Now Its Tight...

Beginning this week, I have changed my work schedule. I used to work three 5 hour days, 15 hours per week. For the next 3 months, I am working three 12 hour days....I know, a huge change! I have been really concerned about how my hip would hold up. So far it hasn't been too bad. Yesterday it started feeling really tight. My psoas started snapping even more than usual and I was unable to take large steps with my left leg bc the right couldn't go too far into extension. It was so strange, all the muscles just decided that they had had enough with this instability crap and kicked into high gear to protect my hip from sliding around. I hate this tight feeling but I also hate the instability........

Timeline Recap

If you have just begun to read my blog now, it may seem confusing, and you may not know how I got to where I am, and how a 29 year old, otherwise healthy person, can have so many issues with one joint! Here is a link to my "timeline", which when I remember, I update!

Hip MRI #5

Patient is status post debridement of the femoral head enck junction with reconstruction of an anatomical offset. The anterior labrum has been debrided and is diminutive but without tear.
There is irregularity of the anterior joint capsule best appreciated on the oblique axial images, more prominent than previous, perhaps representing the recent anterior surgical approach.

Superior labrum has been debrided since previous and is now deficient. Posterior labrum shows a prominent sublabral foramen, unchnaged from previous.

Sagittal images show irregularity of the cartilage of the anterior aspects of both the acetabulum and femoral head, not significantly changed. There is generalized thinning of cartilage over the anterior aspect of the femoral head best appreciated on the oblique axial images, but also unchanged.

Superior aspect of the acetabular cartilage is preserved. Cartilage over the posterior aspect of the acetabulum is thinned.

Small joint effusion is present.

Negative for greater trochanteric or iliopsoas bursitis.

Signal from bone is normal. The sacroiliac joints are preserved. At L5-S1 there is a focal midline disc protrusion causing mild-moderate central stenosis, unchanged from previous.

Signal from pelvic musculature is normal. There is very mild degeneration of the hamstring origins.

Right hip shows approximately 6 degrees of corrected femoral retroversion. Left hip shows approximately 8 degrees of corrected femoral anteversion.

Impression:
Superior labrum has been debrided since the previous examination. Cartilage wear over the acetabulum and femoral head is unchanged. The increased prominence of the anterior capsular defect most likely represents the recent surgery.

An Answer???? I Think Not!

So I did get a reply to my email which is still not helping me really understand what is happening! There may be "soft tissue(capsule/psoas/scar) pinching in the front of the joint with flexion. Whether it is the psoas getting stuck, or just capsular thickening, or scar, I don't know, that is what I hope to see with the ultrasound".
My problem with all of this is that my psoas snaps, always has...but in extension, not flexion. I don't seem to 'get' what is happening in flexion. Of course it didn't do it while I was there, and I can't reproduce it at will! I haven't had a huge, standing subluxation in almost 2 weeks, which is a good sign, just the sitting one this past week.

My other question was about my increased ER, which is quite excessive. His response was that I have so much ER probably due to the improved offset superolaterally, as seen on my most recent MRI.

So still no concrete answers, which is why I am having such a hard time with this.

The Appointment

I'm not sure how to describe today's appointment. I went with J for moral support because I have been having a hard time dealing with my continued hip issues. Before coming in to see me, BK looked at my MRI and from what I could hear through the door, he was confused by what he saw. He had to call the radiologist to go over it with him.
When he came in to see me, he did some moving of my hip and it clicked, he said that was psoas. I have no pain in ER which again, he found strange. My "secret" PT joined us so we were all able to discuss the situation. BK thinks that based on my MRI, I am having a problem with my psoas. It is getting caught in the joint, this is why I have so much pain, the psoas is inflamed. The reason I have posterior pain is because of the way I am sitting to avoid pinching the psoas. He doesn't think the joint is shifting or subluxing...I don't know if I agree or if I even understand everything he said.
He wants me to get a dynamic ultrasound so he can see exactly what is happening. He would like to try to be there for it, as well as my PT. This should be interesting to schedule!
When we left, I was visibly upset. J wanted to know what was wrong, he thought it had gone very well! I don't know what I thought but I was very confused and didn't seem to understand everything. I still feel like I am missing something...I think we all are. I ended up emailing BK about it and explained that I am confused and asked if he could go over it again with me. I hope I hear back soon!

Valium.....Ahhhh

Ok, what the heck was I thinking for the past 4 MRIs....MRIs with Valium are the equivalent of getting a massage...and having your insurance foot the bill!! I have never actually enjoyed an MRI...until today. I was sorry it was over because I was so relaxed and happy. It flew by! I didn't want to get up when it was done! I could kick myself for not having requested it the other times...Oh well, live and learn!!!

Got Confirmation Yesterday

I got a letter saying that UHC has received my appeal and do I or anyone else want to add something. This gives me the perfect opportunity to send the new policy over to them. Anyone else have anything to add??? I know we all have something we want to say to them but I think I should watch my language in these letters!!

How Akward Is This

Yesterday, my good friend C called and told me that she had hurt her back, and was wondering if I could help her, and if I wanted to go to Target. Of course I said yes (to both). Around 7:00 she called to see if I was ready to go, I was, just had to change...until I went to pick something off of the floor and boom- my hip subluxed and totally threw my a curve ball. It hasn't subluxed "that much" since I have been more aware of the problem. I have been really careful and usually, once I feel the tiniest amount of sliding, I somehow manage to guard and not allow ti to sublux. Last night I couldn't. Within minutes, I was in a ton of pain. I called C back and had to explain why I could no longer fix her back or go to Target: "Ummm...I need to re-schedule, my hip kinda dislocated and it hurts a lot now...can you do tomorrow?" I think I should start taking my MRI Valium NOW!

Instability Is The New "Black"...

...Or at least the new "mystery" diagnosis that is being studied, kind of like FAI used to be, according to my OS. So once again, I am just a mystery...he has never seen anyone quite like me before. I am going to get an MRI hopefully this week and hopefully he can get an idea of what is going on. I am getting Valium for this one!!!

UHC- Revised Policy- Great News For Hipsters!!!

Surgical treatment, both arthroscopic and open, for femoroacetabular impingement (FAI)syndrome is proven*.

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Femoroacetabular_Impingement_Syndrome.pdf

Great news for all of us with UHC!! Thank you to everyone who wrote letters, appeals, made phone calls and was interviewed. What an accomplishment!

In An Unrelated Story...

This week marked the 3 year anniversary of my left hip arthroscopy. Things have been great with Left, one surgery for a labral tear, cam and pincer FAI, 12 weeks of PT and done!!! Right hip....take a lesson!!

And The Nightmare Continues...

I got a response to the email I sent to my OS. He was at a meeting with my PT and they were discussing my unfortunate turn of events. He first wants me to get an MRI...this will be my 5th MRI in 3 years...did I mention I am claustrophobic??
All I keep thinking is that this is not going the way I had hoped...at 14 weeks post op, I am not supposed to be having MRI's, or depressing email conversations with my OS...what went wrong???? Why is this happenning????

Article on Capsular Laxity

Thank you to the generous people at JBJS for providing free articles to patients. I have a full copy saved on my desktop, if you would like it, email me suzq613@aol.com

Anterior Dislocation of the Hip After Arthroscopy in a Patient with Capsular Laxity of the Hip
A Case Report
Anil S. Ranawat, MD1, Michael McClincy, BA2 and Jon K. Sekiya, MD3
1 Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address: ranawatanil@hss.edu
2 University of Pittsburgh School of Medicine, 567 South Negley Avenue, Pittsburgh, PA 15232
3 Department of Orthopaedic Surgery, MedSport – University of Michigan, 24 Frank Lloyd Wright Drive, P.O. Box 0391, Ann Arbor, MI 48106. E-mail address: sekiya@umich.edu


Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania

The first 150 words of the full text of this article appear below.



Introduction

Capsular laxity is a poorly understood but increasingly recognized cause of hip pain1,2. As with shoulder instability, hip instability represents a wide spectrum of pathologic entities, ranging from acute traumatic dislocation to chronic capsular laxity. Primary capsular laxity is often associated with underlying collagen abnormalities, such as those seen with Ehlers-Danlos or Marfan syndrome. Secondary capsular laxity is seen more commonly in athletes and is secondary to overuse or repetitive activities2.

Although the mainstay of treatment for these conditions has been nonoperative, surgical intervention may be indicated because of either recurrent instability or lack of pain relief with nonoperative measures. Surgical treatment may require access to both the hip capsule and the labrum through either an open3-5 or an arthroscopic6-12 approach. Although the latter techniques are relatively new, two studies have demonstrated that arthroscopic surgery can provide stability to the hip joint10,11. However, while arthroscopic techniques are . . .

