Tuesday, May 27, 2008

Am I Being Ridiculous? Neurotic? Or Just Plain Naive?

My activity level has increased slighlty over the past few days in the way of walking but decreased in the way of spinning due to some other things going on (I won't get into that yet).

I have had some pain on my right side that bothered me a few days ago, and I wondered if I was going crazy. I had some medial sided pain, but the usual anterior medial, it is purely medial hip pain. It is not bad at all, but being that I am generally not in pain or discomfort, this was slightly disconcerting. It happenned Sunday, and then Sunday night, my leg felt tired, as I lay in bed. It started up again yesterday,and today,I walked about 80 city blocks and experienced it again.

Yes, 80 blocks is excessive, am I asking too much of my hip? I am not sure what is going on other than some crazy hormonal shit at the same time (not getting into it though), I did wear my Danskos all day to prevent knee and hip pain.

Obviously, I know things will never be perfect again, and I am nitpicking here bc things have been so great, I just want NO DISCOMFORT at all.

I do try to not think about the fact that this hip will eventually deteriorate into a nasty case of arthritis, but when I do, I hope and pray that this is not the beginning of it. I know, I need to chill out, but I am very "high maintenance".

Thursday, May 22, 2008

I am Defnitely Going To Hell

Today started out like any other Thursday, I was in housewife mode, I went food shopping in the morning, and then decided to meet my sister in the city. I decided to leave my car at home and take public transportation since the car usually becomes more of a burden in the city, plus, with the price of gas and parking, I was trying to be economical and eco-friendly. See, I am also VERY lucky, I have a parking spot. It is not in the indoor, valet garage in my building. That one has a long waitlist. It is about a block away, outdoors, on a poorly paved empty lot, but it is a HUGE luxury in NY. For the 6 months that we did not have a spot, I hated going out early in the day bc I would surely home home during "alternate side" and not be able to find a spot. I also didn't like to go out too late bc then there would be no spots left on the street. Having a spot gives me freedom, plus I sleep a lot better at night knowing my car won't be ticketed (again).

So today I received a call from a woman who works at the office who manages the garage. We are being kicked out of our spot bc someone who lives in the building adjacent to the lot needs a spot. What a load of crap. I have been parking there for 1 1/2 years. Apparently, I was the last one in the lot, so I am the first to get the boot. Well, I was furious, and yelled and screamed, but to no avail. So I had J call, bc I am too emotionally involved.

J didn't know what to do, so here is what happened in the conversation between J and the man at the parking place:
Man: Look, I am really sorry but the owner of the lot also owns apartments in the building and he is renting one out and needs a parking spot for the tennant.
J: But we have been with you for 1 1/2 years, we are good tennants, and we had no idea this was a possibility, we would have had a back-up plan in this case.
Man: I know, I'm sorry, but you are tenants at will, there is no contract, we don't even bill you, you just send us a check each month.
J: Look, I work in the city, I have 2 kids and my wife is disabled
Man: Oh, she's disabled
J: Yes, she just had 3 surgeries.....
Man: Oh, I see, I'm so sorry, let me see if there is someone else we can kick out, I will get back to you

So you see, we have a little white lie going here. Yes, I had 3 surgeries, but I am far from disabled. We are sooooooo going to hell for this. But parking is such a HUGE deal for me....
Can you feel the jewish guilt????????????

Monday, May 19, 2008

Revision Hip Arthroscopy/ Failed Hip Arthroscopy

I always wonder how many other people have fallen into this predicament as well. What I have noticed is that these are key words that often bring people to my blog. I have no way to really keep track, but often I will scan my sitemeter which will tell me the search words used by readers. It doesn't always work, for example, "Landsickness" through google brings up my blog, o the top 10 (I checked), but so do other key words, like FAI, hipscope, hip arthroscopy,psoas....and my all time favorite, "Bryan Kelly hipscope", my blog is #1 on google if you put in those words. This is quite embarrassing as well as pretty funny, if you ask me! (If he knew, he probably wouldn't agree!)

So, my point is, I was curious, who has had a failed hip arthroscopy? or failed FAI surgery? or failed surgery for a labral tear? Who has retorn their labrum?And even more importantly....why...what reason were you given??
Now would be a great time for all lurkers to share their story, so we can all learn from each other.
Me? An conservative surgeon who didn't want to take down too much bone if it was unnecessary. We found out the hard way that it indeed was necessary, but a happy ending for all involved parties!!!

