Surgery Day

We checked in with a secret yellow card they hand you and went straight to pre-op.

At pre-op, we took out my contacts, shaved the area, took blood and vitals and then the relatively long wait for the surgery.

Vitals were really good.  Blood pressure was normal and heart rate was under 60bpm. 

We arrived around 9am, and the surgery was scheduled for 11:15.  For unknown delays, 12:51 was the official start time.

I remember waiting in the real pre-op for a while.  I had expressed concerns about my anesthesia on the last surgery, so they assigned the actual anesthesiologist to do the procedure.  I spent a while chatting with him and his assistants.  I remember meeting a couple of them and discussing how the last spinal block should not have failed.

The anesthesia prep people talked about how I'd be asked to bend over where they'd give me the spinal while I sat relatively upright.  But I don't remember any of that.  It's really odd- because they say you're lucid.  The drug they use must have some type of short-term memory loss that goes with it, which is kind of scary.

I'm not sure what the delay was in getting to my surgery, but I do remember meeting the doctor and asking if he was "warmed up", because I know he had other surgeries scheduled that day.

The surgery apparently took just under two hours.   Comments made to us afterwards were pretty somber:

• There was no chance it could have healed.
• No sign of healing.  None.  No callus, no scar tissue.
• The hardware was loose.  It wasn't my 'muscles going over hardware' that caused the pops, I felt, it was just moving bone.
  
• The loose hardware had shaved out the inside of the femoral head.  It was a shell.
• The femoral head was dead.
• I had signs of arthritus

Surgical Anticipation

Tomorrow's the big day.  I get a hip replacement.

It's been a long and honestly painful journey.  I still haven't come up with a reason that all this happened- no striking 'life lesson' to share.  I do have one I've been tossing around, but I'll wait until I recover to write it up.

I go into the hospital at 9:15 with the surgery scheduled to start at 11:15.  My doctor told me it would be a two-hour operation.  Add in the pre- and post-operative stuff and I figure I won't be back to my room until the early evening. 

They're going to open me up and take out the old hardware.  Then, my damaged femoral head will be removed.  They'll ream out my acetabulum and insert a metal cup. They'll trim the top of my femur and insert a stem.  They'll test the new components for range of motion and sew me up.  Two hours- it'll be busy, I'm sure.

Hopefully by the end of this week, I'll be able to walk without my walker.  Slowly.  Carefully.  But I'll walk for the first time since September 4th.

The technology of hip replacement

Even before I was resigned to having a hip replacement done, I was already reading up on them.  I had heard that they only last a certain amount of time before they wear out.  Apparently those estimates were on the low side- the original ones lasted about double what they thought.  And with the newer technology, I was told that mine will last upwards of 25 years, even with my high level of activity.

The prosthetic I'll be getting is this one: a J&J (DePuy) Pinnacle.

The issues in the past with hip replacements is that they used a small ball which limited the range of motion.  It also had a smaller surface area- yet the same amount of force, which causes higher wear.

Newer designs use a large ball, trying to approximate the original femur.  The Pinnacle design isn't the largest one, though it is pretty big.  The Pinnacle socket is a two-piece. There's a titanium cup which is put in the pelvis, and a liner.   That's the selling point of the pinnacle- the liner (and ball) can be swapped out.  The have balls in metal and ceramic, and liners in plastic, ceramic and metal, giving the surgeon a lot of choice.  Ceramic has fallen out of favor because some squeak after time.  Plastics are popular, but they don't wear as long as metal.   Metal has concerns because metal on metal causes ions of the metal to be released with some uncertainty as to what happens over time.   This new joint is design to have much lower wear because it allows the synovial fluid to lubricate the joint as if it would a normal joint.

The other half of the joint is a stem which goes into the femur and the ball on the end.  As I mentioned earlier, the ball is a relatively large diameter at 36mm or so (compared to the early balls which were 24mm), but not as large as the original femur which is around 54mm.  I did some searching on studies, which found that head sizes >32mm had a huge improvement in range-of-motion and lessened the chance of dislocation.

So, I'm satisfied with the choice of component.  And its modular design will allow the liner to be changed (I assume) at some point if the materials wear or there's a problem.

