Hip Replacement

[Flatspin Fumble]

Hi,

I had a full hip replacement a week ago and am now recovering, using crutches. I hold a Class One medical ( temporarily suspended ). My consultant tells me I can't fly for 12 weeks, which is the average recovery time. So on that basis, the earliest I can return to work is mid March. Have any other pilots experienced the same procedure ? I am planning on a return to work late March or early April, I appreciate that everyone is different, in terms of getting well, but just wondering if that's realistic time scale and anything to avoid during those first few weeks on line. I am 62 years old, and have been flying professionaly for over 40 years.
Thank you.

[cavortingcheetah]

The most potentially pernicious thing you could probably do would be to twist your new hip as you shoved a leg over to climb into your seat in the cockpit.

[Phalconphixer]

Possible compromised rudder control?
How about toe brakes?

And as Cavorting Cheetah points out even twisting to climb into a seat puts the hip at great risk from dislocation. At 62 your bones are becoming brittle and more easily broken than those of a 22 year old..

A lot depends on the style of operation carried out; my wife's emergency hip replacement operation used a cementless procedure and she was told quite forcibly under no circumstances to put any weight or strain on her left leg for six weeks; after that period a further 6 to 12 weeks of limited exercise and a full six months elapsed from the date of the operation before she could get permission to fly even as a passenger... even now a full 3 years after the operation, the hip joint can be heard to be clicking especially in cold weather... and she always sets of the metal detectors at airport security and has to submit to a body scan. Even a 12" scar isnt enough to convince the Security people that she's not some mad terrorist...

Where bone cement is used, I understand that limited exercise and physiotherapy is permitted after a couple of days but for a left hip replacement its a case of no driving until cleared by the surgeon.

Hip operations despite their frequency are very expensive, the replacement ball joint is custom machined to the requirements of the individual patient and its all too easy for the new hip to become dislocated; this is the reason surgeons are very specific about recovery periods. With emergency ops such as my wifes, the surgeons select the nearest appropriate stock item; no machining just slap it in, hammer it home. and hope for the best...

On the whole I'd say the timescales you refer to are pretty accurate...

[cavortingcheetah]

You could buy one of those telescopic walking sticks, carry it in your flight bag and then use it to help support your weight as you squeeze, one leg at a time, into the command seat. It might be a little painful on the ego, using the thing for a month or two, but it's nothing compared to the fairly extended agony that a tumble could cause, let alone a further grounding. You might even hit your head and knock yourself out. Cockpits are full of pain inflicting knobs!
Having had a Birmingham resurface some years ago, I'd say that the time scales are about right. It's not so much about what you think you can do but rather the damage you can cause if you slip up.

[Flatspin Fumble]

Thanks to those replies. Pretty much what I expected, just have to see how it goes, it was the potential for twisting that is of possible concern.

[Clare Prop]

I had THR on the right side in July. I was told ten to twelve weeks off work but was back at work six weeks later after the surgeon was satisfied I could put all weight on that leg and my DAME wanted to see me climb in and out of a Cherokee. I am an instructor in two and four seaters so much potential for twisting when getting in and out and having to override students doing wierd things with pedals on touch-and-goes.

I saw an exercise physiologist before the op who gave me lots of exercises and as soon as the staples were out I was also swimming and riding my exercise bike and doing lots of weights. I didn't see a physio after leaving hospital and did DIY. hydrotherapy at home. The worst thing was not being able to drive though I did get tentatively behind the wheel after three weeks I soon realised my mistake and hubby had to take over!

I had considerable leg length discrepancy before the op, now they are the same length and I'm getting a lot of knee pain and am still quite lame but have had no problems in my work.

Good luck!

[VP-F__]

My wife had a double hip replacement a few years back and regained her class one 11 weeks later and has never looked back.

Good luck with the recovery.

[gcap]

I have had both hips done. The first in 2004, and the second in 2012. In both cases I was back in the cockpit within 30 days.
Until 3 years ago, i still jogged for exercise. Still skiing, but not aggressively.
I'm 68.

