Finally Some Relief

I don't know if it was the multiple massages last week or the distraction of my practice, but I am finally feeling better this week.I have also had a ridiculous amount of anxiety, which causes me to feel no pain at all, so I guess I have to pick my poison!!! Its hard for me to really know what is helping as I have always had good days and bad days and for no apparent reason, but I have had a bunch of good days in a row so I am keeping my fingers crossed!

I saw my OS today and since things seem to be better at the moment I didn't really press any of the issues I have been having. He did review my MRI with a hip MRI specialist and she thinks there was a good deal of synovitis in my joint. It could be a reaction to the allograft or part of the normal healing process. She did recommend a new MRI in 6 months just to check on the progress of the healing of the allograft. There is still some fluid in the joint but not too much, the capsule is intact. In my opinion, this is going to require more time to heal. My OS said normal tissue takes 3 months to heal and this is by far normal tissue.

The one thing that doesn't thrill me is the amount of ER I have in the right hip. My OS is not all that concerned but it doesn't feel normal to me. He attributed it today to a differece in version angles between my right and left hip, right is 6 degrees and left is 13 degrees, making it more likely to ER. I don't really buy that answer right now, especially because the left has some acetabular retroversion so the 2 hips should be pretty equal.

One thing I keep telling myself is that this is no longer a normal hip and I can't expect it to do normal things. It has been operated on 4 times, it will never be the same again. I think in another 6 months we should know if the surgery was successful and how much permanent relief I will have.

I am Just Completely Worn Out With This

Interestingly, my husband and I bought our current home in 2006, immediately after, things started to go downhill for me health-wise. That was when I was officially diagnosed with Crohn's and immediately after that, FAI. You know the FAI story......It seems that the previous owners developed a liking for multiple mirrors, and my house is lined with mirrors, in a lot of places, and in a lot of places where you wouldn't ordinarily expect a mirror (bathroom ceiling???). My point is that I can't even walk from my bedroom to the kitchen without having to catch a glimpse of myself, and what I have noticed is as time has gone by, I am just looking completely worn out. I do think I do an excellent job of not letting see what is going on, I don't have a visible limp, I am able to attend PTA events, social outings (usually), my kids' sporting events, but the toll this is asking on me is becoming quite evident to me in the multitude of mirrors.

I sent an email of desperation to my OS last week. We spoke on Fri, I am not sure what he really thinks is going on but he said he wants an MRI of my hip, to see what is going on and why it responded so well to the cortisone, and to get an image of the tissues etc. He also said he wants one of my back. I said look, I don't think there is a problem with my back, I am pretty sure it is all coming from my hip, but if you feel strongly about it then I will get an MRI of my back too. He decided to wait until I see him in 1 1/2 weeks to make the decision about my back. He thinks that at this point my problem has now become even deeper and is a neuromechanical problem. He said he thinks I am having trouble finding a balance in my hip, and that is why I go from hip to back pain over and over again.  This article may provide insight into what that means.

The layer concept: utilization in determining the pain generators, pathology and how structure determines treatment.

Draovitch P, Edelstein J, Kelly BT.

Source

Hospital for Special Surgery, 525 East 71st Street, New York, NY, 10021, USA, draovitchp@hss.edu.

Abstract

The level of understanding of pain in the non-arthritic hip has made significant strides in the last couple of decades beginning with the discoveries of Reinhold Ganz, MD. However, even with the detection of subtle bony abnormalities, including femoroacetabular impingement, a clinician's ability to differentiate pain generators in the hip has been ambiguous. Deciphering the etiology of the pathology versus the pain generator is essential in prescribing the proper treatment. The Layer Concept developed by Dr. Bryan Kelly, is a systematic means of determining which structures about the hip are the source of the pathology, which are the pain generators and how to then best implement treatment. Four layers will be discussed in this article. Layer I, the osseous layer, Layer II, the inert tissue layer, Layer III, the contractile layer and Layer IV, the neuromechanical layer.

PMID:

 

22371303

 

[PubMed - in process]

 Of course this is what they know the least about at this time. He also spoke about finding a PT that I can work with, that will WORK. I said its been 5 months, I'm pretty sick of PT and I really don't want to be in PT for the rest of my life.He agreed with that. I asked if I should go back on Lyrica, he said to try it and see if it helps. I also had an acupuncture treatment 2 nights ago, it definitely helped the spasm in my back and I slept better than I had in weeks. I also had a massage 3 days ago but I might as well have flushed the money down the toilet. What was interesting though was that it actually helped the pain in my back temporarily but made the pain in my hip worse.

What I started doing to help my pain and core is a series of exercises that I have been using on my older patients, those that are either low-functioning, are post-op from spine surgery, have osteoporosis etc. I find that while I am doing them I get pain relief, so I will continue. they are from a book called "Walk Tall" by Sara Meeks. I highly recommend this to anyone who is having back issues that are not responding to any other therapy. These are simple exercises, each one very carefully and specifically explained with pictures, they are easy to do and easy to follow, I keep the book with me when I am treating.

So the current plan is Valium+MRI, see OS to review MRI and possibly obtain back MRI.

Post Injection

It has been a week and a half since my cortisone injection and I am happy to report that the pain in my joint has finally decreased. I actually feel human again and have been functioning normally the last few days. The pain in my back is not gone though, but the referred pain to my lower leg is improving. One of my greatest achievements is finally coming to fruition, I have started my own private practice. This comes just at the perfect time, sometimes life works in mysterious ways! Check me out www.hudsoninhomept.com
Like me on facebook

