February 14, 2009

I am 16 days post op. I am a 54 y.o. male and had a bi lat hip resurfacing by Dr. Su at the Hospital for Special Surgery in NYC. My staples were removed 7 days post op. I still have steri strips but all other bandages have been removed. There is no noticeable drainage. I began a 3 hr per day outpatient rehab program at Bryn Mawr Rehab beginning 7 days post op. I attended for 6 days. I am now going to rehab 1hr. per day 3 days per week.

At rehab I am doing 20 - 30 minutes on a bicycle at a low level resistance, i.e., L3. I also did standard table exercises, i.e., sitting or supine position leg extensions, glute squeezes, heel slides, sliding one leg abductions, leg lifts ( one leg per time), and seated or supine hamstring stretches, as well as bar exercises. The bar exercises, knee lifts, hip extensions, side raises, toe raises and squats, are done alternating legs after each repetition since they do not want to keep weight on just one leg for any length of time. I also stand b/t the bars so I can put weight on my arms while doing the bar exercises. At first, I tried doing 10 reps per leg on the bar exercises before shifting legs and became sore so I switched to alternating b/t repetitions. The last two days I did the bar exercises with a yellow PT band.

February 15, 2009

I want to thank Vickie, Pat and other bloggers for their support over the past 6 months as I investigated and prepared for my bi lat hip resurfacing. I also want to thank Vicki for assisting me in getting in to see Dr. SU promptly.

My surgery was performed 17 days ago and I am up and about with minimal pain. I take Arthritis Tylenol 1 - 2 times per day and Percocet 1 - 2 times per day. Percocet is limited to bedtime and before rehab, especially long PT sessions.

At my pre surgery consultation Dr. Su recommended I go to a acute rehab facility post hospital discharge b/c I was receiving a bi lat. I fully intended to do so and told the case manager at the Hospital for Special Surgery. My surgery was completed early evening on Thursday night. I stayed in the PACU overnight and until the next afternoon due to a shortage of beds on the med surgery floors. Other than the issues I had with the Post Op Case Managers and PTs which I detail below, the care at HSS was outstanding. The staff is responsive, helpful and caring. The food is very good and the atmosphere is great. How can you complain about a bed by the wall to wall windows overlooking the East River. My only regret is that they would not let me have my nightly glass of red wine.

Dr. Su visited me everyday but Sunday while I was in HSS. On Sunday he called me to see how I was doing. Also one of his staff came to examine me everyday I was in HSS. Dr Su and his staff were very attentive.

I loved the staff at HSS with the exception of the Post Op Case Managers who took over post surgery and the PTs. That said the PTs were knowledgeable about physical therapy they just didn't coordinate with the Post Op Case Managers and didn't advise me regarding what I should do or not do in order to qualify for inpatient acute rehab.

In general the Post Op Case Managers had a negative/pessimistic attitude. They are really Discharge Planners, i.e., primarily concerned with finding a place for you outside the hospital in order to open up beds, rather than Case Managers who proactively help you find the best options post discharge. In addition, the Post Op Case Managers were incompetent b/c they waited until Monday before filing a request for coverage at an acute rehab. This should have been filed on Friday, i.e. asap post surgery as long as you've had at least one PT session. As a result of waiting until Monday to file with the insurance company, BCBS of PA, my request for acute rehab coverage was denied. I appealed 2X and lost both appeals. Note: that approval of acute rehab for bi lat hip patients is usually granted if you don't do something stupid to disqualify yourself.

In this regard, the Physical Therapists were complicit with this mistake b/c they did not tell me what the parameters for acute rehab approval are and encouraged me to try to do things that would disqualify me for acute rehab. For example they let me walk 250 feet with a walker on the 3rd day post op. This apparently disqualified me for acute rehab. Also, as a result I spent 2 extra days at HSS, pending unsuccessful appeals. During this time I was in a catch 22. I got minimal PT and didn't want to do too much less I hurt my case for acute rehab coverage. Meanwhile, by restraining my PT you I risked slowing down my rehab progress.

Advice: Don't do something stupid like this if you are a bi lat. Bi lats should qualify for inpatient acute rehab coverage, single hip patients generally do not qualify for acute rehab, however. In acute rehab you get 3 hrs of rehab a day, w/o paying a co pay for out patient PT. Otherwise, most patients get a PT to come to their home, 2 - 3 times a week for 1 hr/ day. The PT is much less rigorous and complete compared to inpatient acute rehab, so get acute rehab if you can. Make it very clear to the Case Manager that you want to go to acute rehab AND make sure that the Case Manager files for acute rehab approval with your insurance company the first day you get PT. The longer you wait the more likely that your PT progress will disqualify you for acute rehab coverage. IN ADDITION, make it very clear to the PTs that pending approval of you coverage for acute rehab you do not want to do anything that would disqualify you, i.e. walk too far, go up and down steps or succeed at performing ADLs, i.e. activities of daily living.

