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THR Surgeon telling me to wait due to BMI 45 - he only performs posterior

Ottamiway

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Hello,

I just found this site so here’s where I’m at. 57 year old female in California, USA. I have a BMI of about 45 after losing 50 lbs with keto and exercise starting Sept 2019. In January my hip got so bad I could no longer walk around my nearby park and my knee on the same side has worsening osteoarthritis as well, which has precluded me from exercising using my recombinant bike. So, I’ve lost like a lb or two since January.

I just saw orthopedist last week. He wanted to see how my knee was and ended up giving me a cortisone shot in my knee in the hope I can use my recombinant and reboot my weight loss. He’s adamant that I lose as much weight as possible before surgery (he won’t even consider THR surgery until I’m below 40 BMI). He says there’s increased infections, dislocations, etc., with added weight.

Now I’m more than fine losing more weight but if this knee shot doesn’t help in that regard, I need another solution. As it stands, if I can’t get my surgery this summer while my spouse is off (teacher), the surgery can’t be performed until December during winter break.

California is currently under a shelter in place order, so surgeries are limited. it appears the governor is beginning to reopen areas.

My concerns, which I expressed to my orthopedist, is that 1) I don’t want to wait until something goes wrong (that’s what the maternity doctors told me 25 years ago when the inductions weren’t working and they wouldn’t move forward with a c-section. I eventually said no more inductions and had to have a c-section because my wonderful son was soooo big, 2) I’m more than happy to lose more weight but I need to be able to exercise to do that (the keto is great but I’ve found I need the combination to lose lbs), 3) I don’t want to wait forever as I have a life and my demeanor with the pain is damaging my relationship, 4) I don’t want to be soooo careful that nothing improves.

He emphasized that when he’s let people pressure him into surgery before weight loss, there have been complications and that he doesn’t want me to end up in a wheel chair.

He wants me to keep a pain log (in progress) and see him in two weeks.


In the meantime, I researched other Sutter Health orthopedists in the area and they only perform anterior (no SuperPATH). I find it odd that my surgeon is the only one in the area performing posterior.

I understand that posterior has a longer cut (visually I don’t care, pain wise if it’s more, I’m leery). It’s easier for the surgeon to get around using posterior. Anterior is newer so get an experienced surgeon and recuperation tends to be easier.

Medical situation: Not diabetic, some hypertension controlled by meds, hypothyroid, past surgeries include c-section (they had to put me totally under for) and gallbladder removal.

So...my questions to you are 1) what are your experiences with a 45 BMI and having THR surgery (posterior and anterior)? 2) I understand that I need to keep the scar area dry to not suffer an infection - how difficult is that for a larger woman given one scar is in the front of the leg and the other is in the back? 3) I’m having a very difficult time not being able to exercise and want this surgery ASAP although I don’t want to end up in a wheelchair - how realistic is that scenario?

I’m sure I’ll have more but these are the main ones. Thank you.
 

Elf1

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:wave: @Ottamiway and welcome to Bone Smart.
You have some good questions but I'm not really that well versed in BMI but will try to provide you some help.

I've attached a score chart that you can print off and use to show your Surgeon your pain levels. Hopefully you find it helpful.


Also including a link to some information in our library about high BMIs that might be helpful.


Others with a bit more experience will probably be along before too long.
 

Jaycey

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@Ottamiway Welcome to BoneSmart!
what are your experiences with a 45 BMI and having THR surgery (posterior and anterior
First off - the approach has nothing to do with your weight. The surgeon will use the approach they are most comfortable with given your own situation.

In terms of BMI - yes there can be complications in patients with a high BMI. But there can be complications with anyone. You are caught in the middle with this as it is impossible to exercise with bad joints. And I do agree - there is only so much dieting can do. It would seem your only option is to find another surgeon more willing to work with you.
I understand that I need to keep the scar area dry to not suffer an infection - how difficult is that for a larger woman given one scar is in the front of the leg and the other is in the back
The wound area does need to stay clean and dry. Larger patients do have issues with the anterior incision as the folds of skin at the top of your thigh can cover the wound. You should be just fine with a posterior approach. And BTW - anterior is not necessarily an easier or quicker recovery.
I’m having a very difficult time not being able to exercise and want this surgery ASAP although I don’t want to end up in a wheelchair - how realistic is that scenario
To be honest I think your surgeon is being a bit alarmist. Again - is there an option for you to get a second opinion. The surgeon needs to be someone not connected in any way to your current OS.
 

GrannyC

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After reading your post, my first thought is that you need to search for a second opinion and not anyone in the same group as your current OS. You should be able to do research on this over the phone, especially during this pandemic time. You can explain your dilemma to the receptionist or nurse and they should be able to tell you if there is any possibility the OS would consider surgery on you. From what I’ve read the overall recovery for both approaches is very similar. I had anterior but it wasn’t something I requested. It was my surgeon’s choice and I wasn’t about to argue as he knew much better than me what was best for me. After surgery my incision was covered with a waterproof bandage so it allowed for showers and it did not need to be changed.

I can understand your dilemma. It would be very difficult to lose weight when you can’t move around much. You’ve come to the right place as there is always someone here to try and help and/or offer support. Please keep us posted on how things are going and don’t hesitate to ask any questions you may have. I wish you well.
 

Hip4life

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I had posterior approach and have no complaints. It is fairly long but has almost completely faded. It didn’t seem to bother me sitting or in any other position that I remember except initial surgical discomfort. Again, it is really dependent on the skill and preference of the surgeon. I, too, would be looking for a second opinion. I think your dedication to your weight loss, exercise, and overall health should be factored in, not just BMI. If you have trouble finding a surgeon for second opinion, maybe @Jamie could help. This will tag her for a response. Hang in there and keep asking your questions.
 