Monday, May 12, 2008

6 Month Post-Revision Update

Wow, I can't believe it has been 6 months already. 6 months since I tossed the hip brace, 6 months since I retired my crutches, 6 months since I was praying to a higher power to either make me stop vomiting or take me out back and shoot me, 6 month since I have had an argument with a surgeon :-)

For those of you just joining my blog, here is how it all went down: In March of 2007, I had my right hip scoped for a labral tear and pincer FAI. In July, the left hip was scoped for a labral tear, cam and pincer FAI. At that point, the right hip went bad and I realized I needed surgery again. It took a lot of diagnostic tests, injections, pleading and begging, but finally, my surgeon agreed to do it, but.....there was a catch. He was convinced that my pain was from a tight, impinging psoas, I did not think so. In fact, I was so sure, I made him promise he wouldn't touch my psoas. I wouldn't even sign a consent for for it I was so sure. So, he hesitantly agreed to do the surgery with the psoas promise, and as a compromise, I agreed to let him do a psoas bursectomy, if needed. Lo and behold, I woke up with an intact psoas as well as sans bursectomy since the psoas was not the problem.

3 months of long, intense rehab, with a few blips and bumps and knee injuries along the way, as well as some intermittent PRN PT visits, here I am.

I can't believe that 6 months later, I still walk around and gleefully think to myself "whoohoo, I am no pain", with a little smile. I still feel like I am walking on clouds some days and as if this was a dream, and I will soon wake up with that dreaded groin pain. I still say to myself almost every day. "shit, I am one lucky chick to have a happy ending after so much bullshit", 3 surgeries in 8 months really takes a toll on you, physically and emotionally.

So, what is still going on? My psoas has its moments, and more than once I have had to return for a quickie PT session to have it worked on. It also has caused me to have some back pain in addition to the muscle aches. My adductors are weak and tight, and I swear I think I have had a "snapping adductor". My psoas does snap now, I am not sure if it did, or to what extent it did pre-op. My theory to why I have so much muscle pain now is well described in prior post. I have soooo much more ROM now than I ever did and my muscles are trying to compensate by tightening up. I need to continue to strengthen them, but I prefer Spinning to PT, so who knows how this will end!

All in all, muscle pain and soreness 6 months later is a good deal for me if it means I have no more joint pain! If you need a surgeon, I have only positive things to say about mine! And what can be better than a happy ending!

Wednesday, May 7, 2008

Woe Is Us Part Deux

My Turn!
If I ever doubted that the entire body is connected and works as one impressive chain, today would have changed my mind.
I have been having incredible muscle pain over the past few days, it hasn't been this bad in a while. Yesterday and today I have been dealing with the right side (2 scopes), I feel my psoas pulling at my vertebrae again, and then I get awful pain on medial side of my thigh, not quite groin. This is palpable too. I am so stiff and clicky as well.
Yesterday was a sore day. As I was waiting for the elevator to go down and pick L up at school, I started stretching and trying to get my hip to extend, and hopefully stretch, or possibly break up scar tissue. I got it to pop, but then it hurt. It did get better at some point, I don't remember exactly when or what happened. Which leads me to beleive it was scar tissue
Today, that side was a mess again. I felt like my hip was so tight I was losing extension again, like in the early pre-op days. I did the "stool stretch", where I put my knee on a rolling stool and stretch my leg out behind me. It felt good, I got up to walk, and my right knee was a disaster (i.e. the good knee), I was limping for a while. This too, cleared up, but the hip remains tight.

Like the uncompliant,impatient patient that I am, I had a good ride on my spin bike tonight. I know this is not helping the psoas issue since I am sitting, and spinning my legs, fast, in a small arc of motion. The psoas just winds tighter and tighter.
I have been strtetching it, still, and still doing my abductor and adductor exercises, as if this balances out the "don't spin" part.
Time to get on the floor and stretch stretch stretch!!!

How Can I forget This One

"You always take the easy way out with surgery"

Tuesday, May 6, 2008

Woe is Us

To even the playing field around here, J has a possible torn meniscus. You would think orthopaedic issues were contagious. He did something yesterday and heard or felt a pop, and today, he has been complaining of clicking and locking and and medial sided pain. He also has pain with palpation to the medial joint line. Tonight, he couldn't put Jk to bed bc "his knee hurt", couldn't change a diaper and had to take the car to go 8 blocks to a friend's house (to watch a basketball game). Just as a reminder (J), I never stopped my "motherly responsibility" during a year of hip shit, 3 surgeries and a crap load of PT. So, either a) suck it up b)make an appointment with an OS to have it checked out, and suck it up or c)keep complaining to me but suck it up anyway. Or maybe I can throw back some of the lines you gave me:
"Why do you have to look for problems?"
"I really think there is something seriosly wrong with you"
"Do you need surgery...AGAIN?"
"It can't be that bad, you don't even limp"
"Can you get off of the computer, stop blogging and stop looking for articles"
"You are crazy" (said in reference to many other things)

