This chapter describes the second phase of my recovery, starting with the six-week follow-up visits with the surgeon and the rehab physician. I describe those visits, as well as my experience with out-patient rehab. Then, I share my experience with various areas of life in which I was able to resume activities as well as or better than I had done before surgery.
The usual time for the first, crucial follow-up visit with the surgeon is six weeks post surgery. This appointment is usually set before the patient leaves the hospital. It was included among my discharge instructions, which I did not scrutinize closely until I got home. When I did, I noted that the appointment was scheduled eight weeks after surgery instead of six. I called my case manager, Linda, to note the discrepancy. “The residents scheduled that; I didn’t” was her response. I chuckled at the implication that orthopedic surgical residents could not properly count to six. Linda, among her many other positive qualities, knows how to count. She fixed the problem, moving my appointment to a more appropriate date.
The rehab physician had also scheduled a follow-up appointment for earlier that same week. I believed that this was a good idea, inasmuch as it would provide an appropriate forum for discussion of the path forward through continuing physical therapy.
My first follow-up was with the rehab physician, Dr. B. I was a bit irritated with the administrative incompetence of his office and the medical industry in general.* Even though the rehab hospital at which Dr. B had treated me had all my information, I was handed the ubiquitous clipboard in order to construct yet another personal medical history. I think I would have felt better if they had sent me the form in the mail during the five weeks since the appointment was scheduled. I finished the task and waited to be called. I noted that other patients were being called by their first names, a big pet peeve of mine.† While I know that this country is becoming a much more casual place, the last place I wish to be treated impolitely is a doctor’s office. My name is Mr. Goldfarb. We are not on a first name basis unless we are friends or family or until I introduce myself that way. My turn finally came. Fortunately for her, the assistant who called me used both first and last names.
I was ushered to an examining room where vitals were taken. The doctor arrived shortly thereafter. He marveled at the quickness of my recovery, stating that he had never seen anyone recover from total hip arthroplasty that quickly, especially with only three days in rehab. I beamed, but then quickly contained my pride. It was the surgeon, Dr. G, who deserved the credit, not me. I might have put some hard work into rehabilitation, but the extremely skilled and competent surgery put me in a position to be able to do so. I had none of the pain or muscle spasms that were frequent complaints of Dr. B’s other patients. He agreed that the surgery was extraordinarily good, without even minor complications such as swelling or a painful incision. I silently congratulated myself once again for choosing Dr. G as my surgeon.
Dr. B discussed the path forward with me. I would reduce the pain medication to Tylenol (acetaminophen), and I would continue with the physical therapy. I wanted to do outpatient physical therapy, even though he thought it might not be necessary. My reasoning was that I was on my own, and I was therefore likely to be doing something wrong. I wanted some supervision by a professional physical therapist in order to keep myself on the proper course. Sometimes, we think we are doing the right thing but we do not quite do a particular exercise as we were instructed. This can be benign, but it also can cause much damage. I would be seeing a physical therapist twice a week to ensure that I was doing things right and moving forward.
Two days later, I visited Dr. G for the six-week follow-up after surgery. I walked in without a cane or crutches. As I mentioned previously, Dr. G was unhappy that I was not using any support for walking. I was so enthusiastic about being able to walk painlessly that I had unwittingly ignored Dr. G’s orders. At six weeks, I should have been using a cane on the opposite side to reduce the weight borne by my operated leg. This would continue through the twelfth week.
In addition, I was not to be doing any fancy maneuvers on the stairs. It was back to one step at a time, with additional support to keep the weight off the left leg. I would continue to observe all other precautions, getting into and out of chairs and cars properly. Six more weeks. I could tolerate it. I would have to.
Dr. G explained the reasons for this. No matter how good it feels, the uncemented prosthesis is not stable until bone grows around it and into its roughened surface. The critical period for this process is the first twelve weeks. Dr. G has had experience with thousands of hips, which is one of my reasons for choosing him. It was time to listen to the voice of experience.
“At some point five years from now, you don’t want to be kicking yourself for doing something stupid now that causes the joint to loosen then,” he said.
Of course, I did not. Loosening is one of the most frequent causes for revision surgery. I wanted this new hip to last as long as possible, perhaps 15-20 years, not a mere five or fewer.