Preop is done

I just back from hours that the hospital getting ready for the next operation.

Besides all the paperwork, I spent a lot of time with the anesthesia department because I was concerned about the October surgery.  It was supposed to be a spinal block like the first surgery- and something went wrong.  What it was I was never told.  So the anesthesia interview nurse had me meet with the head of anesthesiology.  He was a great guy and told me it was likely one of two things- occasionally a medication will be less than effective and they end up sending back the whole lot.  The other one is what I suspected is that a nurse anesthetist student was working with the doctor and did the procedure.  Or failed at it.  In any case, the doctor promised me that only one of his doctors on staff would do the procedure.

I met with my surgeon and he was sharp.  I had a list of tough questions to ask him and it was almost like he was ready for me. Now that I think about it, maybe he had been warned after my extensive talk with the trauma specialist.

• Will the existing hardware cause complications?  No, it will need some additional time, but it should come out easily.
• What kind of hardware is it?  It will be a metal/metal titanium prosthesis with a textured surface for new bone to bond to.
  
• Will a new cut need to be made?  No, the line of the fracture is appropriate for where the new hardware will go.  
• What diameter is the ball going to be?  36mm most likely. 

I also spent time with the physicians assistant, who was very sharp.  We talked about recovery (staples out in 10 days, 6 weeks for full motion, 8 weeks full recovery) and also looked at my x-ray.  It was pretty scary what had happened since my last x-ray.  The top of the hardware is loose and moving around in my femur.  There's a black area that looks like it has been 'wiped' by the hardware moving back and forth.  It wasn't there the week before- no wonder my pain got so bad so quickly.

In any case, the paperwork is done.  Next Tuesday morning I'll be back at the hospital for the third time this year.

Primary Care Mellowness

I met with my primary care doctor yesterday.  It was really just serendipitous that I had an appointment with him.  He stays very busy but an opening for my yearly physical popped open and it happened to be during 'exam week'.  I really welcomed it because he's very laid back.  I'm in kind of a rush with trying to get surgeries scheduled and such before the end of the year, and he's one to give me a check as to if I'm doing the right thing.

The good news is that I'm in great health- other than the leg.  My heartrate is 54, my BP was 112/78.  And that's while being in constant pain (which often raises it).

My doctors says I need to inform my regular doctor about what I'm going to do.  I'm somewhat dreading that call.

I'm not a candidate

I just got back from Duke, meeting with a trauma specialist.

The doctor I met last week was unhappy with my surgeries and said I won't heal.  He referred me to a trauma specialist to see if he thought I could be repaired.

The doctor today said he was excited to read the notes from last week because he looks at this kind of operation as a challenge and one that rewards him because he can get someone back on their feet with their own bones.

He took lots of x-rays and we sat and talked for a long while.  I had heard good things about this guy from his own staff and they were right.  I've never had so much personal time with a senior doctor like this.  We went over everything, from the original surgeries to the current prognosis.

I'll cut to the chase and repeat that he said I'm not a candidate to salvage my bone.  The problem is that the femoral neck has shortened to the point that even if it were to be operated on, there's not enough neck for the joint to function properly.  My leg is already much shorter than it should be, and even though the operation could take a wedge out of my femur to make it straighter, it still wouldn't be long enough.  So, taking the reduced neck, shortened leg, the fracture site has shifted and what isn't in contact with bone would have to be reworked.  So he summarized that it just wouldn't work.  He said he'd also get a referral from the senior doctor in the practice (joking that it meant he had more gray hair).  I got the followup call this afternoon, and it was as he expected- that neither of them thinks it can be saved.

I've now had six MDs tell me it won't heal, with a couple more by the end of the week.  I haven't heard a dissenting opinion other than those who did my surgeries.   Which means a hip replacement.  I've been reading on them for a while,lots of options out there- and it's not surprising because there are 400 thousand of them done a year.   Next week I plan on researching doctors and their availability. 

Atrophy

My leg is getting weaker and weaker.  The past few weeks it must have looked a lot smaller because several doctors have commented on it as they manipulated it.

