing for any length of time. I decided to forego massage, chiropractic, homeopathy, and acupuncture because they were too expensive and had not worked for me in the past. Lastly, my arthritis was much too advanced for an arthroscopy.

Instead, I started swimming twice a week and following the program set out by Dr. Robert Klapper and Lynda Huey in their excellent book Heal your Hips: How to Prevent Hip Surgery — and What to Do if You Need It. This instructive manual advocates a program of specific exercises to strengthen and restore mobility to the hip joint. The exercises are to be done ten minutes per day on land and ten minutes per day in the swimming pool. Klapper warns against repeated use of cortisone shots, which can damage the joint. This is an informative and sensible book that may work well for people whose joints have not deteriorated significantly. All of my hopes for the aquatic cure vanished one day when I got stuck at the pool because I could no longer get my socks and shoes back on after swimming. I had no choice but to ask the woman next to me for help. I began to understand why James Dean said, "Live fast, die young, and leave a good-looking corpse." Yes, and preferably one whose joints functioned! If this was middle age, I needed to investigate cryogenics.

The pool episode left me feeling discouraged but it helped to break my cycle of denial. There was no doubt in my mind after the incident that I was going to need the joint replaced. The question became when I would have it done and with whom. Although I had booked surgery with the first surgeon I saw, I decided that I would not be comfortable with him operating on me, so I cancelled my surgical date and began to look for another orthopod.

GETTING A SECOND OPINION

Specialists are busy people. They do not have vast amounts of time to spend with patients. However, I wanted to find a doctor who would provide me with a reasonable amount of time, answer my questions, and alleviate my concerns about the effect of the surgery on my other health problems. I am a consumer of medicine and have every right to shop around for a good doctor.

When I was young, I was full of admiration for physicians. My late father was a medical doctor. Those were the days of Marcus Welby, M.D. and Ben Casey. Doctors were held in such high regard that they were seen as almost mythical creatures. There is an old joke about a Jewish mother whose son was elected President of the United States. A friend turned to the woman during the inaugural ceremony and said, "Oh, but you must be so proud!" The mother replied, "Yes, but you should see his brother. He’s a doctor!"

Nowadays, doctors are not necessarily held in high esteem. In my 23 years as a career patient since the car accident, I have dealt with dozens of doctors and have seen an abundance of their shortcomings. Many were abrupt, arrogant, and presumptuous. Others were well intentioned but quick to jump to diagnostic conclusions without taking a proper history. They did not listen well. Specialists, in particular, were notorious for their haste and lack of empathy.

A 2002 study conducted by Fuschia Sirois and Mary Gick of Carleton University in Ottawa, Ontario examined the beliefs and motivations of patients who sought out alternative medicine practitioners. Sirois and Gick concluded that the individuals who were most likely to choose an alternative or complementary practitioner were people who had multiple health problems, greater awareness of health behaviors and predictably, dissatisfaction with conventional medicine. Unpublished findings from the same study indicated that many patients who abandoned traditional medicine complained that their doctors had failed to take the time to listen to them. In order to make a proper diagnosis, it is crucial for doctors to hear their patients. Some participants in this research project compared their medical visits to being on "a conveyor belt," or to being moved through the office "like cattle," an experience that I can certainly relate to.

Most of the doctors that I saw during the 1980s and 1990s did not spend enough time with me. As a result, they misdiagnosed my problems. Physicians routinely dismissed my multiplicity of physical complaints as nothing more than depression. I believe that there is a bias against patients with chronic health problems. Often, the size of my medical file alone would lead a doctor to conclude that I was a hypochondriac. In addition, although I do not see sexism lurking behind every dark corner, I do suspect that my health problems would have been treated more seriously if I had been male.

In fact, a study from the Toronto Rehab Center indicates that women in high socioeconomic brackets have less access to joint replacement surgery than do men of a similar income bracket. Toronto Rehab is an organization that specializes in rehabilitating people who have had joint replacements. This research, published by Dr. Gillian Hawker and co-developed by Dr. Jack Williams, revealed that people communicate differently with their doctors according to their gender. Women are the greatest consumers of health care. The 8th annual ACNielsen study of consumer health-related attitudes and behavior found that women are more likely than men to visit a doctor, consult with a pharmacist, and take vitamins and/or minerals. Men, on the other hand, are more likely to "tough it out" when they experience medical symptoms. Women are more verbal about their bodily ailments whereas men are apt to be more stoical. If women complain more often than men do, doctors may perceive women's health problems as being less serious than men's physical challenges.

It took many years for me to assemble a team of doctors whom I felt were bright, compassionate and on target with my health. Now I have a group of physicians whom I like, admire, and respect. My family doctor is a kindhearted and intelligent soul, who always takes the time to listen to me and to be thorough. I wanted to find an orthopedic surgeon with similar qualities. Having a hip replacement is not like having a gallbladder removed. I will remain in close contact with my surgeon for some time and will continue to see him or her many years after the operation. I wanted someone who was highly skilled and would give me the facts about the operation without terrifying me.

A friend of my mother's had just had her hip replaced by a prominent surgeon at a local hospital. I called her and asked a number of questions about her doctor. I spoke to other people who had had hip replacements and asked how they felt about their surgeons. I decided to book an appointment with the surgeon who had operated on my mother's friend to see if I liked him. A doctor at my neighborhood clinic made the referral and I waited several months for a consultation.

The doctor was bright, warm and had a twinkle in his Irish eyes. After viewing my x-rays, he immediately agreed to do a THR and apologized for the length of his waiting list, which was 12 months long. He informed me of all of the potential risks of the surgery but unlike the earlier surgeon, this man did not overwhelm me. He assured me that the procedure was routine and generally successful — some studies estimate that the probability of patient satisfaction following a primary total hip replacement is as high as 90 percent — and he did not seem to have a problem operating on someone who was under the age of 50. I was impressed with his reputation and his bedside manner. The surgeon had performed numerous hip replacements and had a specially designated orthopedic floor in his hospital, as well as a short-term rehabilitation unit. I felt comfortable with him and knew that I could work with him.

During our interview, I told the surgeon how much my hip was affecting my daily activities and my mood. I added that hip pain and restrictions on my range of motion in the joint were preventing me from having intercourse. The surgeon seemed surprised by this and assured me that most of his patients were able to maintain a reasonable sex life. I was hard-pressed to imagine just who these gymnasts could be. Were these the same little people in his waiting room who could not walk a city block, were bent over their walkers and canes, and were popping Advils just to get through the day? Was there a Kama Sutra that I had yet to discover for the arthritically challenged? Sex was only one of many activities that were no longer possible for me as my hip continued to deteriorate. Walking, standing, bending, and lying down were all extremely painful. Shopping, cooking and doing laundry were very difficult; recreational pursuits were impossible. The more pain that I experienced, the more I limited my activities, which resulted in boredom and depression.

# posted by Sigrid Macdonald : 10:41 AM