I told J to wait a week, if he does not feel better, make an appt with Dr. Kelly. He said he does not want to see Dr. Kelly bc he is afraid that I will have to contradict everything he says, and bc he is afraid he doesn't like me bc I am so opinionated. Haha

Sunday, May 4, 2008

You Know its Not Going To Be A Good Day When......

for starters, you wake up with pain on the inside of your ASIS, on the hip that was operated on 10 months ago. When your back feels so stiff it hurts to lean forward. When you have 3 parties within 4 hours...and you are hosting one of them...and the guest list is comprised of twenty five 4 year olds.

My psoas has been giving me issues lately, on both sides, I think. It is hard to remember sometimes, although today we are talking of the left side. Operated only once in July 2007. Last night I began to diligently exercise adductors and abductors on both sides to help my "ailing" knee and "psychotic psoas". I also have been stretching the hip flexors a lot more lately. But this morning, I felt like I made a 9 month backtrack in muscular issues (Joint is still good, you can all breathe a sigh of relief, joint is actually amazing and I am super thrilled, which is why I save my muscular issue complaints for when they are really bad). My iliacus is a mess for some reason. Iliacus is the top portion of the combined muscle called "iliopsoas", iliacus+psoas=iliopsoas. It is found posterior to the ASIS and can be palpated by bringing your fingers just under the ASIS. I have not attempted to manually work on it, but have been stretching it as much as possible (all hip flexors). I stretched before I took L to ballet, after I picked her up from ballet, while she was at a ballet birthday party, and before we left to go to her birthday party! I still have a lot of pain localized to that area. It is an improvement from this morning, I think I could almost feel it pulling on my vertebrae, and that is why my back was bothering me. The stretching seemed to have helped with that a lot.

L's party was at Gymboree and I have never seen so much chaos in my life. The 2 teachers (we had to pay extra and hire a second one bc we had so many kids) were useless. They could not run the party and it ended up being mostly free play. For some reason, walking barefoot on the mats made my bad knee crazy, and then once we got home, it starting having shooting pains.

We just unwrapped all the presents, cleaned the living room and put the kiddies to bed!
I am praying that tomorrow is a better day(probably less fun, but hopefully less pain too!)

Saturday, May 3, 2008

Hmmm.....Can Anyone Else Relate Too??

Doctor Who? Are Patients Making Clinical Decisions?
ScienceDaily (Feb. 12, 2008) — Doctors are adjusting their bedside manner as better informed patients make ever-increasing demands and expect to be listened to, and fully involved, in clinical decisions that directly affect their care. In a study just published in Clinical Orthopaedics and Related Research, Dr. J. Bohannon Mason of the Orthocarolina Hip and Knee Center inCharlotte, NC, USA, looks at the changes in society, the population and technology that are influencing the way patients view their orthopaedic surgeons. As patients gain knowledge, their attitude to medicine changes: They no longer show their doctors absolute and unquestionable respect.
Demographic change, education, affluence, availability of information via the Internet, patient mobility, direct-to-consumer marketing, patient age, patient activity demands, cost pressures and physician accountability are converging to present the practitioner with a patient who is more informed and has higher expectations than any prior generation of patients.
Today's patients do not simply have a medical complaint, they desire a particular operation and sometimes even a particular implant. The doctor is no longer the sole source of medical information. Patients have enough snippets of information to stimulate a dialogue and clearly express their expectations for a particular outcome and technique to achieve that outcome. They are also demanding quicker recovery, return to higher-level sport activity and earlier discharge from the hospital.
"Patients have come to expect miracles in medicine as the norm, yet these miracles are not without inherent risk," cautions Mason.
Providing true patient-centered care relies on doctors' ability to supply patients with accurate, evidence-based information and to improve communication. However, patients are not necessarily motivated by evidence-based medicine. They are often willing to adopt the promises of direct-to- consumer marketing.
In Mason's view, the doctor's responsibility is "to maintain control of validated information sources and of the exchange of information with the patient. [Doctors] need to be interpreters and balancers of scientific information to help guide [their] patients through the maze of medical hyperbole. [They] need to discuss new treatments and technologies openly and honestly."
And crucially, they must also understand that although patients' demands are changing, the surgeon's accountability and responsibility for their patient's safety and care have not.
Journal reference: Mason JB (2008). The new demands by patients in the modern era of total joint arthroplasty. Clin Orthop Relat Res (DOI 10.1007/s11999-007-0009-2)
Adapted from materials provided by Springer.