The Injection

If there is anything I have learned up until this point is that my hip is no longer a normal hip and will not respond to treatment the way normal hips do. Case in point, my cortisone injection last week. This was the 10th time I've had an injection into my hip so it no longer phases me.  I got good relief initially from the local anesthetic. At the 2 hour mark I started having posterior joint pain. At first I assumed that this pain was just something that would not be affected by the injection but a few moments later the pain in my entire hip became so bad I don't know what had hit me. I couldn't believe I had only gotten 2 hours out of the local. A little while later the pain subsided and I got another hour or 2 of pain relief. For the rest of the day I had a terrible headache and was breaking into a cold sweat. I think I may have had some sort of reaction to the steroid.  The next few days were pretty rough, I've been taking narcotics and muscle relaxants and some anti inflammations which I usually avoid. Again, my anterior hip muscles are in such bad spasm that they are pulling on my back and now I am having really bad back pain. The back pain is a lot more debilitating than the hip pain, IMHO. Additionally, to complicate matters, when my hip pain is bad, I am getting referred pain into my calf. I don't know if this is related to the nerve injury from the surgery or something different The last few days have been immensely challenging for me. I could barely get out of bed yesterday due to pain and then due to me not being able to function on narcotics. Today I tried taking it easy again but tomorrow I have to live my life and move forward. I am at a loss and don't know what to do, what to think or what will happen with my hip.  I haven't worked in almost 5 months. Initially I was on disability. When I thought I was ready to return to work, I found out I no longer have a job. This definitely threw me a curve ball. For a while, I have been thinking about starting my own practice and this was the kick in the pants I needed. I have been planning and am almost ready to start, I am hoping and praying that u can be successful and that my hip problem will not stand in my way. 

4 1/2 Months Post-op

As my hip journey continues to drag on, my hope for normalcy is slowly fading away. I have pretty much lost faith that there is help for my hip and am trying to  tell myself that I would be better off with a hip replacement in the near future.

Last week I sent my OS an email asking him for a cortisone injection, I hope to be able to have it this week. I also am quitting PT (again). I can't stand the thought of spending my entire day going and coming, and being in worse pain for days after. The price is also becoming prohibitive with a high copay and city parking prices. My hope is that the cortisone takes the edge off and I can take my mind off of this for some time.

PT, besides for irritating my hip, is also causing me back pain. I think that my hip is still unstable and the anterior muscles go into spasm to try to stabilize in turn pulling me into excessive lumbar lordosis. I had to ask my PT to please not sacrifice my back for my hip!

CT Scan Results

Right Hip

Maximum alpha angle (9:30): 44 degrees
Coronal Center Edge Angle: 29 degrees
Sagittal center edge angle: 62 degrees
Femoral neck shaft angle: 146 degrees
Acetabular version: (1:00) 11 degrees
Acetabular version (2:00) 15 degrees
Acetabular version (3:00) 20 degrees
Femoral version angle (6 degrees)

Left Hip
Alpha angle: (1:00) 49 degrees
Coronal center edge angle: 36 degrees
Sagittal center edge angle: 57 degrees
Femoral neck shaft angle: 132 degrees
Acetabular version (1:00) -6 degrees
Acetabular version (2:00) 12 degrees
Acetabular version (3:00) 18 degrees
Femoral version angle: 13 degrees 

CT Discussion

I spoke with my OS a few nights ago to go over the CT scan. Overall everything is pretty normal (will post numbers soon). My right hip is a tad more shallow than my left but still normal. The right is also a little more retroverted than the left, but within normal. He still stands by his theory that the problem is a neuromuscular control issue and more/ more consistent PT should help. I am seeing a new therapist since my PT has drastically cut back his days/ hours and I can't see him on a consistent basis. My OS said he would come to PT the next day to speak with my new PT and go over things with her.

My new PT initially had to undo the damage from last week, get me out of spasm and realigned. Then she worked on core control and glute control, saying I don't fire my muscles in the proper order unless she cues me to. She did release some of my hip muscles a little bit, including my psoas, iliacus and obterator. It didn't change the level of joint pain. It was discouraging that some simple exercises increased the joint pain. My OS came by and once again discussed my hip angles, assured me he didn't take down too much bone and reinforced his theory about the neuromuscular control. The plan is to see this PT for 4 weeks in a consistent basis and see what is happening at that point.

A Concussion In My Hip

That is what I am feeling. According to WebMd, a concussion is a type of traumatic brain injury that is caused by a blow to the head or body, a fall, or another injury that jars or shakes the brain inside the skull. I feel like my hip is in a constant battle inside the joint, slamming into the front and back side of the joint, causing groin pain or butt pain. I can address one but then the other returns.

My PT has taught me how to get the femoral head back inside the socket, or at least to move it back a little and it alleviates the groin pain. But what has been happening is that the posterior pain returns and the anterior muscles go crazy, the spasms I have been having are breathtakingly painful. I have been taking Baclofen like candy the past few days to try to get some control over this. The spasm go into my back as well so along with hip pain I have developed back pain too. I'm going to try to not do the repositioning exercise today and see what happens.

I am supposed to speak to my OS on Tuesday to go over the results of the bilateral CT scan that I had last week. I will keep you posted.

Me and Zk

Sometimes You Have To Keep Trying

My poor physical therapist works so hard when I see him to try to find a way to make my pain decrease. I am 3 1/2 months post op and things recently took a turn for the worse. Today, after almost a month of pain, he was able to give me some relief.

His theory is that my femur sits too anterior and is causing a lot of problems for me there. Why it sits too anterior I'm not sure (I will get the answer from him tomorrow). So what he had me do today was increase the coverage of the femoral head by rotating my pelvis over the femoral head. It worked!!! My pain level decreased significantly (this was after many attempts at different exercises and different manual techniques). It has been 2 hours since I left him and I'm not 100% pain free like I was then but I am feeling a lot better. He is also having me do abdominal setting/ bracing exercises to try to help keep the femur in proper position.

I had my CT scan yesterday and wont be speaking to my OS until next week.

I had this "anterior femur" thing before, it was a problem after my last surgery as well. It makes me believe even more that my acetabulum may be a bit too shallow now since the femur keeps wanting to come out. I hope to god that I am wrong bc you can always take more bone off but you cant put it back on :-(

A Look Inside My Head

As I have been telling you, I have been in a lot of pain. I have had a lot of free time on my hands lately and just a little too much time to think about things. Why does my hip continue to return to being painful? What are we missing? Is it possible that too much bone was taken down from my right hip? There is definitely more bone on my left hip and my left hip is great. I did ask my PT last week but I think I made him uncomfortable with that question. It's a tough question, an uncomfortable question. But it had to be asked and I had to get it out there.
I broke down on Monday and emailed my OS. I know something is not right with my hip, I'm having a lot of joint pain, in the groin and the back of the joint. At times the pain is unbearable. We spoke tonight and he immediately blamed my dysfunctional muscles. He wants me doing more PT ( my PT only works every other week right now) and getting more hands on treatment. We got around to discussing the bones and comparing both sides, and I just came out and asked him if it's possible that too much none was taken down from my right hip, resulting in all of these issues. In a nutshell, he doesn't think so but wants me to get new bilateral CT scans to really see what the 2 sides look like and compare them. We finished the conversation with him assuring me that we both have the same goals in mind, to get my hip to stop hurting and to keep me out of the OR. I replied to him that I want him out of my life just as much as he wants me out of his life!!!