[cavortingcheetah]

Something's been niggling at the back of the mind and it came to me in a big red bubble. One of the hazards of any flying after a hip replacement is deep vein thrombosis (DVT). That's something best avoided because it can be debilitating in its painfulness and a nuisance thereafter. I believe that UK/NHS guidelines suggest two months before short haul flights and three months before long haul.

[Radgirl]

Interesting point cc if only because a DVT is not just a nuisance - it can be fatal. However I am not aware of any evidence that sitting in the office as opposed to further back causes DVTs. BA looked into this some years ago and couldnt identify a risk for pilots as opposed to passengers.

The reason is obscure, at least to me, but I wouldnt worry too much about it. More patients are being put on the newer oral anticoagulants that dont need monitoring with blood tests in any case - has anyone any experience of the CAA's position on returning to flying while still taking them?

[cavortingcheetah]

Well, here's a Kiwi take on the subject of anticoagulants.
The UK CAA seem relatively laid back on the matter. The SA CAA, as might be expected since they seem to prohibit more than they understand, are fairly rabid about the stuff.
Perhaps it's more appropriate say that it's complicatedly variable. Perhaps too, since it is sometimes difficult for flight crew to walk around during flight, a two month short haul and three month long no fly zone following hip replacement or resurface would at least be sensible? What a curiosity!