I asked a few questions about various related issues, such as whether to continue sleeping with the abduction pillow and whether to continue to wear the compression stockings. I also wanted to know, per requests from my doctor and dentist, which drug Dr. G preferred for antibiotic prophylaxis before and after invasive medical and dental procedures. This time I listened to the answers and this time I would not improvise on my own.
Because I was planning to do more physical therapy, I asked Dr. G whether he had any specific instructions for the physical therapists. In addition to ensuring observance of the 90 degree bending restriction and the 80 per cent weight restriction, he implored me to avoid any exercises that involve heavy abduction or adduction.
Dr. G will keep an eye on my right hip (the “good” one) to get some data points, which would help him in determining about how much longer it would be before I would have to consider total arthroplasty for it. Obviously, I want to wait as long as possible, but I pledge that I will not let it deteriorate to the extent that I did the left one, where pain dominated my life. The right hip was asymptomatic at the time this book was written. However, if and when the time comes, it will be no surprise to anyone that I will choose Dr. G as my surgeon once again.
My next follow-up was scheduled for one year after surgery.
Having been cleared to start out-patient physical therapy, I scheduled the first session for Thursday of the follow-up week. My insurance company had cleared me for 10 sessions.
At my first meeting with my physical therapist, Vivian, I gleaned that I was dealing with a very experienced professional. We discussed my progress to date and the restrictions imposed upon me by the surgeon. She asked me to demonstrate the exercises I had been doing at home, commenting on my technique as we went along. It turned out that I was rushing through some movements that I should have been belaboring.
Vivian measured my leg strength and range of motion in several directions. Like the rehab physician and others, she was surprised by my progress at that stage. Then it happened. I heard the question I had been waiting for: “What are you doing here?”
My answer was that I was there to increase range of motion, strength, and endurance. Vivian promised to do what she could, although she felt that in view of the restrictions imposed by Dr. G, which would not allow the use of some of the machines, I could probably obtain good results by continuing what I was doing at home, with appropriate adjustments. Nevertheless, I felt that I would benefit by having a knowledgeable physical therapist directing my rehabilitation for a while.
Thus, we began my out-patient sessions with some standing and supine exercises. Vivian seemed apologetic that she could not do any more. There was no need for such concern. We both wanted to observe Dr. G’s restrictions. I stressed to Vivian that it was worthwhile having her observe me and that she should be vocal if she saw me doing something wrong.
We scheduled two sessions per week. These proceeded uneventfully until the sixth session at which Vivian announced, “Today is your graduation.” The following week, I was to see Dr. B, the rehab physician, for another follow-up. In view of that, Vivian felt that she had completed her job. I was to let her know if Dr. B felt that any more work was necessary. She measured my strength and range of motion again, noting that my range of motion had increased about five degrees.
I had originally expected that out-patient therapy would be much more intensive than it was. Of course, the restrictions imposed upon me limited what I could do there. Nevertheless, it was worthwhile if all it accomplished was showing me how to do the exercises correctly.
A week after my last physical therapy appointment, I saw Dr. B. He continued to marvel at my rapid progress. In fact, the first thing he said to me was, “Six sessions of physical therapy and they let you go?”
Dr B gave me a cursory check-up, obtaining the now expected, positive results. Everything from my surgical incision to my strength and gait was as close to perfection as it could be. “I want to work more with [Dr. G]!” he exclaimed.
I asked about what sort of exercises I should be doing from that point, now that I was done with formal physical therapy. Aside from continuing with the exercises I was doing, Dr. B advised me to start walking increasing distances once I got past the 12-week period of restrictions. Also, “anything in the pool” would be fair game.
We had a brief conversation about dislocation precautions. By this time, I realized that no doctor was ever going to go out on a limb by advising me to exceed any of the standard restrictions. Also, avoid low toilet seats. OK, so I was on my own.
I would not need any more follow-ups with Dr. B, but he told me to keep in touch with him regarding my progress with this book.
Finally! After 12 weeks, I could ditch the cane and walk normally. I really mean normally, too. For such a long time, walking meant limping severely, compensating for my painful left hip. It was no longer necessary to do this. However, telling the body to do something it had not been able to do for years required concentration. The natural tendency, forged by years of habitual limping, was to continue limping. I would expect that first blast of pain upon getting up from a seated position, then when I did not get it, I would continue to walk gingerly, anticipating its return at every step.
I had practiced walking straight and true both with and without the cane. I used a long hallway in my house for this purpose. At one end is a window, which would function as a mirror at night. Thus, I was able to watch myself walking and correct problems as I walked.