Not Happy

About a week ago I mentioned that I'm having a flare up in my hip. It has not gone away :-( it has progressively gotten worse. My first day of PT this week was incredibly unproductive, everything we tried hurt. I was so sad and frustrated. I had been doing so well for such a long time. My second day of PT this week went better and we found that avoiding exercises in the sagittal plane was the key to reducing my pain. Things went much better but the next day I woke up in horrific pain. I seem to be in a cycle of pain that is so intense and irritating, inside my joint, that it brings me to tears and narcotics. Then, I can feel so much better without doing anything specific. It is a terrible cycle that I can't break. I told myself I'd give it until the end of he weekend and then decide what to do. I am not happy.

2 weeks since PRP

I don't know if it's too soon or if this is the placebo affect but I don't really care, I CAN SIT !!!!!

3 months post op

It has been 1 1/2 weeks since my prp injection to my hamstring and 3 months since my surgery. Initially after the prp injection I had soooo much pain. It has resolved and I am finally feeling better from it. Hopefully over the next few weeks/ months it will continue to help.

My hip had been consistently getting better and I seem to be having a set back at the moment. It is very hard for me to deal with this given my poor history with "issues" with this hip. When I had the prp injection the physiatrist commented that he thought some of my issues were partly a result of having Crohns disease and difficulty healing and being more prone to tendinitis.

A lot of the pain I had pre op has returned in the last week or 2. I am also having a ton of clicking and clunking, same as I had before this surgery. I'm not sure what is going on but I am extremely unhappy with this. I am tired if being in pain and this has become unbearable at times. My OS told me to give it 6-9 months before things are fully healed. I return to PT this week and hopefully it will bring me back to where I was before.

PRP Injection to Hamsring

Unfortunately, PRP is considered experimental by most insurance companies. As my OS office was trying to get pre certification for the injection, it kept getting denied. I urged them to try different codes but to no avail. They thought the problem may be partly the facility I wanted to have it done at, in the end we decided it would be better to have it done as an office procedure with another doctor. I forgot to mention that all of this took place in person, not over the phone, since I was getting nowhere trying to do this over the phone.

My OS office took care of canceling my first appointment and I went to schedule with the new doctor. Lo and behold he had an opening for 30 minutes later. I jumped on it!

I quickly went to grab a bite to eat so that I wouldn't pass out when they took my blood. It's a good thing I did because they took ALOT of blood and with a HUGE needle. The fellow came in to talk to me first, she was actually able to find the painful spot and reproduce the pain, no one has ever been able to do that before. As she found the spot she said " yep, you def have tendinosis".

When the doctor came in he also felt around for the spot and did a ultrasound to see where he would be injecting. He started injecting and took multiple passes at the tendon, it seemed like the needle was in me forever, and it was really really painful. I think it was worse than my psoas injection 5 years ago and that was bad.

His instructions were to do nothing for 2 weeks and then come to see him. I got home and the pain was intense. I ended up needing a lot if ice and a lot of Percocet last night.

My Ass Hurts

After 5 surgeries and years of on again off again pain I reached my breaking point. I am having so much pain at my ischial tuberosity that I am on the verge of a nervous breakdown. I've never gotten to this point but the pain has just worn me down and I'm becoming depressed, moody, and just unpleasant to be around. I emailed my OS last week and by Tuesday I hadn't heard back. My pre-op MRI stated that I have hamstring tendinosis and a tear, this fits my symptoms which is ass pain, specifically at the ischial tuberosity and pain with sitting. I was at PT which is about 50' from his office on Tuesday morning. I had tears in my eyes from the pain and downright frustration. I turned to my PT and said that I will give up my treatment time with him and I need him to go speak to my OS bc I can't take this anymore. I said tell him I need something Now. My preference is cortisone but I'll take what I can get. He quickly returned and said that my OS said I should do a PRP injection into the hamstring. They have had athletes who have had great success with this. So I am in the process of deciding who to have do it. The radiologist who has done all my other injections is looking into it for me, he needs to be able to get the PRP equipment. I called 2 physiatrists that my OS recommended in the meantime just to have something set up in case my radiologist can't do it. They want $1250. Upfront. Gulp!!! I really have no choice at this point bc I can't continue to not be able to sit comfortably.

On a positive note, I saw my shoulder OS and he is thrilled with how things look. I don't need to see him again, he said you don't have to keep coming back to tell me things are great! He told me to be careful for the next month bc it is still healing but after that no restrictions!

9 weeks postop

I have once again gone missing for a while. In my defense, I've had a rough few weeks which included at one point using a crutch and sling simultaneously! I will be 9 weeks out tomorrow from the hip surgery. I am making slow improvements each week, getting stronger and gaining endurance. My biggest and only complaint is that I still have butt pain. It is pain right at the ischial tuberosity that hurts the most with sitting. It also comes in with too much activity but nothing compares to the sitting pain. I am extremely frustrated by this and not sure what to do for it, what is causing it and what can be done to make it go away. I know my hamstring is torn but I can't imagine that I would have pain his intense for this long.
My shoulder could not be a smoother recovery. I did have a small issue in the beginning when my hand was going numb. I stopped using my sling which helped and it hasn't happened at all in a few days. The pain I have is isolated to the clavicle, nothing else hurts at all. Today I was able to use my over the range microwave with my operated arm! If only my hip would improve this quickly!

