The HSS Operative Record
Patient Name: Me Date: 17 September 2007
Attending Surgeon: Dr. Kelly
Operating Surgeon: Dr. Kelly
Preliminary Diagnosis: Right hip labral tear with snapping psoas, Synovitis, Combines Cam and Pincer Impingement
Postoperative Diagnosis: Same
Name of Operation: Right hip arthroscopy, Labral tear, debridement, synovectomy, partial psoas and acetabular rim decompression with labral re-fixation and a cam decompression.
Anesthesia: spinal
Estimated blood loss: less than 20cc
Inoperative fluids: one liter of ringer's lactate
Drains: none
Indications: The patient is a 37 year-old female with progressive right hip pain, right worse than left. The patient had combined Cam and Pincer impingement with snapping psoas and inflammation. The patient had persistent symptoms despite non-operative measures and given these persistent symptoms, the patient was indicated for right-hip arthroscopy and associated procedures.
Procedure:
The patient was correctly identified in the Holding Area and the patient was brought to the Operating Room. The spinal anesthesia was administered. The patient was placed in supine position and approximately 10mm of distraction was achieved from the acetabular joint. The right hip was prepped and draped in the standard surgical fashion.
The lateral portal was established under fluoroscopic guidance using the Seldinger technique. A distal lateral accessory portal and a posterior portal were both established under direct visualization. The arthroscopic examination of the central compartment demonstrated a labral tear anteriorly with a significant synovitis with areas of early delamination of the anterior and superior cartilage consistent with Cam impingment and crushing of the synovium and labrum anterior, superiorly consistent with Pincer impingement. There was also extensive tension on the psoas anteriorly consistent with psoas impingement.
The cartilage on the femoral head was otherwise in good condition. The ligamentum teres was in good condition. The patient had a (looks like a word was whited out) injury posteriorly. At this point, a wide synovectomy was performed using the Tac-radio frequency probe starting posteriorly and working our way anteriorly. The labrum in the front where it was torn was debrided gently preserving the majority of the labrum. A capsular cut was then made connecting the anterior and anterolateral portals for elevation of the capsular tissue off the acetabular rim lesion.
The acetabular rim lesion was identified and then a 5.5 mm high speed bur was used to recontour the acetabular rim. The fluroscopy confirmed the appropriate resection. At the completion of the acetabular rim decompression, the psoas was partially released over the front of the joint where it appeared to be compressing the labrum anteriorly. The labrum after it was debrided was stabilized through the transition zone cartilage using the radio frequency probe but no suture anchors were required.
All cartilaginous loose debris was evacuated from the central compartment at the completion of the synovectomy. A partial psoas release, acetabular rim decompression and labral debridement. The scope was placed in the peripheral compartment as the traction was released. The hemi hip joint was placed back in the socket. A Cam lesion was identified and then a Cam decompression was performed using fluoroscopic guidance to confirm the appropriate resection.
The dynamic arthroscopy was performed demonstrating the absence of any residual impingement. At the completion of the Cam decompression, no further pathology was identified. The instruments were removed from the joint and the arthroscopic portals were closed with 3-0 nylon sutures and a marcaine cocktail was placed into the joint. The wounds were cleaned, dried. Sterile dressings were applied. The patient was awakened from anesthesia and brought to the Post Anesthesia Care Unit having tolerated the procedures well.
Showing posts with label labral tears. Show all posts
Showing posts with label labral tears. Show all posts
07 October, 2007
16 August, 2007
Answers
The doctors PA rang me and we were on the phone for half an hour! I truly appreciate all of her time and patience on the phone. I did have quite a list and did get some answers. I tried to write down everything but it was hard so here are the q's and what her answers were (I've made them short and to the point though she was quite specific)...
In general she said the surgery should help with the pain, and also asked if I had ever been tested for a collagen disorder (not that I am aware). She is going to check w/ the dr to see if he thought I should and to recommend a rheumatologist that could do the testing. My main issue she said is the laxity I have.
Will these procedures help to “tighten” the tissues and muscles supporting the joint so that it will not be so lax? Will they help my “hyper mobility” in this joint? to an extent it will help but you cannot cure laxity.
