after my husband moved out, I curled up into a psychic ball, and could not bring myself to see anyone who might offer sympathy, or deserve an explanation. I needed to come back together after tearing everything apart. so I avoided them, but I did tell them in an email that I loved them, but that I just needed to be left alone for awhile. they were sad about this but very understanding.
today, the visit on their breezy, second-story porch felt quietly celebratory.
ken is a tall man with a long white beard and a persistent crinkling smile, and he earns his living translating german literature. he’s originally from austria, being sent first as a youth to a boarding school in switzerland when hitler was getting his lather up, and then, later, to the states, where he has remained since. he was married once, long ago, and I recall him telling me it had not been a happy union. it’s a story of which I still want to hear more.
eve is bright and adorable, shuffling about her world in a slightly rumpled and wondrous way. she earned a medical degree in her youth, specializing in psychiatry, but had run screaming from the profession after a mere two years or so following her residency. she never returned. I admired her tremendously for that, because it’s exactly what I have wanted to do since becoming a physician assistant in 2006, executing my 2nd or 3rd career change. Given how I have floundered through my medical career since, I don’t think this change will be my last.
eve created a work life for herself writing scholarly articles for physicians and other medical academics who are fundamentally illiterate, at least in terms of constructing coherent, academic articles about their work. eve does that for them. both ken and eve work at home, and I don’t think I’ve ever seen one without the other.
eve was telling me about her hip. she was having a lot of pain in her right hip, and she knew I had had both of my hips replaced in the past 7 years.
“well, this started when I fell quite a few years ago, and I don’t know if my feet hyper-flexed or hyper-extended when I landed, but ever since then I’ve had this dull, molten-metal pain in the front of my shins”, she said as she rubbed her hands down the front and side of her bare legs. “and here, on the sides, too”, she finished.
as we talked, she described falling forward in the dark, landing with her feet in one or the other of the unnatural positions she had mentioned. she couldn’t remember which. she thought they were hyper-flexed, and she thought she had this fall had done some sort of nerve damage. she was very frustrated and annoyed that the none of the doctors whom she had seen for this chronic discomfort, and the two other things causing her some significant leg pain – as well as significant concern because she likes very much to walk (“for pleasure”, she said, in her solemn, wide-eyed way) – seemed to hear her when she talked about it.
“they don’t take it seriously”, she complained.
the other things going on with her right leg had happened over the last month-and-a-half, with a suddenly ballooned-out right knee one day, which was aspirated and then figuratively sent back to it’s room until it could behave a little better, as well a lot of right hip and groin pain when she walked.
“I’m a girl that can walk 5 or 6 miles without a single thought, and now, suddenly, I’m hobbling around, barely able to cross the street”, she said, blinking from behind her thick glasses.
I could identify. I was in the process of trying to find out what had happened to my right leg during a hip replacement in 2012. since the repalcement, I lived in constant, excruciating pain, as if a butcher knife was jammed into my hip joint, searing into my bone with every step. the length of my femur was continuously tender to the touch, and I was now finding myself half-waking in the night, with a dull, throbbing pain, twisting under my duvet in a half-animal attempt to stretch out the painful tissues and locked-up joint of my right leg.
also with the surgery, my external rotators were left paralyzed. external rotators are the little muscles that wrap around the outside of the hip joint and allow one to rotate the leg outwardly. no matter how hard I tried to fire those muscles and rotate my leg – say, to lift it up and place my right ankle over my left knee – it hung static below my right knee, held mutely in gravity’s pull.
I tried to describe this to my surgeon in my follow-up visits after the surgery. he would do a cursory exam, having me lie on my left side on the examination table and raising my right leg, then him pressing down on my raised right leg, which would instantly collapse back to it’s resting position atop my left leg. “strength 5/5, B/L” he would write in his notes.
“so…he was lying…”, ken said. I said yes he was.
Twice I sia on the floor of this surgeon’s sumptuous office, trying to demonstrate for him the way my legs would not equally frog-leg apart, such as when I would rest my laptop on my legs, sitting up in bed, and how I could not fire my external rotators.
“uh-huh, uh-huh…”, he would say, nodding, and intently typing away at his computer as he “documented” the visit. he never even gave me a glance as I struggled around on the floor.
he told me in these follow-up visits with him at two weeks….at one month, “oh, it’ll get better. just give it time”. and at three months…six months…nine months…until he finally took it seriously and said, “I’m sorry. something’s clearly wrong, and I don’t know what it is. I don’t think its time yet to try to revise it, we should give it more time”.
easy for him to say since the statute of limitations on a bum hip replacement is three years, and we were now almost one year post-op. I was beginning at that time to think about legal action, but I couldn’t take any until I had a diagnosis. I spent the next three years trying to get just that.
