Hip Preservation Surgery

What is hip preservation surgery?  It is surgery that preserves the joint. Not a joint replacement, rather repair of the issues within the joint. In my case, this involved shaving bone to correct bony impingement, repairing the labrum, etc. It is fascinating to me what all can be fixed via only a couple of small portals. My repairs included anchoring the labrum back in place, shaving excess bone from femoral acetabular impingement (FAI), decompressing the anterior inferior iliac spine (AIIS) for subspine impingement, cleaning up a torn ligament, tightening the capsule, etc. Hip arthroscopy is technically a minimally invasive, outpatient procedure. But, it is still a major surgery.

I was both overprepared and underprepared for this surgery.  Having had prior surgeries, I knew the basics of what to expect in some ways, but this was beyond anything I'd had before. I had never been on crutches or used a walker before, etc. These were a huge learning experience. But, overall, I was pleasantly surprised with how much easier it was than I expected! Preparation and rehabilitation each deserve their own separate post.

Some things that have surprised me a bit with any surgery, but especially orthopedic surgery, is no mention whatsoever of how to support healing with nutrition, relaxation, etc. I am never certain if the reason nutrition is not mentioned with me is because it is typically not addressed, or if it is because most of my physicians and other providers know my background is in nutrition. Regardless, I notice it does not get brought up. The approach I take with myself is to make sure I am supporting my body for recovery the final weeks/month before surgery and the initial few months after surgery. This means no weight loss, greater emphasis than usual on protein, strict avoidance of sugar. There are other approaches I take as well. I recently found this link which has great information regarding pre- and post-op nutrition. Most of these are things I have done. Plus, I do some additional strategies as well. I had started moderately high dose vitamin C prior to a surgery a couple of years ago when fighting a respiratory infection, trying to support my immune system in order to be well in time of surgery. Then, knowing that vitamin C is an essential co-factor for collagen synthesis and that collagen is needed for wound healing, stayed on the vitamin C after surgery to help support healing. Further, without any evidence, chose to remain on vitamin C knowing I had a torn hip labrum. I had no expectations of the labrum healing, but figured the vitamin C would not hurt. Then, went into hip surgery--so just kept on taking vitamin C. Interestingly, when I was diagnosed with Ehlers-Danlos syndrome (genetic connective tissue disorder due to defects in collagen), high dose vitamin C was one of the recommendations! Thus, I have gradually increased dose some over time.

Preparing for surgery. This topic deserves its own post, so this will be a brief overview, not comprehensive. Preparation included "prehabilitation" in physical therapy. This helped me go into surgery as strong as possible, which in turn, aided with rehabilitation post-op. With hip arthroscopy, the goals of "prehab" included hip and glute strengthening, core strengthening, also upper body strengthening in preparation for being on crutches. I made sure I had work and school tasks caught up and to good stopping places prior to surgery. I made meals in advance to make things easier after surgery. I made sure regular prescriptions were current, refilled. I arranged to have a family member able to drive me to/from surgery, stay with me the first days after surgery. Friends pitched in to help with rides until I could drive.

Although I said, and still say, recovery was much easier than anticipated, it was certainly not easy. I like to be up and doing things. My body needs to keep moving. Patience is not one of my virtues....just something I have been given numerous opportunities to practice. I strongly dislike restrictions and limitations. However, I understand their purpose and am capable of dutifully following them.

I mentioned in my post regarding hip impingement, and diagnostic process that I was eventually sent out of state for another opinion, and this second surgeon is who recommended surgery. Thus, I traveled for surgery. However, he and his office made it as easy as possible for my family and me. I had an early morning surgery time, so my sister and I drove there the evening before, stayed overnight in a hotel, checked into the surgery center bright and early the next morning. I was discharged same day back to the hotel. My surgeon did request I stay in town overnight, start physical therapy the next morning there before traveling home, but fine to travel after PT.