UHC Contacts

As I sit, wondering what will be with my appeal, I came across this website with some UHC contacts with email addresses. Since so many of you are finding my blog by googling terms like "UHC FAI" or similar things, especially in regards to denials, I thought this may be helpful.
IN the event that you do need to use these, keep in mind that it wasn't until I sent 2 emails to their VP of PR that someone responded to me.


http://consumerist.com/2008/03/email-addresses-for-united-health-care-executives.html
Read the comments, I found them interesting!

My Appeal Letter To UHC To Cover My FAI Surgery

TO: UnitedHealthcare Appeals Department

DATE: February 29, 2010

FROM: Name
Member #
Claim #:

RE: Appeal Letter Regarding Arthroscopic Hip Surgery



Mailed to _______________________




Dear Sir/Madam:

This letter serves as an appeal to the UHC denial of the arthroscopic hip surgery performed by Dr. ____on 11/30/2009. This surgery was performed to debride a torn acetabular labrum as well as to correct my femoroacetabular impingement (FAI) syndrome. United Healthcare’s rationale is that arthroscopic surgery for FAI is unproven; this was documented in a letter dated 12/30/09 from Bradley J. Osborne, MD, Medical Director. This letter states that these services are “experimental or investigational”.

United Healthcare’s decision should be reversed for three reasons. First, I have undergone this procedure by the same in-network physician in the past, and it has been covered by UHC (3/5/07, 7/2/07 and 11/12/07). Second, my medical history demonstrates that a surgical alternative was necessary and appropriate. Third, the medical literature and coverage by other major insurers supports the use of arthroscopic surgery for FAI, therefore, it would appear to the reasonable person that UHC is discriminatory in their policies.

I. This Procedure Has Been Covered In The Past

I have undergone this procedure 3 different times in the past, the first one was performed on March 5, 2007, the second was performed on July 2, 2007 and the third was performed on November 12, 2007. These procedures were covered at the negotiated rate with UHC, as Dr ____ is an in-network provider. I was never notified by UHC that this procedure would not be covered. Obviously, my concern is the reliability of UHC. There must be consistency of processes in order to avoid costly mistakes like this


II. My Medical History Supports A Surgical Response

Femoroacetabular impingement (FAI) occurs when the ball (head of the femur) does not have its full range of motion within the socket. It is the main cause of early damage to the acetabular labrum and articular cartilage of the hip, particularly in young, active patients and high level athletes. Impingement causes pain, decreased range of motion and mechanical symptoms such as locking of the joint.

I relentlessly attempted to manage my FAI with conservative measures, including strengthening of the hip muscles, activity modification and several injections into my hip; however, my pain became debilitating and my range of motion became quite limited. As a young, active, and very healthy 29 year old, and only after conservative treatment failed, I decided it was best to pursue surgical treatment because chronic pain and immobility can lead to risk for multiple health conditions, such as obesity, depression, diabetes not to mention the very realistic probability of needing a premature total hip replacement.

My doctor, Dr.____– a world renowned expert in arthroscopic hip surgery –explained that I had exhausted all of my conservative options and in order to relieve my symptoms, he recommended arthroscopic hip surgery because it involves minimal complications, minimal pain, very low risk of infection, and a short recovery time, all on an outpatient basis. There are other treatment options that include open surgical dislocation as well as a total hip arthroplasty, but unlike arthroscopic treatment, these require that the hip be dislocated which increases the risk of avascular necrosis. As you are aware, avascular necrosis by itself is a complication that can contribute to serious morbidity. Thus, the risks and the potential costs to United Healthcare and the patient, are lower with the arthroscopic procedure. This is also confirmed by the Hayes report as the clinical options. Additionally, at my current age, activity level, and amount of cartilage wear, I do not qualify for a total hip replacement.


Please note that I am well on my way to an excellent outcome thanks to Dr.____’s ability to provide me the state-of-the-art treatment that has been developed and tested, as evidenced by scholarly publications and as an approved surgery by Blue Cross, Kaiser, Blue Shield, Cigna and other insurance companies. This surgery has improved my quality of life and ability to function, which will allow me to avoid premature total hip arthroplasty and the medical treatments associated with chronic disease.



III. The Medical Literature Supports this Procedure for FAI

As indicated in the outset of this document, United Healthcare has denied coverage because this procedure is “unproven.”

United Healthcare’s definition of “unproven services” is as follows:

“Services that are not consistent with conclusions of prevailing medical research which demonstrates that the health service has a beneficial effect on health outcomes and that are not based on trials that meet either of the following designs.
-Well conducted randomized controlled trials
-Well conducted cohort studies
Decisions about whether to cover new technologies, procedures and treatments will be consistent with conclusions of prevailing medical research, based on well-conducted randomized trials or cohort studies, as described.”

A review of the “prevailing published peer-reviewed literature” shows that arthroscopic surgery is not “unproven” for FAI.

In regards to my condition and the treatment Dr. ___provided, UHC should fully understand that FAI is a condition that is painful and debilitating as was my experience as well as countless others. As Dr. Osborne, the original UHC denying doctor, is a general surgeon he may not know the extent of the disability associated with FAI. It is a condition that has been recognized in the literature since the 1930’s (Smith & Peterson, 1936). Femoroacetabular impingement syndrome is the result of abnormal contact between the proximal femur and acetabulum and can result in intra-articular pathology and eventual osteoarthritis (Beck et al., 2004; Ganz et al., 2003).

Furthermore, FAI is one of the most common causes of premature osteoarthritis in men and women (e.g., Ganz et al.., 2003; Murray & Duncan, 1971; Smith & Peterson, 1936).

Although the open hip procedure has historically been the “gold standard,” perhaps due to previous technological limitations, there are extensive complications, chronic disability and pain associated with it as well. Additionally, UHC has recently taken the position to not cover open FAI surgery. Again, UHC is being discriminatory in their coverage for FAI. UHC has refused to pay for ANY required surgical repair of this syndrome.

Bedi et al. (2008) published a systematic review of the surgical treatment of FAI syndrome. These authors report that there are only five scholarly articles (peer reviewed journals) published reporting outcomes of the open surgical approach with 20 or more hips included. Good outcomes achieved ranged from 65-85% of hips (Beck et al., 2004; Beaulé et al., 2007; Espinosa et al., 2006; Murphy et al., 2004; Peters & Erickson, 2004).

There are more outcome studies published in peer-reviewed journals on the arthroscopic correction of FAI syndrome and/or other intra-articular pathology that include 20 or more hips, which is a stronger compilation of evidence than for that of the open procedure (Byrd & Jones, 2000; Farjo et al., 1999; Ilizaliturri et al., 2008; Larson & Giveans; O’Leary et al., 2001; Philippon et al, 2007; Potter et al., 2005; Santori & Villar, 2000).

Of high importance, the success rates of the arthroscopic procedure were achieved without the complications, such as avascular necrosis, associated with the open hip dislocation. In fact, the Hayes report indicates that there is a 1.3% complication rate with the arthroscopic procedure compared to a “10-12%” complication rate of the open hip surgery. Additionally, more recent studies not included in the Bedi et al. article, support evidence for long-term benefits (Ilizaliturri et al., 2008; Philippon et al., 2009).

Although the Hayes report provided a superficial analysis of the evidence for United Healthcare, there is one thing in the Hayes report that clearly stood out: arthroscopic FAI surgery must be performed by an orthopedist with special training in hip arthroscopy. Not only does Dr. ___have special training, he is an international leading expert in arthroscopic hip surgery, which is partially reflected by prestigious publications in multiple peer reviewed journals.

United Healthcare seems to believe that arthroscopy is unproven because studies only cover a two-year period as indicated in “Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up.” Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. J Bone Joint Surg Br. 2009 Jan;91(1):16-23. My question for United Healthcare is would four years be enough? Ten years? This seems like nothing more than a convenient excuse to avoid coverage of a procedure that has proven to be safe and effective.

In a more recent article published by Byrd and Jones, “Prospective Analysis of Hip Arthroscopy with 10-year Followup”, response to hip arthroscopy was investigated in a consecutive series of patients with 10 years followup. All patients undergoing hip arthroscopy were assessed prospectively with a modified Harris hip score preoperatively and then postoperatively at 3, 12, 24, 60, and 120 months. The median improvement was 25 points (preoperative, 56 points; postoperative, 81 points). This study substantiates the long-term effectiveness of arthroscopy in the hip as treatment for various disorders, including labral pathology, chondral damage, synovitis, and loose bodies.