I mean, I kind of knew what was wrong because of how it felt, and because of the limitations of movement I was left with after the surgery. it seemed to me that the ceramic acetabular cup, which is fitted into the pelvis during surgery following a reaming out to smooth and deepen the rough, arthritic acetabulum, was most likely misaligned; pointing in a too forward-facing anterior (forward-facing) orientation. if this was the case, there would an impingement of the new prosthetic femoral neck against soft or bony tissue as my leg moved from flexion to extension with each walking step; and, further, it would be blocked from full outward rotation because the neck of the prosthetic would be unable to rotate past the most lateral rim of that same misaligned acetabular cup.
I thought this partly because I could not manually push or pull my femur past a certain point when trying to sit in a frog-leg position. it just wouldn’t go any farther; and because my right leg, left to its own devices, would consistently rotate inwardly when left at rest.
maybe too there was too much pressure on the interface between the femoral component and the platform cut flat across my femur, on which to secure the prosthetic. my right leg had been measured since the surgery as between one centimeter and one inch longer than my left; something about “allowing some leg-length discrepancy which will settle in with use”; much the same way one would collapse a telescope by pressing it against the floor. mine evidently had not settled in, and the length discrepancy put even more pressure on the very painful interface between cut bone and the femoral component of the prosthetic.
further, it was clear that the external rotators had not been re-attached when my surgeon closed at the end of the operation, or perhaps damaged the nerve feeding them. one of the three orthopedic surgeons I saw for consults in the first two years after my surgery, said that “not all surgeons reattach the external rotators; they assume other muscles will take over the job”. an MRI I got about one years ago showed that the main muscle which should have taken over, the gluteus medius, was 100% atrophied. it had never been used since the surgery (because it was cut?), and would never come back. so I seemingly had no external rotator function, and, as a result, no stability. now, if I catch a toe or even slightly lose my balance, I go down, because my leg will simply not move in the way I might need it to move to catch myself.
but without a diagnosis – based on a detailed history-taking and physical examination, appropriate imaging, or possibly even an exploratory surgery to see what structures are awry, I have nothing to work with. and one of the other surgeons I had gone to for a consult, a revision whiz-kid at MGH (with the personality of a fig), said he wouldn’t touch my leg surgically because if it came out the same or worse, how did he know I wouldn’t sue him?
so I was telling eve about a surgeon I was going to see in a couple of weeks, one I had found in my relentless web searches over the past few years using the key words “post-op pain”, “total hip replacement”, “impingement”, “acetabular cup”, and “external rotators”. last winter, which was just shy of three years since the surgical destruction of my hip, I came across an article that gave me great hope. it documented the work of a surgeon in westchester county, new york, who had been an engineer in his undergraduate years, and had then gone on to become an orthopedic surgeon. his training as an engineer informed and guided his work as an orthopedic surgeon, and he had patented several technologies to more precisely and correctly align the placement during surgery of the essential foundation of a successful total hip replacement: the placement and alignment of the acetabular cup.
in this article he documented that according to the literature, an astonishing 74% of all hip replacements were misaligned, primarily because of the use of osteotomes in the operating room. osteotomes are fixed to the bony structures which are cut during hip replacements, and are used to calculate and mark the correct angle of bone cuts and prosthetic placement. according to this engineer-surgeon, these tools do a poor job of aligning the prosthetic for various reasons, but which include the way the patient is moved about during the their suurgical procedure.
I googled this surgeon on the web and found, to my delight and amazement, that he is now practicing right here in massachusetts. I made an appointment to see him eight months ago. my appointment is in one week. that’s how booked out he is. I am counting the minutes to see him, and am praying he will be able to make a diagnosis explaining the reason for all my pain as well as the loss of my external rotator function.
I told eve that her knee pain and its subsequent fluid overload was likely an isolated event, that it can “just happen”, and then go away, never to happen again. as for her lower leg pain, on sides and face of her shins, I thought she might benefit from a visit to a neurologist, and further, get an EMG to measure nerve conduction in her leg.
“I just want to know what it IS”, she said. I could understand her frustration.
I asked her if she had had her hip xrayed, because it sounded very much like osteoarthritis had moved into her right hip joint, and she said she had, as well as an MRI.
I also told her that it might be worth booking an appointment with this surgeon I was going to see. she said she will be turning 65 in three-and-a-half months, and that she will then have medicare to cover the hip replacement she is likely going to need.
“don’t worry”, I said with a laugh, “it might be eight months before you see him. but I think it will be worth it”.