Would I recommend bilateral BMHRs?

johnnybravo84 said...
Hi Lori, I'm in need of bilateral hip replacement due to Avascular Necrosis in both femoral heads. My Doctors in Madison, Wisconsin, USA, has advised me to consider BMHR and am thinking about flying overseas to get it. Have looked at Dr. McMinn in Birmingham, UK and Dr. Bose in Chennai, India. Just wondering if you would summerize your entire experience thus far as a good one. Also, would you advise to do both hips at once, or did it prove to be somewhat "too much"? Thanks in advance for your reply!

Short answer:  Yes, the experience has been positive for me and I think if you can do both at once, it is worth serious consideration.

The long answer:  Even though I had a pretty rough time immediately post-op, I don't regret the decision that I made.  I made the right decision and I am already seeing just how much more I will be able to do.  I'm not a medical professional and my experiences are my own and are going to be individual to my particular case but I hope that sharing these will help others in both the decision making and rehabilitation process.

I'm happy to hear that your doctors have given you options that aren't just within their realm of expertise and services that they provide.  From some of the stories that I have heard, it isn't the norm unfortunately.  If you are a candidate for a BMHR, I would certainly recommend this over a THR based two things that were important to me: the BMHR is more bone conserving allowing for easier revision many many years in the future and the information I've read indicates that there are less restrictions on this prosthesis as compared to many total hip devices.   If '84 is your year of birth, I'd give your doctor's suggestion some serious thought.  Conserve as much bone as you can - you don't know what will be around in 20+ years when you need revision.

As part of the pre-op process, I signed authority to the surgeon to make the final call on this once he'd cut.  There was a small chance that I would need a total hip.  I wouldn't have wanted just any surgeon make this call. It was the first question I asked when I woke up.  I probably got a little too invested in the BMHR being the solution for me but my research had made me extremely positive about this option as being the 'one' for me.

My reasons for requiring hip replacement were related to damage caused by juvenile arthritis.  The damage had been there for a large number of years and my body had been compensating for this damage for almost as many years.  It has been explained to me that how our bodies recover very much depends on the condition that we are going in.

I don't know much about AVN so it really is hard for me to compare our experiences so that I can  have a guess at how well you will feel post surgery.  The two surgeons that you have mentioned are leaders in the field and I am sure that they will be able to give you a far better indication as to when you will be up for travelling home after the surgery.

I have seen a lot of information relating to travel and surgery on a discussion forum called Surface Hippy though most relates to BHRs.  Though not completely the same there are a lot of similarities in our recovery processes and some of the experiences that the members who have AVN and travelled might help with your decision making process.  The people are awesome there and no matter which decision that you make, I would highly recommend posting your question as they will have a lot of helpful things to add about the process that might differ from mine.

I have come across one BMHR lady who travelled on a forum.  It's only relatively new and there aren't as many people there so I'm not sure how successful you will be in contacting her there.  Rosemary references being a part of the yahoo group hipresurfacingsite so she may respond to a message there.  (I haven't really used yahoo groups as I loved the surface hippy group of people)  She travelled to McMinn for a ceramic BMHR recently and had her early recovery time in the UK away from home.  If you can find her, I'm sure that her story will be of great interest to you.   From what I can gather she spent about four weeks in the UK before travelling.  I would expect for bilateral, it should be at least that.  At that time, I don't think I could have handled a long plane trip home though from the stories I have read, many resurfacing patients have done it sooner - so it is possible.

You can't get better than Bose or McMinn.  There are a few others in their league though given the choice and that you have to travel anyway, why not go for the best!  McMinn was involved with the development of the BMHR and has the longest history of using them.  If you haven't already, read every page of his website! 