Luckily, in my search for the best acute rehab ortho programs in the Philadelphia area, I found that Bryn Mawr Rehab had a out patient day ortho program. This program began in August of 2008 and is one of only two such programs in the US designed to treat ortho patients, primarily hip replacements and resurfacings and knee replacements. It provides 3 hrs per day of PT plus nurse supervision, on an outpatient basis. The program is designed to go on for 7 consecutive days. Generally, each patient is examined by a nurse b/t 9 and 10 AM. From 10 AM to 12 PM you get PT. Lunch is provided from 12 PM to 12:30 PM. From 12 :30 PM to 1 PM your rest in a recliner and ice down. You get PT from 1 PM to 2 PM. After 2 PM you ice down and leave. NOTE: this is an outpatient program so under your insurance you may be responsible for a co pay for each visit and the visits are deducted from the number of days of outpatient PT covered by your insurance plan.

IF you can find one of these programs, make sure that they understand that while you as a hip resurfacing patient don't have hip restrictions like hip replacement patients, you do have to prevent prolonged unassisted weight bearing. Stay off the treadmill ( instead use a stationary bike with no or low resistance) and also don't stand on one leg too long. If doing single leg exercises alternate from one leg to another after each rep instead of doing 10 or 20 reps on each leg before alternating.

I am now discharged from the outpatient day ortho program and begin PT for 1 hr per day 3X per week beginning tomorrow. Meanwhile, I am doing about 30 minutes a day on a stationary bike and doing seated or supine upper body resistance training at the gym. I also do standard floor or table exercises, i.e, glute squeezes, bridges, heal slides, abductor slides, leg extensions, and ankle pumps twice a day.

I am looking forward to getting into a pool but I need to be sure that my incisions are fully healed first. I had the staples removed 6 days post op. I only have steri strips remaining. All drainage has stopped. I hope to get clearance in 9 days when I have my first follow up appointment with Dr. Su. I am looking forward to my appointment so I can get clinical feed back re: my progress. I am very pleased with the procedure and my progress to date. I can't wait to be able to resume an active lifestyle.

My pain level has been very manageable. Initially I had some discomfort/tightness in my left hip, need the ball, when I transferred weight for my heal to my toe. That pain is going away. I also have to focus on keeping my left foot and knee turned inward. Otherwise I walk with my toes rotated slightly outward. Sometimes when I walk and keep my toes pointed straight ahead I feel some tightness in the left hip area.

If you are a bi lat resurfacing patient I recommend getting inpatient acute rehab if at all possible. Why? Its a no brainer. If you go to impatient acute rehab you will get 3 hrs per day of PT for 4 to 10 days, instead of 1 hr/ per day, 2 or 3 days per week if you get PT at home. The inpatient acute rehab will maximize your full recovery.

That said unless you have other disabilities, complications or poor at home circumstances, resurfacing patients most often don't qualify for inpatient acute rehab unless they have had bi lat resurfacing. Even if you have bi lat resurfacing you need to be proactive to make sure you qualify for inpatient acute rehab.

My advice is as follows:

Make sure you let your Pre Surgery an Post Surgery Case Manager know that you want to go to inpatient acute rehab.

Make sure your Post Op Case Manager applies to your health insurance company for inpatient acute rehab approval on the same day that you have your first PT session in the hospital if at all possible. You want to show as little progress as possible when you request approval. The insurance company will require submission of all PT notes in making their evaluation. Stay on top of the Post OP Case Manager and make sure they do their jobs properly and promptly!

Also, make sure you let your Physical Therapists know that you very much want to get approval for inpatient acute rehab. Tell them that you do not want to do anything that will potentially disqualify you for the coverage. They should be familiar with the criteria. If they are not insist that they become very familiar with the criteria right away. Do not walk to far, go up or down steps or successfully perform activities of daily living, i.e. get in and out of bed, put on shoes and clothing, climb steps, etc... before your request for approval of inpatient acute rehab is approved. It shouldn't take more than a day or so after the application for approval is filed with the insurance company.

When should you have your surgery??? The timing of your surgery can be problematic. If the application for approval is filed on Friday afternoon or even Friday morning you may not get a ruling until Monday, b/c they insurance company is closed on Sat and Sun. Meanwhile, pending approval you must be VERY CONSERVATIVE WITH YOUR PT AND YOUR IMPROVEMENT. Hence, it would be best to have your surgery scheduled not later in the week than Wednesday afternoon. This way you have your first PT on Thursday and the application can be filed on Thursday afternoon at the latest. If the application for approval is submitted and completed properly and promptly by the Post Op Case Manager and PTs, by Thursday afternoon, you should get a ruling by Friday. That said, if doing it over again I'd rather have surgery on Mon thru Wed. morning if I had my druthers.

IF THAT IS NOT POSSIBLE, Friday afternoon may be the best time for surgery. You may be in the PACU until Sat. afternoon. Your first PT will be Sat afternoon most likely. You can take it VERY EASY during you PT pending submission of your application for approval on Monday morning. If the app is completed properly and submitted Monday morning, you should get a ruling Monday afternoon or Tuesday morning.