Dr. Larry Door is an orthopedic surgeon who focuses on hip replacement. He went to the University of Iowa for medical school then to the University of southern California for his residency and finally he did a fellowship at Hospital for Special Surgery in New York where he learned how to do joint replacements. He also is a professor at USC. Dr. Door explains what is really means to have an arthritic hip and what factors can lead to needing a hip replacement. He really believes that for someone who is a significant amount of hip pain that this is a “quality of life disease” that can be solved trough hip replacement surgery, the country’s number one surgery on a scale of patient satisfaction.
DR. DORR: My name is Dr. Larry Dorr, and I'm an orthopedic surgeon, but mostly I'm a hip surgeon. And I grew up in Iowa. I still love Iowa. The Hawkeyes are my team. So football was really important to me all the way through college, and I think it gave me a lot of self-esteem and really kind of made me think I could do anything if I could play college football. I went to the University of Iowa for medical school, and then I went to USC, LA County here for my residency in orthopedics. And I did a fellowship at Hospital for Special Surgery in New York, and that's where I learned total joint replacement. Special Surgery New York has always been ranked the number one orthopedic hospital. It was particularly the leader in joint replacement, and it was where all the real development and research on joint replacement was happening. That's where I learned my skills, and-and it's where I developed my passion for-for hip and knee replacement. Now presently, I'm a professor at the-the Keck USC S-School of Medicine.
DR. DORR: There's a lot of misconception about what causes hip arthritis. And I think the first thing I should do is just say that hip arthritis is not a bone problem. Most people that arthritis means a bone problem. But it's a loss of the cartilage. And the cartilage is a lining of the joint. You have it in every joint, from fingers, small joints, to big joints like hips. And i-i-if you break a chicken leg and you look at the end of it and you see the white stuff there, that's cartilage. And that's what allows a joint to move freely and evenly and painlessly. So if you lose your cartilage, now the joints having trouble. And once you've lost all your cartilage, then that's where the term "Bone on bone" comes from, because now the cartilage is gone, the two bones are touching. And so that's what arthritis is.
DR DORR: For sure, everyone under the age of 65 or70 that has an arthritic hip has it because of the way their hip was born. It's therefore also somewhat genetic. Now it's very common in European heredity, very uncommon in Asian. And so if the hip is not formed exactly right, what happens over the years is that there's gradually a little shearing of the cartilage because it doesn't fit right. In simplistic terms, maybe you say it's a square peg in a round hole. So people don't need to feel guilty that it's something they did. It's not what they ate. It's not where they grew up. Now if you really want to put the blame on something, you could put it on your mother. So it's more what happens in the womb than after you're born.
DR. DORR: I have a hip replacement and I never knew I had anything wrong with my hips. I played football all the way through college. I j-jogged, I ran, I played rugby, I did lots of sports. But until I started getting symptoms, I didn't know I had it. So that's the way it is for most people.
DR. DORR: So if you have arthritis of the hip and it gets bad enough you're gonna go to the doctor, then what's happened is that your hip symptoms have gotten to the point that they're literally contracting your social world. You aren't able to exercise anymore. You have trouble walking more than a block or three blocks. You get out of your car and you gotta really limp and struggle for s-several steps before you can get going. Stairs get hard. Sleeping at night can be a trouble, particularly turning over. So when you say it's a quality of life disease, it is a quality of life disease. But the quality of life can r-really get disturbed. And for somebody who has a really bad hip and they're really afraid of doing the operation and they let it go on and on, they can become housebound. They won't go anywhere. N- they get depression. Uh, they literally get to the point where they kind of want to give up. And I've seen that many times because people are afraid of surgery.
DR. DORR: It's normal to be afraid of surgery. When I see a patient in the office, the first thing I do is go through their history and, uh, that allow me to kind of get to know them and they can kind of get to know me. I kind of know whether they exercised and liked sports or didn't like sports and what they did. So the next question I say then is, "Well, do you want an operation?" And most of the time it's, "No, I want-you know, is there anything else I can do?" And then my next question is, "Well, if you go through an operation, what are your goals? What do you want?" And then they lay out really what's important to 'em. And you know, very seldomly is the first thing out of their mouth is I want to be rid of the pain. I think maybe they-they assume that's gonna happen. But they go through what their functional goals are. The number one goal for patients is I want to be able to walk as far as I want to walk without having trouble. I want to take a walk at night with my husband or my wife. I want to travel. That's a big one. Play golf's a big one. I want to be able to exercise is a big one. So their goals are all functional. People always think they need to have an MRI or some fancy imaging test to diagnose this, but really I could diagnose it without an x-ray at all, because all I really have to do is see you go walk down my hall for me and I can watch your walk and I can tell a hip limp from a knew limp, for instance. Then you get on the examining table and I just have to move your hip around and see where your motion is, because someone that has a bad, arthritic hip is stiff. They have trouble putting their shoe and sock on, or trying their shoelace, or-and certainly can't cut their toenails.
