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.
16 August, 2007
Pain pain go away, don't come again - EVER!
I'm in a slightly whinging, aching, miserable mood, mostly due to the weather acting up my fibro and also the fact that my left hip has been starting to hurt more and more. I think this is b/c the right one is bad so I've been limping more, but I still don't like it! I apologise in advance for a negative update, but I've got to vent for a bit. This week has been one annoying thing after another.
On Monday I had a doctor's appointment for a check-up. To begin with I feel like a beached whale! I've never been so overweight in my life, and it's driving me batty that I can't do any cardio. My doctor kept asking me how long it will be till I can exercise. Not very subtle, but it touched a very sensitive nerve. I never thought I'd miss exercise so much in my life!
Speaking of...I had PT yesterday. I haven't gone for two weeks because of insurance reasons. I have been doing my PT at home in the meantime and trying to do some exercises in the pool as much as I can tolerate. The last few days I've been in a lot of pain so my PT wanted to do some stim with a weight. Fine, not a problem, except...his trainee came over and set it up and then put a 5 pound weight on my ankle, unbeknownst to me. The most weight I've done on my ankles has been 3lbs and though that does not sound like a lot to most people, for me it has been a huge achievement. I tried to move my leg up and it was not moving. I asked her how much she put on and she said 5!!! I'd be quite happy if I could do 5 lbs but I am the one that suffers after and I don't mean just being "sore" from muscles. I mean, can't move the leg or put pressure on it and feel like some one's stabbing a knife in me - type of pain. Anyway she kept saying oh sure you can do it, like that was somehow going to miraculously make my leg strong enough. If sheer will power could get me better I'd be there already. The point of this rant is she just made me feel how slow it's all been for me and I've not even had surgery yet, and with all the concerns and fear and worries in my head, I was about to cry from this.
To add insult to injury, last night I came home to a message from the Dr's PA. She said that she thought ringing would be better b/c she's never seen so many questions before. I'm quite happy to speak to her directly, but it seemed as it was a bit of a jab. Seriously, this is my body, I have a right to know what they're going to do! I know people who are not very proactive and just go along without asking questions, so perhaps the dr's are used to that. Anyway, it was too late to ring back so I left a message for her this morning and hopefully will hear back from her today.
Ok, glad I got that all off my chest.
On Monday I had a doctor's appointment for a check-up. To begin with I feel like a beached whale! I've never been so overweight in my life, and it's driving me batty that I can't do any cardio. My doctor kept asking me how long it will be till I can exercise. Not very subtle, but it touched a very sensitive nerve. I never thought I'd miss exercise so much in my life!
Speaking of...I had PT yesterday. I haven't gone for two weeks because of insurance reasons. I have been doing my PT at home in the meantime and trying to do some exercises in the pool as much as I can tolerate. The last few days I've been in a lot of pain so my PT wanted to do some stim with a weight. Fine, not a problem, except...his trainee came over and set it up and then put a 5 pound weight on my ankle, unbeknownst to me. The most weight I've done on my ankles has been 3lbs and though that does not sound like a lot to most people, for me it has been a huge achievement. I tried to move my leg up and it was not moving. I asked her how much she put on and she said 5!!! I'd be quite happy if I could do 5 lbs but I am the one that suffers after and I don't mean just being "sore" from muscles. I mean, can't move the leg or put pressure on it and feel like some one's stabbing a knife in me - type of pain. Anyway she kept saying oh sure you can do it, like that was somehow going to miraculously make my leg strong enough. If sheer will power could get me better I'd be there already. The point of this rant is she just made me feel how slow it's all been for me and I've not even had surgery yet, and with all the concerns and fear and worries in my head, I was about to cry from this.
To add insult to injury, last night I came home to a message from the Dr's PA. She said that she thought ringing would be better b/c she's never seen so many questions before. I'm quite happy to speak to her directly, but it seemed as it was a bit of a jab. Seriously, this is my body, I have a right to know what they're going to do! I know people who are not very proactive and just go along without asking questions, so perhaps the dr's are used to that. Anyway, it was too late to ring back so I left a message for her this morning and hopefully will hear back from her today.
Ok, glad I got that all off my chest.
