Tuesday, January 29, 2008

Hip, Hip.... Hooray? Or...?

As many of you know by now, I have been battling some issues with my right hip since late 2005. Today I met with (who I am told is) one of the country's most talented orthopedic surgeons and have finally reached a decision point about my treatment. But oh what a roller-coaster ride it was.

First, a little history for those of you who don't already know it:

After several months of my hip popping in and out of joint and some intensive physically therapy, in mid 2006 I was diagnosed with a labral tear and my orthopedic surgeon at the time recommended surgery. Unfortunately, in 2006 I was heading into two plannned foreign vacations and a wedding, so I decided to postpone surgery until the following January. Except in January 2007 I changed jobs. Then my boss went on maternity leave for six weeks. Then I had to travel for work. And then more vacations loomed. All of which left little time (yes, somewhat by choice) for a surgery with a 2-month recovery period.

In my defense, part of me felt that, just maybe, if I kept up with the physical therapy the problem would sort itself out. Certainly my surgeon at the time didn't seem to think there was any rush nor any long-term impact to delaying the surgery.

Then, in August of 2007, Hubbie and I moved to a new house. The moving process, as we all know, involves much bending and lifting and pushing and pulling - all of which placed a big, bright spotlight on the problems with my hip. I can't squat, I can't lunge, I can't bend over with pressure on my affected leg, and it became plain as day that, through a slow process of compensation, I've lost stability and strength in the muscles surrounding the joint.

I decided: I have to bite the bullet and get this thing taken care of because it obviously isn't solving itself any time soon.

During this period I also changed doctors and medical groups. As those of us in the U.S. know, this isn't just as simple as registering with a new person. This means, essentially, starting all over again, especially with something like my hip problem. While my medical records were shared with my new doctor, x-rays and MRIs were mysteriously absent. In addition, the othopedic surgeon I had last seen wasn't even part of the same group, so my PCP (Primary Care Physician) couldn't even refer me back out to him. So, late last year I had to be referred to another orthopedist who, of course, wanted more x-rays.

The new orthopedist also guessed that I had a labral tear and this time found an anomoly on my x-ray that wasn't there before (although he didn't have the old x-rays he did have a narrative in my file describing them) probably the result of some kind of impingement. He also diagnosed a problem with my IT (iliotibial) band and recommended more physical therapy - most of which, it turns out, I was doing anyway. He didn't refer me out to a surgeon at the time because he wanted me to see a surgeon he had worked with at Kaiser Permanente (another medical group) and who was moving over to my medical group in early 2008.

Last week I had my follow-up appointment with this same orthopedist and it went something like this.

Him: "Well, I think you have two different things going on. One is a possible labral tear that is causing the pain in your inner groin and the other is a tight IT band that is causing the pain in your side and your knee. I think that if you can take care of the pain in your IT band, then a lot of your discomfort might be eased."

Me: "Ok, but isn't the tight IT band a result of what's going on with the labral tear?"

Him: "Well, maybe but I think you'll get significant relief from taking care of the IT band. If I refer you out to a surgeon, he'll just recommend surgery and this isn't just a small surgery we're talking about here, it's pretty painful."

So, basically what you're telling me is that you (as a sports medicine/orthopedist) are going to advocate physical therapy whereas the orthopedic surgeon is going to advocate surgery, just because that's each of your specialties? Hang on here: who's advocating for the best thing for me, the patient!?

Understandably I was a bit miffed but made the appointment with the orthopedic surgeon for this morning anyway.

Now to today's roller-coaster ride...

The surgeon's first-guess diagnosis was Hip Dysplasia (Aka: the climb to the first and highest drop on the ride. )

Of course, my eyes crossed at the term - I had no idea what it was but it didn't sound good - so I asked him to explain. He pulled out his pen and began to draw a hip joint on the paper liner next to me on the bed. Basically what he showed me was that an abnormality in the way that the femoral head sits in your hip socket (either that has been dormant since birth or that has developed over time), causes degeneration of the connective tissue, cartlidge, and eventually bone over time. So, for instance, dysplacia can cause something like a labral tear.

In many cases, orthopedic surgeons go as far as diagnosing the labral tear but don't search for the underlying cause - what caused the patient's labrum to tear? Aparently, it's usually pretty hard to tear your labram through regular wear-or-tear or even injury - only high-level athletes or people who have had a fairly traumatic injury (like falling off a horse or something) manage to do it with one catastrophic event. Usually, labral tissue tears because it has been worn away over time due to some other underlying, structural issue with the hip joint. Makes sense so far.

In short, we moved from a tiny bit of torn connective tissue to a structural abnormality in a major joint in my body within about 5 minutes of him walking into the room. While I was making light of everything with the doctor in an attempt to "bond", I have to say my heart was racing and my blood pumping in my ears, especially as I asked the question: "So, what's the treatment for that then?"

As I feared, dysplacia is not treatable through an arthroscopic surgery. In the surgeon's own words, this type of surgery is about "as big as they come for othopedics." For a start it's open surgery (meaning slice-and-dice-and-cross-stitch-you-up) and involves all sorts of joint dislocation, tendon stretching, bone twisting, and other manipulation which brings me out in a cold sweat just thinking about it. And the recovery time? 4+ months! That's without even taking into account the 3-4 month wait period posted on a bright yellow piece of papaer on every door throughout the place. (I might also add that, not only could I try for a family during this time, it was completely inadvisable to get pregnant at all if I had dysplacia.)

The thought of the surgery and the post-op pain was one thing but the idea of being out of action for 4 months had me hyperventilating. I'm not the sort of person who has the patience for that amount of recovery time. All the joys in my life revolve around independence, travel, movement... having me be dependent on others and encumbered in movement for a significant amount of time is like caging a wild lion in a 5x5 public storage space.