Thursday, May 1, 2008

A Work In Progress

The previous 2 posts will be added to and updated as I have time and will be able to be accessed from a link on the right side of the page. I hope everyone finds this useful and helpful.
I have also added a few additional links along the right side of the page, which also gets updated periodically!

Failed Hip Arthroscopy and Revision Hip Arthroscopy Articles

Radiologic and Intraoperative Findings in Revision Hip Arthroscopy
Presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons, San Diego, California, February 2007.
Benton E. Heyworth, M.D., Michael K. Shindle, M.D., James E. Voos, M.D., Jonas R. Rudzki, M.D., Bryan T. Kelly, M.D.
Arthroscopy. 2007 Dec;23(12):1295-302.
Purpose: The purpose of this study was to identify possible causes of failure of hip arthroscopy by reviewing the intraoperative and radiologic findings in a series of patients requiring revision hip arthroscopy. Methods: We retrospectively reviewed 24 revision hip arthroscopy cases performed in 23 patients (14 female and 9 male; mean age, 33.6 years; 1 bilateral). The review included indications for surgery, intraoperative findings, and arthroscopic interventions for both the primary and revision surgeries. Imaging studies, including radiography, magnetic resonance imaging, and 3-dimensionally reconstructed computed tomography scans, were analyzed for the presence of preoperative bony impingement lesions (e.g., femoral head-neck junction “cam” lesions or anterosuperior acetabular “pincer” lesions). Results: The mean interval between previous hip arthroscopy and recurrence of symptoms was 6.1 months. In 13 of 24 cases (54%), patients had no significant improvement at any point after the primary hip arthroscopy. The mean interval between the previous hip arthroscopy and revision surgery was 25.6 months. Unaddressed or undertreated bony impingement lesions were found in 19 of 24 cases (79%) and were identified on imaging studies before revision hip arthroscopy. A tight psoas tendon and corresponding labral impingement lesion were identified by arthroscopic visualization in 7 of 24 cases, for which partial psoas tendon release was performed. Eight cases of failed labral repair were addressed with labral debridement and removal of suture material. Of these 8 cases, 6 also had bony impingement, which was also addressed at the time of the revision surgery. Conclusions: Failure to address bony impingement lesions of the hip and a tight psoas tendon are key factors in unsuccessful hip arthroscopy and may require revision surgery. Furthermore, failure of labral repairs may be the result of unrecognized bony impingement at the time of initial surgery. Level of Evidence: Level IV, prognostic case series.

Revision Hip ArthroscopyMarc J. Philippon, MD*, Mara L. Schenker, Karen K. Briggs, MPH, MBA, David A. Kuppersmith, R. Brian Maxwell and Allston J. Stubbs, MD
Am J Sports Med. 2007 Nov;35(11):1918-21. Epub 2007 Aug 16
Background: Hip arthroscopy has become increasingly popular; however, little is known about revision hip arthroscopy.
Hypothesis: Revision hip arthroscopy is associated with unaddressed femoroacetabular impingement. The purpose of this study was to describe reasons for revision hip arthroscopy.
Study Design: Case series; Level of evidence, 4.
Methods: Between March 2005 and March 2006, 37 revision hip arthroscopies were performed by the senior author. Data were collected through retrospective review of clinical and operative notes.
Results: All patients required revision surgery because of persistent hip pain. There were 25 women and 12 men with an average age of 33 years (range, 16–53 years). The average time from prior surgery to revision was 20.5 months (range, 2.9–84 months). Common findings among patients needing revision were hip pain, decreased range of motion, and functional disability. The average modified Harris Hip Score was 53 (range, 22–99). Thirty-six patients had radiographic evidence of femoroacetabular impingement at the time of revision. Revision procedures included 34 (95%) for femoroacetabular impingement, 32 (87%) for labral lesions, 26 (70%) for a chondral defect, 23 (62%) for lysis of adhesions, and 13 (35%) for previously unaddressed instability. Two patients had total hip arthroplasty after revision, and 3 patients required further revision. Of the remaining 32 patients, early follow-up was obtained on 27 (84%) at an average of 12.7 months postoperatively (range, 6–19 months). Outcomes showed patients regained some of their lost function within the first year.
Conclusion: Patients commonly required revision hip arthroscopy because of persistent impingement.

