How I picked the surgeon for my hip replacement.
This is a big one, the big one after you’ve decided to go for the op. How do you find qualified hip replacement surgeons, let alone choose the right guy? And yes, they are pretty much all guys. When I started I didn’t have a clue. What I did have was an understanding that there are a wide range of competencies out there, numerous options for hardware and surgical approaches; and that my choice could dramatically impact my future quality of life.
I’d gotten a book out of the library on how osteoarthritis sufferers might be able to avoid hip surgery years back. It was written by an orthopedic surgeon who lived about a four hour drive from my house. I made an appointment, this was still in my “hope to fix it” stage. I had done most of those things in his book over the years to no avail. His comment was that I was “an outlier.” He said I had no alternative to surgery. He’d be happy to do it but thought being so far from my home was not optimal. “You need a good carpenter, don’t bother with me as you can get a fine one in your local area.”
Research
So I started to look on the internet. I searched for “surgeon” combined with “hip replacement”, “osteoarthritis”, osteoarthritis hip” even “bilateral hip replacement” and “anterior hip replacement”. I got lots of names, some slick presentations, some boring lists. I had no idea what I was looking at or looking for. I needed some better guidance than get a good carpenter. I had a niggling suspicion that the “good carpenter standard” might be setting the bar too low. Years back I’d seen a Rheumatologist who told me I did not have Rheumatoid arthritis. He wasn’t a surgeon but he knew the territory. He was older and well respected. I figured I could find out from him how to search and maybe get a few names of surgeons he knew who had good reputations. I would say that going to someone intimately involved with the field who does not have a direct stake in operating on you is a really good step to take for obtaining objective information. Lesson here – enlist professional allies in your search.
So I’m in the office and he’s staring at the x-ray. Looks like Swiss cheese in there he says. I can’t believe you’ve waited this long. Still nothing is damaged that they aren’t going to chop out and throw away so no harm done with that. Lesson here – if you can stand the pain take your time.
My appointment yielded more than I had even hoped for. What the doctor gave me was a checklist – “if I were getting this operation here is what I would ask”. Before even starting the list he gave me the advice to not be shy, be direct and ask questions that might be uncomfortable. Use basic psychological skills to sense whether you are being told the whole and true story – like looking for eye contact, listening to tone of voice. His interview questions consisted of experience –how many operations (300 minimum was his take), what surgical approach, changes in approach over time, expected outcomes and future capabilities, convalescence protocols, complication types and rates and infection rates. He was especially concerned about infection rates, surgeons can harbor MSRA in their nose he said, you want to avoid anyone with a rising rate.
He gave me the names of three surgeons within about a 60 mile radius who he knew did a lot of total hips and had excellent reputations. One taught at a well respected medical school. He also encouraged me to meet with whoever was the main hip guy in my local hospital. I had been to that hospital for x-rays over the years and the surgeon who was in charge of my case had just retired. He, apparently, was quite good at total hips.
So I have a list. I pass on the surgeon who is also a teacher. I want a guy focused on patients. As I later found out you can get a super competent surgeon for the operation but the surgical agreement can allow significant portions of the operation be performed by less experienced doctors and you’ll never know who did what. That is something to add to your question list.
Surgeon Interviews – Just because they can do it doesn’t mean you want them to do it to you
The first surgeon I visit was very well respected both for his outcomes and his ethics – he does a lot of pro bono ops in the third world. He was deliberate, maybe even slow and seemed a bit old fashioned. He was supremely confident, had done thousands and probably could do them in his sleep. The booklet he hands me has an old lady smiling as she kneels in the garden potting a plant. His recovery seems long and his outcomes (no skiing) seem restricted. He kept calling me young man. I thought he would do an adequate job but I wanted better.
Next surgeon I saw was the kind of guy you might want to have a beer with. Very personable, full of stories, informative and casual. He was a generalist, did knees, ankles, and posterior only hips. Generalist was already one strike against him on my checklist. I’d already been tipped off that he was someone to avoid (in the coded language of nurses and physical therapists – “you might do better”) so I was on the lookout for issues of quality. The interview ended in my mind when he responded to my question about leg length discrepancy (a major complication that reduces quality of life) with “it ain’t so bad, you can wear a riser in one shoe for the rest of your life”. This guy just slapped them in there and went with the flow. That’s not how I get my car fixed let alone have inside my body for the rest of my life.