There are many published studies indicating the effective results of arthroscopic treatment of FAI. The largest study to date is Sampson, T.G. (2006) “Arthroscopic treatment of femoraoacetabular impingement; a proposed technique with clinical experience.” In this study of 183 hips, 94% achieved a high degree of satisfaction with the surgical outcome. Only six patients had subsequent total hip arthroplasties. The results further showed that for the majority of patients’ pain decreased by 50% in 2 to 6 weeks, 75% by 5 months, and 95% by 1 year. In addition, there has recently been a publication in the British Journal of Bone and Joint Surgery by Dr. Marc Philippon. He is an authority on the subject and has published extensively on the topic, as you should be aware. In this article he documents the improvement provided to a group of patients undergoing the arthroscopic procedure with over two years of follow-up. The reference for the article is: “Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up.” Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. J Bone Joint Surg Br. 2009 Jan;91(1):16-23.


Again, United Healthcare relied on a Hayes report that UHC says was updated based on studies from 2007 and 2008. However, the key study by Philippon from 2009 was not utilized in UHC’s “science” based determination of my claim. Additionally, the small print in the Hayes report indicates that this report “is not intended to be used as the sole basis for determining coverage, reimbursement or technology acquisition” (Hayes report). There was no indication that my clinical information or communication initiated by UHC with my physician was taken into account.

United Healthcare claims that there may be (not are) problems in the long term. United Healthcare can cite no study showing that there are problems in the long term. In fact, there is no evidence of this, and what we do know is that this procedure avoids avascular necrosis, the risk of which is inherent in an open procedure. So what has to be balanced is the risk of avascular necrosis and other serious complications against the entirely speculative possibility of long-term problems with arthroscopic surgery. In other words, we are balancing a known complication against an unknown, entirely speculative one.

The circumstances in which this surgery was performed, and the literature pertaining to this surgery, have not yet been reviewed by an orthopedist. United Healthcare’s reviews have been by a general surgeon. I strongly believe that, if a proper review was conducted, the finding would be that this procedure ought to be covered as it is covered by Kaiser, Blue Cross, Blue Shield, Cigna and others.

In conclusion, it appears that UHC needs to catch up with the evidence, and reverse their policy of viewing arthroscopic, as well as open treatment of FAI as unproven. Not only is this false, as evidenced above, it is discriminatory to those afflicted with the condition. Specifically, denying the procedure to patients is clinically wrong and misguided. There is clear literature to support the lasting improvement afforded by this operation. More importantly, not performing the procedure and letting patients wait until they are in enough pain or have enough deformity to warrant a total hip replacement keeps patients in pain and suffering for an inordinate amount of time. There is a procedure that can help patients and improve their quality of life with a minimum of surgical trauma, yet you choose to disallow it, based on a superficial analysis of the available clinical series.

IV. Conclusion

Despite my good physical recovery, I have been unnecessarily stressed by the lack of a fair and consistent policy UHC has demonstrated since my claim was filed. Be assured that I intend to use every available means to get this matter resolved as I’m interpreting UHC’s actions to be discriminatory. In the meantime, I will await a thorough and scientific review of my appeal by an orthopedic specialist apprised of the current knowledge base surrounding FAI. I am expecting payment on my claim as I believe the literature does support that this procedure is not unproven. This is also evidenced by multiple other insurers covering this procedure.

Please do not hesitate to contact me with any specific questions or if additional information is needed.

Sincerely,

Susie








Additional References

Prospective Analysis of Hip Arthroscopy with 10-year Followup. Byrd JW, Jones KS. Clinical Orthopaedics and Related Research

Sports and Recreation Activity of Patients With Femoroacetabular Impingement Before and After Arthroscopic Osteoplasty. Brunner A, Horisberger M, Herzog RF.
Am J Sports Med. 2009 Feb 26. [Epub ahead of print]

How accurately can the acetabular rim be trimmed in hip arthroscopy for pincer-type femoral acetabular impingement: a cadaveric investigation. Zumstein M, Hahn F, Sukthankar A, Sussmann PS, Dora C.
Arthroscopy. 2009 Feb;25(2):164-8.

Arthroscopically assisted anterior decompression for femoroacetabular impingement: technique and early clinical results.Hartmann A, Günther KP. Arch Orthop Trauma Surg. 2009 Jan 6. [Epub ahead of print]

Arthroscopic femoroplasty in the management of cam-type femoroacetabular impingement. Byrd JW, Jones KS. Clin Orthop Relat Res. 2009 Mar;467(3):739-46.

Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up. Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. J Bone Joint Surg Br. 2009 Jan;91(1):16-23.

Femoroacetabular impingement treatment using arthroscopy and anterior approach.
Laude F, Sariali E, Nogier A. Clin Orthop Relat Res. 2009 Mar;467(3):747-52.

Arthroscopic management of femoroacetabular impingement: early outcomes measures.
Larson CM, Giveans MR. Arthroscopy. 2008 May;24(5):540-6.

Complications of arthroscopic femoroacetabular impingement treatment: a review.
Ilizaliturri VM Jr. Clin Orthop Relat Res. 2009 Mar;467(3):760-8.

Arthroscopic treatment of cam-type femoroacetabular impingement: preliminary report at 2 years minimum follow-up.Ilizaliturri VM Jr, Orozco-Rodriguez L, Acosta-Rodríguez E, Camacho-Galindo J. J Arthroplasty. 2008 Feb;23(2):226-34.

Arthroscopic treatment of femoroacetabular impingement secondary to paediatric hip disorders. Ilizaliturri VM Jr, Nossa-Barrera JM, Acosta-Rodriguez E, Camacho-Galindo J. J Bone Joint Surg Br. 2007 Aug;89(8):1025-30.


Early outcome of hip arthroscopy for femoroacetabular impingement: the role of femoral osteoplasty in symptomatic improvement. Bardakos NV, Vasconcelos JC, Villar RN.
J Bone Joint Surg Br. 2008 Dec;90(12):1570-5.

Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: a preliminary report. Philippon MJ, Yen YM, Briggs KK, Kuppersmith DA, Maxwell RB. J Pediatr Orthop. 2008 Oct-Nov;28(7):705-10.

Treatment of femoro-acetabular impingement with surgical dislocation and débridement in young adults. Peters CL, Erickson JA. J Bone Joint Surg Am. 2006 Aug;88(8):1735-41.

Arthroscopic offset restoration in femoroacetabular cam impingement: accuracy and early clinical outcome. Stähelin L, Stähelin T, Jolles BM, Herzog RF.
Arthroscopy. 2008 Jan;24(1):51-57.

Influence of femoroacetabular impingement on results of hip arthroscopy in patients with early osteoarthritis. Kim KC, Hwang DS, Lee CH, Kwon ST.
Clin Orthop Relat Res. 2007 Mar;456:128-32.

Quality of life following femoral head-neck osteochondroplasty for femoroacetabular impingement. Beaulé PE, Le Duff MJ, Zaragoza E.
J Bone Joint Surg Am. 2007 Apr;89(4):773-9.

Femoroacetabular impingement in 45 professional athletes: associated pathologies and return to sport following arthroscopic decompression. Philippon M, Schenker M, Briggs K, Kuppersmith D.
Knee Surg Sports Traumatol Arthrosc. 2007 Jul;15(7):908-14.

Debridement of the adult hip for femoroacetabular impingement: indications and preliminary clinical results. Murphy S, Tannast M, Kim YJ, Buly R, Millis MB.
Clin Orthop Relat Res. 2004 Dec;(429):178-81.

Hip damage occurs at the zone of femoroacetabular impingement.
Tannast M, Goricki D, Beck M, Murphy SB, Siebenrock KA. Clin Orthop Relat Res. 2008 Feb;466(2):273-80.

Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R. Clin Orthop Relat Res. 2004 Jan;(418):67-73.

Revision hip arthroscopy. Philippon MJ, Schenker ML, Briggs KK, Kuppersmith DA, Maxwell RB, Stubbs AJ. Am J Sports Med. 2007 Nov;35(11):1918-21.

































Attachment 1


Examples of Other Insurance Carriers Policy on FAI Including:

Cigna

BlueCross BlueShield of North Carolina

BlueCross BlueShield of Mississippi

Regence

Anthem

(I printed out the above companies policies and included them)
BCBS N. Carolina: http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/arthroscopic_surgery_for_femoroacetabular_impingement.pdf
BCBS Mississipi:
http://www.bcbsms.com/index.php?q=provider-medical-policy-search.html&action=viewPolicy&path=/policy/emed/Surgical%20Treatment%20of%20Femoroacetabular%20Impingement.html
Cigna:
http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/mm_0485_hip_arthroscopy_for_femoroacetabular_impingement_syndrome.pdf
Anthem Blue Cross
http://www.anthem.com/medicalpolicies/policies/mp_pw_b099013.htm
Kaiser demonstrates their surgery for FAI:
http://xnet.kp.org/misg/procedures/orthopedic.html
Regence covers it as well.