What could have caused the labral tear? lax patients are more prone over time to develop tears. she said b/c of my laxity i can move my joints into positions that don't seem over extended for me, but over time it could wear on them.
Is FAI degenerative? yes
Is the underlying femoral neck misshapen and also causing the impingement or a result of the impingement? my FAI is believed to be mild, but I still have impingement. they can shave down the bones if they need to and get rid of any bony abnormality
For the PSOAS release, what is exactly done? Is it the muscle or tendon that is released? Would ART help rather than surgery for it? they release (cut) the tendon portion and only 10% of muscle, the part that is snapping over the acetabulum. Patients tend to do well and not snap after, but b/c of my laxity it is tricky b/c it is a stabilizer for my joint. the dr will decide in surgery, but if it is done i can expect to be weaker than patients that don't have laxity, and they will work on that in rehab. The ART is not recommended for me, again b/c of the laxity, and it would only be a temporary fix, so surgery in my situation is the way to go.
Is my IT band tight? Do you anticipate having to do a release for me? Would you lengthen the tendon or remove a section? my IT band is probably tight if it snaps, which it does. they will check this in surgery as well and if necessary will release it with a knife cut through the IT band, lengthening it.
Re: the trochanteric bursitis debridement, are you definitely removing the bursa or will it depend on what it looks like when you go in? if inflamed they will remove it, and there is a pretty good chance it will be removed. she said i should be ok w/o it because now it is only causing pain from inflammation as it's located between the bone and IT band.
Can you tell if I have any large chondral lesions? they can't really tell this on the MRI so will observe when in there. This is the articular cartilage (the type you have in your knee that is affected when you have chondromalacia), which is different from the labrum which is more like a meniscus cartilage.
Could the PT have made the FAI worse? yes it could hurt the tear, not the FAI, if the pt has been really working you hard and moving leg in extreme positions. i haven't been doing anything extreme so hopefully it didn't make it worse. basically so long as you listen to the pain and not do what causes you pain - though at this point walking and sitting cause pain!
What is the success rate you have had with these procedures? hard to say in a number value, but she feels most people who had a labral tear were glad they had the surgery, but it also depends on what caused the tear. The five categories are laxity, degenerative (arthritis), trauma, psoas and fai. She feels that I am in the laxity category which is one of the worst to be in, and that I will most likely not have 100% improvement, maybe 80%. At this point I'll take the 80! Also, b/c of my situation I really have no choice but to do surgery b/c w/ laxity the options are limited. I am not the best candidate, but at the same time forced into it b/c of the lack of other options. And this surprises me why?
How long for a full recovery, on average? four to six months, but up to 12 months.
After recovery, are there any restrictions? Can I ever ride again? granted the thought of riding at the moment is extremely unappealing, i would eventually like to be able to do this, and happily, she said that they do have patients that have gone back to riding, so after about 4 mos it should be fine. I'll wait longer but glad that i will be allowed to. on the other had, she said riding probably didn't help the situation, and though i haven't done it very much in the last few years, i did it a lot when i was younger, so i could have affected what is happening now.
What are the chances the surgery will need to be repeated? Dr. Kelly does not like to do surgery again, unless, in some cases, it's a revision b/c the tear did not stay repaired after they repaired it, as opposed to debridement it.
Does this surgery increase the chance of needing a hip replacement in the future? there's no data out there b/c this procedure is relatively new. A hip replacement would only help if there was an arthritic condition.
In general she said the surgery should help with the pain, and also asked if I had ever been tested for a collagen disorder (not that I am aware). She is going to check w/ the dr to see if he thought I should and to recommend a rheumatologist that could do the testing. My main issue she said is the laxity I have.
Will these procedures help to “tighten” the tissues and muscles supporting the joint so that it will not be so lax? Will they help my “hyper mobility” in this joint? to an extent it will help but you cannot cure laxity.
What could have caused the labral tear? lax patients are more prone over time to develop tears. she said b/c of my laxity i can move my joints into positions that don't seem over extended for me, but over time it could wear on them.
