Sunday, 31 May 2015

Hip reconstruction - background

Those who know me, know I have dodgy hips ("hip problems", for the non-Aussies). Most people are happy to leave it at that, but some are interested in more detail. After my most recent procedure I was contacted by somebody overseas who is facing similar surgery and saw my Instagram images, so I thought I would document the journey for anybody who is interested.

Hip arthroscopy is a fairly new sub-specialty which is only performed by a limited number of orthopaedic surgeons. The way it was explained to me was that many people who are reaching their 60's and 70's and requiring a hip replacement, most likely had similar but undiagnosed issues to mine in their earlier years, and one of the goals of this type of procedure is to identify and repair these issues in earlier years and perhaps prevent, or at least delay, hip replacement surgery in later life.

Some background - left hip:

In May 2009 I underwent a left hip arthroscopy performed by Mr Michael Pritchard of Hip Arthroscopy Australia, after ongoing hip and back pain over several years. Don't ask how I did it - I don't know! I remember chronic pain while I was pregnant in 2006, and I played years of netball and other sport since childhood so it could have been anything - but there was no defining "ouch" moment.

I had x-rays and an MRI but it is difficult to see into a hip joint, so we weren't 100% clear on what the problem may have been - it could have been small bone protusions on the femur, or in the hip cavity, or a ligament tear, or any number of other things.

As it turns out, I had a small labral tear which was repaired, and a very damaged ligamentum teres, which is the ligament that stabilises the head of the femur, into the hip socket. There are a lot of very complicated images online that show what this looks like, but here is a very simplified version:



This is repaired by scraping away the torn part of the ligament, which leaves it thinner and a bit more brittle, but still stronger than it would have been with a tear. Unfortunately, my ligamentum teres was so damaged that by the time Mr Pritchard finished scraping, it was gone.

I was on crutches for about a week, then spent several months doing physiotherapy with Amir Takla, a physiotherapist who specialises in hip rehabilitation, and after 12 months I felt great. Amir told me that Mr John O'Donnell of Hip Arthroscopy Australia, one of the pioneers of all this hip arthroscope stuff, was starting to experiment with reconstructing the ligamentum teres, but hadn't actually performed any yet. I said that if I needed it I'd be happy to give it a go, as long as I wasn't first!

Right hip:

One day in 2010 at the gym, there was a big "ouch" moment - in the OTHER hip! Apparently this is relatively common, as there is a tendency, even after extensive physiotherapy, to favour the "bad" side, which puts additional strain on the "good" side. I went home and rang the physio straight away, and was booked in for surgery several weeks later. The physio assured me I'd done everything right, but sometimes these things just happen.

In the meantime, the physio suggested a cortisone injection into the hip, which would help reduce inflammation while waiting for surgery. So I did that and if anybody wants my advice - NEVER EVER DO THIS! You know that scene in Pulp Fiction, where they jam the adrenaline needle into the drug-overdose lady's heart? This looked similar, but I was awake (and obviously, it was into the hip, not my heart). Incredibly, horribly painful and the cortisone effect only lasted a few weeks. Ergh.

In October 2010, I underwent a right hip arthroscopy. Luckily this time the ligamentum teres only had a small tear, so Mr Pritchard was able to repair it. The rehab was similar, although I had to be a bit more careful because a repaired ligament is more fragile than "no ligament".

Left hip, part 2:

Fast-forward a few years, and I started experiencing left hip and lower back pain again, which I tried to ignore or justify with "when I lose weight..." type excuses. When people have a hip replacement they lose the ligamentum teres, and apparently 95% of people are fine without it - what are the chances?! Turns out, I was one of the 5% ... :-/

The problems occur for people who have "stretchy ligaments", who can hyperextend, etc. I did several years of calisthenics and gymnastics in my youth so I guess I'm stretchy. The physiotherapy I did after each hip arthroscope was designed to tighten up muscles, ligaments and tendons surrounding the hip joint, but unfortunately stretchy people tend to experience a loosening of all this as years go by, with the result being "microscopic instability" of the hip joint.

In November 2014 I returned to my physio (who couldn't believe I was back AGAIN), who confirmed the instability and advised that surgery was probably my only option, but he thought I was too young for a hip replacement (of course, geez, I'm only 40-something!!), and wasn't sure if I was too old (!!) or otherwise eligible for a reconstruction. He referred me to Mr John O'Donnell (as Mr Pritchard has moved to Tasmania) to discuss a ligamentum teres reconstruction. More x-rays and another MRI to ensure I was suitable for the procedure, and I was booked in for May 2015.

At the first meeting, Mr O'Donnell advised he'd done approximately 12-13 of this procedure in the last 3-4 years, and all patients had experienced some level of improvement post-surgery, ranging from "good" to "outstanding". He could make no guarantees as to which level I might experience but by that point I didn't care - even "good" would be better than what I'd been living with.

The procedure involves taking a tendon from the knee (the same tendon that is used in knee reconstructions), and inserting it into the hip joint. This doesn't technically recreate the ligamentum teres, but it simulates it to provide stability. This is done by drilling a hole into the head of the femur and bolting the tendon in, then pinning it around the hip capsule in similar locations to where the ligamentum teres is attached. Over time the tendon transforms into a ligament. (What's the difference?). Sounds gross, eh?!

This post is long enough, so I'll start a new one to document my op and recovery!
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