The second opinion (and the greatest line ever uttered by a surgeon)

If you had to think of something you never want to hear an orthopedic surgeon say upon looking at an x-ray of your hip, what would it be?

Ooh, I've got one! How about:

"You're WALKING on that?"

But that was the reaction I got this week when I sought out a second opinion about what to do about these hips of mine. That, along with the rest of the visit, left no doubt: I'm headed for two surgeries. The only question now is, how extensive will the first one be, and who does them?

In my initial post on this drama, I laid out the treatment course proposed by the first surgeon I saw last week, whom I'll call Dr. No. 1. (You know, since he's the first; isn't that clever of me?) As I wrote, the diagnosis made sense once I absorbed it. And I liked Dr. No. 1 tremendously, and he appears to be a surgeon of incredible talent.

But this is big, big stuff. So I decided to find another surgeon, also recommended by my primary care doctor, to take a fresh look. I told Dr. No. 2 nothing of what the first guy had offered up, but his diagnosis was pretty much the same thing -- the initial implant that I had in 1993 has "failed" and the cup inside the socket has moved into a dangerous position.

Well, it's easier to understand if you see it:


The cup should be ABOVE the ball joint, resting like an upside-down bowl on the counter, more or less. It's moved 90 degrees from where it should be. With that, you'll understand better, as I did, what's happening in there that's so dangerous. The cup is so far out of place that the titanium ball at the end of my artificial joint slams into bone in the socket of my hip every time I take a step. The bone is, of course, damaged. But the course of treatment is the same: Fix the bone with the help of an artificial graft, replace the cup, and move on to the next one.

But there's a wrinkle, of course, and here it comes. Dr. No. 2 doesn't do these kinds of surgeries -- "revisions," in orthopod parlance -- anymore. Not that he can't, he just thinks it's better if you do a lot of 'em, and he concentrates these days on the minimally invasive replacement procedure that I'll have done for my left hip. So he leaves and goes to get Dr. No. 3, who utters the above -- the greatest quote ever by any doctor, I'm convinced -- as soon as he walks in. When I tell him it really doesn't hurt all that much, he just shakes his head and says: "You must be one tough guy." (More on this later.)

So Dr. No. 3 does a lot of revisions, and he's convinced he can fix this one. So now we're looking at 2 different surgeons instead of one. That may not be a big deal, but then he says, "I think the ball joint at least, and possibly the rod in the femur, too, need to be replaced."

Hold on. That's not what Dr. No. 1 said at all. Dr. No. 3 acknowledges that he won't know for sure until he gets in there, but he would go in prepared to do a full blown replacement again, in addition to the socket rebuilding. That, of course, would necessitate cutting into the femur more, and presumably a longer, tougher and possibly more difficult recovery. Yow. But Dr. No. 3 wants more info, so he writes me up for a bone scan and a CT scan, which I had today.

There are other little differences. Dr. No. 1 wants to find a replacement cup that fits my replacement. Drs. 2 and 3 say they'd use a different cup entirely. Ceramic, if possible, because the polyurethane types throw off tiny little fragments that your body works to get rid of. I don't have the results of today's tests yet; I'll see Dr. No. 3 on Tuesday to get his take on them. And then at that point, I'll have to pick a doctor, based on preference or coin-flipping or something else I haven't thought of yet.

How on earth does a layperson go about figuring this out? I plan to go back to Dr. No. 1 and say, hey, 2 and 3 over there say do the whole set and whatnot. But what if he says that's not right? How the hell am I supposed to know who's right? But then again, shouldn't Dr. No. 1 be prepared to do the full replacement if he gets in there and sees it needs to be done? What if he's wrong and the other piece fails in 5 years; how pissed off would I be? Or what if he's right and the other guy cuts bone that I might need in another couple of decades when I need another replacement? (Oh, the mind reels at that thought!)

As for the left hip, these guys also confirmed Dr. No. 1's immediate declaration that it also must be replaced, with no other options. The cartilage is gone, he says, and bone is rubbing on bone, and the damage is already apparent. This one's not as easy for us laymen to read, but check it out:


See the rounded part, the end of the ball joint? There should be some space between it and the socket. The space would be cartilage. No space, no cartilage.

This is all pretty heavy stuff, but there is good news. Dr. No. 2 is quite bullish about the improvement I'll get out of all this. Particularly with the left hip. "Dramatic" improvement, he says. Once it's healed, he said, you can hike, bike, bowl, water ski, snow ski, pretty much anything except run a marathon or play basketball (no worries on either of those, Doc.) He predicts full range of motion and little or no pain. I told him, I'm not looking to conquer the world, I'm looking to have a relatively normal quality of life. "That's what a hip replacement is all about," he said, "quality of life." And he says he's done about 400 of these procedures, with no failures yet. That's how good the technology and the technique is.

Last thing: I've thought a lot in the last couple of days about the astonishment that these guys greeted me with when I told them I didn't have a ton of pain. When Dr. No. 3 made the "tough guy" comment, Dr. No. 2 looked at him with a smirk and said: "And the left needs a total replacement, but he says it's just stiff." Which is true. That's how I define it.

But when I recounted this story to a friend and said I didn't have a lot of pain, she gave me a look and said: "Or do you?" And she's got a point. This deterioration has been so gradual, and my tolerance for pain so high, I've just come to deal with a lot of little pains that probably shouldn't be there. I'm noticing them now, and they are pretty substantial. For instance, sometimes when I get up out of a chair, I stand there for a minute, waiting for my right hip to feel like it can bear the weight of a step. It always comes around, even if the first step or two is a little gimpy. But really, even if it doesn't hurt, that's the kind of thing that should have made me say, "Huh, that's not right."

Now, I could look back with a lot of regret at how I ignored the pain and deterioration and the time (and other things) it's cost me. But what's important now is getting it fixed, getting in the right frame of mind for the best possible recovery and outcome, and then opening the door to the vastly improved life that I so desperately want. The first step is to hear out the surgeons and make a decision on who and when and get on with it.

Tomorrow, I'll recount the story of the bone scan. I'll just say this: My re-entry to the world of complicated health care reminds me why this crap is so damn stressful.