Is FAI degenerative? yes
Is the underlying femoral neck misshapen and also causing the impingement or a result of the impingement? my FAI is believed to be mild, but I still have impingement. they can shave down the bones if they need to and get rid of any bony abnormality
For the PSOAS release, what is exactly done? Is it the muscle or tendon that is released? Would ART help rather than surgery for it? they release (cut) the tendon portion and only 10% of muscle, the part that is snapping over the acetabulum. Patients tend to do well and not snap after, but b/c of my laxity it is tricky b/c it is a stabilizer for my joint. the dr will decide in surgery, but if it is done i can expect to be weaker than patients that don't have laxity, and they will work on that in rehab. The ART is not recommended for me, again b/c of the laxity, and it would only be a temporary fix, so surgery in my situation is the way to go.
Is my IT band tight? Do you anticipate having to do a release for me? Would you lengthen the tendon or remove a section? my IT band is probably tight if it snaps, which it does. they will check this in surgery as well and if necessary will release it with a knife cut through the IT band, lengthening it.
Re: the trochanteric bursitis debridement, are you definitely removing the bursa or will it depend on what it looks like when you go in? if inflamed they will remove it, and there is a pretty good chance it will be removed. she said i should be ok w/o it because now it is only causing pain from inflammation as it's located between the bone and IT band.
Can you tell if I have any large chondral lesions? they can't really tell this on the MRI so will observe when in there. This is the articular cartilage (the type you have in your knee that is affected when you have chondromalacia), which is different from the labrum which is more like a meniscus cartilage.
Could the PT have made the FAI worse? yes it could hurt the tear, not the FAI, if the pt has been really working you hard and moving leg in extreme positions. i haven't been doing anything extreme so hopefully it didn't make it worse. basically so long as you listen to the pain and not do what causes you pain - though at this point walking and sitting cause pain!
What is the success rate you have had with these procedures? hard to say in a number value, but she feels most people who had a labral tear were glad they had the surgery, but it also depends on what caused the tear. The five categories are laxity, degenerative (arthritis), trauma, psoas and fai. She feels that I am in the laxity category which is one of the worst to be in, and that I will most likely not have 100% improvement, maybe 80%. At this point I'll take the 80! Also, b/c of my situation I really have no choice but to do surgery b/c w/ laxity the options are limited. I am not the best candidate, but at the same time forced into it b/c of the lack of other options. And this surprises me why?
How long for a full recovery, on average? four to six months, but up to 12 months.
After recovery, are there any restrictions? Can I ever ride again? granted the thought of riding at the moment is extremely unappealing, i would eventually like to be able to do this, and happily, she said that they do have patients that have gone back to riding, so after about 4 mos it should be fine. I'll wait longer but glad that i will be allowed to. on the other had, she said riding probably didn't help the situation, and though i haven't done it very much in the last few years, i did it a lot when i was younger, so i could have affected what is happening now.
What are the chances the surgery will need to be repeated? Dr. Kelly does not like to do surgery again, unless, in some cases, it's a revision b/c the tear did not stay repaired after they repaired it, as opposed to debridement it.
Does this surgery increase the chance of needing a hip replacement in the future? there's no data out there b/c this procedure is relatively new. A hip replacement would only help if there was an arthritic condition.
30 July, 2007
Background
OK, so I guess I should give some background as to how I got here though that seems to be the big question. How did I get here? I never had an accident or injury to my hip. I do not do heavy duty sports either. So how is it my hip decided to fall apart on me?