I believe that I couldn't have coped with one at a time as I would have chosen my right side to be done first, my left unoperated leg would have been the 'good' leg, the one that I would rely on a lot more.  I don't think it would have held up and actually quickly become the one that let me down and caused pain.  I don't think that I would have had the same opportunity for long term successes with one at a time, though this is really a gut feeling.  Unfortunately there is no 'control group' for scientific exploration of what is the best option for anyones exact particular experiences.   

The one thing that I wish I knew going in was that I was allergic to the hard drugs.  If I hadn't of had the hallucinations and nausea from the endone and oxycontin, I think that I would have had a bit more of a kick start the recovery process.  It might not have put me too much ahead now and there will be little difference by the time my new parts are a year old but I think that mentally/emotionally I would have been better off.  Major surgery is major surgery and if you have trouble with the meds or any other complications it's going to happen with one side or two.   Both at once means that your risk periods are going to finish at the same time and at twelve months you are going to have two new hips working well where as if you did one, the old one will probably need to be done by then starting the whole process over again.

Attitude is a big part of the recovery process for bilats.  You need to be prepared to put in the hard yards and fight to stay positive and do whatever you need to do get the best possible outcomes.  It is harder but I don't think it's 'twice' as hard.  There were moments where I thought I made the wrong decision though this was in the early days where I just felt like absolute shit.  I think the memories of this are already fading though as my husband chastised me the other day for saying something was worse than hip replacement (Mildly of course!).  He couldn't understand how I could speak so flippantly about that time.  I guess the good that I can see now outweighs that time so much so that the memories have faded. 

I really thought it would be easier than what it was.  In that regard, my expectations were a little unreasonable.  Time is the only thing that I've been off with though.  Everything else is looking great and I don't regret it at all.  In a way, my timing was right as the other set expectation was that at three months out, I was no worse of than pre-op.  At that time I was significantly better in a number of areas.  I guess that I just didn't quite realise exactly what that would mean.  The piece of wisdom that can be gleaned from this, it is probably not wise to set conflicting expectations!

I did this at the best time for me and the outcomes so far have been stellar.  I'm no longer on pain or anti-inflammatory meds.  I have a range of movement that I don't ever remember having.  I'm already doing things that I couldn't do before and though these might seem minor to some, these are huge to me.  I still have another 7 months of improvements before the progress levels off and I'm expecting big things!

I wish you well on your search for information to help make your decision.  Please feel free to ask any other questions that you might have.  Please keep us posted as to what you decide to do and how you go!

Surgical Review Day

I was actually on time to see Paul this morning even though it has probably been the earliest appointment that I have ever had at the clinic.  Some of the muscles are already better than they were pre-op and everything else is coming along nicely.  I was pretty confident that the day was going according to schedule when I arrived in at the hospital before 10am even after stopping for a takeaway coffee on the way.

I headed into QScan to get the x-rays required for my appointment, only their machine was broken and I had to find my way to QLD X-ray to have them done.  After a few navigational errors, I found myself ready for a long wait.  At a few minutes before my appointment I wasn't sure that I was going to make it since my x-rays hadn't come back yet.  Thankfully the surgeon's office was still going to let me come to see him even though I was late.  A few people had already been delayed by the same issue so it turned out ok.  I really should have gone to have them done on a completely different day to allow for things to go wrong and though I would have been disappointed to reschedule, I would have understood.

The surgeon is happy with my progress so far and I got told to keep doing what I'm doing.  The x-rays look good and I'm due again for review on 9 April next year.  Providing there isn't anything requiring closer monitoring, I will go onto an annual review schedule from there on in.  