Prior to the 12 week mark, I had been doing a little walking here and there with support by a cane or other device, of course. Around the house sometimes I would forget the cane as I moved from room to room. The hip felt so good and natural that I had to remind myself to use it. When I went to the supermarket to buy groceries, I could use the shopping cart for support. I tried not to overdo it, but a large supermarket with long aisles provides plenty of opportunities for practicing walking.
Once the 12 weeks passed, it was time to start walking in earnest. There is a nice, shaded walking path around my community that is conveniently 1.5 miles around. This would be a great place to start walking were it not summer in central Florida. Shaded or not, the daytime temperatures in excess of 90F, with humidity to match, are a deterrent to walking. In the evening, when it cools down, we have the voracious mosquitoes. Therefore, the solution was the shopping malls, which are about as prolific as the mosquitoes in this part of the world. Being air conditioned, with long, straight runways and a few steps and ramps here and there, the malls were ideal for those first long, unaided walks.
For the first walk, I did two laps around one nearby mall. The following day, the new hip felt sore. I allowed it to rest a couple of days before I tried another. The next walk around a different mall twice produced only minor soreness. I will keep up the mall walking until the outside temperatures come down a bit, when I will revert to the walking path in my neighborhood.
I have always enjoyed walking for exercise. Recalling the drudgery of walking in my pre-surgery days, I am enjoying it all the more. Instead of wincing and grimacing with each step, I am marveling at the absence of pain!
I told you in a prior chapter that sleeping on my back was not natural for me. Because of the induction pillow, I was not able to roll over. My usual sleeping position is on my side or on my belly. It was sometime between six and twelve weeks that I ditched the abduction pillow and began to experiment with sleeping my way. I bunched up a soft pillow between my knees and rolled over onto my right side. It felt fine. I slept this way for a while. Ultimately, I was able to roll over onto my belly, which is the preferred sleeping position. When I could do this, I felt that life was really heading back to normal.
After 12 weeks, it was still necessary to use the sock helper to get a sock on my left foot, but I could do the other side without assistance. I needed the grabber less and less as time went on. The long-handled shoehorn was still a handy thing, though. I still could not ties shoelaces, so I was “stuck” with slip-on shoes for quite a while. I had purchased several pairs of both casual and dress shoes in slip-on styles before my surgery. Hence, this requirement really did not get in the way.
I could do anything in the garden that did not require stooping. Obviously, the weeds would have to wait for me to develop the capability for getting down to their level or, more likely, for me to buy a long-handled weeder. My garden had declined a bit because of my neglect during the long summer of my convalescence, and summer can be brutal to a Florida garden. My plants no doubt breathed the vegetable equivalent of a sigh of relief when I became able to achieve communion with them once again.
* At the risk of boring you with my continual harangue about the modern day U.S. healthcare industry’s sad lack of concern for the individual patients, I shall beat on this again. Why can’t one hospital or “provider” pass information along to the next when there is a sequence of activities concerning the same patient and the same ailment? The lack of communication might be somewhat understandable in a situation in which diverse entities were handling various parts of the treatment. However, when the staff at the rehab physician’s office tell me that they cannot get information from the rehab hospital at which the physician practices, requiring the patient to repeat the same paperwork exercise as had been done for the hospital, something is drastically wrong. I do not know whether this sort of thing is an expedient that is created by either overworked or lazy doctor’s office personnel and condoned by patients who are used to being told what to do. The more work offloaded onto the patients, the lower the overhead for the doctor’s office, and in the macroeconomic sense, for the entire industry. Alas, that saving is not passed through to the patients and the process is prone to errors and omissions.
† OK, so I am on the soapbox again. I feel that submitting to the prodding, probing, and loss of dignity through which one must persevere when undergoing medical treatment is bad enough without the further dehumanization of being patronized by doctor’s office personnel. Anywhere else where you buy products or services, you receive respect commensurate with your status as a customer. A patient is also a customer, sometimes responsible for very large amounts of revenue to the medical organization in question. Why, then, am I shown proper respect by personnel at the offices of my stockbroker, my banker, or my auto dealer, but not at the offices of my doctors and dentists? I let them know when they cross the boundaries of propriety. If enough of us complain, this disrespect for patients might eventually abate.
Copyright © 2001, 2002, Benjamin
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