Well, my brief medical history is as follow:
age 14 - diagnosed with bilateral chondromalacia in my knees
age 18 - right wrist started to hurt, A LOT! went to 7 dr's in 3 years, most of whom had no clue and one who even told me to call him instead of my mother when it hurt, b/c he was convinced it was in my head.
age 20 - met the hand surgeon of my dreams. (yes this was more important than any other average man!) his team diagnosed me straight away and i was off to have surgery in two weeks time. surgery was relatively successful, until...
age 23 - my right hand/wrist developed chondromalacia so i had to have surgery no. 2 to fix that. then at
age 25 - my left wrist was so jealous that it decided to want surgery too, actually this was surgery no. 3
age 30 - my right hand/ thumb and other bits decided to become a crazy mess of instability so i needed surgery no. 4
Now, in between all of these joyous surgeries, I was diagnosed with fibromyaglia syndrome whilst living in London when i was 22. I love, LOVE, L O V E London, but the weather over there puts me through the ringer. turns out low pressure and high humidity are one of my FMS triggers. I was in PT over there and when I came back to NY. My hand surgeon would not operate until I was stable with that and doing better. He sent me to a rheumatologist, who turned out to be not the brightest or most enlightened or even open to anything other than drugs.
OK, so moving along, my hips have been annoying me for ages, but not to the point where I couldn't really walk or exercise or bike ride. The would hurt, I would shift around, and relatively soon they would be quiet.
That was until last summer...
Ah, last summer. The right hip especially started to pop and click and do all sorts of wonky things on a much more regular basis. I was used to the occasional hip sublexation/dislocation that had been happening for a while, but this pain became all too frequent. It was hurting mostly on my outer hip, which I would later learn was trochanter bursitis.
I had a trip booked to London for a week in October. I decided I would wait to make an appt. to see a dr for the hip after the trip. I wanted to enjoy myself and not worry about appointments or diagnosis or anything of the sort. After all of the medical issues I've had, you start to put of the inevitable.
Big oops by me. I arrived on a Saturday am and left a week later on Sunday. During this time I walked a lot! I usually walk a lot, but in London somehow it always seems to double, especially now that the tubes are horrid. One day I went riding in Hyde Park, something I'd been longing to do. That made all the muscles in my legs ache for a couple of days so I was actually walking funny. I guess one shouldn't do an hours ride when one hasn't been on a horse for a bit! Still my hip wasn't doing hurting too much (I did keep lidoderm patches on it so that was probably masking the pain).
Saturday my friend and I went to do a walking tour in lovely Hampstead. Now, if you've not been, Hampstead is a very, very hilly village. So here we are on the walking tour, going from one lovely old place to another, and on one incline, POP! There goes the right hip. I seriously don't know how I was still standing from the pain. My friend was quite happy to turn back, but I am a bit stubborn (to put it mildly) and refused to let my last night in London be ruined by my crap body, so on we went. All I can say is thanks be to G-d for all the pubs in Hampstead that we stopped at on our tour! Afterwards, I hobbled onto the tube, then to the rail to go out to my friends house where I was staying. I was just hanging in there, and sitting on the train helped a bit, but then I had about a mile walk to his house. That was the longest walk of my life. To this day I do not know how I made it. I was able to take about 3 steps at a time. Stop, whimper, talk myself into moving again, and then another 3 steps. Longest mile of my life! I was a wreck when I got back and literally had to pull myself up the stairs to bed. At this point I'm thinking - yeah, really should have made that dr appointment already! Daft me.
Back in NY I ring some dr's that my main dr recommended. I had to go to the darling rheumatologist that I had written off a few years ago (long story) b/c she was the only one I could seem to get an appt with in the near future. My logic was at least I would be able to have the xrays and mri's started and then hopefully I would know what type of dr I needed to locate. The x-rays were fine, perfectly normal, the MRI not so much. After finally getting the radiologist's report she said I had an FAI, labral tear, bursitis, and some other random things. (btw, my right shoulder had been bad too so she did an xray of that which was fine, but not an mri, something about insurance not doing two mri's at a time). The rheumatologist told me to go see an orthopedist. I asked her for more details, as all of these words were like a foreign language to me, but trying to get an explanation out of her was like trying to find water in the Sahara desert during a drought. The only good thing she did was send me in Dr. Kelly's direction.
