Riding with a new hip
There are many riders continuing to enjoy riding after a hip replacement, some of which have been required due to an accident, but more commonly it is the slow deterioration of the hip joint that leads to this operation.
For those who require a hip replacement due to trauma then many of these recommendations will still apply. You have the advantage of not previously living with a deteriorating hip and are likely to be more fit and mobile, which will stand you in good stead for your recovery.
For those riders who are on the path of deteriorating joint function, you will have managed for as long as possible but realise the time to act is coming.
Cindy was horrified when told by one surgeon that “at her age” (55 years) why would she want to ride? “Go and take up golf” he said. For Mal it was finding a surgeon who understood the physicality of riding, so he found one whose wife was a dressage rider.
For rural people, and those without private health insurance, your options may be limited. Tony’s search was much harder without private health insurance, as his first two preferred surgeons did not operate in the public system. It is also worth knowing that in the public system the surgeon you meet may not be the surgeon who does the procedure – particularly in a teaching hospital where junior surgeons are learning the craft. Cindy chose not to go with a surgeon in the city four hours away due to the travel and isolation from loved ones.
Interview your surgeon!
After all, you are going to trust them with a procedure that will potentially return your life back to normal or even better. Get good, plain language explanations about why they are recommending a certain approach. Ask if they have done replacements on horse riders or other sports people. Cindy found several surgeons mainly dealt with older patients who did not have the same expectations as she did for what constituted an active life post-op. If possible, talk to nurses, physiotherapists and other health care professionals who see the outcomes of the surgeon’s work. Tony’s surgeon was recommended by another surgeon.
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Choosing your surgeon is perhaps the biggest challenge of all, as you need to find a surgeon you can trust, but who also respects and understands your desire to return to riding and an active life.
Putting your fears regarding riding after a hip replacement to rest.
Options to discuss with your surgeon
cemented Vs non-cemented
Special cement or glue can be used to attach the prosthesis to the bone. This can give you a very strong joint almost immediately, and the recovery is usually quicker. The alternative is a porous material that allows the bone to grow into the pores of the prosthesis. This has a much longer recovery but is thought to last longer so is often recommended in younger replacement patients. Loosening of the cement over time will result in a revision in the future, however Mal has had no problems with his cemented joint after ten years of active living, riding and a few falls!
classIc Vs mInImallY InVasIVe
Research has shown that satisfaction (with the hip replacement and function) scores are better with a minimally invasive approach in the immediate post-op period, but after one year there is no difference in the outcomes. The classic posterior surgical approach is thought to have a much higher risk of dislocation, and associated abductor muscle weakness can be a particular issue and will be a problem when returning to riding if the time is not taken to fully rehabilitate. However, the classic also has good outcomes for long prosthetic life and stability.
general anaestHetIc Vs sPInal anaestHetIc (sPInal Block)
A general anaesthetic (GA) means you will be “asleep” on the table. GAs can have complications unrelated to the surgery so nowadays it is possible to have the procedure done under sedation and spinal block. You will be numb from the waist down and usually won’t remember the procedure due to the sedative drugs. This helps your recovery as you will have fewer physical effects than you will from a general anaesthetic and often better pain control immediately after the operation due to the local anaesthetic effect of the block. Mal elected to have a spinal block for his last replacement, but for Cindy she wanted to “not know anything” and elected to have a GA
Know your costs and your budget
Not only will you have to factor in caring costs for your horse, you need to look at your own costs. Will you have sufficient sick leave or will you suffer loss of pay? Are you going public or private? Even in the public system you may incur some costs that are unexpected, such as outpatient physiotherapy costs. Tony still had about $1000 in out-of-pocket costs in the public system. Ask your surgeon about out-of-pocket costs and also if they use a surgical assistant, who may also bill you for assisting in the procedure. Surgeons and anaesthetists usually work as a team, so make sure you ask who your anaesthetist will be so you can find out about their out-of-pocket costs. It is increasingly common for patients to not see the anaesthetist until the day of surgery, only to find that there will be a significant additional cost for the procedure. Does the hospital charge a procedure fee or gap fee even if you are privately insured? If you have private insurance know how much rehab the fund will pay. If you have the option of supported rehab at a dedicated rehab facility before going home, this is well worth it to focus on initial exercises and techniques to keep your new hip safe. Check if your ambulance membership will cover your transport home if you have a long way to travel. Continued
C INDy F RANCIS
Pre-Hip Replacement Rider
Cindy - a school teacher originally from Melbourne, married a farmer and moved to the Wimmera region in far Western Victoria. Everything came together for Cindy eight years ago when she teamed up with the super little OTT horse, King Chorus. Achievements and highlights include: the HRCAV 300 point Showing & 100 point Dressage Award in the same year; Racing Victoria Best Performed OTT, AOR Champion EA Elementary at the Victorian Dressage Festival and Victorian Masters Games EA Medium Bronze Medallist 2019. Ten years ago Cindy was both a keen long distance runner as well as a horse rider.