I don't know what's happening- maybe from the pain I'm not even trying to move it anymore.  In fact, I just can't.  I can no longer lift my leg on my own.  For example- to get in and out of the car, I have to pick up my leg and move it in.  It's not the pain- I just don't have any strength.

It's not like I had huge thighs to start with, but this is getting ridiculous. 

Exam week

I've got many tests and operations this coming week.  I'm going to get a third opinion, I'm going to see my regular practitioner, I'm supposed to get a CT scan, and see a 'trauma' specialist.  I also see my current orthopaedist in the middle of the week.  The big event will be the highly recommended hip specialist for whom I had to wait several weeks to get an appointment.

The pain is really bad in the morning.  Once I'm up and about, I can manage, but I dread going to bed- because the transition both going to bed and getting up is terrible.

I'm trying to reconcile that I'll be convalescing one way or another during the winter months, so spearfishing won't be so tempting, as the water is cold, and the fishing restricted because of the spawning season.

But I was talking with my daughter today about snowboarding and recalled that I had tentatively planned a trip out West with my buddy in Salt Lake City.  I have a feeling that's not going to happen- but maybe they'll get a late season for me in April or something.

Hopes Dashed

I couldn't sleep last night- the conversation I had with Charlie and others had me excited- and alongside a midday nap made me well rested.  At 3:45am I decided to take an ambien.  That stuff works- and when I got up I could still feel its odd effects on my perception.

The exciting news for the say was to visit an independent doctor for a second opinion.   This physician was very matter of fact- and not at all hopeful.

"Very little chance of it healing."
"If it does heal you'll have a leg an inch shorter than the other."
"The first surgery was going to fail because the screws didn't have the right separation."
"The second surgery was going to fail because it didn't have a proper reduction."

Not words I wanted to hear, but that's why I got the second opinion.

The part I'm confused about is what's the next step.  He said I needed to see a trauma specialist and I was given the name of one.  Unfortunately, that guy was booked until March!  So I was given a backup, whom I initially though was very junior since he had an opening next week, but has an impressive pedigree as well.

Next week is very busy with a physical, a referral, another 2nd opinion, a CT scan, and a visit to my doctor's office.

A glimmer of hope?

I collected my xrays as I left my doctor's office to send to a friend who is a radiologist.  He's been very interested in my injury and recovery and was one of the first to offer a fresh perspective on my fracture.

He was pleasantly surprised by my latest xrays.  He agrees that the ball looks good, but he thinks that there has been a reduction of the gap in the fracture. Furthermore, he thinks there is some new bone forming on part of the facture.

This may be because I had started to put some weight on the leg the past few weeks.  Maybe that little bit of pressure forced two bones together with the nail acting as a guide.

The long term question (besides AVN) is if it heals this way, will it be strong enough to support my weight and activities?  The fracture itself is about as bad as it can get- it is vertical- aligned with the forces of my body upon it.  So, an incomplete healing will mean it is weak- maybe able to support my body weight standing- but jumping or lifting?  In the long term, my titanium hardware will stay in and help support as well.  There's always the fallback of a replacement if it fails.

Stuck in limbo

I went to the doctor today and got more x-rays done.  Things looked about the same as last week.  The femoral head looks solid.  No progress and no failure of the hardware.  The doc keeps saying that the hardware will fail eventually, so the body's healing needs to take over before that happens.

From reading about bone healing, if new bone doesn't form, scar tissue can form isntead.  For low-stress bones, you might not even know, and eventually it can calcify.  That won't work on a femur.  So, it really needs to be growing bone, or something else needs to be done.

The something else is either a total hip replacement (doc didn't think a half-replacement would last more than 5 years with me), or a much more invasive procedure.  The invasive procedure would be to go in and clear out the scar tissue, debride (debreed?) the bone and re-pin it.  Of course, he mentioned that doing it again could result in the same failure as the first time.

I really prefer my own bone- the body maintains it for life.  So if there's a chance of it working I want to go with that. But, the issue all along is will the femoral head live?  The doctor has set me up for a CT scan this week and another appointment next week.

With the CT scan, we'll be able to see a 3-dimensional view if the bone is really aligned and how well.  Then we can make a better decision.