____________________________________________________________ ___

DRAFT - CAA MEDICAL INFORMATION SHEET - DRAFT
CAA MIS 023
Rev 1: 05/2014
DO1215573-0
An anticoagulant is something that prevents the blood from clotting, or coagulating.
Anticoagulants can be found in nature1 but are also widely used in medicine. Sometimes
anticoagulants are referred to as blood thinners. People are prescribed anticoagulant
medication in a variety of situations where the clotting of their blood is likely to cause
problems in the heart, the brain, or elsewhere in their body.
While there are many reasons for the medical use of anticoagulant medication the
situations most often seen by the CAA are: Prevention of Deep Vein Thrombosis (DVT)
and / or Pulmonary Embolism in susceptible individuals; Prevention of complications after
heart surgery; and the prevention of embolism and stroke in people with Atrial Fibrillation.
This Medical Information Sheet outlines the CAA’s approach to those medications, mainly
warfarin and dabigatran, in the context of aviation safety.
What do anticoagulants do?
Our blood has a number of mechanisms that cause it to clot in certain circumstances. When
the blood’s clotting systems are working well the formation of a blood clot is something
that is beneficial, such as when you get a cut and the clot helps prevent excessive bleeding.
Some people, however, have abnormalities of their clotting systems and are much more
likely to form clots, resulting in DVTs or clots in the blood stream (emboli) causing
damage to other parts of the body (e.g. the brain). Other people have medical problems that
interfere with their, otherwise normal, clotting systems. Problems with the heart, such as
heart surgery, abnormal (or prosthetic) heart valves, and abnormal heart rhythms are a
relatively common cause of small clots forming while bed rest and cancers can cause larger
DVTs.
Anticoagulant medications are used to interfere with the clotting of the blood and so reduce
the likelihood of large or small blood clot formation. Like so many other medications
anticoagulants can be associated with other risks, most notably an increased likelihood of
bleeding problems. This means that it is often important that anticoagulant treatment be
kept in a fairly tight range. Too much anticoagulant effect and there is the risk of bleeding
problems, and too little effect results in the risk of dangerous blood clot formation.
Oral Anticoagulants: Warfarin
and Dabigatran CAA MIS 023
Page 1 of 4
CAUTION
This Medical Information Sheet contains general advice concerning the CAA’s regulatory handling
of medical conditions. This sheet is not intended as clinical medical advice and should not
ever be used as the basis of decisions concerning your medical care. You should consult your
medical advisers and discuss your options thoroughly with them before making any decisions
about your medical care.
1. Mosquitoes and leeches, for example, inject anticoagulants to make it easier to consume their prey’s blood.
DRAFT - CAA MEDICAL INFORMATION SHEET - DRAFT
CAA MIS 023
Rev 1: 05/2014
DO1215573-0
Is it ok to fly while taking anticoagulant medication?
Sometimes! All anticoagulants have risks associated with their use, and the underlying medical condition that requires them is generally also of aeromedical significance. Despite those risks there are many situations where anticoagulant use is considered to be adequately safe, for private and professional aviation activities.
In some cases, such as after stenting surgery to the heart, the risks of the underlying condition are the main consideration and a stand-down period is utilised (See MIS 0082). In other cases, such as the treatment of recurrent DVT, a fine balance must be maintained with the anticoagulant effect stable and within the therapeutic range. In still other cases some newer oral anticoagulant drugs help make medical management easier and may not result in an unacceptable overall medical risk.
The difficulty — for aviation personnel, their health care professionals, and regulatory authorities — is that no two cases are identical and so the individual medical circumstances of each applicant / certificate holder must be considered.
Which anticoagulants are ok and not ok?
The aeromedical risks associated with anticoagulant medication can never be considered in isolation. The underlying medical condition, and its risks, must also be considered.
All the same, there are some situations where anticoagulant usage is acceptable for aviation purposes. These include:
 Aspirin3 use is usually acceptable. However sometimes aspirin is inadequate for reducing the risk of the underlying medical condition, and sometimes the risk of the condition itself is unacceptably high.
 Warfarin use may be acceptable, providing it is stably and reliably within the therapeutic range. Often, however, the risks associated with the underlying medical condition are unacceptable.
 Dabigatran use may be acceptable. This is a new oral anticoagulant medication which appears to have a risk profile at least equivalent to warfarin, without the need for such careful monitoring of the therapeutic range.
 Other new oral anticoagulant agents. Generally not acceptable, although future trial results may modify that stance.
 Heparin. Generally not acceptable. Risk associated with underlying medical condition is also likely to be unacceptable.
Page 2 of 4
2. Medical Information Sheets
3. Aspirin does prevent clotting but is technically referred to as an anti-platelet agent rather than an anti-coagulant.
DRAFT - CAA MEDICAL INFORMATION SHEET - DRAFT
CAA MIS 023
Rev 1: 05/2014
DO1215573-0
My doctor wants to start me on an anticoagulant. What should I do?
The decision concerning anticoagulation is one for you to make, in discussion with your health care providers. It is important that you tell your doctor that you’re a pilot or air traffic controller so they can tailor their medical advice to your condition and your aviation activities.
If your doctor needs more information about the aviation implications of your planned anticoagulation then they will be welcome to discuss the matter with your CAA Medical Examiner or the Medical Staff at CAA.
If you have a medical condition that results in your doctor wanting to start you on anticoagulant medication you will need to report that to the CAA, either directly or via your Medical Examiner. Your doctor also has an obligation to advise the CAA (See MIS 002 and 0032).
What will the CAA do?
The CAA’s response to your anticoagulation will depend on the overall medical circumstances of your case. It is likely that suspension / disqualification action will be taken initially. In taking that action the CAA will request further information as your medical management continues.
The main things that the CAA will be looking for are:
- Confirmation that the underlying problem has resolved or is adequately and reliably under control or in remission;
- Confirmation that the anticoagulant usage is, in itself, adequately safe; and
- Confidence that that particular anticoagulant can be relied upon to remain safe.
Once these things have been determined, and assuming everything else is ok, it is likely that a medical certificate will be returned—often subject to ongoing surveillance and monitoring conditions, and sometimes (especially professional pilots) subject to ‘multicrew’ restrictions.
Will I be grounded if I am treated with an anticoagulant medication?
Initially suspension / disqualification is most likely. In the majority of cases, once everything is sorted out, medical certification resumes. In some rare cases either the nature of the underlying condition or the risks associated with the anticoagulation itself preclude further medical certification.
But my doctor says I’m fine.
Unfortunately it is not unusual for a treating medical practitioner to believe their patient is ‘fine’ and ‘doing well’ while a regulatory medical practitioner may not be willing to issue a medical certificate. This does not mean that those two doctors necessarily disagree, although it is possible that they do, but is usually an indication that they are viewing the same information from a different perspective.
Page 3 of 4
DRAFT - CAA MEDICAL INFORMATION SHEET - DRAFT
CAA MIS 023
Rev 1: 05/2014
DO1215573-0
The treating medical practitioner has a primary responsibility towards the health of their patient, while the regulatory practitioner has public safety as their main responsibility. So somebody’s medical situation may, quite correctly, be seen as being very good by the treating doctor but not (yet) safe enough for certification by the regulatory doctors.
What if I don’t agree with a CAA decision concerning my anticoagulation?
You are always able to seek review of CAA medical certification decisions. For further in-formation on review / appeal options you may wish to consult MIS 005 ‘What Are My Re-view Options?” or the medical section of the CAA website (Civil Aviation Authority of New Zealand).
Medical Information Sheets can be downloaded from the CAA website at — Medical Information Sheets
Looking at the law
Civil Aviation Rule Part 67: Medical Standards
Rules 67.103(b)(3) (Class 1), 67.105(b)(3) (Class 2), and 67.107(b)(3) (Class 3) contain the main medical standard that relates directly to medications such as the various anti-coagulants. An earlier rule (67.103(b)(1), 67.105(b)(1), and 67.107(b)(1) respectively) provides a more general requirement that also applies to the use of medications.
Many of the medical standards include a reference to the term “aeromedical signifi-cance” which is expanded further in Rule 67.3(a): “A medical condition is of aeromedi-cal significance if, having regard to any relevant general direction, it interferes or is likely to interfere with the safe exercise of the privileges or the safe performance of the duties to which the relevant medical certificate relates”.
In the class 1 medical standards rule 67.103(b)(3) requires that an applicant not be −
(i) taking any drug, medication, substance, or preparation nor undergoing any treatment; or
(ii) experiencing any side-effect from any drug, medication, substance, preparation or treatment -
That, having regard to any relevant general direction, interferes or is likely to interfere with the safe exercise of the privileges or the safe performance of the duties to which a class 1 medical certificate relates.
The general class 1 provisions, rule 67.103(b)(1), also requires an applicant to −
(1) have no medical condition that is of aeromedical significance.
There are other medical standards, also contained in Rule Part 67, that relate more directly to the underlying condition that necessitates the use of anticoagulants but it is beyond the scope of this document to list all of them.
CAA Medical Help Desk
Tel: [phone] Fax: [phone] Email: [email protected] web site: Civil Aviation Authority of New Zealand
CAA Central Medical Unit, P O Box 3555, Wellington 6140, New Zealand
Page 4 of 4

