THR Why Do Surgeons Advise to Wait?

[Boxmaker1917]

I have learned that most orthopedic surgeons advise waiting for THR until the pain is excruciating. My question is why?

In my case, two different surgeons have confirmed that I will require a THR in my right hip. Looking at the x-rays, it is pretty clear to see that my hip is bone-on-bone. Before my visit to the surgeon last month, I could not find a comfortable position in which to sit or sleep. I'd had steroid injections before at a different surgeon's office and only one of three worked. I also had been taking meloxicam, which helped tremendously and then seemed to stop working. This surgeon suggested I try a steroid injection again. (The previous doc used ultrasound to guide the needle while this surgeon used a fluroscope and dye to insure the medication went into the joint properly.) He also prescribed celebrex instead of meloxicam. I trust this doctor and he told me to wait because I "still could do too much."

This approach has helped tremendously, but the ache still is there. I also have to limit what I do in gym classes, especially yoga and pilates. I still occasionally limp but am not in any kind of unbearable pain.

I know these measures are temporary. So, my question is why do so many surgeons advise waiting until the pain is unbearable? I understand this surgery is MAJOR. Is it because the pain and discomfort from surgery and recovery are so bad you need to have experienced something that was worse? Or, knowing I will need surgery anyway, would my recovery be easier if I am in better physical shape than if I wait? (If it matters, I am considering SuperPath, but I've not yet consulted with the surgeon who is three hours away. If I go this route, there is not supposed to be any cutting of muscles or tendons.)

 

[Jaycey]

So, my question is why do so many surgeons advise waiting until the pain is unbearable?

This is very old school thinking! It used to be the case that patients were advise to wait to avoid having to have too many revision surgeries. But technology has come a very long way! Hip implants are now lasting 30, 40 or even 60+ years.

If your surgeon is telling you to wait - find another surgeon who is more forward thinking. Waiting only results in a longer and more painful recovery.

Here are a couple of articles from our Library that might be of interest:
Hips that have lasted 32, 40, 41 and 45 years
67½ year old - the THRs, not the patient!

 

[subie2021]

In my experience it appears that surgeons can be constrained by red tape and insurance company requirements. They can know that a patient needs replacement surgery, but the patient has to jump through a mess of conservative treatment hoops before insurance will approve the surgery.
For instance, simple xrays before a diagnostic MRI, PT and anti-inflammatory meds before injections, injections before surgery.
It can be a long painful process.
I learned that being stoic and a "good" patient doesn't advance the road to an improved life. At office visits and PT, complain. Don't minimize the impact a bad joint is having on your life. Let care providers know that there is significant daily pain, escalating limitations on function, and decrease in quality of life. They'll enter those comments into their visit reports and it becomes part of your medical record and thus, evidence to insurance providers that conservative treatments have failed and joint replacement is the next step.

 

[Going4fun]

Basically surgeons want the patient to be ready to move forward with the surgery. Hip replacement is elective surgery, which means the patient elects/chooses (with approval of the doctor) to have this surgery. The surgery is usually not a medical emergency for most people.

My sense is that surgeons want to make sure they aren't pushing elective surgery on anyone. They're not supposed to push the surgery on anyone. Only we can decide that the pain we're suffering and the limits the pain is placing on our life is such that we want to move forward with the operation.

If you are ready for the surgery--as in you want to have the surgery--I would suggest this. Before consulting the surgeon again, pull out your calendar and decide when would be the ideal time and season for the surgery. I schedule my surgery six months ahead of time. Talk about this to any family members or friends who would be in on helping you. Think about weather, being able to walk outside safely, life events and so on. Have a date in your head about when you would like to have the surgery.

Now when you call to schedule the appointment, go ahead and say I want to meet to schedule surgery. And when you walk into the office with a date in your head and a decision to go forward, your body language will be different. You'll respond to the questions differently. There is a huge difference between saying to the surgeon that you have pain and you want to "learn" about possible surgery vs. saying I'm sick of this pain and I'm ready for the surgery. Huge difference.

Looking back, I believe I really decided to go forward with the surgery when I called my job's HR department, nailed down leave and pay and length of leave and what I needed to do to qualify for leave and all that. And I picked the month and even week when I thought the surgery would be ideal for me. I chose fall because I love fall and there's rarely snow or ice on the ground where I live during the fall.

I was also clear in my own mind about why I wanted to have surgery. I wanted to get back to being able to run and dance (my big hobby) without pain. And I was ready to do this now.

Well, both of the two final surgeons I met with read my body language. One stopped himself midway through offering shots. "Sounds like you don't want shots. Sounds like you want the surgery."

"Yes!" I said. "Don't want to waste time on shots."