14 August, 2007
driving myself crazy
I have been going back and forth trying to decide about asking the dr all the new questions I have come up with in the last couple of days. A friend said that I have every right, and they are valid questions. I agreed and figured it would put my mind to rest to hear back, so I emailed the dr's administrator this afternoon and she said she would get the questions to the PA. Hopefully I will hear back in the next few days!
13 August, 2007
Descriptions of (possible) procedures
I've gone and done a ton of research about the "possible" things the dr may do to my hip. I appreciate that they have to request all the possibilities for approval from the insurance company, but hey, inquiring minds want to know what could happen in there!
Here is what I came up with. If anyone has better descriptions then what I found on the web, please let me know.
Vastus-Psoas release for acetabular exposure in revision hip surgery.A technique is presented for wide exposure of the acetabulum for revision total hip arthroplasty surgery in the presence of a solidly fixed, modular, or monoblock femoral component without the need for trochanteric osteotomy. The technique involves release of the proximal portion of the vastus lateralis, vastus intermedius, and vastus medialis muscles and the iliopsoas tendon form the femur and placement of the femoral head/neck posterior to the acetabulum. The exposure afforded by this release usually precludes the need for trochanteric osteotomy and/or removal of a well-fixed femoral component in revision surgery that is being done for isolated loosening of acetabular components, thereby decreasing operative time, morbidity, and the risks of complication of trochanteric osteotomy.
Arthroscopic psoas tenotomy. Wettstein M, Jung J, Dienst M
Department of Orthopaedic Surgery, University Hospital, Homburg/Saar, Germany.
Tenotomy may be indicated for psoas tendinitis or painful snapping if conservative treatment remains unsuccessful. Because of significant complications with open techniques, endoscopic operations have been developed. We present a new arthroscopic technique to access and release the psoas tendon from the hip joint. This procedure can be performed in addition to other arthroscopic procedures of the hip joint or alone. To exclude additional hip disease, a diagnostic round of the joint should be completed. After hip arthroscopy of the central compartment has been performed, traction is released and the 30 degrees arthroscope is placed via the proximal anterolateral portal lying on the anterior femoral neck. The medial synovial fold can be identified. This fold lies slightly medially underneath the anteromedial capsule at the level of the psoas tendon. The arthroscope is turned toward the anterior capsule. Sometimes, the tendon shines through a thin articular capsule, or it may even be accessed directly via a hole connecting the hip joint and the iliopectineal bursa at the level of the anterior head-neck junction. If this cannot be done, an electrothermic probe is introduced via the anterior portal to make a 2-cm transverse capsular incision. The tendon is released with the back side of the electrothermic device turned to the iliacus muscle that lies anterior to the psoas tendon. A complete release is achieved when the tendon stumps can be seen gapping at a distance and the fibers of the iliacus muscle are visible. The first 9 patients who underwent surgery performed according to this technique developed no complications, and their hip flexion strength was restored to normal within 3 months. Published 14 August 2006 in Arthroscopy, 22(8): 907.e1-4.
ITB release (Iliotibial Band Release Surgery)
What is iliotibial band syndrome? Iliotibial band syndrome (ITBS) occurs when there is irritation to this band of fibrous tissue. The irritation usually occurs over the outside of the knee joint, at the lateral epicondyle--the end of the femur (thigh) bone. The iliotibial band crosses bone and muscle at this point; between these structures is a bursa which should facilitate a smooth gliding motion. However, when inflamed, the iliotibial band does not glide easily, and pain associated with movement is the result. ITBS can also occur where the IT band connects to the hip, though this is less likely as a sports injury. Cause: ITBS can also occur where the IT band connects to the hip, though this is less likely as a sports injury.
Title: Endoscopic iliotibial band release for external snapping hip syndrome.
Author(s) Ilizaliturri VM, Martinez-Escalante FA, Chaidez PA, Camacho-Galindo J
Institution Department of Adult Joint Reconstruction at the National Rehabilitation Institute of Mexico Orthopaedics Institute, Mexico City, Mexico. vichip2002@yahoo.com.mx
Source Arthroscopy 2006 May; 22(5) :505-10.
