For Joan H, now in her seventies, the pain snuck up on her in slow but steady increments, subtly increasing as months turned into years. In fact, the pain became such a familiar part of her mental landscape that Joan regarded her pain as “normal” and found ingenious ways to work around it: like walking downstairs backwards, ever so slowly and carefully, because it hurt less; or avoiding those small twisting and turning motions people do while preparing meals, because they caused shooting pains down her legs.Before she retired from a 30-year career as a journalist, Joan was often seen dashing off to an interview on foot, pen and paper in hand, or zipping along in her sporty red MGB convertible. She still has her up-‘n’-at-’em attitude, but she doesn’t zip around quite as much as she used to, and the MGB has had to go. The low-slung driver’s seat, the stiff clutch and the effort needed to shift gears became a literal pain in the butt. Now she drives a nondescript sedan with automatic transmission, dryly noting that the car isn’t quite as “hip” as her old sporty one.Curiously, Joan’s painful symptoms came as the indirect result of a heart attack. After undergoing surgery, her cardiologist prescribed a regimen that was long on exercise – three miles long, to be precise, to be walked in 45 minutes, three times a week. And this Joan did faithfully. But soon another worry intruded on her routine: She began experiencing sharp pain in her groin.
“Gradually, I found there was pain during the first mile,” she recalls. “I was leaning forward to relieve it. For some reason, the pain wasn’t as bad the next two miles.” It never occurred to her that groin pain meant something was amiss elsewhere. Years later, while being assessed for replacement surgery on not one but both hips, she learned groin pain is a common first symptom of hip osteoarthritis (OA).
Join the Crowd
Joan’s story is far from unique; indeed, close to 40,000 joint-replacement procedures are performed in Canada each year. About half of those are total hip replacements (THRs), and most of them are as a result of advanced OA, says Dr. Robert Bourne, professor of orthopaedic surgery at the University of Western Ontario. Dr. Bourne is also 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. In fact “about 2.5% of the entire population [or 1 in 40 Canadians] will have a hip or knee replacement at some point,” he notes.
Osteoarthritis, which is characterized by the slow erosion of joint cartilage, leads to 85% of all joint replacements. Numerous factors contribute to the eventual end result. According to Dr. Bourne, there are primary and secondary types of OA. Primary OA affects mostly women and has tell-tale signs such as stiff, knobby-looking knuckles, and arthritis at the base of the thumb. People with primary OA “often have arthritis in their backs, their knees, and to a lesser extent in their hips.” There are a number of, as yet, unidentified genetic factors, since primary OA tends to run in families. Indeed, one rare variant called primary generalized osteoarthritis (PGOA) results from a single-gene defect that causes cartilage to degrade rapidly in many different joints. People with PGOA often require multiple joint-replacement surgeries while they’re still in their forties and fifties.
The causes of secondary arthritis range from trauma (especially from work- and sports-related injuries) to rare childhood diseases such as Legg-Perthes disease (a clotting disorder that cuts off local blood-flow to bone, causing it to die). Congenital dislocations of the hip and obesity are also linked to an increased risk for OA, as are inflammatory diseases such as rheumatoid arthritis, infectious arthritis and lupus.
The great majority of both primary and secondary causes for OA are likely due to injuries from years ago. Sometimes people may not even remember the initial trauma…but the cartilage does. Unlike other tissues, cartilage takes a very long time to repair accidental damage. Often a specific cause is never determined, and the symptoms are attributed to “wear and tear” throughout the years. About 10% of cases are from inflammatory diseases, and another 5% due to other medical causes.
THRs are becoming more common with each passing year because of the average Canadian’s increased longevity, and the pace will undoubtedly accelerate as 9 million Baby Boomers begin experiencing the frailties to which their flesh is heir (most commonly OA). Data from the CJRR show that in 1994-95, just under 17,000 hip replacements were done across Canada, compared to slightly more than 18,000 in 1997-98. The crunch will really start, though, in about 10 years’ time, as the first post-war boomers (1947-67) join the waiting lists for hip surgery.
So, THRs are just for old people, right? You’d think so, but you’d be off the mark. Here’s the breakdown: Just over a third (36%) of THRs are performed on people in their seventh decade. The second largest group (27%) is aged 60 to 69. The smallest percentage of THRs (only 15%) are done on people aged 80-plus.
The remaining 22% (about 4000 procedures annually) are performed on Canadians under 59. And while some from this sub-population may need surgery because of disease, many will require THR because of work- or sports-related injuries. This latter group is benefitting in particular from advances in design that make implants more durable and stable, allowing a fairly active lifestyle (within limits, as we shall learn later through the cautionary tale of Tom McLeod).
Pain That Doesn’t Stop
Deciding to get a hip replacement isn’t easy – not least because it’s completely up to the person with the painful hips. Says Dr. Bourne: “For most people, it’s elective.” In medical jargon, surgery that’s “elective” means surgery for treating a non-life-threatening condition. “Arthritis is a chronic illness. When it gets to the point where you can’t stand it, we do something. But we never talk or push anyone into getting a replacement.” But medical emergencies come in several speeds. There’s the more familiar life-and-death struggle of cardiac or cancer surgery. And then there’s that definite point in time when “elective” turns into “dire necessity” if quality of life is to be preserved.