I am not back at work but plan on returning in 3 weeks, 3 days per week. I used to see patients on my off days but I won't be doing that for a while. What I find very hard is that I fatigue very quickly. My body obviously took a beating, twice, and I can't expect to recover from surgery like I did when I was 26 and had a simple scope. I will try to write more often and if there are any major breakthroughs with my ass pain I will definitely post!

6 Days Out From Shoulder Surgery

I have been terrible about blogging once again so please accept my apologies. My shoulder surgery was 6 days ago, it was supposed to be just a distal clavicle resection. When my OS got inside he found a type 3 acromion so also performed an acromioplasty and a subacromial decompression.
The first 4 days were incredibly difficult and painful. On day 5 things got a lot better, the pain has gone down, I was able to stop taking narcotics, and I can almost dress myself all by myself.
My hip has been amazing since I've been on painkillers again. The last time I had hip pain was in the PACU immediately after surgery. I actually asked for ice for my hip, not my shoulder initially.
I had a lot of issues in the PACU this time and did not get along with the nurse who was assigned to me. This was my only bad experience ever at the hospital. Unfortunately it was my 6th surgery, I have pretty much figured out what helps my pain and what doesn't, as well as what I can tolerate. She was extremely stingy with pain meds and at one point she gave me 2 Percocet which didn't do a whole lot for me. After 20 min I called her over and asked her to give me something else. She said she could give me ocycodone, I said no, I want Dilaudid. She told me the order the anesthesiologist had put in was expired, so I told her to go call him and get another order. In the end it took her 45 min to get my meds. In the meantime I was lying in bed crying from the pain. She did nothing to help me or show she cared. In fact, the only person who showed any concern was my hip OS' PA who moved the ice from my shoulder to my hip. I finally got dialaudid and my pain got better.
I spoke with my hip OS a lite bit as well. I told him I still have butt pain and I'm seeing him next week so he has time to figure out why!
Once things calmed down with the nurse, I said to her I have has 6 surgeries here, I know what works for me and what doesn't. Of course she had a reply to that and told me that she also knows what works and what doesn't. Later in the day I asked her when I was due for more pain meds, she said 9pm but I should wait until I got home to take more. Luckily her shift ended and I was assigned a new nurse. He was amazing and I had him last time as well. At 8:55 I was ready to leave finally and asked him for pain meds. Without missing a beat he said of course, it would be so helpful for the ride home.

I'm really not sure how my hip is since the pain is been having has been masked by the meds I'm

taking for my shoulder. I has my first outing last night without a crutch so thrilled. It's been 61/2 weeks on crutches.

Shoulder Surgery Tomorrow

The day I posted about my shoulder hurting I never thought would bring on a post with this title. But lo and behold here we are. Yes, I am still using one crutch and still struggling with my hip. I really hope I am making the wisest decision. I know that in about 3 months from now I will be very happy, it's hard to see that moment right now! I will update when I can!

Happy New Year Aetna Members

This was recently posted as a comment under an older post.


Looks like Aetna has finally reconsidered their policy! Aetna posted this Clinical Policy Bulletin on 12/30/11 regarding
"Femoro-Acetabular Surgery for Hip Impingement Syndrome".

http://www.aetna.com/cpb/medical/data/700_799/0736.html

"Aetna considers femoro-acetabular surgery, open or arthroscopic, for the treatment of hip impingement syndrome medically necessary for persons who fulfil all the following criteria:

* Diagnosis of definite femoro-acetabular impingement defined by appropriate investigations, X-rays, MRI and CT scans.
* Severe symptoms typical of FAI and compromised function, with duration of at least six months where diagnosis of FAI has been made as above.
* Failure to respond to all available conservative treatment options including activity modification, pharmacological intervention and physiotherapy.
* Aged between 18 and 50 years (clinical experience has shown that these patients are likely to gain the greatest benefit).
* Absence of advanced osteoarthritis change on preoperative Xray (Tonnis grade 2 or more) or severe cartilage injury (Outerbridge grade III or IV).
* Absence of joint space narrowing on plain radiograph of the pelvis that is less than 2 mm wide anywhere along the sourcil.
* Member does not have generalised joint laxity especially in diseases connected with hypermobility of the joints, such as Marfan syndrome and Ehlers-Danlos syndrome.
* Member does not have osteogenesis imperfecta.

Surgery for FAI impingement is considered experimental and investigational for all other indications."

26 days post-op

I feel the need to apologize to my readers who have come to expect detailed accounts of my recoveries and experiences. I guess with 3 kids aged 7,6 and almost 3, I just don't have the time. Keep in mind that at my first surgery I had 2 kids aged 1 and 2, yes, they are busy ages as well but there was no homework, after school classes, projects etc. 
At 26 days things are going a lot slower than I had hoped. I am still on 2 crutches, desperately  trying to get down to 1. I am using my brace when outside the house and trying to wean off of meds. I am still on Lyrica 2x/day for nerve pain. It is a lot better and I am trying to go to 1. I had to stop Mobic because I went into a horrible Crohns flare up. I occasionally take 1/2 Percocet at night to hep me sleep. I have a lot of pain in 2 out of 3 of my incisions, I'm not really sure why. They look good, have closed up but have a hard, marble like piece of scar tissue under the surface. I have been to PT a few times but am in miami now for 10 days so won't be going until I get home. 
PT until now has included quad sets, glut sets, bridges, prone quad/abs/glute sets, hand heel rocks, bike, gentle shoulder theraband exercises with 25/75 weight bearing. At my last session we added stool rotations but at my own discretion I have stopped them. ROM is not my goal at this point and I don't want to push it. I am concerned that I already have regained too much ER so I don't need  more. 
I am extremely annoyed bc I still have posterior hip pain and pain with sitting and quite frankly it is a pain in the ass. I haven't addressed it w my OS as I just want to give it more time and there isn't anything he can do abt it. If I stay in bed I feel pretty good but when I do any amount of activity I get pain, mostly in the area of the incisions and occasionally it will move medially to the groin. I am using Lidoderm patches in that area, idk if they help or not though. 
I am flying home alone with the 3 kids so I need to be much better in 8 days! Keeping my fingers crossed!