Abstract PURPOSE: The external snapping hip syndrome is caused by slippage of the iliotibial band over the greater trochanter. Most cases are treated conservatively but if this fails, open surgical treatment is commonly performed by Z-plasty or by creating a defect on the iliotibial band. We present a series of 11 hips that were surgically treated by an endoscopic technique. TYPE OF STUDY: Prospective consecutive series of patients.
METHODS: Diagnosis of external snapping hip syndrome was clinical in all cases and anteroposterior pelvis radiographs were taken to evaluate the hip joint. Endoscopic release was performed with the patient in the lateral decubitus position without traction using 2 portals, the superior trochanteric and inferior trochanteric. A standard 4-mm, 30 degrees arthroscope was introduced at the inferior trochanteric portal over the iliotibial band. A needle was placed at the proximal trochanteric portal and visualized endoscopically. The portal was then established and subcutaneous tissue resection was performed with radiofrequency (RF) probes and a shaver until the iliotibial band was identifiable and released with a vertical cut made using an RF hook probe. The arthroscope was introduced into the space created under the iliotibial band and a transverse cut at the middle of the vertical release was then made, creating a cross-shape. Next the 4 resulting flaps were resected to make a diamond-shaped defect.
RESULTS: Between September 2001 and December 2003, we treated 11 patients, 9 female (1 bilateral) and 1 male with an average age of 26 years, for external snapping hip syndrome using an endoscopic technique. At an average 2-year follow-up, we had 1 patient with nonpainful snapping. The rest of the patients in the series had no complaints and returned to their previous level of activity.
CONCLUSIONS: We present a reproducible endoscopic technique for the treatment of external snapping hip syndrome. Our results are comparable to those reported for open procedures.
Excision of heterotopic ossification
Heterotopic ossification (HO) is the abnormal formation of true bone within extraskeletal soft tissues.
Debridement trochanteric bursitis
definition: SURGICAL DEBRIDEMENT - The surgical removal of dead tissue, debris, and contaminants from a wound.
What is hip bursitis? Hip bursitis is a common problem that causes pain over the outside of the upper thigh. A bursa is a fluid filled sac that allows smooth motion between two uneven surfaces. For example, in the hip, a bursa rests between the bony prominence over the outside of the hip (the greater trochanter) and the firm tendon that passed over this bone. When the bursal sac becomes inflamed, each time the tendon has to move over the bone, pain results. Because patients with hip bursitis move this tendon with each step, hip bursitis symptoms can be quite painful. In those few cases where surgery is needed, this can be done through a small incision, or sometimes it can be performed arthroscopically. Either way, the bursa is simply removed (called a bursectomy), and the patient can resume their activities. The surgery is done as an outpatient, and most often crutches are only used for a few days. Patient's do not need a bursa, and therefore there are few complications from this type of surgery. The most common complications are anesthetic-related complications, and infection.
Acetabuloplasty
ac·e·tab·u·lo·plas·ty (s-tby-l-plst) n. Surgical repair of the acetabulum; plastic surgery on the acetabulum intended to restore its normal state (as by repairing or enlarging its cavity)
Osteochondroplasty
Osteochondroplasty is an arthroscopic removal of excess bony osteophyte that affects the geometry of the hip. Treatment for FAI.
Labral Debridement
remove a tear in the hip cartilage
Labral Repair
repair a tear in the hip cartilage
Here is what I came up with. If anyone has better descriptions then what I found on the web, please let me know.
*************
Psoas releaseVastus-Psoas release for acetabular exposure in revision hip surgery.A technique is presented for wide exposure of the acetabulum for revision total hip arthroplasty surgery in the presence of a solidly fixed, modular, or monoblock femoral component without the need for trochanteric osteotomy. The technique involves release of the proximal portion of the vastus lateralis, vastus intermedius, and vastus medialis muscles and the iliopsoas tendon form the femur and placement of the femoral head/neck posterior to the acetabulum. The exposure afforded by this release usually precludes the need for trochanteric osteotomy and/or removal of a well-fixed femoral component in revision surgery that is being done for isolated loosening of acetabular components, thereby decreasing operative time, morbidity, and the risks of complication of trochanteric osteotomy.