Surgeon Interviews – Just because they can do a great job doesn’t mean it is the job for you
Precise I got with the next guy. He had a spectacular reputation, nothing but praise whoever I spoke to. His years of experience made him as good at that approach as anyone (he was too modest to say that but others did so about him). In the interview he was full of interesting new information including some insight into the mechanics of my breakdown. His take was the shape of my socket was narrower than normal giving less area than most for the ball and socket to be stable. He was obviously very good at what he did and had settled into the surgical style he was comfortable with. He talked about his failures as someone who is extremely confident would. They happened as accidents do and they are terrible and he did what he could afterward. He offered a nice short incision and much better range of activities than the first guy. He was somewhat pessimistic about me regaining full flexibility, I was really compromised and had been so for a long time. Operation time 1 ¼ hours, really quite short. He thought he would restore 5MM of lost joint space to my height.
His surgical approach, while minimally invasive, was posterior as was that of all the surgeons I’d interviewed so far and therefore cut through a few muscles. He showed me which ones on a plastic joint model. Unlike the other surgeons he said he could see doing both of my hips at once if I were so inclined, though he was not necessarily recommending it.
When questioned about the anterior approach he was frank about it being the less invasive approach. It did have risks, including a higher incidence of nerve damage. In his case, at this relatively late stage in his career, changing approaches did not make sense. Why subject his first 50 patients to the higher risk of a rookie climbing a learning curve? As I was interested in exploring anterior hip replacement he gave me a few names.
I came out of this interview feeling I finally had a surgeon who was at least adequate, who exceeded my minimum but still fairly high standard. He’d get the job done and the odds of complications were as low as anyone could offer. Knowing I had someone I was confident would do a really good job took a load off my mind. I had my posterior guy, I was pretty sure. But I wasn’t done quite yet. I had the anterior approach to explore.
Another Approach
My thinking about the anterior went this way. There is supposed to be an advantage as far as future range of motion and goes. Dislocation risk was non-existent because it is very difficult to generate pressure from your hip in the direction of the incision. With no muscles cut it is supposed to be great on the recovery. Twofers are easier because you’re already splayed out and they just walk around the table (instead of flipping you on to your fresh incisions to do number two). I don’t care what they say but cutting all three of those muscles off 100% and then expecting them to grow back without issues like scar tissue seemed farfetched. Anterior is becoming more popular despite few medical schools teaching it, so there must be something good about it. By definition it is minimally invasive, with a small incision though not quite as small as a crack posterior guy can get away with.
The scary thing about anterior are all the dire warnings about nerve damage. It is true most patients suffer nerve trauma but the actual effect is mild. Most reported is an area of decreased skin sensitivity on the outer thigh which generally fades over time. Anterior is also is a less forgiving approach. The surgeon has a lot less room to maneuver if something unexpected comes up.
Anterior is a new approach and many of the reported results came from surgeons with limited experience. Anterior also requires specialized equipment so it is not that widely available. Experience was somewhat difficult to gain so the pool of surgeons smaller.
With four posterior surgeons interviewed I went and made four more appointments with anterior guys. Three were recommendations from the last surgeon and a fourth I had ferreted out on the internet.
As it turned out the first surgeon on the referral list really blew me away – and he wasn’t anterior as advertised. This guy had gone back from the anterior approach to an improved posterior technique. Based on personal experience and one study he provided he did not believe there was an advantage to anterior and the more limited exposed area added risk. His posterior op was a 2 ½” incision in 45 minutes, the shortest on both metrics I’d heard. He also thought he’d add about ¼ inch to my height as had two other surgeons. He promised less restrictions and more hope for range of motion recovery than the other posterior surgeons. It sounded really good.
But it wasn’t a solid yes in my mind. The surgeon was fairly young and energetic but also very disconnected on a personal level. There was something disconcerting, like I would disappear into his very busy practice as a number. The inside scoop from my PT and nurse sources was that he was great, almost all of his operations were successful and patients happy with their recovery but in the very few cases where things go wrong you can forget about getting much service. It made sense based on my assessment of his affect. He was a winner and not terribly interested in the losers.
Weighing on the other side, the guy was a perfectionist. He also had a blood recycling system so good he didn’t bother with transfusions. He had a regimented post-op system for all his patients and got stellar outcomes. I liked his rap about how he arrived at his place in the surgical choice spectrum – through a rigorous results based approach.
He rose to number one on the list, less invasive with a shorter recovery period. 100 to 1 I would not have to suffer from inattention in case of failure. Now I was feeling pretty close to done with the process.
