Thursday, July 21, 2011

Thinking and Worrying

Since I had spoken to my OS on a Friday evening, I had to wait until Monday to really explore my options. The first thing I did was call the chiro to see if he was a good fit for me, and to see what his fees are since they do not take insurance. To make it short, sweet and simple, I hated him! He was arrogant, condescending and an all around asshole. There is no way I can work with someone like that.
I also have gone over the MRI report and gone over it again and again. I have discussed things with my husband to no end. He thinks I am being silly and stubborn and need to bite the bullet and agree to an open surgery. I think I am starting to agree, but the thought of it scares the crap out of me. TO scare myself even more, I watched a video of the procedure today....probably a very bad idea.
I emailed my OS because I have a ton of questions and think we need to address a lot of issues, mainly that I am freaking out!!!! Of course he has to be on vacation at the exact time that I am having an emotional breakdown, but I guess it doesn't really qualify as an emergency!
So I will "patiently" wait to hear from him, and go from there!!

Monday, July 18, 2011

MRI # 7 Report

On the current examination, there is no occult fracture or osteonecrosis. No bulky synovitis is seen. There is however, marked attenuation of the iliofemoral ligament with some progressive hyperintensity in the interval since the prior study in 3/10 but overall residual discontinuity and poor tissue remodeling. There is considerable scarring of the synovium adjacent to the ligamnetum teres and this is progressive in the interval since the prior study. Effects of neck debridement are noted. There is high grade cartilage loss over the posteromedial parafoveal aspect of the femoral head extending focally down to the subchondral bone. Marked hyperintensity and high grade partial loss is seen anteriorly over the dome with progressive hyperintensity and partial wear since the prior study. No defined bone on bone contact is seen. There is intrasubstance degeneration of the superior labrum as well as degeneration of the anterior labral remnant but no defined split.

The hip abductors and short external rotators are notable for mild insertional gluteus minimus tendinosis. Insertional iliopsoas tendinosis is seen with a remodeled insertional partial tear. There is no atrophy of the iliacus muscle in the pelvis. There is no trochanteric or iliopsoas bursitis. No ischial bursitis is seen. Bilteral hamstring tendinosis is seen with a nonacute low grade partial tear affecting the semimembranosous origin on the right.

Subsequent quantitative MR imaging demonstrates prolongation of relaxation times, most strikingly affecting the parafoveal posteromedial aspect of the femoral head, some prolongation anterior medial dome with relative preservation over the superolateral dome.

MRI of the right hip demonstrates features of instability with poor remodeling of the iliofemoral ligament and progressive scarring of the synovium, adjacent to the ligament teres in the interval since prior study 03/10. There is also progressive wear of cartilage with corresponding prolongation of relaxation times, as outlined above. Degeneration of the anterior labral remnant is noted without acute split.

Sunday, July 17, 2011

Psoas Release...something to consider

A few years ago, prior to my first revision surgery, I had an argument with my OS about whether my psoas tendon should be released or not. I, under no circumstance, wanted it released. He insisted that I should let him release it. I ended up not allowing him to, and 4 years later, we have this study. I do not have increased femoral anteversion, but I am having other types of instability and cannot imagine where I would be now if we had to add a lengthened psoas to the mix of issues.

Study Identifies Patients Who Should Not Undergo Surgery for a Snapping Hip Tendon New York—July 10, 2011

Researchers at Hospital for Special Surgery have identified a group of patients who may have increased difficulty for surgical treatment of a snapping psoas, a condition that usually develops because a teenager or young adult has a pelvis that grows faster than their psoas tendon. The study will be presented at the annual meeting of the American Orthopaedic Society for Sports Medicine (AOSSM), held July 7-11 in San Diego.

“The conclusion from this study is that you should be cautious about releasing the psoas tendon, particularly in cases where there is some structural instability in the hip, specifically increased femoral anteversion, because although the tendon may be causing pain, it is also providing some dynamic support to the hip so it can cause problems if it is released,” said Bryan T. Kelly, M.D., who led the study and is co-director of the Center for Hip Pain and Preservation ( at Hospital for Special Surgery (HSS) in New York.

The study received the 2011 Herodicus Award given annually by the Herodicus Society at the AOSSM meeting for the best paper submitted by an orthopedic resident or sports medicine fellow.

The hip is a ball-and-socket joint where the head of the femur (thigh bone) rotates within the cup-shaped socket of the pelvis. The head of the femur is supported by an angled neck which joins to the long thigh bone. At the base of the femoral neck is a boney protrusion. The psoas tendon is one of two hip flexor tendons that attaches to this protrusion. When the pelvis grows faster than the psoas tendon, this tendon becomes tight and snaps over the pelvis during walking or other activity. This condition, which can be painful, is known as a snapping psoas tendon.

“The reason that it snaps usually has to do with the anatomy of the pelvis. We usually see it in adolescent hips where the pelvis is growing at a faster rate than the tendon can accommodate for the growth,” said Dr. Kelly. “Structurally the tendon is not long enough to accommodate the bony anatomy.”

Doctors usually treat a snapping psoas tendon with physical therapy that involves stretching and strengthening, anti-inflammatories and corticosteroids, but if this doesn’t work, doctors resort to surgically lengthening the tendon. Because the tendon does not have the ability to stretch, surgeons cut slits in the tendon in what is called a partial release of the tendon or a fractional lengthening. “You cut it in a way that allows the muscle to elongate,” Dr. Kelly said.