Arthroscopic psoas tenotomy. Wettstein M, Jung J, Dienst M
Department of Orthopaedic Surgery, University Hospital, Homburg/Saar, Germany.
Tenotomy may be indicated for psoas tendinitis or painful snapping if conservative treatment remains unsuccessful. Because of significant complications with open techniques, endoscopic operations have been developed. We present a new arthroscopic technique to access and release the psoas tendon from the hip joint. This procedure can be performed in addition to other arthroscopic procedures of the hip joint or alone. To exclude additional hip disease, a diagnostic round of the joint should be completed. After hip arthroscopy of the central compartment has been performed, traction is released and the 30 degrees arthroscope is placed via the proximal anterolateral portal lying on the anterior femoral neck. The medial synovial fold can be identified. This fold lies slightly medially underneath the anteromedial capsule at the level of the psoas tendon. The arthroscope is turned toward the anterior capsule. Sometimes, the tendon shines through a thin articular capsule, or it may even be accessed directly via a hole connecting the hip joint and the iliopectineal bursa at the level of the anterior head-neck junction. If this cannot be done, an electrothermic probe is introduced via the anterior portal to make a 2-cm transverse capsular incision. The tendon is released with the back side of the electrothermic device turned to the iliacus muscle that lies anterior to the psoas tendon. A complete release is achieved when the tendon stumps can be seen gapping at a distance and the fibers of the iliacus muscle are visible. The first 9 patients who underwent surgery performed according to this technique developed no complications, and their hip flexion strength was restored to normal within 3 months. Published 14 August 2006 in Arthroscopy, 22(8): 907.e1-4.
ITB release (Iliotibial Band Release Surgery)
What is iliotibial band syndrome? Iliotibial band syndrome (ITBS) occurs when there is irritation to this band of fibrous tissue. The irritation usually occurs over the outside of the knee joint, at the lateral epicondyle--the end of the femur (thigh) bone. The iliotibial band crosses bone and muscle at this point; between these structures is a bursa which should facilitate a smooth gliding motion. However, when inflamed, the iliotibial band does not glide easily, and pain associated with movement is the result. ITBS can also occur where the IT band connects to the hip, though this is less likely as a sports injury. Cause: ITBS can also occur where the IT band connects to the hip, though this is less likely as a sports injury.
Title: Endoscopic iliotibial band release for external snapping hip syndrome.
Author(s) Ilizaliturri VM, Martinez-Escalante FA, Chaidez PA, Camacho-Galindo J
Institution Department of Adult Joint Reconstruction at the National Rehabilitation Institute of Mexico Orthopaedics Institute, Mexico City, Mexico. vichip2002@yahoo.com.mx
Source Arthroscopy 2006 May; 22(5) :505-10.
Abstract PURPOSE: The external snapping hip syndrome is caused by slippage of the iliotibial band over the greater trochanter. Most cases are treated conservatively but if this fails, open surgical treatment is commonly performed by Z-plasty or by creating a defect on the iliotibial band. We present a series of 11 hips that were surgically treated by an endoscopic technique. TYPE OF STUDY: Prospective consecutive series of patients.
METHODS: Diagnosis of external snapping hip syndrome was clinical in all cases and anteroposterior pelvis radiographs were taken to evaluate the hip joint. Endoscopic release was performed with the patient in the lateral decubitus position without traction using 2 portals, the superior trochanteric and inferior trochanteric. A standard 4-mm, 30 degrees arthroscope was introduced at the inferior trochanteric portal over the iliotibial band. A needle was placed at the proximal trochanteric portal and visualized endoscopically. The portal was then established and subcutaneous tissue resection was performed with radiofrequency (RF) probes and a shaver until the iliotibial band was identifiable and released with a vertical cut made using an RF hook probe. The arthroscope was introduced into the space created under the iliotibial band and a transverse cut at the middle of the vertical release was then made, creating a cross-shape. Next the 4 resulting flaps were resected to make a diamond-shaped defect.
RESULTS: Between September 2001 and December 2003, we treated 11 patients, 9 female (1 bilateral) and 1 male with an average age of 26 years, for external snapping hip syndrome using an endoscopic technique. At an average 2-year follow-up, we had 1 patient with nonpainful snapping. The rest of the patients in the series had no complaints and returned to their previous level of activity.