Well, my brief medical history is as follow:
age 14 - diagnosed with bilateral chondromalacia in my knees
age 18 - right wrist started to hurt, A LOT! went to 7 dr's in 3 years, most of whom had no clue and one who even told me to call him instead of my mother when it hurt, b/c he was convinced it was in my head.
age 20 - met the hand surgeon of my dreams. (yes this was more important than any other average man!) his team diagnosed me straight away and i was off to have surgery in two weeks time. surgery was relatively successful, until...
age 23 - my right hand/wrist developed chondromalacia so i had to have surgery no. 2 to fix that. then at
age 25 - my left wrist was so jealous that it decided to want surgery too, actually this was surgery no. 3
age 30 - my right hand/ thumb and other bits decided to become a crazy mess of instability so i needed surgery no. 4
Now, in between all of these joyous surgeries, I was diagnosed with fibromyaglia syndrome whilst living in London when i was 22. I love, LOVE, L O V E London, but the weather over there puts me through the ringer. turns out low pressure and high humidity are one of my FMS triggers. I was in PT over there and when I came back to NY. My hand surgeon would not operate until I was stable with that and doing better. He sent me to a rheumatologist, who turned out to be not the brightest or most enlightened or even open to anything other than drugs.
OK, so moving along, my hips have been annoying me for ages, but not to the point where I couldn't really walk or exercise or bike ride. The would hurt, I would shift around, and relatively soon they would be quiet.
That was until last summer...
Ah, last summer. The right hip especially started to pop and click and do all sorts of wonky things on a much more regular basis. I was used to the occasional hip sublexation/dislocation that had been happening for a while, but this pain became all too frequent. It was hurting mostly on my outer hip, which I would later learn was trochanter bursitis.
I had a trip booked to London for a week in October. I decided I would wait to make an appt. to see a dr for the hip after the trip. I wanted to enjoy myself and not worry about appointments or diagnosis or anything of the sort. After all of the medical issues I've had, you start to put of the inevitable.
Big oops by me. I arrived on a Saturday am and left a week later on Sunday. During this time I walked a lot! I usually walk a lot, but in London somehow it always seems to double, especially now that the tubes are horrid. One day I went riding in Hyde Park, something I'd been longing to do. That made all the muscles in my legs ache for a couple of days so I was actually walking funny. I guess one shouldn't do an hours ride when one hasn't been on a horse for a bit! Still my hip wasn't doing hurting too much (I did keep lidoderm patches on it so that was probably masking the pain).
Saturday my friend and I went to do a walking tour in lovely Hampstead. Now, if you've not been, Hampstead is a very, very hilly village. So here we are on the walking tour, going from one lovely old place to another, and on one incline, POP! There goes the right hip. I seriously don't know how I was still standing from the pain. My friend was quite happy to turn back, but I am a bit stubborn (to put it mildly) and refused to let my last night in London be ruined by my crap body, so on we went. All I can say is thanks be to G-d for all the pubs in Hampstead that we stopped at on our tour! Afterwards, I hobbled onto the tube, then to the rail to go out to my friends house where I was staying. I was just hanging in there, and sitting on the train helped a bit, but then I had about a mile walk to his house. That was the longest walk of my life. To this day I do not know how I made it. I was able to take about 3 steps at a time. Stop, whimper, talk myself into moving again, and then another 3 steps. Longest mile of my life! I was a wreck when I got back and literally had to pull myself up the stairs to bed. At this point I'm thinking - yeah, really should have made that dr appointment already! Daft me.
Back in NY I ring some dr's that my main dr recommended. I had to go to the darling rheumatologist that I had written off a few years ago (long story) b/c she was the only one I could seem to get an appt with in the near future. My logic was at least I would be able to have the xrays and mri's started and then hopefully I would know what type of dr I needed to locate. The x-rays were fine, perfectly normal, the MRI not so much. After finally getting the radiologist's report she said I had an FAI, labral tear, bursitis, and some other random things. (btw, my right shoulder had been bad too so she did an xray of that which was fine, but not an mri, something about insurance not doing two mri's at a time). The rheumatologist told me to go see an orthopedist. I asked her for more details, as all of these words were like a foreign language to me, but trying to get an explanation out of her was like trying to find water in the Sahara desert during a drought. The only good thing she did was send me in Dr. Kelly's direction.
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