I asked the question about the ranges and was told that I'm actually doing ok with them and will continue to see improvements until at least the 12 month mark.  How far I actually get is going to depend on not only what I do, but the condition pre-operatively is going to affect the outcomes.  I did understand this going in and already everything is better than it was going in, but I am still optimistic that there is more that I can get out of this.  The flexion estimate is about another 10 degrees active (around 100 - 105 degrees).  Apparently what I have now is on par with the outcomes of a lot of total hips that are in the condition that mine were pre-operatively.  I see this as a positive sign for my progress this far.  It makes me feel a little bit better about not being on par with the BHRs and other resurfacing components on a number of discussion groups.  This doesn't often bother me, but every now and then it's nice to be reminded not to compare too closely.  I started off a long way behind them and I think that in the long run I will be far better off as I don't have the 'hey day' to compare my achievements with.  I was never a ballet dancer or a taekwondo black belt that I'm aspiring to be again. These people are likely to recover to a higher standard as they are likely to be in better condition going in but the loss of even just a little bit is going to hurt.  I am all gains, which to me, seems to be the better view.

I also saw a ceramic BMHR.  I even touched it.  They are pretty.  I think my shiny MOM component is better looking but the ceramic is nice (Not that you choose these items for cosmetic reasons!).  Dr Journeaux has done one of these in the public health system so far.  They haven't been approved for use by the private system yet even though the MOM's are (Of those his count is over a hundred and for the BHRs, I think it was nearing a thousand).  Still early days for all surgeons doing them though it is all positive (I linked to McMinn's info on the Ceramic BMHR over the weekend).  There are no revisions for BMHRs for my surgeon at this time which I think is a really good sign.  It means it's tracking well with the longer term statistics available for the BHR.

There are always changes in this field and regardless of what happens next, I got what I needed and at the right time.  The common consensus seems to be that it will be for a long time too!

I'm starting to get a little tired.  Probably due to the change in routine for today.  Though I tried to get to sleep at a normal hour last night, it really didn't work out since I'm used to later nights and later mornings.  I'm sure I've probably missed something in the summary of today, so feel free to ask questions.  If I think of anything more I'll add a new post later!

Surgical Review and Physio

Tomorrow is my next surgical review.  I'm a little nervous.  I shouldn't be as my progress has been steady and I've been doing a lot to work towards getting the most out of the surgery and I have been happy with the results so far.  I also know that I am going to get so much more out of this than I ever imagined.  It's difficult to explain why I'm nervous at all.  The closest thing I can relate it to is maybe parental approval, though that's not quite it.  Besides my surgeon is way to young for that!  If I figure it out, I'll let you know.

It will be an early start tomorrow for a work day (well for me anyway!).  I kick off at 8:30am at physio with Paul before I head in to the hospital to have xrays done in advance of my appointment.  I don't actually see the surgeon until 11:30am but I'm not sure how long it will take at xray as you just turn up and wait your turn.  It means that I'll have a new CD of images of my new parts too.  There really shouldn't be anything new to show there but it is kind of cool anyway.

This will be the first time that I've seen Paul since before the operation too.  It will be interesting to have his thoughts on the differences he sees.  He has seen me quite a bit when I have been at the clinic to see Reese and also outside of the clinic, so he has a good idea of where I'm at but treating will actually give a little bit of a different perspective.

I'll be back at Milton later in the day to get some work done and hopefully wrap a few things up that will leave me free towards the end of the week to start to get ready for my sister's wedding on Sunday afternoon.  It's going to be a great week.

Body Leader of the Month

Hey check me out, I've been awarded the title of Body Leader of the Month!

I've answered some different questions as part of the interview than I've covered here in the past so the article might be interesting to you.

A couple of notes about the article and pics:

Yes, Lori is short for Lorraine.  It's funny how different people know you by different parts of your name.  My husband calls me Lorraine (just as I use his full name rather than Mike as just about everyone else calls him) and this usually extends to certain groups of people where I've been introduced by him, or introduced where my 'legal' name has been provided. My brothers and sister still refer to me as Rain. One of my best friends used to call me Miss Rainee and that's now Mrs Rainee since I've been married.  Mostly though people call me Lori.  It's a lot easier to spell for people, too!

For the locals, you should be able to spot the venue of the first picture.  This was my very first outing and I wanted it to be somewhere that I felt safe so it's somewhere that I spend a fair amount of time. You can see my crutches in the picture.  If you can guess where it is, there might even be a prize for you!