Attachment 2

Copy of an external review for another UHC member who was denied coverage for an almost identical procedure. Please note that this reviewer, an orthopaedic specialist, stated that this procedure should not be considered investigational or experimental at this time. Additionally, this external reviewer indicated that UHC was arbitrary and unethical in their decision to deny this claim.

Good News and Bad News

This is what I told J I had for him when I left PT today. He wanted to hear the bad news first.

Bad News: my hip is pretty f--ked up. My PT has never seen anyone with my issue, meaning someone who has so much instability following a capsule repair. He is not really sure what to do but is not giving up. In the meantime, he gave me one simple exercise to do at home. I see BK in 2 1/2 weeks so until then, this is it. My pain has been excruciating at times. Yesterday I had a 2 hour meeting and thought I was going to die when I left. This is just like pre-op, when I go to work I have pain. I am going to email BK tonight to see if he has any thoughts.

Good News: I had no co-pay at PT because he felt so bad for me!

More UHC.....

As I have noted in the past, UHC has denied payment for my last surgery. It has been resubmitted numerous times and still denied. After Maria's article was published, I contacted Cheryl Randolph, the PR exec from UHC quoted in the article via email, regarding my claim. I cc'd a few other PR people at UHC as well. I got no response. I sent another email to the same group of people this week, but signed it with my credentials (thanks Maria!). When I got home from work today I had a message from Linda @ UHC regarding my emails.

I called the number and got UHC corporate offices...ooh lala! Linda is a consumer advocate, she told me I would need to appeal the decision. What I explained was that I didn't see the need to do this since the procedure had already been paid for 3 previous times. She was stumped. Regardless, she said to write an appeal and send it to her, and she would expedite it and get it to the right people. And to make sure I stated that it had been previosuly paid for.

I don't know if in the end this will help me or not, but it pays to be the squeaky wheel...someone is going to listen...or get really annoyed!

FML

That pretty much describes the way I am feeling right now. I am having a lot of discomfort in my joint, and have felt my hip "shift" or "sublux" or "de-stabilize" or something multiple times. I am not a happy camper to say the least. I had PT today and my therapist is very concerned about this. He thinks that my femoral head is sitting anterior, which is why I don't have full hip flexion, and why I am so unstable. It is anterior because I have nothing restraining it, I ruptured the ligamentum teres on that 'fateful' June night, and he is pretty sure that my capsular shift was ineffective. He thinks that most likely my capsular tissue was no longer of good quality and just couldn't hold the repair.

That leaves me beyond upset, angry, sad, disappointed.....3 fucking surgeries later and I still have pain. He told me not to give up yet....he is not giving up yet. At this time I am really inflamed so I can't do much of anything. He was also palpating around my ASIS/AIIS and found swelling...he is not sure why but thinks that something there is also very inflamed and irritated. Fabulous.

I am to do one exercise for now. Lying on my back with my knees bent, push my hands into my knees and hold for about 10 seconds. This is to activate my abs...which have most definitely shut down. I iced with the gameready afterwards...it felt great. He wants me to rent one for now but I know I won't use it! It is bags of frozen vegetables for me!!!

He also thinks it may be helpful to get an active fluoroscopy of me bending forward to see exactly what is happening in the joint, and to get an idea of how 'fixable' I am!

Back To Work!

Well, the party had to end at some point I guess, and it was back to work for me yesterday! Work itself went well, it was extremely busy and I had a ton of paperwork, but I managed! Yesterday morning I had what I have come to call one of my "episodes", where I will be doing something and my hip feels like it is subluxing. It usually happens when I am bending down to get something from the floor. It really hurts and is really disconcerting, especially after having surgery to stabilize my hip. I had on and off pain throughout the day, at periods I had no pain at all and others I had excruciating pain. Today was the same, on and off pain throughout the day.I am extremely frustrated with this and was hoping that by 3 months I would be past this. Tomorrow I have PT so hopefully we can work on stabilizing me a little bit and avoid this.

Good News For One Reader

Whenever someone posts a comment on my blog, I get an email about it, even if it is an old post. I was thrilled to get this comment today from Tim on the post about UHC's new FAI ruling:

"I just had my 2nd level appeal hearing with UHC today. Great news! They called back within 15 minutes and have agreed to pay for the surgery I had last September"

Congratulations Tim!!! I hope to get more news like this very soon from many readers!!!

Overcoverage, Undercoverage...Why Can't I Just Get It Right!

I have been totally slacking on the blogging front and once again apologize. I just feel the need to be done with hip shit once and for all.
I am totally done with my original PT and now on to PT #2, who works closely with my OS.

I have been having some feelings of instability, especially when I bend down quickly. Also, I went sledding on Sunday and walking up the hill killed me the next day. I had a lot of groin pain and got really nervous.

I told PT #2 that I really want my full hip flexion, on top of the other things that are going on. He said that one of the issues is that my capsular shift is not doing what its supposed to do, and my hip feels "sloppy", when he externally rotates it there is almost no end feel, it just flops. He also felt that my femoral head was too anterior causing it to jam up into the joint, so he wants to try some things to reposition it. He ended up taping me into a little pelvic anterior rotation to try to get more coverage of the femoral head. After a few hours I had a lot of back pain so had to remove it. We are going to work on some exercises from now on to get that back into place.

He also worked on some muscles trying to get my hip flexion increased. There is a spot on the inside of my leg where the adductor meet the VMO that is incredibly tender, he worked it so hard but it increased my ROM...not without leaving behind some nasty marks though!

I go back to work on Monday...I am nervous about it...I will keep you posted!

Take That UHC

Many many thanks to fellow hipster Maria, who is paving the way for the rest of us to have our claims paid. Below is an article she was interviewed for in the New York Times. As you can see, the article quotes Cheryl Radolph, VP of PR at UHC, who says "the company is now rethinking things once again because of "the changing landscape of medical literature" about the procedure"

Funny, because my surgery was not covered, and the reason UHC gave me is that "This Service Is Unproven And Is Not Covered. Therefore, No Benefits Are Payable For This Expense. In Order For This Service To Be Considered For Coverage, Scientific Evidence Must Be Submitted, That Meets The Standards Described In Your Benefit Plan Language, That Demonstrates The Safety And Effectiveness Of This Service For Your Particular Condition".


Fighting Denied Claims Requires Perseverance

MARIA CARR, a 43-year-old school administrator from Tulare, Calif., could not believe it when her insurer, UnitedHealth, denied coverage for arthroscopic surgery she underwent last year to treat a bone spur on her hip.

Her doctor told Ms. Carr he had successfully performed this procedure for eight other UnitedHealth patients suffering from the same ailment in the same year. To Ms. Carr’s mind, arthroscopy seemed a much less invasive and cheaper way to treat the problem than open hip surgery, the traditional treatment for bone spurs.

“When the denial came I was shocked,” Ms. Carr said, “but I figured I’d just have to find a way to pay.” The total bill for the hospital and surgeon fee was $21,225.

Ms. Carr’s form of shock is all too common. The Department of Labor estimates that each year about 1.4 billion claims are filed with the employer-based health plans the department oversees.

Of those, according to data collected from health insurance industry sources, 100 million are initially denied. In simpler numbers, that is one of every 14 claims.

But Ms. Carr, whose hip pain ceased after the arthroscopic surgery, did not give up on the reimbursement. And neither should you. When Ms. Carr, a special education administrator at a local charter school, read her explanation of benefits statement more carefully, she spotted some instructions on how patients can appeal denied claims.

“I decided I would fight,” she said. “After all, what did I have to lose?”

Ms. Carr researched medical journals and other publications to find proof that her procedure was a bona fide and safe treatment. She then wrote a formal letter to her insurer making her case and including copies of the research she had found. Her doctor backed her up with a thorough letter of his own.

The appeal was initially denied, but Ms. Carr kept fighting. She took her case to her insurer’s external review board, where an impartial medical expert weighed the evidence.

The expert agreed with Ms. Carr, saying UnitedHealth had to pay the claim. “The expert felt UnitedHealth couldn’t call the procedure experimental if it paid for other patients to have it,” Ms. Carr said.

UnitedHealth ended up paying $12,282 for Ms. Carr’s claim — at a rate the insurer negotiated with the doctor and hospital. Ms. Carr’s share was about $500.