Surgery. Part of the pre-op process included a very brief tutorial session with crutches since I'd never used them before. I was also given the recommendation not to try using crutches on the stairs once home--rather, sit down and scoot up the stairs. I saw my surgeon before surgery--was able to ask final questions. My burning, final question was how soon I could be in the pool after surgery. (I use being in water as part of total pain management, and past surgeries had disrupted things and made recovery even rockier. So, this was important to me from global management perspective.) Initial response was ~3 weeks, as that gave time to make sure incisions were closed once sutures were removed. Since I wanted to be able to be in water as soon as possible, had experience with being in early, ways to protect incisions, injection sites, etc., I asked if possible to be in sooner if I used Tegaderm or other waterproof bandages. This was conceded to be acceptable. Yay! (But, I also think this is why I was warned against pushing limits later by my surgeon. That question showed my true colors of being a definite limit pusher--something my local physical therapist was already very aware of.)

The surgery itself is the easy part--I slept through it. It helped having a surgeon who is excellent at what he does, who inspired confidence and trust.  I trust him fully.  I was curious about the surgery, but simply from wanting to know what was being done, not because I questioned the surgeon in any way.

I was discharged before noon! Wow! Rested at the hotel, had to problem-solve an effective system for icing. We watched a movie, but I did not remember much. A friend stopped by to visit. I know I woke in the night, but do not recall any major sleep challenges--unlike pre-op. Challenges post-op included I could not move surgical side leg, was completely non-weight bearing. It was hard to get situated in bed, it was hard to get out of bed. I needed help with getting the surgical leg situated. Surprises: I was fully independent in the bathroom! Yay for not needing help! However, I needed help getting out of bed in order to get to the bathroom.

The day after surgery, I was not hungry, but knew I needed to eat. I kept it light but protein dense. I had my first post-op physical therapy appointment. Physical therapy went well and was incredibly helpful! I was given tips for crutches--how to walk correctly with partial weight bearing, stairs tips, etc. I was told it was fine to use my good leg to support and move my surgical side leg. I was given exercises, examples of things to do to help fill in any gaps in surgeon's rehab protocol. I was told how to do quad rocking, allowed to see how low I could get--fully into child's pose! Wow! And, no pain at all! PT let us put my ice packs in the freezer during my appointment, then supplied us with fresh ice for the trip! My discharge info had said to stop every hour on the return trip to get up and "walk" around with the crutches. However, PT told my sister if I was asleep, to just keep driving and let me sleep. We did so. But, this meant I woke after we had just passed a good stopping point, with my hip and leg stiff and sore. I was pretty swollen and uncomfortable by the time we got home.

After surgery, I had a big, bulky bandage, so was not sure where exactly incisions were, how many there were, etc. Bandage made it difficult to ice as well. My discharge info had said I could remove the bulky bandage 24 hours post-op, which was about the time of the PT appt. PT said it did not matter if I left it on or took it off before physical therapy. I opted to leave it on as I figured it was more protection over incisions since I was going to be traveling.  I am also glad I waited as bandage removal was sort of a messy process. One incision had seeped quite a bit. Residual adhesive issues that required scrubbing with rubbing alcohol, rubbing with coconut oil, etc.

Once the bandage came off, I discovered two small incisions, one of which had seeped quite a lot. It was recommended to cover the incision/sutures with bandaids to protect them from catching on clothing. My body dislikes adhesives, so I was reacting to my "safe" bandaids that I had previously tolerated. I was even reacting to the sutures themselves by the time they were removed around two weeks post-op by my local primary care physician.

I was allowed to take a shower 2-3 days post-op. I so badly wanted a shower, but was so exhausted on the first day I was cleared, that it ended up not happening. When I did finally get a shower, it was an exhausting process and required a nap afterward. In fact, everything attempted required a nap afterward. Physical therapy appointments were exhausting...and meant napping once home. I think I slept most of the first week. My existence was sleep, PT rehab home exercises, eat, rest/sleep, repeat. Once I was finally more awake late in the first week, I also discovered I was always hungry no matter how much I ate. I knew recovery from surgery required extra energy, but had not thought about how much more work crutches were as well.