But still, wasn't this a bit of a jump? I asked him. I mean, my pain's not unbearable and I just woke up one day with this, it's not like it came on over a period of time. Still, in his experience he told me, most women my age who present with symptoms of labral tear actually have dysplacia.


So, we set to prove/disprove his theory by taking yet more x-rays (because of course the day my x-rays were taken by the other orthopedist, the computer system was down and so they're not in the system.)

Well, you know how this goes: the surgeon leaves the room to order the x-ray and now you're sitting in a stark white room for 30 minutes with nothing to distract you, not even a People Magazine. This was just enough time to start the tears streaming down my face. I wanted to call Hubbie and panic down the phone but I'd left my cell in the car, so all I was left with was my own fears and thoughts, going over-and-over what this meant for my life, for my plans for the year, for my long-term health...

One hour later we're staring at the x-ray. It's not dysplacia. (Aka: The relief at reaching the bottom of the first drop on the ride.)

But hang on...don't go all giddy on me yet! It's not just a labral tear either. (Remember: labral tears - according to my new surgeon - are caused by something.) My something is a Femoroacetubular Impingement of the Cam Type. (FI for short hereafter). (Aka: Wheeeee, up and over another bump on the ride we go!)

My relief was now instantly mixed with further uncertainty - this was something he hadn't mentioned it could be.

In terms of where this registered on the richter-scale of surgical severity, if the dysplacia was a '10' and a simple labral tear a '3', FI is around a '5-7' depending on the extent of the impingement. My impingement, fortunately, is at the lower end of the scale.

What all this means is that, if you think of your femoral head (the ball at the top of your leg that sits in your hip socket) as a round door-knob, the neck of my 'door-knob' is slightly less concave on one side than on the other, meaning that it could have been rubbing against my hip socket and caused or resulted over time in the labral tear. The abnormality is slight but seems to have been enough to cause a small peanut-sized impingement on the joint, whivh however, could also could be a result of the labral tear setting my hip-socket in a weird position.

All of this leaves me with two choices:

1) Simply treat the labral tear with an out-patient arthroscopic procedure which repairs the labrum and cleans out any other 'stuff' that might be getting in the way of my joint sitting properly. Recovery time: 2 months. This could eliminate 99% of my problem because my FI is only minor. Or it could just be a temporary band-aid and the FI will either leave me with some remaining pain in my hip and/or cause further problems down the line, which may lead me to option #2 anyway.


2) Open surgical hip dislocation involving an incision (approximately 6 to 10 inches), bone cutting of the upper thigh bone, and dislocation of the ball from the socket exposing all parts of the joint. Also during the procedure some metal pins are inserted into my femor. Recovery time: 4 months. This could be more surgery than I need but it would also prevent the possibility of further deteriation of the hip socket down the line.

The surgeon said I'm borderline for either procedure, since my FI is so slight. His feeling is that, if we do #1, I'll probably be back for #2 at some point anyway. Again, this was a gut feeling, not a medically inevitable result.

At this point, I don't know what exactly I'm going to do. My sense of impatience leads me to lean toward #1. It'll be less surgery and I'll be recovered faster plus that could be all I need - and who wants to have more surgery than they actually need?

However, if the FI still continues to be a problem I'll only add to that process later with a second, open surgery and a further 4 months of recovery. I'm also worried about degeneration of the hip joint and the future implications for arthritis and a possible future hip replacement.

I need to think some more...


Edited to add: Just spoke to my friend from The Gerli Life who had a labral tear surgery arthroscopically about 2 weeks ago. Turns out she also had FI also (which I didn't know) and her surgeon said this can be effectively treated (the full 100% solution with the bone removal and all that jazz, not just the band-aid) arthroscopically. She thinks I need a second opinion. Dear God... 3 years on and here we still are. Can this just be over!!???


e said...

I'm so sorry! Ack! It's one of those situations where there is too much info.

Well, all I can tell you is that I had some of my femur shaved off, precisely for the reason your doctor told you, that the tear is caused by the FAI. But I have no indication as to whether it's better to go one way or another. My surgeon said that his policy is to go with only the surgery you need, and no more, but that doesn't take into account the possibility that you might end up with a second one a few years later. So not so helpful.

He also said that I'm likely (but not certain) to need a hip replacement around 80, so maybe if he'd done open hip surgery, that would be prevented.

It's interesting that he didn't even posit open hip surgery for me.

One thing you might ask is how long it will take for you to end up at option #2 if you only do #1. I mean, if it's 5 years, then maybe you might as well do the whole thing. If it's 25 years, by then they might be so far advanced that you'll just need another arthroscopy. Or, as I like to believe, by then there will be the "hip replacement" pill and no more surgery.

Rarus vir said...

That's pretty bad stuff, I hope you find a parsimonious resolution. Meanwhile I suggest some merlot by Gogle, good stuff.

Rarus vir said...

Sorry, that is Bogel melot. Cheers

TravelVixen said...

I did actually ask that question (re: years before I'd be "back"). He said it was unknowable - it could be right away, it could be 2-3 years down the line, it could be 10-20 years. His position is that there's no way of knowing how much of my discomfort is due to the labral tear alone and how much is due to the FAI.

CGBCYouth said...

Honestly I don't know what to say...I thought someone would help you make that decision already but it seems like you're still having to make it on your own. I'm sorry for the roller coster ride but at least now (I think) you have a pretty clear diagnosis. I think it'll be hard for you whether it's 2 months recovery or 4, but bottomline is, you want it to be as effective, as short a recover time, as possible...so...yikes I don't have anything worthwhile to add. I'll pray for you on this matter-- I know you and hubby can probably together make the right decision.

Mala said...

Wow! I'm sure this is all so overwhelming. Let me know what decision you make and stay strong.

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