Man sitting on his bike
Barely five months after surgery to replace both hip joints, Ian Gallagher was back on his bike. These days, he’s dreaming of joining friends this winter for their annual ski trip. (Photo: Courtesy Ian Gallagher)

When it hurt too much to pedal his bike, Ian Gallagher knew his hip pain might be from something more serious than a past enthusiasm for recreational hockey.

Starting at age 34, pain in Ian's hips had forced him to slowly give up sports he loved over the following decade, something he thought might have been caused by those same activities.

"I was a goalie in a men's rec league for many years, playing two or three times a week," he recalls. "The rec schedule means you're usually rushing from work to get on the ice, and I was going straight into a game without a proper warm up or stretching for 20 minutes like one normally would.

"I assumed my pain was from not being diligent about conditioning."

At the time, Ian thought that playing regular hockey meant experiencing regular pain, but he also noticed he was losing flexibility.

Stretching didn't help him. And, within five years, Ian gave up playing hockey. Soon after, he also stopped running. Still, he switched to other activities thinking he would find sports that wouldn't aggravate the pain as much.

"To see me, no one would have known there was anything wrong – I could still walk and do most things," Ian says. "But the pain in my hips kept getting worse."

Biking finally became impossible in 2017, the same year Ian had to bow out of an annual ski trip with friends for the first time. He started to wonder whether there was some form of treatment could help and went to see a physiotherapist.

"Initially, I saw some improvement with physio but that eventually stopped," Ian recounts. "And there was absolutely no improvement in my flexibility which my therapist said pointed to a more serious issue."

In January 2018, Ian was referred to Dr. Michael Zywiel an orthopaedic surgeon who had joined the Orthopedics Division at Toronto Western Hospital (TW) that same month and was in the midst of setting up his practice.

With a clinical interest in hip and knee pain, Dr. Zywiel was already implementing changes that incorporated the latest evidence for management of hip and knee replacement surgery patients.

"If a patient is able to walk on his own to the hospital for surgery," explains Dr. Zywiel. "He will have the best outcomes from surgery if he goes straight home and gets back to regular life as soon as possible."

Dr. Michael Zywiel
Dr. Michael Zywiel has a simple post-surgery philosophy: “The sooner the patient gets moving, the faster he will recover.” (Photo: UHN)

The practice at TW was to have hip and knee replacement patients stay in bed for the day of surgery, see a physical therapist the day after, and then discharge them two or more days after the procedure.

To shift this approach, the anesthesia, physical therapy, nursing and surgical teams worked together to make adjustments that promote quicker patient recovery.

"Every patient gets a walk on the same day after their surgery from someone on the team, including myself," Dr. Zywiel says.  "The sooner the patient gets moving, the faster he will recover."

The team enthusiastically embraced the new approach and, since Dr. Zywiel started at TW, almost all of his elective hip and knee surgery patients have gone home the same or next day after surgery – reducing the in-patient stay from two days to one.

Although next day discharge is becoming common for single hip or knee replacement, Dr. Zywiel also believes in applying the same principles when replacing both joints at the same time in the same surgery – whether it be both hips or both knees.

"Virtually all patients who have both hip joints replaced used to go to rehab," explains Dr. Zywiel. "It's less common to need to replace both joints at the same time, but I see no reason not to walk the patient soon after surgery and send them home the next day as long as they are medically well.

"The evidence shows faster mobilization promotes better recovery in patients and I think, as we learn of better ways to help patients, we need to keep making changes in our practices that will be to their benefit."

This approach appealed to an active patient like Ian. His consultation with Dr. Zywiel revealed he had severe arthritis in both hips. The cartilage in both joints had deteriorated to the point of being bone on bone, and the replacement of both joints was suggested as an option. Still, to have such significant surgery at the age of 44 was something Ian wanted to think about first.

"I leave the decision of surgery to the patient," Dr. Zywiel says. "It's a personal choice and should be based on the impact one's current pain has on what the patient is able to do."

First walk an hour after surgery

Ian says he opted for surgery because, although he could still walk, he was giving up activities he enjoyed and losing mobility. If that was the case in his 40s, he wondered what age 70 would look like.

"I'd also heard that a short hospital stay and being active right away was encouraged, so I was enthusiastic to be part of that approach," he adds.

On Jan. 29, Ian was one of Dr. Zywiel's first simultaneous double hip replacement surgery patients.

Dr. Zywiel used the direct anterior approach to replace both hips, a minimally invasive way to access the joint from the front of the hip rather than the side or back, a skillset that is his specialty. An hour after surgery, a nurse on the in-patient unit came by to take Ian on his first walk.

"I was a bit tentative but I felt sturdy," Ian remembers. "I immediately noticed the improved range of motion in my joints.

"The entire team was fantastic both before and after my surgery, they were available, supportive and completely efficient."

After another walk the next morning, Ian went home. Every patient is assessed on a case by case basis, but for Ian, Dr. Zywiel didn't put any restrictions on what he could do and encouraged him to get back to a normal routine and normal movement.

Though Ian was supportive of Dr. Zywiel's approach, he was a bit anxious at the thought of increasing his activity without the direct supervision of a physiotherapist. However, he was given a physiotherapy prescription in the event he felt he needed it.

"I thought I'd have more time to catch up on Netflix!" Ian jokes. "But I was able to get up, move around the house every day and improved quickly. 

"The prescription for physio gave me peace of mind but, looking back, I can see how encouraging me to just get moving on my own was a better approach for recovery than being dependent on a therapist."

Though he needed a few supports in the immediate days following surgery, especially to get up and down stairs, four weeks after the procedure Ian was only using a cane and had already been back at work for more than two weeks.

"I've had zero pain in my hip joints since the surgery," he says. "I can finally stretch my muscles efficiently because I can actually move the joint through its full range of motion.

"I've been walking a lot and am back riding my bike. I have every confidence that I'll be back for the ski trip next year." ​

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