I was prescribed NSAID for first weeks after surgery, non-optional as prevention against heterotopic ossification (abnormal bone growth). I was also prescribed antibiotics as a precaution, narcotic painkiller as needed, anti-nausea medication as needed, stool softener as needed. The NSAID and antibiotic were taken as prescribed. The others were all as needed, and never needed at maximal dose. In fact, I am not certain if any of them were truly needed. Out of precaution after rough recoveries from prior surgeries, I started out on narcotic, but quickly realized I had no actual pain. I was uncomfortable at times, but not pain. This was a pleasant surprise! I had such severe pain pre-op, and had been expecting even worse pain post-op, but that simply was not the case. I am notoriously unpredictable in my reactions to medications, so I was relieved that each of the medications my surgeon prescribed for after surgery, were ones we already knew I tolerated and worked well for me. Thus, no risk of reactions during post-op recovery.

These are a select few resources that I found very helpful pre-op, when learning about surgery itself. My physical therapist and surgeon also received their share of my questions. I am one of those patients who likes to know what to expect as much as possible. However, I also realize that some things are not knowable and I can be alright with that. My physical therapist gave me an idea of what post-op rehab would look like. My surgeon warned me I'd probably rehab slowly. However, I did not know actual restrictions, orders, specific protocol until after surgery. Everything worked out fine.

For reference.
Nutrition info (yes, same link as above because I think it that important!)
Pre- and post-op nutrition (Midwest Orthopedic Specialty Hospital)

Description of surgery (Bart Eastwood, DO).
Part 1 (Overview)
Part 2 (Periprocedure)
Part 3 (Technique)
Part 4 (Medication)

Video of surgery (Viewer discretion warning as this is surgical video, not scope view only. I am not remotely squeamish and I am incredibly curious. I had no issues watching, rather found it fascinating! However, I am aware others may have issues watching.)
Hip arthroscopy video (JW Thomas Byrd, MD)

Copyright © 2018 by Chronic Wholeness. All rights reserved.

Hip Impingement Awareness

Something I have encountered with several of the conditions I have, is a complete lack of awareness, not only among the general population, but also among some healthcare providers. I suspect part of why it took so long to diagnose some of the issues I have is this lack of awareness. I do realize the sheer number of conditions, plus my ability to appear normal further complicate diagnosing and treating things.

Hip impingement and hip labral tears are something I never heard of until within a few months of diagnosis, in spite of having hip issues for several years. It was first suspected by a physical therapist. Primary care physician sent me off for MRI arthrogram and referred me to an orthopedic surgeon.