Ask anyone who’s experienced it, and they’ll tell you, hip pain is no fun. Sleep goes out the window; there’s no comfortable position when lying down, and the mild twisting and turning people do in everyday activities become excruciatingly painful. Quality of life gradually sinks to rock bottom as the simplest tasks become increasingly painful and difficult.
In Joan’s case, she found her pain had so increased that she needed to walk with a cane. Both legs felt painful, though it was especially bad on the left. Finally it was too much – no more denial. Off she went to her doctor. The resulting x-rays showed the hallmark signs of osteoarthritis in both hips. Joan was referred to an arthritis specialist (rheumatologist), and she began taking anti-inflammatory medications to lessen her symptoms.
Joan is no shrinking violet; nevertheless, she grimaces when recalling a particularly bad flare-up of pain that required a cortisone injection. The steroid, which has powerful anti-inflammatory action, was injected directly into her hip joint: “I bit into my wrist while they gave it to me because the injection itself was horrendously painful.”
Joan started spending several hours a week at a local hospital where she was treated by physiotherapists and spent time in a hot pool. “The hot water gave me some relief from the pain, but it didn’t last long,” she says. The pain came and went. “Some days it was like a toothache from my hip all the way down to my ankle. I couldn’t bend down to wash my feet anymore.” Surgery was discussed, but she didn’t feel ready; there was that inner urge to fight and conquer it. Nevertheless, she got rid of the MGB and settled for the automatic.
Joan learned her trick for going downstairs from her elders: “I remember seeing my grandmother when I was a kid. She used to come downstairs backwards, but I never really thought anything of it, until now. She must have had osteoarthritis of the hip, too, but back then, in the 1930s, they couldn’t do anything about it.” A few times, on really bad days, Joan found herself obliged to crawl up the stairs on all fours.
Finally, Joan underwent twin hip replacement operations 10 days apart. As a rule, most people needing two hips have much more time between the operations, but then Joan never does anything by half measures if she can help it. “I love my new hips! They’re terrific!” she proclaims. Grandmother would approve.
Not everyone experiences the same degree of disability before going in for THR. Fifty-four-year-old Erwin M underwent his surgery just this summer. Erwin says that how well he could walk varied throughout the day but admits the pain was slowing him down quite a bit: ” I was walking like a 90-year-old man.” According to his orthopedic surgeon, Dr. John Antoniou at Montreal’s Jewish General Hospital, the time to get surgery is when non-operative approaches such as painkillers, physiotherapy and cortisone injections have failed to relieve the pain, and a person’s quality of life is severely hampered. “When you have trouble doing normal, everyday activities,” he says, “it’s time to consider a surgical solution.”
Hurry Up and Wait
Once you make the decision to undergo THR, don’t expect it to happen overnight. First, there’s the visit to the family doctor who refers you to an orthopaedic specialist. Many specialists have long waiting lists just to get in for that first visit. Some attribute this, in part, to a shortage of orthopaedic surgeons in Canada. In an effort to save money during the 1980s, governments cut back the number of positions open to medical students, resulting in fewer graduates, and a shortage of qualified orthopaedic surgeons felt throughout the 1990s and today. What’s more, shortages have affected not only surgery but also anaesthesiology – another essential specialized skill in the operating room (OR). Recently, the number of positions has increased in medical schools, but it will take years to play catch-up, as older doctors retire and the younger ones finish training.
Another factor contributing to long waits for surgery is that some surgeons are better known than others, and hence end up with longer wait lists. A CJRR survey of wait-lists for orthopaedic surgeons in Ontario found that, while some surgeons could operate on a patient within a month, others had wait-lists of up to two years. The average wait is about nine months from initial referral to actual operation, says Dr. Bourne. “If you have a well-known surgeon [in a community], some people will insist on having that particular doctor and choose to wait longer for their hip replacement.”
Once you have met with the orthopedic surgeon, more tests and assessments are done before that final decision is made to undergo a hip replacement. Among those are chest x-rays to make sure your heart and lungs are in good shape, an electrocardiogram, and blood tests to check your blood type in case a transfusion is needed. Further tests are done for people who have other ailments or chronic diseases to make sure they can withstand the stresses and dangers of surgery. (See “Follow the Care Path” for more details on the pre-operative routine.)
Hips of Steel … How About Titanium?
Hip joints are usually described as “ball-and-socket” joints. The upper thigh bone (or femur) is topped off by a round head that fits snugly into a cup (or acetabulum) formed by the several fused bones that comprise the pelvis.
Let’s be frank. No one could ever describe hip-replacement surgery as delicate. The procedure entails removing the head from the femur and replacing it with a metal one, usually made from either titanium or a cobalt-chrome alloy. The actual implant (also called a prosthesis) resembles the femoral head with a ball-like structure attached to a long stem that that fits snugly inside the femur’s bone-marrow cavity.
There’s also a metal acetabular component (usually titanium) that’s anchored into the pelvis.