Early investigations showed bone-on-bone osteoarthritis and although Cindy was advised to have a hip replacement at this time, she felt she could fix the problem through a rehabilitation program. Whilst not fixing the problem, Cindy did manage to last another seven years with conservative management. Three years ago she consulted with specialists who were amazed she was even walking given the severity of her disease. Once again she was advised to have the hip replaced immediately, but for Cindy the thought of a hip replacement was too confronting, so she battled on with the pain, continuing to compete with King in Advanced level dressage and showing. Even with professional pain management advice Cindy suffered adverse effects from the many medications she was taking to control the pain, including vomiting and severe headaches. Whilst she knew her hip replacement was inevitable she could not commit to a date – there was always something more important that she wanted to achieve.
“I’ll do it after…” became her motto, and “after” never seemed to arrive.
It was the arrival of her new granddaughter that was the biggest motivator for Cindy to proceed, as she realised that now her hip was very unstable and likely to collapse, and she started to fear that she might trip or fall while holding the new baby. After months of research and consultations with specialists, Cindy found a surgeon - whom she trusted - close enough to home and who understood her fears about the surgery and recovery, but also her passion to return to riding and competing.
Cindy competed up until a week before surgery in excruciating pain, both mentally and physically, fearing she would never ride or compete at a high level again. She felt that the last six to twelve months in particular were extremely difficult, quietly crying in pain when first mounting and then enduring extreme pain for the first ten to fifteen minutes of riding. Cindy agreed to this article as she believes no one should endure the pain that she did through delaying the operation.
Whilst very nervous of her upcoming surgery, Cindy knows the time is now and is looking forward to her life post-hip replacement.
Her onset of pain was slow and initially started with low back pain, which then progressed to pain at night in the hip.
Photo by One Eyed Frog
t erm I n OLO gy B Ox
adductIon – moving towards midline of the body.
aBductIon – moving away from midline of the body.
classIc aPProacH (also known as Posterior Approach) – usually for THJR - most commonly through a long cut down the posterior of the buttocks and down the leg.
deeP VeIn tHromBosIs (dVt) – blood clot that can form in the lower limbs.
HIP artHroPlastY – replace or mend the joint.
HIP PrecautIons – a range of things you can and cannot do to reduce the risk of hip dislocation, both immediately post-op and over the lifetime of the hip replacement.
HIP ProstHesIs – the artificial parts that are used to rebuild the hip.
HIP reVIsIon – redoing a previous hip replacement. mInImallY InVasIVe aPProacH – approach that minimises cutting. Often used for revision and arthroplasty but can be used for THJR. An anterior (front) approach is usually used.
total HIP JoInt rePlacement (tHJr) – the ball and the socket are both replaced.