Hip Labral Tear and FAI Articles

Acetabular Labral Tears
by Cara L Lewis and Shirley A Sahrmann
PHYS THERVol. 86, No. 1, January 2006, pp. 110-121
Anterior hip or groin pain is a common complaint for which people are referred for physical therapy, with the hip region being involved in approximately 5% to 9% of injuries in high school athletes.1 Although anterior hip pain is known to result from a number of musculoskeletal and systemic pathologies, a tear of the acetabular labrum is a recent addition to the list that is of particular interest to physical therapists. This mechanically induced pathology is thought to result from excessive forces at the hip joint2,3 and has been proposed as part of a continuum of hip joint disease that may result in articular cartilage degeneration.2 Although the number of recent articles in the orthopedic literature identifying acetabular labral tears as a source of hip pain is increasing, labral tears often evade detection, resulting in a long duration of symptoms, greater than 2 years on average, before diagnosis.48 Studies have shown that 22% of athletes with groin pain9 and 55% of patients with mechanical hip pain of unknown etiology2 were found to have a labral tear upon further evaluation. In order to provide the most appropriate intervention for patients with anterior hip or groin pain, physical therapists should be knowledgeable about all of the possible sources and causes of this pain, including a tear of the acetabular labrum and the possible factors contributing to these tears. Therefore, the purpose of this article is to review the anatomy and function of the acetabular labrum and present current concepts on the etiology, clinical characteristics, diagnosis, and treatment of labral tears.

Acetabular Labral Tears of the Hip: Examination and Diagnostic Challenges
RobRoy L. Martin, Keelan R. Enseki, Peter Draovitch, Talia Trapuzzano, Marc J. Philippon
J Orthop Sports Phys Ther. 2006:36(7):503-515. doi:10.2519/jospt.2006.2135

The purpose of this clinical commentary is to provide an evidence-based review of the examination process and diagnostic challenges associated with acetabular labral tears of the hip. Once considered an uncommon entity, labral tears have recently received wider recognition as a source of symptoms and functional limitation. Information regarding acetabular labral tears and their association to capsular laxity, femoral acetabular impingement (FAI), dysplasia of the acetabulum, and chondral lesions is emerging.
Physical therapists should understand the anatomical structures of the hip and recognize how the clinical presentation of labral tears is difficult to view isolated from other hip articular pathologies. Clinical examination should consider lumbopelvic and extra-articular pathologies in addition to intra-articular pathologies when assessing for the source of symptoms and functional limitation. If a labral tear is suspected, further diagnostic testing may be indicated. Although up-and-coming evidence suggests that information obtained from patient history and clinical examination can be useful, continued research is warranted to determine the diagnostic accuracy of our examination techniques.
Video of Hip Exam from this Article

The Hip Joint: Arthroscopic Procedures and Postoperative Rehabilitation
Keelan R. Enseki, Peter Draovitch, Bryan T. Kelly, RobRoy L. Martin, Marc J. Philippon, Mara L. Schenker
J Orthop Sports Phys Ther. 2006;36(7):516-525. doi:10.2519/jospt.2006.2138

Recent technological improvements have resulted in a greater number of surgical options available for individuals with hip joint pathology. These options are particularly pertinent to the relatively younger and more active population.
The diagnosis and treatment of acetabular labral tears have become topics of particular interest. Improvements in diagnostic capability and surgical technology have resulted in an increased number of arthroscopic procedures being performed to address acetabular labral tears and associated pathology. Associated conditions include capsular laxity, femoral-acetabular impingement, and chondral lesions. Arthroscopic techniques include labral tear resection, labral repair, capsular modification, osteoplasty, and microfracture procedures.
Postoperative rehabilitation following arthroscopic procedures of the hip joint carries particular concerns regarding range of motion, weight-bearing precautions, and initiation of strength activities. Postoperative rehabilitation protocols that have been typically used for surgeries such as total hip arthroplasty are often not sufficient for the population of patients undergoing arthroscopic procedures of the hip joint. Postoperative rehabilitation should be based upon the principles of tissue healing as well as individual patient characteristics. As arthroscopic procedures to address acetabular labral tears and associated pathology evolve, physical therapists have the opportunity to play a significant role through the development of corresponding rehabilitation protocols.

Video of Hip Arthorscopy from this article

Acetabular Labral Tears

J Bone Joint Surg Am. 2009;91:701-710. doi:10.2106/JBJS.H.00802
Paul E. Beaulé, Michelle O'Neill and Kawan Rakhra

Acetabular labral tears rarely occur in the absence of a structural osseous abnormality.
Labral tears are frequently associated with lesions of acetabular cartilage such as delamination.
Hip arthroscopy is the preferred operative approach in the treatment of labral injuries in the absence of substantial structural osseous abnormalities.

see a later posting for more on this article

Another Anatomy Lesson

L with her latest b-day gift, "Bryan the skeleton". Many thanks to Amy for finding this toddler size one! Click here to have L teach you many bones and muscles!!! Here she is pointing out the radius.