Stay the course
Of my three remaining appointments with anterior approach surgeons I canceled two. On one the scuttlebutt was, “does ok but not so great”. On the other I was not so enamored of his photo (yes one can be superficial and arbitrary) and my appointment was another month down the road which would put the surgery into April. I had done my first surgical interview in October and was ready to be done with the process.
Due diligence says that I needed to go to at least one appointment with an anterior only guy. This surgeon, like the last, had switched from posterior to anterior but unlike the last he remained sold on the new approach. His pedigree included an internship with the USA father of the anterior approach, Dr. Joel Matta. I had no independent information about him as I’d found his practice on the internet. I went in fully expecting to leave his office and call the 2 ½” guy to make the surgical appointment.
Well this last surgeon turned out to have it all. He had a good story about why he switched to doing the anterior and why he does it almost exclusively. He was young but not too young, in good physical shape and obviously happy to be doing what he was doing in life. He’s an individual willing to make a costly change in the face of new evidence in pursuit of excellence. I like that. He’s fully through the change-over following a year of internship with a master and now had many hundreds of solo procedures under his belt.
He addressed my flexibility issues head-on saying he saw no reason not to achieve full mobility with the anterior approach and even supported deep tissue (massage) work as a means to help regain range of motion. His operation protocol included joint capsule restoration which is not that common of a practice but does further lower the risk of dislocation as well as facilitate quicker healing. He was very picky about outcome, committed to making sure I ended up with no limp and absolutely fully functioning, including skiing.
This surgeon seemed quite engaged with my case. He saw it as a challenge. The rap on anterior is that it gives the surgeon less options if something unexpected comes up on the table. That was true in theory but in actual practice he hadn’t hit a situation where the approach itself prevented the optimal outcome. My hips in particular were excellent for the anterior approach, the same shallow hip socket that likely caused my degeneration gave him lots of tissue to work with during the replacement. One thing he told me was I could use a gravity table almost immediately to hang by my legs, something impossible with the posterior approach, even in the long term.
The kicker was his recommendation about doing two at once. Most surgeons had said it wasn’t that good of an idea but he said my particular hip situation meant I would have a lousy first rehab because of how compromised both hips are. On a purely mercenary level surgeons get less for two at once than two on two different dates. Nonetheless, in my case he’d say do it at once. Yes it has more risk due to a longer time under anesthesia and a higher incidence of transfusion but on the flip side I’d be really down for only 6 weeks total. That was something that fit in better with my very busy life.
It took me a few days and some email back and forth to decide on whether to go for bilateral anterior hip replacement. I was assured the nerve damage would only be an annoyance and that I could arrange to have my own blood taken and used for transfusions.
Making the Decision
I can’t tell you how relieved I was to finally make the decision. The date was set a bit under two months in advance. I needed a full 45 days to make and recover from two blood donations. I also needed to get far enough ahead at work to make time for recovery.
When I went in my pre-operative visit he popped up the X-rays and started to almost talk to himself about how this was going to be a really good job. He was excited about doing the surgery. He ticked off the positive factors – I’ve got plenty of bone, I’m not diabetic, out of shape or obese (he actually said I was thin but I know not thin enough to fit in those old jeans). At 59 I’m young. The odds are good despite a long list of low percentage horrific outcomes that I declined to hear about in detail. The grimmest disclosure was that I could wake up with only one done, ugh!
Choosing the artificial hip hardware was sort of like choosing lenses at the optometrist. You have a limited range of important choices. Of course my surgeon had a good idea of what kind of prosthesis would be best. His recommendation is a really solid top and bottom (a full hip instead of a mini) with a “replaceable” plastic liner in between. Can you imagine 20 or 30 years down the road the plastic, which looks half an inch thick, will wear down and need to be replaced like a worn brake lining? Wow.
He told me what factors went into his choice of ball size, specifically my likely level of physical activity. He was agnostic about whether to use a ceramic or metal ball to go in my new socket. Both snuggle up against tough plastic liners. The ceramic is smoother on a microscopic level and that might extend the life of my replacement by five years but it would be slightly more prone to fracture. I chose the metal, I want to jump over that stream with a pack on my back.
He and a few of the other surgeons I had visited no longer were giving patients the choice of metal on metal prosthesis. The grapevine said too many complications. Within a year the FDA, years late if you talk to the top guys, recalled the hip replacements. Dodged that bullet.
Most important thing I’d say to anybody about choosing a surgeon is to be about 10X as picky as you’d be about buying a new car!