Find out what aids you will need and buy or hire in advance. Some hospitals will provide equipment on loan but check to be sure. You may require a walking frame and/or crutches, walking stick, elevated toilet seat, firm cushions to elevate chairs at home to the right height (or hire an elevated seat for the duration of your recovery), a sock puller, long handled shoe horn and a long handled grabber for picking up things while you can’t bend down. It’s amazing how many things you drop on the floor when you can’t bend down.
Preparing for the time off
If you have a slowly worsening hip you will be starting to think about having your replacement done anywhere up to two years before you commit, so there is plenty of time to prepare. Rather than putting your head in the sand start thinking about what this time might look like. Tony followed a strengthening program preoperatively, which he believed helped him greatly with his recovery. Get some help credits in the ‘bank’ by offering to help others with holiday care of their horses, or other helpful tasks like getting a load of hay or taking a trip to the feedstore. Be honest in this approach by telling people you would like to help them out now as you will need help when you are recovering. This will avoid any disappointment when your time comes to ask for help. You may want your horse kept in work, or just looked after. There are many high-quality facilities that offer these services.
Turning out your horse during the recovery time may be another option but consider what day to day tasks are still required, such as feeding, rugging and managing injuries. You really don’t want to be trying to hobble on crutches after a horse running around with a broken rug in the middle of a rain storm!
If you do plan to turn out expect it to be for two to three months and also expect that your horse will lose condition due to lack of work. You don’t want to keep feeding up a horse not in work which may create problems when you return to riding. The time of year may also play a role in your decision as it may be easier for you to manage a horse turned out in the autumn. As long as your horse has the minimum standard of care – food, water, shelter,
M AL M Ay TOM - Long-Term Post-Hip Replacement Rider
A former international eventer and FEI dressage competitor, Mal is originally from north of Newcastle in New South Wales and has been riding all his life in a range of disciplines from hacking to dressage and eventing. Previously ranked number one in Australia for eventing in 1992 and 1993, Mal broke his C7 vertebra in a rotational fall off a young horse in 1995. As part of his recovery plan he moved to the Adelaide Hills in South Australia where he built up a very successful team of eventing horses and campaigned his stallion Caruso through to FEI Dressage Prix St George and Intermediate Levels1 and 2. Now retired from high level competition, Mal still competes and trains horses and riders in Australia, New Zealand and Asia.
In 2001 Mal was a super fit, injury-free rider competing at the Adelaide 3 Day Event. It had been a dry year and the ground was hard in some sections but heavily watered in others, making the going unpredictable. Mal and his mount CP Vavoom (Ricky) were clear and travelling well until Fence 26. Ricky stumbled but had already locked onto the next jump and as he pushed off the ground to a big apex, he had no height and slammed into the fence. The impact resulted in Mal’s left hip being smashed out of its socket.
Due to the dirt contamination of the open break, Mal developed a bone infection and had to return to surgery for a complete reconstruction of the hip socket and had a plate inserted. It was seven months of rehabilitation before Mal could ride again and he went straight back to 1 Star eventing. Over time Mal started to experience increasing pain in his right hip. It looked like he had also sustained a hair line fracture in his right hip in the initial fall and over the years the joint had disintegrated until he had bone-on-bone osteoarthritis. Barely able to move and in extreme pain Mal had to stop riding for six months and took high doses of pain killers to survive until he finally relented and booked himself in for his second hip replacement. Being a planned procedure this time Mal was able to have the operation performed under spinal block, which reduced his hospital recovery time.
He was walking the next day pain-free and after eight weeks he was back riding again.
Unfortunately for Mal, his original left hip reconstruction started to fail, so in 2014 he returned for yet another hip replacement. Four years later Mal is back to full riding capacity and even plays a great game of tennis. His outcome has been so good that he often forgets he has had his hips replaced, and is so grateful to be pain-free and back enjoying all the things he loves.
Riding with a New Hip continued...
companionship and safe fencing it will survive without daily pampering!