“That’s what the appeals process is there for,” said Cheryl Randolph, a spokeswoman for the insurer. “We’re glad it worked for her, and we encourage members to exercise their right to appeal whenever they need to.”

Not that UnitedHealth now happily pays all such claims. Soon after Ms. Carr’s successful appeal, the insurer revised its policy to stipulate that it did not cover that type of hip procedure — although Ms. Randolph says the company is now rethinking things once again because of "the changing landscape of medical literature" about the procedure.

Whatever the treatment or procedure a patient receives or is contemplating, a variety of things can prompt a claims denial. It might be a simple clerical error, like an incorrect address, or a doctor’s use of the wrong diagnostic or treatment code for your treatment.

Then there are the more serious causes — as when a treatment is specifically excluded from your policy, for example, or, as in Ms. Carr’s case, when the insurer deems a procedure experimental and therefore ineligible for reimbursement. Other frequently denied claims involve emergency room visits, especially those at out-of-network hospitals and clinics.

Another big category involves chronically ill patients, who often must try several medicines and treatments to find the one that works best for them. Such patients can become all too familiar with insurance denials, says Jennifer C. Jaff, founder of Advocacy for Patients with Chronic Illness.

But as Ms. Carr discovered, if you are denied coverage you have a right to appeal. And in most cases, experts advise you to do just that. Approximately half of all appeals are successful, according to anecdotal evidence from patient advocacy groups and data from individual states.

“About 53 percent of appeals work in our state,” said the Kansas insurance commissioner, Sandy Praeger. “That demonstrates that the process works.”

Use the following advice to increase your chances of success in appealing a health insurance denial. As you’ll see below, expert help may be available. And if you feel in over your head, and a significant amount of money at stake, it may even be worth hiring a type of specialist known as a billing advocate.

READ YOUR POLICY Always check your policy carefully before you undergo treatment.

Many denials are made because the policy specifically excludes coverage of a certain treatment, procedure or medicine, Ms. Praeger said. When it is spelled out that something specific is not covered, an appeal will not work.

TAKE YOUR TIME When you decide to appeal, do not act in haste, advises Ms. Jaff, of the patient advocacy group.

Most insurers allow a certain amount of time to file for an appeal, usually 60, 90 or 180 days. If you call and say I want to appeal, an insurer may consider that the appeal itself. So you want to take advantage of the time you have (without missing the deadline) to build your case.

Before you file, make sure you have all the information you need from your insurer to start your appeal in earnest. Your explanation of benefits should provide a code for the reason for the denial, and that code should be translated somewhere on the statement. If it is not or if you still have questions, contact your insurer.

Make it clear in your phone call or letter that you are not officially starting the appeal process. You simply have questions. If it is not already clear, you should also ask exactly to whom the appeal should be sent. (You do not want precious time wasted because your appeal was shuffled from desk to desk. )

Whenever you call your insurer, be sure to make a note of the time and date and the person you talked to. If you send a letter, send it registered mail with return receipt, and keep your own copy.

DO RESEARCH Once you learn why your claim was denied, customize your appeal to argue specifically against that reason. A clerical or coding error is fairly straightforward, but just to be sure, enlist the help of your doctor’s or hospital’s billing specialist to back you up with a letter explaining how the mistake was made.

Something more complicated, like an out-of-network emergency claim, will require proof that the situation was indeed a medical emergency and that no in-network provider was available. Obtaining your medical records can help support your argument, so can letters from the doctors who treated you.

Fighting a denial for something your insurer deems experimental can be the trickiest appeal. In addition to support from your doctor, you will need to find articles from established medical journals for evidence that the treatment is not only effective but safe.

You can find abstracts of many articles free on pubmed.gov, the library of the National Institutes of Health. Often the abstracts are enough to make your point. If you need the full article, which can be expensive, ask your doctor’s office for help or check with a local medical school library.

Any proof you can show that other insurers in your area cover the treatments in question can be valuable. Most big insurers list medical policies concerning treatments on their Web sites. Your doctor’s office can probably help with this, too.

You also must prove the medical necessity of a treatment, especially if it is considered experimental.

Ms. Jaff, for instance, learned this when she was denied coverage for a certain drug her doctor prescribed for Crohn’s disease. Her insurer argued that other, more established drugs could treat the problem. True enough, but Ms. Jaff had already tried those drugs without success.

For her appeal, Ms. Jaff collected her medical records that showed when she had tried each drug and how each had failed. The strategy worked, and her claim was ultimately paid.

Be sure to stick to the facts in any argument you make. Emotional or angry arguments, as much as they may feel warranted, will not help your case, said Erin Moaratty, who heads special projects for a group called the Patient Advocate Foundation.

GO THE DISTANCE Even if your well-researched and thorough appeal is denied, do not give up. You still have options, depending on the type of insurance you have.

If you receive coverage directly from an insurance company, say through a private policy or from your small or midsize employer, your insurer is regulated by your state’s insurance department. All but five states, Alabama, Mississippi, Nebraska, South Dakota and Wyoming, allow patients to have their appeals considered by an independent external review board, usually after all internal appeals have been exhausted.

In most cases the board consists of doctors and other professionals with an expertise in your condition. For more information on your state’s rules contact its department of insurance. To find yours, go to the National Insurance Commission’s Web site and click on your state.

Large employers that self-insure — meaning that they pay medical claims themselves, not through an insurance company — are not subject to state insurance laws. But most have provisions for external appeal reviews. Check your plan summary, the large booklet you received when you signed up for health care, for details.

GET HELP Your state insurance department can help answer questions and start an appeal. In addition, groups such as Advocacy for Patients with Chronic Illness and the Patient Advocate Foundation help seriously ill patients file appeals free.

Be sure to check the advocacy organizations for the illness you have. Many offer free advice on dealing with health insurance disputes with specific information related to your condition.

You may also want to seek help from a medical billing advocate (see our earlier column “A Guide through the Medical Wilderness”). Depending on the case, these professionals charge an hourly fee or a percentage of any recovered claim.

My PT Dilema

I told a little white lie today at PT! I told my PT that I went with my friend to her PT and he gave me some exercises to try and some manual techniques to try.

At this point, I am 9 weeks out, the back pain is a lot better just since I have been doing the exercises I got yesterday at "secret PT" and since the "secret PT" worked on my hip.

My complete exercise routine is as follows: Upright Bike, Leg press, single leg press, squats on 2 dynadiscs, sidestepping squats with a theraband, standing hip 4 way with theraband (both legs), squats on a foam roller, seated isometric hip abduction and extension, seated knee flexion with theraband, seated knee extension with 2# weight, seated hip IR with ball and theraband, sidelying hip abduction and end range hip abduction, clam shells, bridges, quadruped hip extension.

My 3 new exercises are: 1)supine, operated leg straight, other leg bent with foot flat, theraband around both knees, operated leg doesn't move, other leg abducts/ER (fall outs) 2) double leg bridge, hold, pick up non-op leg, hold 2-3 seconds, bring it down, raise it again for 2-3 seconds, bring it down, repeat 10 times, then slowly lower bridge maintaining pelvis level. 3) standing on op leg only, bend forward by hinging at hips until torso parallel with ground, keep standing leg straight, arms out to side, slowly bring one arm down to your center and return to start position, repeat 10 times, alternating sides.

My PT is only stretching me and not doing a lot of manual work anymore, there are days when I really need it. the "secret PT" did such a great job on me yesterday, I am considering going back to him. Once I go back to work things will be complicated, but I would rather be complicated for a bit than not well healed. If only P, my original PT were still at my practice I wouldn't have these issues!!!

Secret PT Visit: Part 2

Today was my follow up with my "secret" PT. I most likely will not be seeing him again, but he has been able to give me some great advice. It seems that my back pain is coming from muscle imbalances, mostly my glutes are super weak. He gave me 3 exercises to do for the next 10 days to activate the glutes and hopefully get me stronger and out of pain.

What's great is that immediately when I exercise, my back starts to feel better, so I know that by "waking up" my glutes, I start to move and function better.

In general my back has been better, I have increased my exercises in PT and added a few more challenging ones, and I had my back worked on 3 times last week. I still "spasmy" but definitely getting better.

I have to say that I know I post a lot less than I did for my previous surgeries, but life with 3 kids just wears me out, and by the time they are in bed, I am usually ready for bed too! I am still not back at work yet, but do find myself busy all the time. I plan on returning in 3 weeks. I will be working my regular, part time hours. I agreed to cover someones maternity leave in another office. It would be managing the office and working three 12 hour days....I hope I don't regret it!!