____________________________________________________________ ___

[Radgirl]

Thanks for doing my homework cc

So dabigatran is totally ok with the CAA - as it is being given prophylactically ie there is no clot - if you are ok to fly from the perspective of your hip replacement it seems there is no restriction.

I must say I am rather opposed to fall back positions of ' well let's ban you flying for a little longer just in case'. Some pilots do not have insurance leading to significant financial hardship. In other cases employers may be disadvantaged. But there is a good argument for getting people back to work as early mobilisation in itself reduces the risk of DVT and improves functional outcome.

Many hip replacement units are now putting people on dabigatran for 8 weeks or more - based on anecdotal evidence and so in the future more and more of us will need or want to get back to work still on dabigatran. It is also likely to be approved for other operations

[cavortingcheetah]

It was, as always, a pleasure and yes, the SACAA in particular would seemingly ban any pilot they can get their claws into. Whether this is because their CMO received training in Alabama or whether she is just a useless appendix is something I don't know. That's the tautology as applied to her by a renowned urologist of my personal acquaintance in Johannesburg.

My UK AME tells me that for a Class 1 in the UK................

(There is no fixed protocol for return to flying duties after a total hip replacement. All being well with the procedure I would estimate a usual temporarily unfit period of about 3 months, at which time a DVT would be of no concern.
The principle with musculoskeletal conditions is that the pilot must be able to (obviously) operate all the controls, access and egress the a/c and in the case of professional pilots must be able to assist passengers during an emergency evacuation.)

Professional pilots assisting passengers would I suppose apply to helping the cabin crew in an Airbus thing ditching in the Hudson.