The MRI arthrogram is a story in itself. I had no idea what to expect. I'd had SI joint injections before, had MRIs before, but not contrast injected directly into the hip joint, then MRI. I asked the radiologist giving the injection what to expect and he said he was not sure as they did not see patients again afterward. Oh, OK then. The injection was no big deal. No pain at all. But, I was told to hold my leg with foot in internal rotation. This is a very strongly disliked (painful) position for hips with impingement, labral tears, so holding my leg in an uncomfortable position was not pleasant. I no longer recall if they let me walk to MRI, or took me in a wheelchair. The MRI was fine, anesthetic from injection actually helped. I was able to walk afterward, but my hip felt funny, so I took the elevator back to main level, but by the time I got home, stairs were no big deal, so got my swimming stuff, went back to work, then to the pool, swam laps--no pain in hip! Back to work, then went for a walk--again, no pain!  Wow!  Getting pretty excited by this point. Well, as the evening progressed, the anesthetic wore off, and my hip got really achy.  I knew very little of the process at this stage, but even without knowing that the effect the anesthetic has is used as a diagnostic tool, I guessed that the hip feeling better, then worse, meant it was the hip itself that was the problem. I did not sleep much that night from hip pain, and the next day was miserable--reminiscent of the absolute worst ever pain I'd in the hip. I was working toward a major deadline at work that week, so time off was not an option. Primary care physician prescribed narcotic painkiller, telling me the first few days can be uncomfortable. Well, the following morning when I woke, I somehow stumbled to the living room, but then the hip simply would not bear weight--no position at all.  I had set my phone down....and managed to get a distance from it, but then could not get back. No furniture or walls between me and it to use for support, could not crawl, just leaned against the couch for a bit trying to figure out what to do. I knew I could not get anywhere, so ER, urgent care, or anything, was out of the question. So, max dose narcotic, ice packs, heat, ice, heat (yes, alternating repeatedly), gently trying to put the hip through unweighted gentle range of motion, trying to find a position it would bear weight. It took me a couple of hours, but finally got to the point it could bear weight well enough to get down the stairs, get to work. I realized that the severe difficulties were a result of not moving all night, as I finally slept with aid of narcotic pain killer. Thus, knew I needed to get the hip moving, keep it moving, to avoid repeat. I stayed on max dose of narcotic entire day, made sure to get up and walk every 20 minutes or so, etc. We got the project finished, and I survived the day! I no longer recall the weekend. I do remember being afraid to go to bed that evening out of fear I'd not be able to walk again the next morning, but that day seemed to have been the peak.  Things very slowly improved from there, but never returned to pre-injection baseline.

First appointment with the surgeon, I had no idea what to expect, what was going on, I was terrified of more surgery as past surgeries had not gone well and I knew this was a big surgery. He explained that the numerous issues with me made it more challenging to sort out what the major pain generator was. To help clarify, he gave me a cortisone injection in the hip, telling me to live normal life. If the injection gave dramatic relief, then the hip was the major issue and surgery likely would help.  If the injection did not help much, then other issues were the problem and hip surgery unlikely to be helpful.  I still recall leaving the orthopedic clinic half hoping the injection would work as I was desperate for help with the hip pain, but half hoping it would not work as I was afraid of surgery.

The injection worked. Incredibly well. But wore off in a month.  I was not ready to schedule surgery, but clearly the hip was a problem. I asked if possible to schedule an appointment to discuss things before deciding--yes. At that appointment, I left confused, but relieved.  Yes, clearly the injection indicated the hip was a problem, but the sheer number of other issues, still made my case uncertain, so he ended up recommending against surgery, and managing with injections instead.  I asked regarding frequency as the first injection was already losing effect.  I was informed no more often than every four months.  This was the plan.  I lived for a year with decently controlled hip pain, reasonable functional ability 25% of every 4-month period--the duration an injection was in effect. That meant 75% of the time I was really struggling, very limited. This clearly was not working.

I finally asked regarding long term management, as I could not manage daily tasks with the severity of hip pain. I was referred to a provider for Active Release Technique (ART), and also recommended to send my records to an orthopedic surgeon in another state for review to get another perspective. However, I was specifically instructed not to send images only, but also medication list, diagnoses list, etc. I was told that if it were only my hip he'd operate, it was everything else that made him concerned that surgery would only cause worsening of other issues. I respected his caution and honesty. I realized that to a certain extent surgery can always be done later. However, once surgery has taken place, it cannot be undone. I was still afraid of this surgery, so desperately needed a surgeon who was confident it would help if I were to get it done. I dutifully contacted both of the recommended doctors.

I gave ART a trial. He suggested biomedical dry needling based on my amazing response to injections. The dry needling proved effective. So, he used a combination of ART, needling, some Graston, etc. for several months. However, after the first few weeks, he asked when my next surgeon appointment was, as in his mind I needed surgery and he was not going to be able to help resolve things with conservative approaches. I mentioned that nothing was scheduled, but I'd been told to send pertinent records to another surgeon.