I'm Relieved To See That These Things Don't Only Happen To Me

I have a friend who is having some hip issues, she also had surgery with BK about 1 1/2 years ago. This is a text I received from her this morning after she went for her PT eval

Toll: $8, Parking: $20, Co-pay: $40, Waking up at 4:45am and being seen by an PT intern: Priceless

The icing on the cake was this afternoon when there was a possibility that the PT that was supervising the intern was actually an OT! In the end, it turned out he was a PT, but what a day it was for her!

The Glamours of NYC

Today was my top secret PT appointment in the city! I will get into it when I have more time, but tonight I may have to kill one of my children! No one is going to bed! Anyway, as I was coming home, minding my own business, a super creepy guy came over to me and said "has anyone ever told you you have sexy legs", to which I clearly had no response, other than my jaw dropping, because really, what does one say to a super creepy guy who thinks yoir gimpy legs are sexy. J got a good laugh out of this!

Health Care Reform

A fellow hipster has brought to my attention an interesting blogger, he used to be a PR exec at one of the big health insurance companies, he is now speaking out against insurance companies. Being that many of us are either in a battle with the insurance companies to cover our past or future surgeries, or know someone who is, she has posted a comment on his blog, we all should do the same.
Here is a link to the post as well as a link to her comment. As promised, here is a link to my comment, look for the comment by Susie L. If this link does not work, please email me, suzq613@aol.com

My Aching Back

Even though I am loaded up on Flexiril and Flector patches, my back is still giving me loads of pain. When I have back pain I have no hip pain, and when I have hip pain I have no back pain. I still would much rather have hip pain! I went into my office yesterday for a co-worker to ART my back. It hurt like a bitch, but I felt a lot better after. Today my PT did some deep tissue work on me. Both said that I am having a ton of tightness all along my spine on the right side, with tons of knots and tender points. I think that my legs are too weak still, and my back is working overtime. Tomorrow I have a "secret appointment" with my OS' PT, I am not telling my other PT, but I need to get to the bottom of this before I go crazy!

In Case You Were On The Fence About Surgery...

These are "the boots"! I was supposed to sleep in them for 2 weeks.....Are you really in that much pain now?????

My New Favorite Drugs

Since my back pain had gone from bad to worse, I got a rx for Flexiril, a muscle relaxant. My PT says I am having back spasms from muscle imbalances, and the strong muscles are pulling too hard and the weak ones can't stabilize. I have been in excruciating pain at times. What's interesting is that I NEVER have back pain at the same time as hip pain, it is always one or the other. I have been applying Flector patches to my back and taking Flexiril PRN, mostly at night because it put me out yesterday afternoon! What a difference these have made. Thurs and Fri nights were the first time I have had a good nights sleep in weeks. I wish I would have gotten the drugs earlier!

I have been paying attention to how I move and have noticed that when I extend my back from a flexed position, or try to stand up from a kneeling or crouched position, I am really straining my back bc my leg muscles are so weak. I plan on hitting PT hard this week and doing exercises at home to help with this. I never thought I would say this but I'd rather have hip pain any day over back pain!

6 (7) Week Appointment

Today was my follow up appointment with Dr. Kelly. I have had some concerns but they didn't seem to concern him. One of my concerns is that I don't have full hip flexion back yet. He said that for 6 (7) weeks, I am in a good place. I am concerned about the excessive ER I have, he just said not to push it. I am also concerned about pain I get in my thigh. He thinks it is muscle weakness, and the pain I get throughout the day is from fatigue and weakness. He did give a prescription for Flector patches for pain/ inflammation. I have been having crazy back pain lately, ever since I started having less hip pain. When I got home I put a patch on my back and it was like a miracle. I was supposed to check with my GI doc first about them but the pain was so excruciating I decided to try it first. I do have an email on to him about it though. I asked him of it was normal that my ankle swells when I am on my feet too much, to which he responded "no its not normal, my ankle doesn't swell", to which I replied "well, it didn't swell before the surgery". He thinks it may be from the traction. He gave me a prescription for Ted stockings for this, lovely.

Something I haven't discussed on my blog yet is the fact that my insurance company denied the surgery as of now, a $30k and $15k charge. He was not too concerned and told me to disregard bills sent from his office! This was a huge weight lifted off of my shoulders. Obviously there is still paperwork to be submitted, appeals, etc, but I feel better about it.

That's about it, anti-climactic, just how I like it. No need for MRIs, CTs, injections...just a follow up in 6 weeks!

Snow Tubing

What A Weekend It Has Been

I feel like this weekend things are finally normalizing. I had a crazy, crazy weekend, which included hosting a friends 30th b-day in my apartment on Saturday night, and then hosting an accessories boutique Sunday night. This involved a lot of cleaning, and picking up, and decorating, serving, cleaning, picking up, and setting up, over and over again. I thought I would be inhaling Vicodin but I am happy to report that I didn't touch it. I did drink quite a bit, so that definitely helped! By tonight at the show, I had to sit down a lot bc my ankle was swelling and my foot felt heavy and uncomfortable. My hip was sore and painful but much better. I also walked 10 blocks to a friends house for lunch yesterday with no more than mild to moderate discomfort.

I wonder if the weather is contributing to this turnaround, it is not as cold as its been here, and feeling a lot more mild. Tomorrow we are going snow tubing, I don't plan on actually participating though. You can find me with Z in the lodge near the hot chocolate!

A Glimpse Into My Day

I was at PT today, working hard on the leg press, set to 75lbs. My PT asked how much weight I was doing, I told her, she responded "good, keep it light and easy"...I responded "this is easy? -I'm busting my ass"! I am pathetic!

What I Struggle With

At 6 weeks post-op, I am doing really well. Looking at me, you would never know that I had a hipscope 6 weeks ago, much less my 4th hipscope. I take the kids to school, to after school classes, run my errands and go to PT. What you can't tell is that when I accidentally drop something on the floor, I pray that someone will be nice enough to pick it up for me. My 4 year old knows not to ask me to carry him, although my baby is growing frustrated with that, and at 30 lbs, it is quite a challenge.

I do what I can, or, as a mother of 3, what I have to. On Friday I decided to go back to some simple cooking. Friday night I was in agony but didn't want to take anything for pain and hoped it would calm down by the morning. Saturday morning, after getting the kids fed and dressed, I turned to my good ol' friend Mr. Vicodin! Sunday afternoon was no better and after lying helplessly on the couch for about an hour and a half, with no relief, I had J bring me another Vicodin. Amazingly, once it kicks in, it kicks in! I was then able to make the kids dinner and got through bed time.

Today was another supermarket day. Again, this proved to be tough for me and painful but I made it through the day with any drugs. I have learn to realize that there will b ups and downs, and I need A LOT more patience if I am going to get through this recovery without the use of heavy duty psych meds!!

You Can't Compare...but

I was just thinking...at this point last time, I was back at work. I had also already ice skated once and climbed a rock wall. I was also off the pill and anticipating getting pregnant.

This time I am not at work and just extended the amount of time I will off, I have pain every morning when I get out of bed, I have trouble sometimes crossing my leg or lifting it up, getting it into the car. Standing for too long is difficult, as is shopping. My limp comes and goes, as does weakness and instability.

But...I am making steady progress and I am pretty sure that my pre-op pain is gone. It is hard to distinguish at this point bc there is so much going on, but the deep, achey groin pain is gone. I could not be happier about that, but wish things could move a little quicker!

Working Girl....Or Not

I have been wrestling with the idea of when I should go back to work, and losing quite a bit of sleep over it. I had told my office that I would be back on 1/25, 7 weeks post op, 2 weeks from Monday. I am still REALLY weak and unstable at times, and I don't feel ready to go back yet. In the past I have gone back around 4 weeks post-op, this time that was sooooo not happening. I have weakness in my ankle that causes me to trip all over the place. I have been working on strengthening it to prevent this, also adding some stabilizing exercises to keep me upright and not falling flat on my face. My PT thinks I should take 3 months off, she doesn't see why I need to rush back to work, I think I am beginning to agree with her. I told my boss that I will be back at the end of Feb. I think this gives me plenty of time to heal and recover.

PT has been going well, today she did some soft tissue work on my gluts/abductors...I definitely saw stars. I am limping on and off, she is not too concerned about it and thinks it will go away with time. Her only concern is the lump under one of my incisions, the fluid from when it opened up, there is still fluid pooled under there and causing me pain.