Outing to Jks 6th Birthday Party

Op Report #5

Op report

Preliminary diagnosis:
1. Right hip instability with labral deficiency 
2. Capsular tear
3. Ligamentum teres tear
4. Loose body

Post operative diagnosis:
1. Right hip instability with labral deficiency 
2. Capsular tear
3. Ligamentum teres tear
4. Loose body

Name of operation:
1. Right hip arthroscopy
2. Labral repair:augmentation using semitendinosus
3. Synovectomy
4. Removal of loose bodies
5. Debridement of ligamentum teres tear
6. Capsular shift procedure 

Indications:
The patient suffered from persistent right hip pain and instability secondary to ligamentum teres rupture, iliofemotal ligament and capsular tear, loose fragmentation and labral deficiency. She failed non operative measures. She had clinical, radiographic, and diagnostic studies consistent with this pathology. Given her persistent pain and lack of improvement with non operative measures, she was indicated for a right hip arthroscopy and associated procedures. 

Procedure:
After the patient was correctly identifies in the holding area, she was brought to the operating room. Spinal epidural anesthesia was administered  She was placed in a supine position on the traction table and approximately 10mm of distraction were achieved across the femeroacetabular joint. The right hip was then prepped and draped in a standard surgical fashion. The lateral portal was established under fluoroscopic guidance using the seldinger technique. Then, a mid anterior and a distal anterolateral accessory portal were established. The distal anterolateral  accessory portal was established as a separate incision for removal of loose fragments and also for the placement of the labral augmentation. 

Initial evaluation of the central compartment demonstrated the cartilage surfaces to be in good condition. There was scarring and deficiency of the labrum between 12:00and 3:00. There was capsular attenuation anteriorly. There was a ligamentum teres tear with chondral and osseous loose fragmentation and subtle ligamentum teres tear. At this point the ligamentum teres Debridement was performed with removal of loose fragments, the largest measured approximately 5mm and this required an anterolateral accessory portal for removal. The scar tissue and adhesions were then removed from the area of labral deficiency and the edges of the acetabular rim were clearly demarcated. A good bed of bleeding bone was prepared between 12:00 and 3:00. 

A semitendinosus allograft tendon was prepared on the back table and was inserted into the defect using multiple 1.4mm PEEK anchors. A total of 7 anchors were used to secure the graft in position and then side to side suturing of the labrum was performed to the native labrum anterior-inferiorly and posterior -superiorly.  The labrum was then contoured to a normal anterior-inferior and normal posterior-superior labrum. 

At the completion of the labral augmentation and the labral repair, removal of loose bodies, synovectomy and removal of scar tissue, all debris was evacuated from the central compartment. 

The scope was then placed in the peripheral compartment, after the release of the traction, using the mid anterior portal.  A capsular shift procedure was performed removing the distal aspect of the iliofemoral ligament to the proximal fragment using four #2 Orthocord sutures. Once this was completed and no further pathology was identified, the instruments were removed from the hip joint and 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 and sterile dressings were applied. 

The patient was awakened from anesthesia and was brought to the PACU having tolerated the procedure without complications. 

Post op Appointment x 5

I saw my OS yesterday, he is extremely happy with the way I am looking. I actually think he was pleasantly surprised to see me looking so much better than last week. He showed me the pics from my surgery (op report to follow). He is also really happy that my joint and cartilage look so good, despite having been in there 4 times already. He created me a new labrum with a semitendinosis allograft. At this point the most important thing is to protect the graft. I have to avoid extreme flexion and external rotation. At this time he wants me on crutches another 2 weeks and wearing my brace another 2 weeks.

He is also on board with me taking care of my shoulder in a few weeks. He thinks it makes sense to just get it all taken care of at once. So I will have the shoulder surgery on January 9th.

Things are coming along slowly. But I think that slow And steady is the way to go with this surgery.

Having a Meltdown

Today has really been a challenging day for me. I woke up with all my nerve pain all over again. I know it's only been a week since surgery, and I don't know what I really expected, and I know in the past I have always gone through a rough patch. On top of this I can't get my mind off of the upcoming shoulder surgery. I had a long talk abt it with another hip friend last night, what she said was extremely helpful. She said no one else is going to understand. No one else gets it. You have to ignore the stupid comments and get over it. It's good advice for any of us in these situations. And of course, the worst possible comment is "you must like having surgery"

I texted my PT early today bc I am freaking out about the nerve pain coming back. His suggestion was avoid ankle pumps, avoid prone knee bend and go back on Lyrica. I am really not a fan of Lyrica and was thrilled when my OS told me I could come off of it. I guess I have to suck it up and stick with it bc my pain was great while I was on it

PT day 1

So today was my first day of PT. Let me backtrack a little and tell you how my week has gone. Since I got home from the hospital, I have been incredibly dizzy and lightheaded all the time. I spent the majority of my day in bed with ice and my CPM. I was having a lot of nerve pain and having a lot of trouble getting into a comfortable position. On Sunday my OS and I emailed a little abt what to do. He wanted me on some sort of blood thinner to prevent blood clots since I was so immobile. He also wanted me on Lyrica for the nerve pain.

My husband didn't like the way I looked on Sunday so he called my brother in law who is a doctor to come over. He said the Percocet was dropping my heart rate too much which is why I was so dizzy.

I got off of the Percocet by Tuesday but it seems Lyrica also makes me dizzy.

PT went ok. My ROM is good and my strength too. My OS came by to see how I was doing since it has not really been smooth sailing for me. I told him the nerve pain is a lot better and I asked if I could stop Lyrica. He said yes so I asked for Lidoderm patches for the small areas of nerve pain.

My PT put me on a short crank bike but I developed groin pain after a few minutes. I did quad sets and glute sets and then iced.

I also had the opportunity to visit another hip friend in the hospital who had an FO yesterday.

I am now having groin and butt pain. I guess I overdid it today. I ended up taking half of a Percocet and hopefully I will wake up pain free tomorrow.

My Little Helper

Zk rehabbing for me!

What My Day Consists Of

Apparently nerve pain is worse than surgical pain, and I have a lot of it. My OS prescribed Lyrica and Mobic in hopes that it will go away. In the meantime, I gave a lot of trouble getting into a comfortable position. CPM is now my best friend!