The Pilates picture is actually from this morning.  We took a whole series of them and I'll post some more of them here.  This is a picture of roll ins from curls (bridges).  I've been doing these for a little while and think that some of the other exercises are a little more impressive, so I'll post those soon!

The final picture is from the hospital when I was first learning to walk again.  At this time I was still using the rollater so there was a fair amount of weight being put through my hands on the rails to walk.  The white lines helped me with my alignment.  There was a lot of looking down and focusing on my feet while I was walking within the rails.  In the beginning it almost felt like the messages from my brain  didn't get through to my feet unless I looked really hard at them!  (That plan doesn't really work all the time.  Sometimes you can look really hard at the offending limb and it still won't move.  They do now, so that's the main thing!)

Baking up a storm

Saturday involved about six hours of baking in preparation for my sister's kitchen tea today.  There were red velvet cupcakes, butter cupcakes, chocolate cupcakes, chocolate mud cupcakes, mini lemon meringue cheescakes and amaretti (almond cookies) all in rather large quantities.

I was tired at the end of it all and my feet hurt.  My hips didn't.  There is no way I could have handled that much baking pre-op without some serious consequences.  Pre-op I would have started to have pain after about an hour and would have been hobbling around and feeling a rather intense amount of pain in my right hip.  By the end of the effort, I would have been leaning on walls, tables or anything close to get anywhere as my full weight on my right hip would have been screaming at me.  I would have felt the pain even when I sat and wouldn't have been able to get comfortable enough to sleep.  It is likely that I would have taken a couple  of panadeine forte to try and take the edge of a little bit, just enough to try to relax.  The pain relief wouldn't always take the edge off and never took the pain away completely.  The muscles around my hips would have been tight like rope and there would be some muscle spasming causing sharp stabbing pains as I tried to relax.  This was a a kind of pain that was significantly worse than my post-op pain levels.    

This pain would last for a number of days and see me fatigued for days after that.  My sister's engagement party saw me out of action for the best part of a week.  During that time I was on increased anti-inflammatories and additional pain relief.

Now, the day after, I'm just a little sleepy from having a busy weekend.  There is no pain. My calves and the muscles that run down the back of my feet are a little tight, as are my shoulders but this is what I would consider normal types of muscle tightness after standing with poor posture for that many hours.  I must have been hunched over to be tight across the back of the shoulders.  Awesome, hey!  I really do mean that.  A normal body reaction to poor behaviour.  Normal.  No meds.  Wow.

The countdown to my sister's wedding is on.  Next weekend we have dress fittings, the weekend after the 'Girls Night' and then the next after that is the big day.  I'm going to be in pretty great condition by then.  It's all happening.

Pain Management and Healing: Part II

After the abysmal failure of oxycontin and endone, a solution of ibuprofen and panadeine forte was suggested (all at the highest possible daily doses).  I was a little scared of the ibuprofen as some of the nurses had gone on about it upsetting my stomach again.  I was already on maxalon to stop vomiting and I didn't want anything that could start that again.  I asked the doctor if I could take the Voltaren again instead.  One said yes, one said that the Voltaren was more harsh on the stomach.  The reason that I had asked is that I new that I didn't have any adverse affects to it and while I was still in a paranoid sick state, I really didn't want to take any more risks.  In the end I tried it and it was ok.  I was still on the maxalon for a while as I still had nausea problems when I ate (though that very well could have been a problem with hospital food - not actually meds or illness).  Together the ibruprofen and panadeine worked out and there weren't any further adverse reactions.