At 5 1/2 weeks post-op, I am doing the following at PT: Bike, leg press @ 75 lbs (today added ball in between knees), single leg leg press @ 25 lbs, standing hip flexion (knee straight) and abduction, wall squats with ball in between knees, seated resisted knee flexion, ankle 4 way with theraband, quadruped hip extension, prone hip extension with knee bent with 2 lbs weight, sidelying hip abduction, sidelying endrange hip abduction with leg on stool, bridges, prone hip IR/ER with 2lbs weight, clam shells with theraband

I had to cut it short today bc I was sore and anything in rotation bothered me. I am feeling better now, but still pretty fatigued.

How I Long To Be Normal Again

I got back from vacation yesterday and after 10 days of doing pretty much nothing, I was feeling pretty good. I look normal to someone who doesn't know me, my gait looks pretty good and I am not using any type of assistive device. So I got home yesterday (without luggage....long story, but they lost our 3 suitcases) and headed out to the supermarket. I think it was my first solo trip since surgery, but have to re-read my blog just to be sure!

It didn't occur to me that I may have trouble at the supermarket, since I had been doing well on vacation. It only took about 5 steps in the frigid NY air, pushing an empty shopping cart, that I realized maybe I wasn't quite ready. Oh well, too late, we needed milk and vegetables and dinner etc...so I did it. I looked almost tipsy, and in pain, and when you don't have a crutch, no one really cares if you drop things on the floor, no one holds doors for you.....but I survived.

What I Re-Re-Re Discovered

I have probably said this a hundred times but...when I do nothing I feel better! Since the airport/ Vicodin night, I have done nothing. I have left the house twice, once to go to Starbucks and once to go out to dinner. Zk has been really sick, so I haven't wanted to take him anywhere. He is feeling better, nothing like a round of Amoxicillin with a dose of Prednisone (really bad wheezing and probable ear infection). So for 3 days I have barely moved, and had almost no pain. Its amazing, Zk was finally a little better tonight and I had to try to keep up with him and I could feel soreness returning. Nothing of concern, I mean, I did have surgery 4 weeks ago, but what a difference the activity level makes. This is like after surgery #3, when I couldn't get out of bed for a week because I was so nauseous, my hip felt great!
I have been doing a lot of indoor activities with the other kids too, because I don't want to run around outside just yet. I have sat in indian style more than once, I mean, come on, how can I build a kick ass Thomas track, or a Lego city? I don't do it on purpose, it just happens. It is also hard to sit with Zk on the bed without ER in that hip. I am changing diapers, nebulizing, feeding etc.

I have been sleeping mostly on my non-op side, and I need a pillow in between my knees or else the op side hurts. Also, I am disappointed with the persistent swelling in my thigh all the way to my foot. I need it to go away, it is really uncomfortable.

My Fat Ankle

This morning I had a little incident, nothing really happened, but I will still refer to it as such. I was standing up, doing nothing, and I must have either very slightly turned my leg or turned my body and I felt this very sharp pain deep in the joint. It was a very specific point, and it was a reminder to me that things are still healing and I have a ways to go before things are normal again.

I had PT today and I felt the effects of the incident, I had to lower the weight on the leg press and eccentric SLR were painful and my psoas popped a lot. I stopped doing these.

We are now in Miami, its been a long day, between packing, getting to the airport, the flight... J talked me into taking one crutch since the gates are far, and I am glad bc I ended up using it. Now, I am finally in bed with extremely swollen ankles, heavy legs and a sore hip. Not too mention twice vomited on by an adorable Zk who is sick!

I emailed BK's PT to discuss my concern about the ER. He said obviously don't push it, and he said that I may be one of those people who don't scar down after the surgery...it seems I am always "one of those people"!

Ouch!

Ok, I need to back off a little bit, I can actually feel the inflammation in my hip making a comeback, with more swelling all the way down my leg. So far I've had 2 days off of crutches, and PT yesterday. Again, PT was great, she had me on the leg press at 75 lbs, doing wall squats, hamstring curls with a 2 lbs ankle weight, prone hip extension with my knee bent with a 2 lbs ankle weight, quadruped hip extension, eccentric SLRs, plus a lot of what we have already been doing. Not only was I exhausted last night but I was in pain, so I hit the Vicodin before bed. I am still in bed now and just feeling a lot of heaviness in my leg, soreness in the groin and butt.
We discussed my concerns over the excessive ER. She thinks that it is tight enough now to prevent it from sliding around in the joint now, but that I will have my full range, or close to it, since all the muscles are already stretched out. She is having me strengthen my internal rotators to try to help.

Just as a precaution, I emailed BKs PT about it too, I haven't heard back, but there was a nationwide blackberry outage last night so I hope it went through!

I think I would benefit from a daily anti-inflammatory, but this option is out, I am left with taking Tylenol during the day and if needed, Vicodin at night.

I Think I an Offiially Retire My Crutches

3 weeks to the day of my 4th surgery and I ventured out of the house sans crutches. It was super snowy and icy and I felt that given that I had been walking around the house without them for a while, they may become more of a liability outside. I went to the mall and did way too much walking. On top of that I did a little Target shopping too. Needless to say, I was exhausted by the time I was done. I did have some soreness and discomfort while I was walking, and my gait is definitely off one way or another. I almost feel like I look a little drunk at times, especially if I am really fatigued. I had pain last night but I managed without any meds. Today will be day 2 of no crutches. I have PT later this morning, I will share with my therapist my concerns over the excessive ER and see what she has to say about it. I will report back!

Turning The Bend

I just realized I haven't posted in a few days, my sincerest apologies! Things have definitely gotten a lot better since we last spoke! Thursday I had PT again. She had me doing some more standing exercises, including mini wall squats and hip flexion/abduction. The flexion/abduction was fine on the operated leg but the non-op leg was fatiguing quickly. She also added some passive adduction to stretch the ITB. It went well and I felt really good afterwards.

I think I am officially done with painkillers, yay!!! I am also pretty much done with crutches, I have been taking one with me when I am out of the house but think that starting tomorrow I will ditch it. My external rotation is a bit too good right now, which is my only concern. I don't think there is anything that can be done, but there is almost no tension when I accidentally, without thinking, externally rotate. I like to do this thing where I will half indian style sit on one leg when in a chair, I have done this on the op leg and had no pain or restriction. I also wake up with it externally rotated sometimes. I hope this is ok. I don't see BK until 1/20 and don't think this is an issue that I have to call or email about. I will run it by my PT though, just in case.

My thigh pain is getting better, finally! As is the bruise on the side of my hip. An issue that I am not happy with s that my ankle swells, and my hip still feels swollen. I don't remember this much swelling in the past, and although the ankle swelling is minor, only noticeable to me, and probably not seen by anyone since I usually wear boots when I am out, it is still concerning.

I don't plan on leaving the house today since we are basically snowed in. On the bright side, I finally was moved up on the waiting list and got an indoor parking spot (trust me, in NY, this is huge), especially since I have been getting really fed up with my outdoor lot, but have not had any issues with them since the infamous "hell" issue!

In The Blink Of An Eye

The rest of my day didn't go as well as the beginning. I will fast forward to the end of the night which featured me back on 2 crutches, then in bed with Vicodin.

My day did get a bit hectic, Jk had a doctor's appointment which involved me picking him up at school and walking to the appointment, probably a total of 7 blocks. Then giving the kids dinner, which involved a lot of whining, and "I don't want that". We had a leaky diaper incident, some bratty shower moments, and lots more whining.

I was not happy! Luckily J came to the rescue and took over bedtime responsibilities.Hoping for a better day today!

Crutching Away

I have been going back and forth between 1 and 2 crutches these days. I use one in the house for the most part, unless I am in a lot of pain, then I use 2. Or, if the kids are being especially needy, then I use none. Like when I 'lost' zk only to find him splashing around in the toilet. So I had to give him a bath! We have been ok so far, J came home at a decent hour last night to get everyone into bed.

I had PT today, and am progressing slowly but steadily. I am very happy so far with my PT, and especially happy with her conservative manner. I don't feel the need to rush this at all, and everything will come back with time. I was feeling a little discouraged with my flexion ROM, but she measured it today at 113', so I am pretty happy. She did a little bit of passive extension, to 15', and measured my ER at 30', we won't be pushing that anytime soon. I have been concerned about having excessive ER at this point but this made me feel better.

We are going to Miami next week, I hope to be done with crutches by then!!!

Back On Narcs

I can't seem to win. Every time I think I have turned a corner with the pain, I end up doing too much and needing to go back on narcotics. I woke up this morning and I knew there was no way I was managing with one crutch, and no way I was managing without meds. Incidentally, it is a pretty gross day out. I also did a lot of walking in the city last night (ok, not a lot, but a lot for me) and a lot of stairs at a night club where we went to a concert. I did really well last night, just got a little stiff from sitting too long.
This morning I had a lot of quad/ thigh pain. My entire thigh still hurts, all the way to the knee now. It is most likely a side effect of the traction, I just hope it goes away soon. I also had pain deep, deep in the groin, near the adductor insertion, only deeper. I started with an Aleve, hoping to get away with just that. 20 minutes later I couldn't take it any more and ended up with half of a Vicodin. I feel better!