I collected and compiled enough medical records to tell the story of my hip, included all of the information I had been instructed to include. My primary care physician asked to review, then send from the clinic what I had collected. Then I waited. Nervously waited. Desperately hoping this surgeon in a different state would have pity on my case, think he could help.  I was desperately hoping he wanted to see me, but also still desperately hoping maybe there would be some idea other than surgery. Yet, in the back of my mind knowing surgery was the direction things were headed. I refused to let myself think about it though.

I finally heard back....the out-of-state surgeon thought he could help me! But, he wanted to see me to check things himself, wanted to get more imaging, a diagnostic injection. I was so relieved, so nervous.

The night before the appointment I learned a couple of things. One, if one has taken Ambien every single night to knock oneself out in spite of pain, and one decides to skip a night because of needing to leave very early the next morning for travel, that said person will not sleep at all the entire night due to withdrawal of sorts. Second, with being awake all night, I also learned that both hips hurt at night, not just the severely painful left hip. Oh. I was not mentally ready to consider I had issues with both hips. I knew right had some issues, but it had seemed to calm OK.

This surgeon was thoughtful, thorough, honest, inspired confidence and trust from the start--which I desperately needed by this stage as scared but desperate, had already had one surgeon recommend against surgery. He checked my hip--range of motion, strength, etc., ordered 3D CT scans of my hips, and a diagnostic injection, then rechecked hip range of motion once the anesthetic from the injection was in effect. He also found more even than first surgeon had found. I was diagnosed with femoral acetabular impingement (FAI), subspine or anterior inferior iliac spine (AIIS) impingement. I already knew I had a labral tear, torn ligament (ligamentum teres), ischiofemoral impingement (IFI). Importantly, I was told I did not have dysplasia or version issues. If these had been present, arthroscopy would not have been an appropriate procedure.

The second surgeon agreed I was complicated, but not too complicated, and he felt surgery worth it. He basically told me I'd exhausted non surgical options. Thus, my choice was to continue as I was or surgery. I was clearly not doing well with current approaches. He was honest about expectations--told me I'd probably rehab slowly, that he could not guarantee getting me pain-free or regaining full functional ability. But, he was confident he could give me less pain, better function, and that was all I needed. Long story short, I left with surgery scheduled....and hope. Hope for the first time in years.

Side thoughts. When one has lived with chronic pain for well over a decade, all spine MRIs "normal," one learns to accept pain as part of life and move on the best possible. I automatically took this same approach with the hip.  Once pain had persisted months, I treated it as chronic and moved on. The result was that I quite likely made things worse from not knowing what the problem was, not protecting against further damage. Also, it was oddly relieving to have a positive MRI after so many negative tests. Finally, an explanation for the pain. I was not crazy. There was a real mess inside my hip causing pain.

Surgery. Oh my. Hip arthroscopy to treat impingement, labral tears is a big surgery. I had never had orthopedic surgery before. I had a rocky recovery a few years prior from a simple procedure. All surgeries had rough recoveries for some reason or other. I typically come from a "knowledge is power" mindset, thus read all I could find on the surgery, watched videos--including surgical videos. (No, I am not squeamish.) I asked lots of questions--of PT, others who had the surgery, etc.

I will leave surgery/recovery for another post.  Diagnosis of the hip issues literally took years.  Even once mostly diagnosed, it still took months and a second surgeon to figure out a sustainable plan. There was a lot of frustration during those years, but also lessons on endurance, patience, etc. I will mention that my only regret regarding hip surgery was not being able to get it done years earlier. It was not worth being afraid of, or worrying about recovery. I am beyond grateful I had the surgery.

Image from the arthrogram! I always watch during injections if I can see the screen. I am curious about things, fascinated to see inside the human body.

For reference. Key resources, information I found helpful early on in the diagnostic process. I had numerous sources, but these are a few that I found most helpful.

Description of hip labral tears (Houston Methodist)
Description of FAI (Houston Methodist)
Explanation of diagnostic process, patient selection (Chris Larson, MD)

Copyright © 2018 by Chronic Wholeness. All rights reserved.