There was some other drug that I could try if this didn't work out though from what I can gather the back up plan wasn't a favourable one.  In the beginning as I got closer to the times when I was due to have medication, I would wait on it.  I knew when it was due as the discomfort was increasing.  I never waited so long that it was unbearable, though there was one day when they were just over an hour late and I was stuck in a chair in my room when I really was ready to press the buzzer again almost at the point where I thought I couldn't handle it anymore.  I still wouldn't say that the pain was high on the pain scale, maybe a five, but I was exhausted and I felt like I didn't have the strength to hold my body up any more and everything was uncomfortable and I wanted to move but I couldn't.    I had learnt the hard way that the doctors were right, staying on top of the meds at that point was important to my rehabilitation.  There was no way that I was doing anything that afternoon for at least three or four hours while I rested and got on top of things again.  Normally I would have done another set of my physio exercises.

In the last week or so we started to cut down the amount of codeine that I was having, so the panadeine forte was changed to panamax and codeine tablets.  I didn't notice a huge difference.  During a big rehab day, I'd say I was more aware of the joints but overall I wouldn't say that the pain had increased.  There certainly wasn't any sharp pain anymore, just occasionally a dull ache which was only a one or two on the pain scale and significantly less than what I was used to pre-op.  I had started to be able to stretch some of the muscles a little and as my overall wellbeing improved, my confidence in my body also started to improve.  I think that this was the turning point for getting results as I was less tentative in trying to trigger point tight areas (obviously within reason - I wasn't digging into the wound just yet) and moving more (within the range of restriction).  As muscles loosened, I felt that I could do more and it felt like the joint was moving more freely and with more control.  Exercises like heel slides on the left and abduction were still difficult to start off but I could do a lot more without assistance and I could now visibly see some definite results.   The more I could do, the better my body felt.

Pain Management and Healing: Part I

I have touched on the issue of pain management in some of my other posts though the issue really does need a bit more attention as it really is a major issue in my history, decision making process, post operatively and even now as I am on the recovery path.  Since I've been asked recently about my current pain levels, I'll start with the present and work my way backwards.

Today, I'm taking Panadol Osteo at night before bed.  It's nothing really.  I've gone without it for a couple of nights in the last week or so as well.  Since I've been home, I've been choosing the level of medication that I require on a day to day basis.  After two decades of managing pain I get it right most of the time.  Throughout the rehabilitation process they tell you it's important to stay ahead of the pain as it's more difficult to fix the problem after it's gotten too bad.  Bad pain also restricts the amount of exercise that you are doing which can delay recovery times so it makes sense to manage the medication carefully.  On the flip side of this, I want to be off medication.  Being off anti-inflammatories was one of the hopeful outcomes for the surgery which I have now met so I've moved the goal posts a little.  It won't be the end of the earth though if I need to take two panadol at night for the rest of my life.  It certainly is better than the other meds that barely managed the pain pre-op.

The pain I have now is only muscular.   The joints don't hurt.  They move freely and don't grind or stop me from moving.  I'd say that the pain that is left is probably similar to work-out pain (without straining anything).  If the worst pain I had pre-op was a ten, I'd say today was only one or at most a one and a half. (I'm sure that there are things more painful that my worst flare but for the sake of the scale, I'm putting the worst one up the top end and working down from there)  I'm completely worn out and everything feels fatigued but it isn't real pain.  There is the friendly muscle ache going on letting me know that I did work hard today and my body really has had enough for the day.  Every now and then it's a little sharp if I sit too long and stretching and moving will help release it out.

A lot of the exercises that I am doing are to build the hip flexors and hip stabilisors.  To work these a lot of other muscles are getting a work out as well.  Pretty much everything around that area needs to be stretched out as it gets tight.  The adductors are some of the worst offenders.  Gluteals, quads and hamstrings are pretty close behind.  The muscles that are above the top of the pelvic bone on the right side are getting a bit of a look in at the moment too as I am practicing walking on one crutch. Knees ache and are swollen a bit more than normal.  They are getting a work out too given my gait has changed as I'm straightening up and not compensating as I used to pre-op.  As the muscles strengthen, I'm able to do more before things get worn out.