Warning: Graphic, Read At Your Own Risk

No, this is not a sex post!

Now that that is out of the way, I can begin. I have been having a lot of pain on the outside of my hip, it is swollen and ugly and bruised, and tender to the touch. The sutures came out Wed. and have been covered with steri strips, but one of them has felt very hard and had a huge lump around it. I decided that this may be scar tissue so began working on it earlier in the week. It didn't change much. Last night I decided to take off the steri strips (even though I had been told to keep them on for a week) and see what was going on. Indeed, there was a hard lump around one of the incisions. I began once again trying to work on the scar tissue when suddenly, a gush of blood shot out from a small opening at the bottom of the incision. As this happened, I felt a release around the incision. As I squeezed the lump, blood oozed from the tiny opening. It was very dark blood. The lump got smaller and smaller as I squeezed. I suddenly had less pain in the area and the lump was disappearing. Last night I was able to sleep on my operated side for the first time since surgery. It seems I had a pocket of fluid collecting under one of the incisions. I had a similar issue after my c-section with L, a pocket of fluid collected under the incision.

As far as yesterday went, I was really getting depressed. Today wasn't too much better so I put myself on a low dose of Zoloft, leftover from my first 2 postpartum weeks. It did the trick then and should do the trick now!

I have a lot less pain today, I haven't taken any type of pain medication (including OTC) in 24 hours. I can walk in the house almost all the time with one crutch, when I fatigue I need 2, usually I feel it in the IT band first and then I know its time for 2 crutches. I am going to a concert tonight...wish me luck!

My Breaking Point

It seems as if I am hitting a rough patch this morning. I am beginning to feel frustrated and sad at the same time. It just doesn't seem fair. As I sit at my computer, holding back tears, I wonder what I could have done wrong to end up back in this situation, 3 small children to care for on crutches. Up until now, my mom has been here and has been doing pretty much everything. She went home today and I am feeling extremely overwhelmed. I am using 2 crutches for the most part, I am able to get around the house a little bit on one crutch, but the pain in my ITB gets worse when I do this, so I know it is not a good idea. Jk wants me to take him to school, L is concerned about how I am going to dance with her at her school Chanuka party next week, and Zk just wants me to hold him.

I know this is temporary. I have been here before. I am almost positive that I can read back to another post and I will have written the same thing at around this point post-op. It is just so hard to have to rely on others for just about everything.

If I continue to mope, I start to wonder why I was destined to have 4 surgeries, in less than 3 years? I try to be positive, I guess this is not the worst thing to have. It is not life threatening, more of an inconvenience. But as I am living with the reality of it, it is hard to be positive. And just like in the past, I know that this too shall pass.

Fourth Op- Report

Preliminary Diagnosis: right hip labral tear status post instability episode, status post prior hip arthroscopy with re-tear of labrum

Postoperative Diagnosis: right hip labral tear status post instability episode, status post prior hip arthroscopy with re-tear of labrum

Name of Operation: Revision right hip arthroscopy, labral tear debridement, synovectomy, debridement of ligamentum teres, and capsular shift procedure with revision decompression cam and rim side.

Indications: The patient suffered from persistent right hip pain 2 years status post a prior hip arthroscopy after she had been in a forced external position after she had a baby. She had a stretch of the anterior capsule with persistent pain, re-tear of the labrum, and also tearing of the ligamentum teres. She had failed non-operative measures and given the persistent pain and lack of improvement, she was indicated for right hip arthroscopy and associated procedures.

Procedure: After the patient was correctly identified in the holding area, she was brought into the operating room. Spinal epidural anesthesia was administered. She was placed in the supine position on the traction table and approximately 10mm of distraction were achieved across the acetabular joint. The right hip was then prepped and draped in the standard surgical fashion.

A lateral portal was established under fluroscopic guidance using the Seldinger technique. Then a mid anterior and additional anterior lateral accessory portal were both established. Arthroscopic examination demonstrated a labral tear anteriorly with evidence of a defect in the anterior capsule. There was some residual mild bone spurring bone spurring on the acetabular rim as well as mild superior lateral cam impingement lesion. Residual remaining aspects of the decompression were in good condition. There was synovitis adjacent to the capsular rent, and there was synovitis in the fat pad in addition to a partial tear of the ligamentum teres.

At this point the labrum was debrided of non viable tissue. The capsule was elevated off the residual rim impingement and then a rim decompression was performed. The ligamentum teres was then debrided of non viable tissue and a fat pad debridement was performed. The cartilage on the femoral head was in excellent condition as was the remaining aspect of acetabulum.

The scope was then placed in the peripheral compartment where a T capsulotomy was performed for good visualization of the superior lateral aspect of the cam lesion. There was some extension of the cam superior laterally. Cam decompression was completed up in the superior lateral 11 to 1 o'clock position with good visualization and protection of the retinacular vessels during this period of time. There was some irritation and erythema around the labrum in this position consistent with the residual impingement. At the completion of the residual cam decompression, no further impingement was present.

The T capsulotomy was then shifted for solid clossure of the anterior capsule. The medial limb was brought lateral with 5 sutures passed side to side using ideal suture passer and a bird beak penetrator with good secure fixation of the capsular repair. at the completion of the capsular repair, no residual defect was present. the head was well contained with the socket. At this point no further pathology was identified.

The instruments were removed from the hip joint. It was drained of fluid and the arthroscopy portals were closed with 3-0 nylon sutures. A marcaine cocktail was placed in the joint. The wounds were cleaned, dried, sterile dressings were applied, and the patient was awakened from anesthesia and brought to the PACU having tolerated the procedure well.

Sutures...Gone!

I don't know if I have mentioned that sutures really gross me out. Yes, I see them all the time but it just seems so unnatural to have them in your skin, and my PT thought they may be part of the reason I feel so tight and pinchy.

It was no surprise to me that I showed up for my appointment today, which was scheduled the day I scheduled surgery....with a whole discussion on whether it would be ok to have them out 9 days post-op...and I had no appointment. The same thing happened with surgery #1. At least this time I hadn't thrown up in the car on the way down, and was in the correct office. And just like last time, there was no way I was coming back another day!

I think from now on I just won't make appointments because I get seen a lot quicker this way, no waiting in the waiting room, little waiting in the room! J/K

So the incisions look good, except for one which is still good but needs some time with the steri strip. My flexion ROM is good, and I have decent ER, I can stop wearing the @###$$%&$ boots at night! The bruising and swelling is probably bleeding from the capsule. He had to do a capsular shift, so he cut the capsule and instead of just approximating the edges together and suturing, he overlapped the edges and folded over the extra tissue, I now have a tighter capsule with a REALLY strong repair. He showed me the scope pics, the psoas looked great and is "unscathed" (guess he knows who he is dealing with). He was really impressed with the quality of the cartilage, I am thrilled about this.

I am very concerned about the repair and the ER so I spent some time discussing this with his PT. He said stick with gentle ROM for 6 weeks, it will come back. No joint mobs for 6 weeks. He said treat it like a shoulder with a repair, you want the mobility but you also need the stability. I feel better but still nervous about it. I see him again in January, I hope the ROM is good by then.
I have the op report and will post is as a separate post.

Swollen Swollen Swollen

That is the best way to describe my thigh right now. It is so gross! I really feel like it will burst open any minute, I feel like when the sutures come out tomorrow, the leg is going to explode. My bruise is getting more purple each day. I also have a faint black and blue line around my shin, must be from the boots in traction.

I had PT today and was complaining about tightness and tenderness to the ITB. My PT worked on it, and kept asking if I was ok, if it hurt, could I tolerate more etc.....it was basically numb. She could do whatever she wanted and I barely felt it. Its not numb numb bc I feel something, so we will refer to it as parasthesia, or decreased sensation. The front and lateral aspect of my thigh have decreased sensation. Hopefully once the swelling goes down it will get better.

I am afraid to put on anything other than sweatpants, I don't want any material rubbing on my thigh, or anything tight around it. So I am going into week 2 of sweats only!

I have my post-op appointment tomorrow, I plan on asking why I look like I had the crap beaten out of me (i.e. huge purple bruise on the side of my thigh) and if I should possibly go back on an anti-inflammatory for a while to bring down the swelling. I will let you know what he says...