Studies have shown that arthroscopic and open surgery can achieve similar outcomes for this condition. Few studies, however, have studied whether abnormalities in hip structure, specifically femoral anteversion, can impact outcomes. In most people, the center of the femoral neck points toward the center of the hip socket. Femoral anteversion is a condition in which the center of the femoral neck leans toward the front of the socket. This causes the knee and foot on the affected side to rotate internally or twist toward the midline of the body.

In December 2006, HSS researchers started a prospective registry of all hip arthroscopy procedures performed during a three-year period, 2006 to 2009, by a single, high-volume arthroscopic hip surgeon, Dr. Kelly. The study presented at AOSSM included all patients who underwent a psoas tendon lengthening at the time of surgery, a minimum of six months follow-up, and a preoperative high-resolution computed tomography (CT) scan to detect femoral anteversion. Patients were not included in the study if they had previous tendon hip surgery or hip trauma.

Sixty-seven patients underwent arthroscopic lengthening of a symptomatic psoas tendon, either in isolation or in conjunction with treatment for hip impingement. CT scans showed that 19 of 67 patients had high anteversion. The researchers assessed clinical outcomes both before and after surgery with modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS) questionnaires. These are commonly used to evaluate a patient’s ability to carry out specific activities that involve the hip: activities of daily living, such as climbing stairs, and athletic activities, such as running and jumping.

Prior to surgery, patients who had high anteversion scored significantly worse in terms of athletic activities on the HOS, but there was no difference in either questionnaire scores in terms of daily living activities. After surgery, patients who had high anteversion scored significantly worse on the MHHS questionnaire with regard to athletic and daily living activities, but the HOS scores were similar between the two groups. Twice as many patients who had high anteversion had to undergo revision surgery.

The researchers say the psoas tendon may be an important stabilizer in the hips of patients with high anteversion, and the tendon’s release in these patients may result in a delayed return to activities after surgery and inferior outcomes.

“The results of this study indicate that there are certain groups of patients that respond very favorably to surgical treatment of the psoas tendon, but there are other groups of patients that due to mechanical reasons, surgeons should exercise extreme caution in proceeding with any tendon release around the hip,” Dr. Kelly said. He said these patients should be considered for alternative treatment strategies.

Other authors of the study are lead author and orthopedic surgery resident Peter D. Fabricant, M.D., and Katrina Dela Torre, R.N., M.Sc., at HSS, and Asheesh Bedi, M.D., former HSS fellow now at the University of Michigan.

MRI Verdict

I spoke with my OS abt the latest MRI. We did a T2 mapping study to visualize the cartilage and get a better picture of the hip. He reviewed my MRI w the radiologist and says that there is no question that I have micro instability bc: 1) the ligamentum teres is torn (not sure if more torn since last surgery bc its the most difficult structure to image) 2) labrum is very small and can no longer provide suction to the joint 3) the anterior capsule is thinned out near the iliofemoral ligament, this is an area that was previously thickened (after the last surgery).
All of this is causing small, excessive motion in the joint. He is not 100% sure what is causing the posterior pain but says it is most likely the ligamentum teres. The cartilage in the back of the joint is a little thinned as well.
He wants me to continue to strengthen the muscles around the hip in order to provide stability to it. The only surgical option is an open surgery- which I told him makes me want to throw up! He knows I feel very very strongly abt not wanting more surgery. We did not get into details abt what he would actually do in said surgery, other than the fact that its a big deal and he has only done 5 of them before.
He is recommending I see a chiro who deals with musculoskeletal issues and treats professional athletes (not sure how he will feel about treating an everyday housewife :-) and does "different" types of therapies. I obviously don't need ART or any release work since I already have instability, and I looked up the chiro and all his techniques are release techniques...but I guess we need to try everything, and I know enough (and have a big enough mouth) to not let him do anything I think will make me worse.
So it's off to the chiro I go!!!!!

Thursday, July 7, 2011

Micro Instability???

I'm sorry that I haven't been updating my blog too frequently, it has been tough lately since a) I'm not really sure what is happening in my hip and b)I have very little free time.
I have been in PT for 2 months now and overall have not seen a change in pain level or symptoms. I'm pretty frustrated bc I was really hoping that this would be the solution for me. I saw my OS yesterday to review things again and decide what to do.
PT has been addressing the muscles, and trying to correct a muscle imbalance, I have not made progress :-(
My biggest issue is that I am having all this pain, off and on, yet my MRI shows nothing. To me, this is worse than if it showed a lot of issues, I feel like I am crazy!! My OS assured me that I am not crazy :-) and agrees that we need a better way to image this hip. He is recommending a new MRI with a stronger magnet that can map out the cartilage in the hip. He thinks that I probably have some micro instability due to issues in the capsule and ligamentum teres, and hopes that this new MRI will show something. He also thinks that my labrum is very small, so it is possible that it is no longer providing the suction in the joint that it is supposed to provide.

He explained that he looks at hips in 4 layers- 1) the muscles 2) the 'inert' labrum, ligaments, capsule 3) bony structures 4) nerves. He suspects my problem is with level 2
If you have read previous posts, you will know that me and MRIs do not get along. So I was not thrilled to hear that my first MRI was not of the greatest quality and that I would need another one....So to 'cheer me up' he gave me a rx for Valium for it!
He thinks that if the ligamentum teres is the problem, it will show some changes to the cartilage around the ligament.
If this is the case, then he thinks it would require surgical intervention...then he started talking about the possibility of an open that point I freaked out....really really freaked out!!! I told him that I just couldn't discuss it right now, and that I thought the best thing would be to get the MRI first, then discuss it, if needed. He agreed and is happy that we are both on the same page, meaning wanting to avoid surgery at all costs.