Surgery#5........ Done!

My surgery went well. My OS found exactly what he expected, a torn ligamentum teres, small labrum and very stretched out capsule. He debrided the ligament, augmented my labrum with an allograft and re-tightened the capsule.
The surgery was long and with prolonged traction time. The total time in the OR was about 4 hours and total traction time was 2 hours. My OS never keeps ppl in traction longer thx 1 hour. He needed the extra time to place the allograft down perfectly. He didn't think it would cause major issues given the instability that I have, there wasn't very much resistance when i was in traction.

I had a lot of trouble in the PACU between pain control and being dizzy so I spent the night in the hospital.
The traction is causing my leg to feel tingly and heavy and hard to move/walk. This is my 5th scope and I have never really used the hip brace but I am finding it to be extremely helpful in supporting my leg. I am also getting my money's worth w the cpm, I stay in it all day, even if it's off. I find the position comfortable. My OS doesn't want me in that position all day bc he's nervous I'll develop a contracture. If the leg issues r not better by Monday he will put me on Lyrica.
I think I covered the basics.

From what I recall, the report from my OS was that the looked great despite everything that it has been through. He also wants me to be extremely careful and mentioned something crazy about being on crutches for 4 weeks. I see my PT on Wed for my first visit so we'll see what he thinks.

Surgery is still going on

for all you interested folks, susie is still in surgery. she's going on almost 3 hours now. here's a little pic of her walking into the or.

speak to you all later

- the most supportive husband susie has ;)

Surgery #5...Tomorrow

I am having minor panic attacks but I should be ok! took Valium this morning and will probably take another one tonight. I am also going to try to have an acupuncture session tonight to help calm my nerves! Will keep you posted.

Fighting for out of network reimbursement

Its funny how time flies and how little free time I have. Over the past week I have finally been able to make some real progress on my appeal to UHC for the amount that I was reimbursed for my out of network expenes. this was for the hand surgeon in August and my hip second opinion in August as well. I'll give you a hint of how things went...I did not get 70% of what was billed by the doctor as UHC makes you think you will. Check out this link to see what really has been going on with UHC concerning out of network reimbursement.

http://www.ama-assn.org/resources/doc/psa/ama-uhc-lawsuit.pdf

PS- In summary, the resolution of the class action litigation provides for UHC to pay a total of $350 million to fund the settlement for health plan members and out-of-network providers related to out-of-network services from March 15, 1994 through November 18, 2009. The settlement will be entirely funded by UHC and no recovery of funds will be sought from any self-funded customer plans.

T-10 days

I can't believe my surgery date is just around the corner, I feel like I scheduled this ages ago, but yet here we are. I am eerily calm these past few days, I think once the whole snafu with the blood work was worked out I felt better. There was another issue with the letter form my gsatro, my OS office said they think it should be within 30 days of surgery. It is 33 days before surgery. I am not getting another one, this is going to have to be good enough, I am putting my foot down. They told me its possible that my surgery will be cancelled if the anesthesiologist has an issue, I am willing to take that chance! So the countdown begins now!

Aetna's policy #0736 is UNFAIR and UNETHICAL

As many of you can attest to firsthand, Aetna is still not covering FAI surgery and still calling it "experimental", despite hundreds of peer reviewed articles that say otherwise. Although I do not use Aetna, I feel for all of you who do, and are not able to have your surgery paid for. Below is a link to a petition started by fellow FAI sufferer Ryan. Please take a few moments to look over the information and sign the petition if you agree.

http://www.change.org/petitions/aetnas-policy-0736-is-unfair-and-unethical

Sodium

Well, the good news is that I was indeed dehydrated, my new labs showed that my sodium levels are normal!!! So, the good news is that I don't have some crazy hormonal issue, the bad news is that I have no excuse to get out of this surgery!! 17 days to go!

The Stress is Killing Me

I am so sorry that I have not been keeping you updated with what is going on with my hip, but since we are 3 weeks away from surgery #5, I figured I'd better catch you up.

A few weeks ago, my OS office told me they would need a letter from my gastroenterologist saying it is ok for me to undergo a "low risk" surgery, since I have Crohn's disease. Keep in mind that they have never asked for that before. Fine, I took care of it. My gastro also wanted to run blood tests. As an added side note, the week I went to see him I was really sick and completly abusing Mucinex and Robitussin! I emailed him for the results of my bloodwork and was rewarded with this message: "your sodium level is too high. You cannot have surgery with these levels. You are probably dehydrated, drink lots of water and we will do the test again".

You can imagine that that email did not help my stress levels in the slightest bit. I was also leaving on vacation the next day, so I had all the time in the world to worry but no time to get the test redone!

Today I finally went for the blood work, I did notice that the first time my blood came out sluggishly, probably due to dehydration. Today it flowed nicely! Keep your fingers crossed that it is ok this time!

Vacation is a wonderful time to relax, rest, and de-stress. I did all of those. unfortunately there is absolutely no carry-over. When you get home all the shit you left is still there for you to deal with.

Today was also my second pre-op appointment. I was hoping that this appointment would calm my nerves but it didn't.

The message I left with is that my OS is really confident about this surgery (apparently he hasn't always been this confident in the past!) and a lot of my questions will not be able to be answered fully until he actually goes in, sees the damage, and repairs it. His repair will also dictate a lot in terms of how the rehab will go.

So I was hoping for a lot of concrete answers, and a little bit of inner peace. I got none. I did get to try on the new hip brace he is using and decided to get one. He also wants me using the CPM machine for 2 weeks post-op.

I wake up in a mini panic attack every morning. Dec 1 can't get here fast enough!

Shoulder Update

I was able to get an appointment today for my shoulder, luckily, as I don't think I could have gone on for one more day with that pain. My shoulder OS was not happy to re-inject me at all :-( He was worried about fat atrophy and warned me that if ti happened I would not be happy. I explained that I am having hip surgery on 12/1 and cannot address shoulder until after that. I also added that it is hard for me to work and function at the moment given the pain. He thinks I need to get it taken care of, possibly before hip. Given my current mental and emotional state regarding my hip, that is not even up for discussion. He asked me how often I use my hip to manipulate a patient!!! Good point, but I'm still not even considering that. I think I am probably going to schedule it about 5 weeks after hip surgery, I know it is crazy but I need to get everything taken care of once and for all.