DR. DORR: There's four places you get hip symptoms. Groin is really common. I think the most common story is "I thought I pulled a muscle in my groin", and that's how it starts. But the outside of the hip, that people get misdiagnosed with bursitis of the hip a lot of the time, goes to the knee. When I had my own arthritis in my hip, didn't have much hip trouble, but my knee hurt all the time. Low back is really common. If I see five new patients in a day, three of 'em have been-been told their back was bad and nobody even looked at the hips. You can just tell it from exam and a regular x-ray.
DR. DORR: Then I explain to 'em that here's your options, you know. We can take medicines. we can do injections. We can go to therapy. So your capsule's inflamed, you take anti-inflammatories, you take ibuprofen or something. That helps, because it-it counters the chemicals put out by the inflammation. But when you get down to the stage where you're bone on bone, you're past the inflammatory stage. You got mechanical problems in the hip now. So it's an education process, and my advice is you [LAUGH] should do the operation. There are some consequences if you wait. One is your life. You're gonna suffer each day and-and you're gonna get depressed. And secondly, the longer you wait, the more the calcium kind of drains out of the bone and your result might not be as good. It's more important to do the operation when your bone is really good and your muscles are good, because your recovery's easy and your result's better.
DR. DORR: I think anybody's a candidate for the surgery that has a bad hip and needs the operation. There are very few complications with this operation. Infection only happens if somebody that has an immune problem, such as cancer or rheumatoid arthritis has higher risk. And obesity has a high risk for infection. Well, those patients are gonna take a little extra care, a little extra counseling. They have to be aware of their increased risk so they can participate and not get in the complication. And basically, a hip replacement's a mechanical operation in a biological environment. That's what we do here. And the whole principle of this operation is just to replace your cartilage.
DR. DORR: We're gonna put a metal against plastic or ceramic against plastic new joint for you, but we gotta hold it to your skeleton somehow. So we put a metal shell in the acetabulum. We put a stem into the bone. They're hook-on mechanisms, just to hold your new joint in place. And that's what the operation is. And that operation only takes an hour, hour and a half. And the next day, the day after your operation, this pain you have right now is gone. And you're putting all your weight on your leg and you're walking. And you're gonna walk out of here and you're gonna go home, and the main therapy you're gonna do is walk. And within a couple weeks, I expect you could walk a mile. This operation isn't that hard to go through. That's the first thing I want you to understand. That this is not gonna be torture to go through this. You're not stuck in bed. You're not stuck in a wheelchair, and you can go out to dinner the night after you get home if you want to, because you're okay. You're healthy. You got a new hip. You have a sit down job, you're back at work within a week or two if you want to. And you're gonna play golf at six weeks. If you want to play doubles tennis, you can play [that?] a couple of months. If you want to go snow skiing, you'll do it around four months. I think this operation could go 30 years, maybe 40 years with the materials we have today.
DR. DORR: Almost always, it's depression because they got a bad hip. And so you know, once the operations over, they always come in and say, "I should have done this sooner." I mean, hip replacement is probably the number one operation, period, for patients. Probably more patients get m-better result from hip replacement than any other operation done. The data clearly shows that hip replacement allows more people to remain productive in their life, live longer than they would if they didn't have it, and have a quality of life that is normal. I think those implants fixed with bone in a patient that's 40 with the operation or 50 can probably last in their lifetime. If they need another operation, it's probably be because their bearing surface wears out. But in older patients, the minute fixation is still the best fixation, because it's fixed right away. You don't have to wait so long for the bone healing and they're-they're more comfortable sooner. And they are more functional sooner. And so patients that are 70, for sure 75 or older, I still submit their stem, because the longevity is no different.
DR. DORR: Beginning in the early 2000's even until today, the focus has been more on the patient and how can we make the experience for the patient better. When I first started doing this operation in the '80s, we brought people in two days before and we kept 'em in the hospital two weeks. That created a lot of complications because they got, um, they got blood clots from being in bed in the hospital and their bladder wouldn't work. They'd get il-ileus. Their belly wouldn't work. Those were all hospital complications. One of the first changes was making the incisions a lot smaller. When I first started doing this operation, the incision went from the middle of the thigh, uh, curved into the butt. I mean, it must have been that long. [GESTURES] Now that we use four inch incisions instead of 25-inch incisions, you kind of wonder why you ever did all that. But that's what the evolutionary process is, of course. It can be either in the front of the hip or the back of the hip today. It doesn't matter. There's no scientific data that one is better than the other. So if you're gonna have a hip replacement, if your doctor does it one-way or the other, anterior or posterior, don't worry about that, because the results are definitely the same.