Same story with the second surgeon. He realized I wasn't interested in shots.

Since I was ready for the surgery, when the surgeon entered the room and said the "how can I help you?" bit, my answer was, "I want to schedule surgery." I'm sure something pretty close to that came out of my mouth. I didn't say I wanted to "find out" about surgery. You could also say, "I'm ready to have surgery. I want to hear your view of recovery and what I can expect." Words like that communicate readiness. The surgeon I chose made me say directly to him that I wanted the surgery now since he thought I was in an iffy category because I could still walk so well.

Surgeons don't want to be like car salesmen who try sell a car that day to everyone who steps into the dealership. and they're not supposed to sell the surgery since it's elective. They're supposed to say something like, "When you're ready, I believe the surgery can reduce your pain." And this makes sense. When recovery gets frustrating (which it will for a lot of people) it's best that the patient know that they decided on the surgery and the timing of the surgery.

My recovery got extremely frustrating at points, and if I sensed that my surgeon had led me into the surgery, I would have just been mad at him. Instead, I with the encouragement of this community just plugged away and I'm so happy with my hip right now. I'm just a little bummed that because of Covid my local dance scene has been shut down for a year and a half now. Hopefully with the Delta variant now declining, the dance community here will resume soon. In the meantime I run and lift weights and occasionally bike and dance with myself.

Addendum. There are some surgeons who are master communicators, listeners and people readers, who can sense that someone is ready for surgery but just shy maybe. And these surgeons know how to speak in such a way, without being pushy at all, that allows the person to speak up and say they're ready for the surgery. I think patients leave these visits and schedule with the office scheduler and then maybe come back one final time before surgery to get the final spiel on complications and risks and all of that. These are the surgeons, I think, who REALLY love people and the people interaction part of the job in addition to enjoying performing the surgery. Not all surgeons, even excellent surgeons, have this skill.

 

[Boxmaker1917]

Thank you all for your insightful observations and suggestions. I live in Florida and would like to schedule surgery after our tourist season is over, viz., late April or early May; and presumably, lower Covid patients in Florida hospitals. That is why I am doing shots (helps somewhat) and medication (also helps somewhat). I still occasionally limp and often find that I am limited in my workouts.

I am hoping I can hold off until Spring. However, if one would require a THR anyway, I was looking for help in understanding why so many physicians recommend waiting.

Again, thank you for your replies.

 

[subie2021]

I don't know the procedure in Florida, but I thought I'd mention that where I am, there is a 3 month waiting period between the last corticosteroid injection and THR surgery. I had an injection in June ( that was effective for a whopping 18 days ) and had to wait until September for the surgery. Maybe ask your surgeon about that so you can schedule the way you want.
Good luck!

 

[HelenaM]

I had a different experience. I saw one os who had just retired from doing surgery, and he wanted to wait and monitor even thought the mri and pain picture indicated a problem with arthritis of the right hip. Then I saw two very highly qualified and well recommended surgeons who said that I needed the hip replacement. The MRI said stage 3 - intermediate. I sensed that there was some competition among surgeons. For example, the surgeon who did posterior said that anterior was too dangerous.
A year later my husband visited three surgeons regarding a tkr, and I sensed the same competition. He was scheduled for surgery within a month.

While it is probably not a good idea to delay too long, the competition was a worry for me. I had had a flare, and I am fairly sure my hip was in bad shape, and I am mostly better but…

I wish you luck in finding a great solution!

 

[Boxmaker1917]

Again, my thanks to everyone for their wisdom and suggestions. Prior to having my latest steroid injection on 9/20, I asked my surgeon about having another injection (especially since the previous two, administered by a different md office, didn't work). He said that injections inhibit bone grow. However, since it was clear that a THR was in my future, it didn't matter. The existing, natural hip bone was about to be junked.

In Florida, we are flooded with tourists and seasonal resident once Thanksgiving hits. Any shortages in anything, including the availability of surgeons, staff and OR space, is much worse during "Season." If I am able to postpone surgery until May, scheduling surgery won't be an issue. I already have an appointment with the SuperPath surgeon I probably would select, should I go that route. The goal, apart from confirming him as my surgeon of choice, is to set up as much as possible, should I need to schedule surgery earlier .

For the time being, I am metaphorically -- and sometimes physically -- limping along!

 

[TheOne]

Florida here as well. I honestly put my L THA off too long. When I first consulted with the Surgeon he was surprised that I could even walk as much of the L Femoral head was gone. I had the Super Path performed on 11.3.21. Today is one week post op. Great surgeon and the hospital staff were wonderful. I look forward to seeing how all of us are doing in our various stages of our journey to complete recovery