CONCLUSIONS: We present a reproducible endoscopic technique for the treatment of external snapping hip syndrome. Our results are comparable to those reported for open procedures.
Excision of heterotopic ossification
Heterotopic ossification (HO) is the abnormal formation of true bone within extraskeletal soft tissues.
Debridement trochanteric bursitis
definition: SURGICAL DEBRIDEMENT - The surgical removal of dead tissue, debris, and contaminants from a wound.
What is hip bursitis? Hip bursitis is a common problem that causes pain over the outside of the upper thigh. A bursa is a fluid filled sac that allows smooth motion between two uneven surfaces. For example, in the hip, a bursa rests between the bony prominence over the outside of the hip (the greater trochanter) and the firm tendon that passed over this bone. When the bursal sac becomes inflamed, each time the tendon has to move over the bone, pain results. Because patients with hip bursitis move this tendon with each step, hip bursitis symptoms can be quite painful. In those few cases where surgery is needed, this can be done through a small incision, or sometimes it can be performed arthroscopically. Either way, the bursa is simply removed (called a bursectomy), and the patient can resume their activities. The surgery is done as an outpatient, and most often crutches are only used for a few days. Patient's do not need a bursa, and therefore there are few complications from this type of surgery. The most common complications are anesthetic-related complications, and infection.
Acetabuloplasty
ac·e·tab·u·lo·plas·ty (s-tby-l-plst) n. Surgical repair of the acetabulum; plastic surgery on the acetabulum intended to restore its normal state (as by repairing or enlarging its cavity)
Osteochondroplasty
Osteochondroplasty is an arthroscopic removal of excess bony osteophyte that affects the geometry of the hip. Treatment for FAI.
Labral Debridement
remove a tear in the hip cartilage
Labral Repair
repair a tear in the hip cartilage
10 August, 2007
you learn something new everyday
I came home one night this week to find a letter from my insurance company. I knew the surgery was approved, so I wasn't too concerned. The letter listed the Requested Services Summary and various service codes and descriptions of said service codes. One of the descriptions concerned me as I had not discussed it at all with the doctor. As I am prone to jumping to conclusions at the moment, I flipped out a bit. Thankfully my mum put up with my waking her and ranting on for an hour on the phone. (I owe her a couple of hours of sleep now :-) )
I emailed the dr's office the next day and thankfully they got back to me within a few hours, which is good for them. They asked for the codes and then sent me back a list of code descriptions that the dr uses. It seems the insurance co uses different descriptions, probably to intentionally torment you!
The email from the dr's office basically said (I'm paraphrasing)
"XXXXX is a very tricky insurance company. We have to get authorization for all of the possible codes he might do. If I know the CPT Code (service code) I can tell you what our description is. Each insurance company has their own descriptions and can confuse patients!"
This list helped a lot as it clarified what I was concerned about, but I will still discuss with him before surgery. I am going to bring a list to review before, I'm sure he'll love that!
So learn from my hysteria and talk to the dr before trusting what the insurance company says.
I've also now have a list of the technical medical terms and have done more searches on the web and printed out articles to read. Maybe not a good thing, but I am curious about the details of what will be done to me!
I emailed the dr's office the next day and thankfully they got back to me within a few hours, which is good for them. They asked for the codes and then sent me back a list of code descriptions that the dr uses. It seems the insurance co uses different descriptions, probably to intentionally torment you!
The email from the dr's office basically said (I'm paraphrasing)
"XXXXX is a very tricky insurance company. We have to get authorization for all of the possible codes he might do. If I know the CPT Code (service code) I can tell you what our description is. Each insurance company has their own descriptions and can confuse patients!"
This list helped a lot as it clarified what I was concerned about, but I will still discuss with him before surgery. I am going to bring a list to review before, I'm sure he'll love that!
So learn from my hysteria and talk to the dr before trusting what the insurance company says.
I've also now have a list of the technical medical terms and have done more searches on the web and printed out articles to read. Maybe not a good thing, but I am curious about the details of what will be done to me!
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