Jamie

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Hi, and welcome to BoneSmart. First, I want to congratulate you on your weight loss and your wonderful attitude toward getting even healthier in the future. What you're saying makes perfect sense as it's impossible for a person to exercise when they are in extreme pain and need joints replaced.

It's possible that your surgeon is being influenced by your insurance company, as many of them place BMI restrictions on patients for surgery (usually 40 or lower). However....there sometimes are circumstances where that is just not feasible. It also sounds like your surgeon may be wary of performing surgery because of some bad experiences in the past. While that's understandable, it certainly isn't going to work for you.....so it may be that he's not the best choice for you.

I have the following surgeons that you could contact in the general San Francisco area. I don't have any in Sacremento at this time. Is it possible for you to make that drive? If so, I suggest you contact each surgeon's office and ask if they would consider a consultation for someone with your BMI and situation. If this is not an option for you, please let me know (tag me, if you would so I see it quickly) and I'll do some additional research.

San Francisco, California

Recommended by Knitter4444 (Merrie) - she used Dr. Hartford
Dr. James Hartford
or Dr. Johhn Lannin
Sutter Health
Palo Alto Center
795 El Camino Real Lee Building, Level 3
Palo Alto, CA 94301
650-853-2951

Dr. Bradley Graw
Palo Alto Medical Foundation
795 El Camino Real Bldg Lee
Palo Alto, CA 94301
650-933-5074

Dr. James Huddleston
Stanford Medical Outpatient Center
Redwood City, CA
Hip and knee revisions
Speaker at 2018 ICJR workshop on problem hips and knees

Erik Hansen, MD
Assistant Professor
Arthritis & Joint Replacement
1500 Owens Street
San Francisco, CA 94158

415-353-2808

Dr. John Dearborn
Co-director of The Institute for Joint Restoration.
2000 Mowry Ave
Fremont, CA 94538
510-818-7200

Recommended by member Cheryl Glaiser.

He has done multiple surgeries on my hip replacement. "He treats infections and does revisions. My revision was not an easy one as I had bone loss from the old plastic. My original hip replacement was in 1985 when I was 23 and lasted 31 years."
 
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Ottamiway

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Wow. Thank you so much!

I’m actually located in Vacaville which is a little west of Sacramento (most people know if Sacramento). Palo Alto and SF are probably too far and I’ll need to have it be a Sutter Health doctor because I have Anthem Blue Cross with a Sutter Health PCP.

My spouse agrees that I should obtain a second opinion and I’ll be asking my PCP about it tomorrow (Tuesday) when I see him for an unrelated issue.

My knee has osteoarthritis, is very painful, and it seems to be making “clicking” sounds similar to what my hip is doing. When I asked my orthopedist about performing both hip and knee at the same time (if needed), he said no. He said he would want my hip problem resolved first. Since the osteoarthritis progressed from minor in Nov. 2018 to bone-on-bone in February 2020 worries me that my hip (and knee) will disintegrate in short order. Consequently, I’m currently leaning towards a sooner surgery (if possible due to pandemic). Unfortunately, we’re not wealthy so can’t just go to any surgeon. I’d also be concerned what happens if I experience complications following surgery and need to travel to a surgeon in Palo Alto or SF.

Something I forgot to include in my original post is that I have avascular necrosis (AVN) in my right hip.

THANK YOU.
 
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Jaycey

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When I asked my orthopedist about performing both hip and knee at the same time (if needed), he said no.
I can well understand why he said no. Two complex recoveries at once - I would not want that either.

Let us know what your PCP recommends.
 

leejaa

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I had my left hip replaced in 2017 and my bmi at that time was between 45 and 42 ( I do not remember my exact weight at that time) and then I had my right hip replaced in 2019 and my bmi was 40. I did not have any issues with recovery in 2017 or 2019. I had posterior approaches for both because that is what my surgeon prefers and I really prefer him so I was fine with that. I am glad that you will be getting a second opinion. Congratulations on your weight loss. I am also working on that right now and started last May. Best wishes for finding a surgeon you like and trust who will help you soon.
 

GrannyC

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One point about the bone on bone diagnosis. I have OA in both my knees and I was told 2 yrs ago that my right knee is bone on bone and left knee is getting close. However, neither of my knees hurts. They both get quite stiff after sitting for a bit but they don’t actually hurt. I’m sure that will come eventually but just because they tell you it’s bone on bone doesn’t necessarily mean it is going to give out in the very near future.
 
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Ottamiway

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I also have avascular necrosis (AVN). My knee on the same side hurts as well. The X-ray showed osteoarthritis there as well. It hurts so much I had a steroid shot and am now wearing a knee brace.

Thanks for the response.
 

ANP63

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Hi Ottamiway,

I agree with getting a 2nd opinion. My BMI is above 40 also and the surgeon that did my Bi-Lateral core decompression at the same BMI refused to do my THR. I was able to find a different OS, and he said that while yes it is better to be a lower weight, but you have to get it taken care of.

Best of luck in finding another surgeon and keep us posted.
 

TomT

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I just joined the forum today and haven't undergone my surgery yet but I'm also having a very difficult time to exercise due to the pain in my joint.I have recently started swimming laps rather than the cardio I used to do in the past, and this has helped me a lot. Do you have access to a pool? With swimming you could get exercise that would help with your weight loss while not putting you through a lot of pain.
 
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Ottamiway

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No access to a pool. Pandemic has closed gyms and pools. No friends with pools. Thanks.
 

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