I spoke to my PT since I was at the hospital and we discussed my upcoming hip surgery and I wanted his take on the shoulder. He agrees that it needs to be taken care of and thinks 5 weeks after is not at all unreasonable.

So...hip then shoulder.......HEELLLPPP!

Why Why Why

Aside from my ridiculous, drawn out hip issues, I think I have mentioned that I also have a shoulder issue. I have had 2 cortisone injections, the each last about 6 months. I am at that 6 month mark right now and in excruciating pain. the last time I saw my shoulder doc he warned me that he won't keep injecting me forever, eventually I will have to "address" the issue. "Addressing" the issue obviously means surgery, which at this point is just plain funny to me, I mean, how many surgeries can one person have in such a short amount of time?

At the same time though, how much pain can I deal with in such a short amount of time? People have suggested that I have my shoulder and hip done at the same time which must be just about the dumbest thing anyone could say. But, I am seriously considering doing it 4 or 5 weeks later...the pain is that bad. I have an appointment with my shoulder doc in about a month but there is no way I can wait that long. I am going to call today and beg and plead for an appointment tomorrow, I need an injection just to work, sleep, take care of my kids etc. And I will be open to discussing (not scheduling) surgery...I can't keep living like this.

On a brighter note, I have had to pop Advil like candy just to function with this shoulder pain and my hip is reaping the benefits!!!

The Pre-op Appointment

I field a lot of questions from fellow hip pain sufferers, whether it be about surgeons, surgeries, insurance questions etc. I am more than happy to help since I know first hand what it is like to be alone and afraid and not have the answers. The only question that often times annoys me is "what should I ask my surgeon"? I really can't answer that, you need to ask him the questions that YOU have about your hip. What may be important to me may not be important to you and vice versa. With that being said, I went to my appointment with a LONG list of questions for my OS.

I needed this to help calm me down and get all of my questions answered. I also needed this to make it more "real" for me! It went really well and he answered a lot of my questions before I even asked them! Its good that we can still joke around about things bc it makes difficult decisions a lot easier! When I told him that I need the post-op/ rehab to be perfect bc this is the 5th time we are having this conversation, he jokingly said "No, its the 4th time, don't exaggerate!!"

So below are the questions I had written down to ask him followed by his answer. I also scheduled another appt a few weeks before the surgery bc I'm sure I will have more questions. If u think I left something out plz let me know and I will bring it up next time.




1)What r we calling the procedure?
Labral reconstruction
2)How long will the procedure take?
Forgot to ask!
3)Will I be able to go home that day?
Yes
4)What will u be using for the allograft for the labrum and the capsule?
Labrum- sometimes uses a rectus femoris autograft but will use semitendinosus allograft
Capsule- achilles allograft with synthetic scaffold
5)How do u secure the allograft?
The same way as a labral repair- with anchors and sutures + scraping bone to make it bleed a little
6)What exactly is the scaffold that u want to use for the capsule?
He used a name but I forgot! It has been used for rotator cuffs for abt 10 years
7)I really think its impt for the capsule to scar down- brace? For how long?
Not the philippon brace bc its not too effective, not hip dislocation brace bc I will be miserable- he found a different brace at bauerfiend, looks like philippon brace but "better", also 1 boot @ night to prevent rotation
8)What will my WB status be and for how long? Do we need to protect the graft?
Same as labral repair, labrum is not load bearing and only stressed in extreme ROM, so 2 weeks of 20lbs wb and mostly to my comfort
9)How long until I can drive?
When I am off narcotics
10)My hamstring tendon has a chronic tear, r u going to address it?
Prob not, it tends to tear with hip pain bc you post tilt your pelvis and it becomes shortened and can tear and in severe cases rupture. He may put in PRP
11)Sub spine impingement- do I have it?
Prob don't have it but will double check- doesn't really matter bc the part he will be scraping down to attach the allograft is where he would shave down
12)What do I do abt PT? I only want P...does he only see professional athletes these days :-)
Yes- professional athletes and me!!! Absolutely, he wouldn't have me go to anyone but P
13)Shoulder- when to get cortisone injection? I already had 2, shoulder OS said only one more- so do I get it now? Or will my shoulder be worse on crutches, should I save it for then? Or can I convince shoulder OS to inject 4x?
It will prob hurt on crutches but don't worry, I can inject it for u a 4th time but don't tell him :-)
14)Pre-op Class, do I have to go?
Yeah, if u want to teach it!!
15)Pre-op online questionnaire do I fill it out?

Yes, its like a report card on me! Hopefully one day ur score can be high!!
16)Post op appts- I want to see my OS at suture removal- receptionist said I can only see nurse- I was pissed!
I can see OS

I Scheduled It...AAAHHHHHH

I was at work today, minding my own business, and my cell phone rang. It was my OS' surgical scheduler. And in a peppy voice, she said "Hi, I'm calling to schedule your surgery", as nonchalantly as someone would call and ask what I would like to order for lunch. I was a little caught off guard, but managed to hold it together long enough to get this done!

So, surgery #5 is scheduled for....drum roll please....December 1, 2011

Let the countdown begin! (anyone have a Xanax)

More Problems With UHC

I know a lot of you are drawn to my blog because of the battles I had with United Healthcare at the time of my last surgery. I hope my blog has been helpful to you. Now I am back in the trenches with them and extremely mad. This time, it is not about my hip, but it is about reimbursement. If anyone can share some advice on this, I would be grateful.
About a month ago, I had a bad infection on my hand that required me to go see a hand surgeon. I needed to be seen right away and ended up going to someone out of network who saw me that day. I paid upfront, she did a procedure in the office, and my hand got better. United Healthcare is allowing a fraction of the amount I paid the surgeon and reimbursing me very very little. Has anyone ever dealt with this before? I have to appeal this now, but don't have as much time as I did with the last appeal since I am currently working, and not home recovering from surgery.
Please comment here for others to see as well, or email me suzq613@aol.com

The Plan...Finally

So after 6 months of pain, x-rays, MRIs, injections, talk of alternative therapies and talk of crazy surgeries, I think I have found my happy medium. I spoke with my OS and this is what we decided.