Over the years of working with Paul at Body Leadership, I have learnt a lot of skills to help relieve muscle pain.  Squeeze, Stretch, Trigger, Move are the four tenets of body maintenance and when applied make a massive difference to how my whole body feels.  I probably won't explain this anywhere near as well as either Paul or Reese would but I know what I'm supposed to do and they check in regularly to make sure that I'm doing everything properly and add in extra stretches and exercises to my program. Trigger pointing myself isn't anywhere near as effective as when either of those guys are doing it either, though it does make a huge difference.  Pain is more easily managed with the help of these guys.  I can't wait until I can comfortably lie on both sides on the beds at the clinic so that I can get all my connective tissue released.  The thought of all the muscles all loose and nice feels like floating which would be awesome right now!

When I'm in bed I can lie on the wound on either side. The time limit before I have to move is a couple of hours so I am waking to move still and as time goes on, I can stay mostly asleep to move so my sleep feels less interrupted and I wake feeling like I have actually slept.  It's probably close now as I can comfortably rub a moisturiser into it and put quite a bit of pressure into it.  Apparently this is good thing to do while the scar tissue is still pliable to try and minimise it.  I've only really just started this in the last week or so as I've been pretty tentative with it until I was sure it wouldn't hurt.  I don't think I'm going to end up with a really big scar anyway as it looks like the surgeon has done an awesome job putting me all back together again.  The line is quite a fine line and a lot less than I would have expected when you consider how deep the incision would have been to get down to the femur.

When I arrived home from hospital, I was taking the maximum dose of ibrupofen and panamax.  The dose of codeine that I was taking had been cut down to 60mg at night and three lots of 30mg through the day.  30mg is what is in a single Panadeine forte tablet.  Codeine is an opiate and it isn't one of the common ones they use for pain management for this surgery apparently.  The narcotics usually prescribed are oxycontin and endone which I couldn't take as I had a bad reaction to them.

I hadn't really thought of Panadeine Forte as a stong pain killer.  I guess that's because if I had used them pre-op to handle pain and I thought that post-op the pain would be so much worse and I'd need something so much stronger.  Surprisingly I didn't.  The surgical pain really wasn't that bad.  Don't get me wrong, I wouldn't have wanted to put too much pressure on the wounds in the early days but mostly the site was numb around the wound.  It isn't completely back to normal yet but it isn't numb like it was then.

Every now and then there was a quick sharpness but it didn't last.  I like to think of it as the point where the nerves that were healing were first taking the electrical impulses through them and that first sharp pain is the first one as it pushes through the damaged piece the first time to forge the new pathway.  I'm not sure how it really works but the visual of that made the whole thing a bit more positive in my mind.

The most pain I ever had was the second night in the ortho ward and it wasn't in my hips or legs.  It ended up being my back from being in one place for so long without moving.  The first night I still had the PCA to help out but the second night it was gone (I think the PCA is the name for it.  It is the button that you can press to self administer drugs straight into your drip.)  The night it was gone things weren't as comfortable.  I'd also lost the air mattress thing that I had in ICU and they don't roll you in the ward to help relieve the pressure.  The next day I managed to get the air mattress back and that made all of the difference.  Over the next few days I could move a bit more, they got my haemoglobin under control and sorted out meds that worked and I was starting to sleep for a couple of hours at a time which helped.  I think this is the main reason that the goal is to get you up and moving the day after surgery.  Unfortunately when that doesn't happen, muscles start to tighten up and within two days muscles start to weaken.  So I guess the moral of the story is to at least try to get up the first time the physios come in.  If it works out, you'll be so much better off.

When I moved to the rehab ward, the back pain moved to further up the back.  I'd lost the air mattress topper again but the pain was likely from poor posture while using the rollator.  The muscles across the middle were really tight and difficult to stretch out.  I found that the solution was a rolled up towel that I lay on as it ran down the length of my spine and my shoulders could fall back over it and get a good stretch.