Preparation and Care
Ask for help and gratefully accept any offers of help. Create a carer’s roster with tasks, dates, days and times. Accept your carer may not provide the same level of care as you would normally provide. Will it really matter if your horse lives on hay for a while and goes without a twice daily hard feed? Spend some time cooking up and freezing easy nutritious meals, as you will not be able to stand for long periods.
Hospital Preparation
Pack your bag wisely. It helps to get out of pyjamas as soon as possible post-op, so pack lots of loose fitting clothes and good slip-on shoes with non-slip soles. Have all your hospital paperwork together, as well as your Medicare card and other applicable cards, such as a Health Care Card, Private Health Insurance and Ambulance membership cards, some small change for newspapers and incidentals and a stash of horsey books and a Hoofbeats magazine!
Hospital Recovery
You can expect to be in hospital for a week. Most surgeons will have you up and walking anywhere from one to three days after surgery, and your rehab exercises will start immediately. Initially, you will be using a walking frame or crutches, depending on your stability and strength and your operation type. Hip replacements pose a high risk of lower limb blood clots (DVT) so you will either be prescribed a daily injection or tablet of blood thinner medication. You will also wear very thick stockings (commonly called TED stockings) immediately post-op and up to six weeks post op. Depending on your surgeon’s preference you may have drain tubes into the operation site to take away any excess blood and you will have either stitches or metal clips. Often, the stitches are internal and do not need to be removed. If you have drain tubes they usually come out within 12 to 24 hours and clips or external stiches are removed at around 10 to 14 days, depending on your healing. Some surgeons use dissolvable stitches that do not need to be removed.
Your new hip is very vulnerable to dislocation so follow post-op instructions carefully. This includes not taking the joint past 45 degrees, no pivoting or bending down on the affected leg and only sitting on elevated chairs and toilet seats.
Next issue covers going home and rehabilitation before bringing your horse back into work.
About The Author: Deidre Rennick
Deidre is an older rider who has suffered from osteoarthritis for the last 15 years. She had one hip replacement ten years ago and is heading towards another. Living with osteoarthritis in her hands and hips has brought some challenges for her riding, but she has used her knowledge as a nurse to ensure her remaining hip will last as long as possible whilst still enjoying riding. Deidre was the Project Lead in the development of the resource for general practice nurses “Osteoarthritis Nurse Clinics: A Resource for Primary Health Care Nurses”.
TON
Immediate Post-op (bilateral) hip replacement
A well regarded horse trainer, Tony travelled around local Agricultural shows for many years demonstrating liberty and trick training with his Appaloosa stallion Regal. Whilst he has been around horses most of his life, he decided there was a better way to start them. This led to him working with some inspirational trainers including David and Sandi Simons, John and Josh Lyons and Guy McLean to develop his own successful foundation training method. Tony now trains and competes in Stockman’s and other challenge events.
Two years ago Tony had a serious accident where a horse reared, flipped over and landed on him. Whilst there were no obvious injuries, he was unable to ride for 10 weeks. When he tried to go back to riding, he noticed his hips were very stiff, he was having trouble mounting and riding was painful. Thinking that maybe something had been missed at the time of the accident, he underwent investigations only to find that his decreased function was not related to the fall but rather extensive bone-on-bone arthritis in both hips.
Tony experienced little pain walking around, but once in the saddle the pain was unbearable.
As he did not have private health insurance, Tony’s search for a surgeon took a little longer – eventually finding someone who would operate on him as a public patient. Due to the severity of his disease he was operated on within six months of his referral. His first hip replacement was in November last year, and his second less than 3 months later, with both hips done using the classic approach.
Tony has translated his philosophy about horse training to his own recovery. “When I train horses I work on feel, so it’s the same with me” he says.
He has set small, achievable goals and says he will get on a horse again only when the time feels right and he feels right. His long-term goal is to attend a clinic in November, 12 months after his first replacement, and he feels he is on track to achieve this.
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“Like horses, we are all individuals and will recover at different rates, so it’s important to listen to your own body”.