DR. DORR: In all the science that's been studied on this, the one thing to remember is how good are the parts put in. We've also concentrated on what we call pain management, so that patients, when they come in the hospital now, we don't use morphine anymore. We don't n-b-parenteral narcotics where they're getting Demerol shots or morphine shots, 'cause all that does it make you nauseated. The studies clearly show that the number one cause of dissatisfaction with a hospitalization is nausea and vomiting, even more than pain. So we've basically eliminated nausea and vomiting. We've worked hard on that over the last decade. I published on it and the method that we use is used in-in a lot of centers today, because it avoids parenteral narcotics, and that's what makes people sick. And the older you were, the more likely you were to do what we call "sundown". You know, I mean the lights would go out and people would get disoriented and the medicine and they'd hallucinate and sometimes for three or four days, they'd be totally disoriented.
DR. DORR: So what we do today now, is that we focus on-on pills, oral medicines. And we start before the operation. So you come into the, um, preoperative area and we'll give you an anti-inflammatory, and an anti-nausea medicine. So that we start that right away, and we keep giving you anti-nausea medicine even-the anesthesia does it during the surgery. When you come out of the operation, you have that pain medicine in your bloodstream and you've already got pain medicine in you, because you've got to be ahead of it. If you're always giving the pain pills after the pain starts, then the brain gets conditioned to the pain. And pretty soon every little stimulus becomes pain. After the operation in the hospital, we give you the medicines preemptively. We don't wait for you to ask [them?]. We give you medicines every four hours and at night. Every four hours, so that if you stay in the hospital that night you take medicine. And it's all pills or anti-inflammatory medicine. And that's replaced all the morphine. Now you're gonna go home. And we figured out in the hospital what pills are better for you. If you're in your 40s or 50s, you'll go home more on a stronger pain medicine. And we send everybody home on an anti-inflammatory for three weeks. And also, everybody goes home on aspirin, which also helps your pain a little bit, but we use that as a medicine to, uh, prevent blood clots. If you're older, you get up above 75, 80, that age, almost all those patients go home just on Tylenol. That's all they need. We have everybody use ice for the first 72 hours. Keep the swelling down and keep the inflammation in the tissues down. Use ice round the clock for 72 hours after you get home. And then they can use it intermittently after that if they get sore.
DR. DORR: Many of our young patients are totally off medicines within a week. And I use walking as my main therapy. I don't even send people to physical therapy much with a hip. They just go outdoors and they walk. And if you get a left hip operated, you can drive right away, 'cause your right hip's your braking and accelerator leg. If you get your right hip operated, you're gonna drive within a couple of weeks. Uh, one thing that people want quickly after an operation, is they want control of their life again.
DR. DORR: We call everybody on the phone the week after the operation. Our nurse calls people. I call 'em personally. So we're in phone contact two or three times over the first couple weeks, be sure everything's all right. But when they come back at six weeks, 98 percent of the patients are able to walk a mile. They're all off pain medicines. They're driving. Two-third of 'em if they work are back at work. They're already back pretty much into kind of a normal life day. Which is really important to the patient, because that allows the patients to exceed their expectations. And when patients exceed their expectations, they get the best result from an operation.
DR. DORR: I get the question lots of times from patients, "Well, should I wait? Are things gonna be better in two years or five years than they are now?" And you know, the fact of the matter is at two years or five years from now, the operation you're gonna get is the same one you're getting today. There'll be evolution but not revolution. I think the evolution is more toward biologic. Now there will be some changes in materials, but they won't be major. We're really good with our materials today. But what's gonna change in terms of the operation with the mechanical parts that we do today, is that the precision's gonna get better. And the precision's gonna get better because we're gonna get better at using computers in the OR and enhanced instrumentation that allows us to put the implants exactly where we want them. If you don't walk out of a doctor's office with confidence that this guy can do the surgery, or this lady, can do the surgery, and they're gonna make me better, and I want them to work on me, then go find another doctor, because that confidence in that doctor-patient relationship is absolutely a big part of getting better. The art of medicine is almost as important as the science of medicine. And the art of medicine is a doctor and the patient connecting. And I always say that doctors touch patients' lives, but patients touch doctors' lives, too. And so it goes both ways, and you have to have that to kind of get that bond going.
DR. DORR: Now if I'm in the office and I see a patient that maybe-that has a bad attitude, those are kind of rare, but depression is common, 'cause this causes depression. Pretty easy to divide the depression into someone who's got it just 'cause they have a bad hip versus somebody that's depressed with life.
DR. DORR: I think the most important thing for patients to understand is that this is the best operation they could ever have, because it returns them to normal and it's not hard to go through. Not a big, bad, painful operation. And you're back into your own world very quickly after the operation. And you are able to expect that operation to last you for 30 or 40 years if it's done well. So don't be afraid of doing this operation, because it takes you from being crippled back to normal.