First of all, he is not upset at all that I went to see OS2, he said he prob should have sent me himself.
The only reason he has suggested open surgery for me is bc he feels that after 3 failed scopes, we prob should try something different. But at the same time, the scopes were all done for different reasons. Other than having to send a young patient for a hip replacement, one of the things he really hates is unnecessary open surgery. He told me there is nothing he cannot do arthroscopically that can be done with an open surgery. I think this was one of my happier moments of the past 6 months!
He said usually, in a scope, he will use an autograft from the capsule and rectus femoris to augment the labrum. Since my capsule is already compromised he will do it with an allograft. Since my capsule has already been repaired once and failed again, he will use allograft tissue there as well, he will also use a scaffold to strengthen it (this is apparently done often in shoulder surgery).

We discussed the ligamentum teres and my wishes for a new one! He said that u don't need it unless ur capsule is compromised. My thought is if ur already scoping me, just do it. He said it is EXTREMELY experimental surgery, they still don't know a lot about the biomechanics of it, and he wouldn't know how tight to make it, and he thinks I will hate it. He said right now I am having trouble bc the ligamentum teres is torn and getting caught. Once he debrides it and fixes the capsule, I will be happy again.

I am concerned about the post-op period, since I tend to be lax with the brace and weight bearing. I asked him to put me into a very restrictive brace post-op. He said absolutely, he will have me fitted for a hip dislocation brace and have it set to slight IR, and not allow more than 30' ER for the first 6 weeks. He warned me that I will hate it!! I'd rather be miserable for 6 weeks than be back to where I am right now in another 2 years.

I asked if he's ever scoped someone's hip 4 times, he said never his own patients, other ppls screw ups yes, but never his!

So I have to let him know when I want to do this, so he can plan accordingly, get his allografts and scaffolds together!
Even though it will be my 5th surgery, I am so happy that we have found a way to do it that doesn't make me want to throw up every time I think about it!

The Second Opinion

Surprisingly, I got a call back from the second opinion doctor's office on Monday, and they were able to see me on Wednesday due to a cancellation. I was so happy but a little nervous because I was not really prepared yet. To simplify things, he will be referred to as OS2. OS2 took about 30 minutes to go over my films, re-checked all of my angles on my x-rays, and read my latest MRI. He was wonderful, I explained my long history to him. He did a clinical exam. He found that I had almost no IR and about 90' of hip flexion (I was having a really bad day yesterday). The test he did for instability was positive, but not as positive as he would like it to be. He would have liked me to have jumped off the table with that. I dont know what to think, I don't think I have "instability", I think it is "micro-instability", so I am not sure what that test should show. OS2 then suggested that it would probably be a good idea to call my OS...uh oh!!!! This was a 'top secret' appointment. I explained to him that my OS hadn't sent me, and didn't know I was here. He assured me that he wouldn't be upset, that he would actually be relieved to have help with this complicated case. I told him that what I wanted to do was hear what he thought and what he proposed, and then decide if he should call my OS. He agreed to that!

He thinks I have a loose body in the joint. He does not think that my labrum is too small at this point and he is recommending a scope to look around and try to fix things. He thinks an open dislocation is a huge deal and thinks that by trying a scope I am not burning any bridges, and if there is a possibility that I can be helped with a much smaller surgery, then he sees no reason to try it.

I decided to let him call my OS and discuss. And he did, while I waited!! They spoke for a while, and I patiently waited. When they finally got off the phone, OS2 called me into the room that he was in to discuss.

He said my OS agreed to do a scope, he wasn't too keen on the idea since it failed so many times, but OS2 pointed out that my left hip is awesome! So I should have scope potential! OS2 said that he still doesn't think my labrum is too small or should be causing me issues, but my OS fought him on that and said he has been in my hip 3 times and knows what it looks like and it is definitely too small. So he will put in an allograft to create a new labrum, re-repair the capsule, and...here is the kicker....they will do it together!!! OMG...I was laughing so hard, but I was so happy. I've never been happier being told I need surgery, but a scope vs open.....I am thrilled!!!

What A Long Journey This Has Been

I definitely owe everyone a quick summary of what has been going on lately with my hip, but today is my 10th wedding anniversary, and all I can think of is that I have been dealing with my hip for half of my married life. It is making me very depressed.

To quickly summarize what has been going on, my OS really would like to avoid operating on me, for the 5th time. I can't blame him! So he is proposing we try something called ARP wave therapy. No one really can tell me what it is, other than a certain type of electrical stimulation. No one really knows if it will work but it can't hurt, so why not. I will hopefully know more about it in the next week.

In the meantime, I have decided to get a second opinion from another surgeon, an unbiased, no baggage, black and white, second opinion. I think that my OS and I have too much history for either of us to make the right decision at this point. If in the end I do need surgery, I will probably go with my OS, but I would like someone else to look at my films and tell me what they think. Someone who doesn't know me, and frankly, doesn't care if I have more surgery or not. The appointment is not set up yet, I left a message for his office staff.

In the meantime, I go through good days and bad days, and of course, this makes the process so much more difficult. If I always had good days, well, you wouldn't be reading about this. If I only had bad days, I wouldn't question anything. Its the good and bad that make me doubt everything, make me question everything, and quite frankly, are driving me crazy. There is no rhyme or reason at times either as to why I feel the way I do. I wore heels for a few hours yesterday without a bit of pain. I can actually usually wear heels and my hip doesn't hurt. It does feel awful in the sense that I don't walk well with them, I feel unstable, and my feet hurt!! I actually often have a sense of instability in my right hip, I try to avoid extending it fully when I walk by doing a strange rotation thing with my pelvis. Very strange!!

So the waiting game continues. I am waiting to hear more about the ARP wave, waiting to see if it works, waiting to get an appointment from my second opinion, and waiting to see if this will all go away, just as quickly as it came on!!!

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!!

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.

Impression:
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.

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 (www.hss.edu/hippain) 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.