Roger Meyer is used to moving fast. That is what he did when he ran track in college and later when he played softball, and it was always true when he played tennis. But he steadily lost speed on the tennis court, which brought him to the office of John McInnis, MD, an orthopedic surgeon at Emerson. A few months after having hip replacement surgery, the Boxborough resident, who is 74, got back on the court.
It took a while for Mr. Meyer to realize the source of his problem. For a few years, the pain he felt was in his back. "In general, I was stiffening up," he recalls. "I started working out to strengthen my core and regain flexibility. But I was losing my mobility on the tennis court. I felt like a car that was beginning to break down. It was frustrating."
Barbara Peters, MD, his primary care physician, suggested he have an x-ray taken of his hip, which led to an appointment with Dr. McInnis. Mr. Meyer will never forget what happened that day. "Dr. McInnis put the x-ray on the board and said, 'you have no cartilage; the ball of your hip is right up in the socket,'" says Mr. Meyer. "I wondered how that was possible, because I was still running on the tennis court and riding a stationary bike. I wasn't even limping."
Dr. McInnis explained that osteoarthritis of the hip does not behave in a predictable way. "Unlike knees, hips don't always correlate to what we see on the patient's x-ray," he says. "A hip joint can look very bad on an x-ray, but the patient won't necessarily be in pain. Or they might instead feel the pain in their back or their side, or notice their leg has become weak."
Even then, Mr. Meyer, a real estate broker until his retirement a few years ago, assumed that hip replacement surgery was well down the road. "I was thinking the time frame was three or four years," he says. But Dr. McInnis surprised him when he said that, based on his x-ray and symptoms, he would likely need to have surgery within a year or so.
"He even drew me a picture of what I could expect," says Mr. Meyer. "It was a line heading slowly downhill. After all, I didn't have any cartilage in that hip." It was June 2015, and Mr. Meyer's tennis season, which included playing on an indoor court, would begin in October.
Surgery, minimal pain and great results
As it turned out, Dr. McInnis's drawing was prophetic. "Once I began playing tennis last fall, I just wasn't moving well," Mr. Meyer says. "Off the court, I started limping a bit on the stairs." He returned to see Dr. McInnis, and his surgery was scheduled for March.
"I always prefer for the patient to tell me that they're ready for surgery," says Dr. McInnis, who specializes in joint replacement surgery. "If they're unsure, I ask what activities they've given up because of pain. Once someone says they can't sleep at night, it usually means they're ready for surgery.
"With younger patients, we try to help them hold off, if possible, so that they won't require a revision — having another joint replacement later. The design of today's hip implants has improved to where most patients can expect to get 30 years from a new hip."
Dr. McInnis encourages his patients to attend Emerson's two-hour class Preparing for a Hip Replacement. "I thought it was great," says Mr. Meyer, who attended the class and continued his regular workout in advance of his surgery. "My wife and I were in Florida for six weeks, and I decided to join a gym so I could stay in shape."
When the day of his surgery arrived, Mr. Meyer says he was a bit apprehensive, but he was ready. "It couldn't have gone better," he says. "After surgery, I felt no pain or discomfort in my hip. They got me up and, six hours after hip replacement surgery, I used the walker to head down the hall."
Thanks to minimally invasive surgical techniques and better pain control, that is now standard procedure. Still, Dr. McInnis says patients often are surprised to be walking on a new hip or knee the same day as their surgery. "It accomplishes a few things at once," Dr. McInnis notes. "It builds the patient's confidence, it prevents deep-vein thrombosis — blood clots, a potential complication — and it gets physical therapy started. Many patients go home two days after having a joint replacement."
Mr. Meyer is one of the lucky people who continued to experience almost no post-surgical pain. "The nurses kept asking how my pain was, on a scale of 1-10," he recalls. "I kept saying I had none. They wanted me to stay ahead of the pain, because it would be easier to treat.
"Even Dr. McInnis stopped in to say that no one gets through a hip replacement by taking just Tylenol, especially when they have physical therapy to do. I did take a pain pill, and it was easier for me to get out of bed and walk even further. Pretty soon, they had me going up and down the stairs."
Once at home, Mr. Meyer had regular visits from Emerson Home Care staff, including a nurse and a physical therapist. "They were great," he says. From there, he moved to an exercise program approved by Dr. McInnis. "I wanted to do more than 50 minutes of exercise a day, but I knew I had to follow the protocol."
"Some patients feel so good and have so little pain that we have to hold them back a bit," says Dr. McInnis. "I tell them: remember that you have to let the bone grow around the implant to complete the healing process."
Mr. Meyer started early — in June — and slowly, to move around on the tennis court and steadily increased his activity level over the summer. "When I realized I needed a hip replacement, a few people suggested I go to a different hospital," he says. "But I know Emerson, and I know it's a first-rate hospital."
New approaches to pain control have transformed joint replacements
There's a reason Mr. Meyer experienced so little pain after his hip replacement: multi-modal pain management has transformed joint replacement surgery. He benefited from a carefully designed approach to pain that kept him comfortable — as well as ready to begin his rehab just a few hours after arriving in his room.
"Two things occurred in the operating room," explains Dr. McInnis. "I placed long-acting Novocain into Mr. Meyer's incision, and we started him on Toradol, a non-steroidal anti-inflammatory medication, through an IV." As a result, Mr. Meyer woke up in the recovery room with no pain. After that, he received a combination of Tylenol and Toradol and a narcotic painkiller — but cautiously and only as needed for breakthrough pain or in advance of a physical therapy session to prevent pain from developing.
Regional anesthesia plays a substantial role in the new world of pain control. "Most of our knee replacement patients and some of our hip replacement patients receive regional anesthesia prior to their surgery," says Dr. McInnis. "They're numbed from the waist down and, by avoiding general anesthesia, experience less post-surgical confusion. Regional anesthesia is associated with less pain, less blood loss and less chance of blood clots."
The knee is more exposed than the hip and has less tissue to protect it. As a result, knee replacement surgery is associated with a greater degree of post-surgical pain. "The use of nerve blocks has revolutionized knee replacement surgery," says Dr. McInnis. "All credit goes to our anesthesia department colleagues, who manage our patients' pain control problems. They now provide nerve blocks that address the patient's pain without affecting the quadriceps muscle.
"As a result, they can move with confidence and begin their rehab right away. Our patients are very pleased."
