One year hipaversary

One year ago today Dr Mayo surgically dislocated my right hip to clean up some damage (torn labrum, remove a sort of spur on the femoral head, and shave down the femoral neck). Five days later he performed a PAO to align my hip socket in order to make the joint last longer.

Much has happened since then, and now it's all done. PT ended in August, and I won't see Dr Mayo again for another year. When I left Mayo's office, I was saying goodbye to new friends.

Everything looks good. I neglected to get copies of the x-rays from my last appointment a few weeks ago, but they look the same as the final x-ray from my cleanup surgery, so here you go: before and after. Notice the cloudiness around the joint is gone.

Before

My range of motion is good--less than before, but pretty good. My hip flexion (bending forward) is still a bit limited, but it does bend a little more than 90˚ so it's good enough. The joint itself feels great, better than the left side (which recently has started hurting), but there is still some tightness to work out. I can sit cross-legged but not for too long. A patch of skin the size of my hand between the incisions is still numb. And thankfully that rash has not returned.

After

I've done quite a bit on my new hip since the cleanup: walked all around the San Diego zoo, hiked 5+ miles in a stand of old-growth fir in the Olympic mountains, and biked a few miles on the road and many more on the trainer. Driving feels mostly normal, but I do have a bit of trouble moving my leg to position my foot when switching between the accelerator and the brake, and I can't sit as long as I used to.

The next major thing I'll do with my new hip is move to Pittsburgh for my new job.

A lot of water has sure gone under the bridge in the last year! Thank you God for taking such good care of me--and Krista!

Ectopic bone

So you wanna see what ectopic bone looks like after it's been "morselized"? Here is a picture of what Dr. Mayo removed. He said there was actually more; some had already been taken before he told them to get a picture for me.

Looks like stew meat, or a tasty treat for Fido.

Post HO-removal two-week followup

Monday we went in for a two-week follow-up. Renee and Dr. Mayo checked my incision (looks good), peeled some of the glue off, clipped the ends of the sutures (Dr. Mayo used nylon instead of the dissolving kind this time, in case it was causing skin irritation), and checked my range of motion. I get close to 90˚ flexion, and rotation is improved, though significantly less than my left leg. I have a lot of stretching to do, to make up for almost eight months of relatively little activity.

To the right is a picture of the screws (or replicates) that Dr. Mayo removed. The two little ones were replaced (I think in my iliac crest), so counting the two in my trochanter from the SDH surgery I still have four screws embedded.

Since I'm active again, Renee said I could ditch the TED hose and the last three Fragmin shots. I'm still on meloxicam until I finish out my 30-day supply.

I got orders for PT, with the same no-straight-leg-lifting and no-active-abduction restrictions, until my next appointment four weeks from now. Dr. Mayo gave the OK to drive if I feel safe. Best of all, he said I could ride my bike on the trainer, but not to power with my right leg.

So last night, for the first time in about eight months, I set up my bike in the kitchen and went for a ride. It was a challenge to get on the bike, since it's a road bike (and therefore tall) and mounted on the trainer it's a couple inches taller. I ended up stepping on a chair to get high enough to get into the saddle. But once I got on, boy did it feel good! Very natural, enough that I had to be careful not to power through with my operated leg. I tried to take it easy and just spin, and ended up riding 11.5 miles in 45 minutes. My cardiovascular conditioning is weak; even though I was taking it very easy, after 30 minutes my stamina was dropping fast. I don't think I overdid it because today my hip feels about the same as it did before I rode. Very encouraging!

My hip is already much more flexible than before the HO removal. It feels tighter than before this surgery but is loosening more and more each day. I fit behind the steering wheel much more comfortably than before, but I'm not quite 100% because the no-straight-leg-lifting restriction and the corresponding weakness of that muscle make it hard to lift my leg to move it between the gas and brake pedals. But good enough that I'm driving the boys to school in the mornings.

The swelling has gone way down, to the point that my operated hip looks about the same size and shape as my other hip.

I continue to be amazed at how little pain I've had. I haven't needed to take anything, or even thought about it, even in the hospital. I'm eager to get past all the post-op distractions so I can get a sense for what it's going to feel like long-term.

Thank you God for such a smooth recovery!

Days 1-3 post HO removal surgery

For those of you who are interested in all the little details:

My time in the hospital was uneventful (if you can call being flayed and chiseled, then screwed, sewn, glued, and taped back together uneventful). The most remarkable thing to me was how relatively little I hurt. I didn't take any pain medication by choice during the four days I was in the hospital, and other than during the surgery itself I was only given pain medication three times: one hit on the PCA to test it after they hooked it up (2 mg dilaudid), two Vicodin the next day before PT came at the insistence of the nurses, and two more Vicodin the following day at the nurses' insistence (though PT didn't end up coming until nine hours later, when it was probably no longer effective). The next day I insisted I didn't want anything, so I haven't taken anything since the third day.

So what did it feel like? Of course right after surgery I was in a fog with all sorts of sensations, including nausea for a few hours (puked once). But after that wore off, I didn't hurt much just lying in bed. When I had to move I felt very sore but I didn't have that bundle-of-dry-sticks feeling of fragility inside my hip like after the PAO. Standing up I could feel a lot of muscle soreness and exerting the muscles was somewhat painful. But the muscle pain diminished noticeably every day.

The first time PT came they sat me on the edge of the bed for a few minutes, then stood me up. Cumulatively I was upright for about five minutes before I began to feel light-headed, which was a big improvement over last time. Opting out of the epidural was a good call, since the epidural made me very light-headed (it results in the blood vessels in the legs enlarging, causing blood to pool in the legs, with the result that not enough blood is left in the head). I experienced some light-headedness one other time, but that was all. I think it was the second day that I got up to use the toilet, and felt so good that I went to the sink to wash my hair and generally wash up, 20 minutes or so, all under my own power. We were very encouraged by that.

Lying in bed got to be uncomfortable. The second or third night I got tired enough of lying on my back that I worked my way out of the CPM machine and onto my non-operated side, where I slept for an hour or so. That made a big difference.

The regimen is very much like for SDH and PAO:

• green leg from surgical scrub (including Margie washing it off herself again, surprised that no one else had)
• TED hose
• Plexi-pulse
• CPM machine
• two surprisingly long drains hooked up to a Hemovac (came out the third day, I think)
• catheter, out when you're ready (the second day, I think)
• IV drip
• PT once a day
• blood draws in the middle of the night
• daily Fragmin shots
• no straight leg-lifting and no active abduction
• Dr. Mayo and/or his PA popping in once or twice a day

I did lose a fair bit of blood, enough so that they hooked up a cell saver during surgery and recycled 600 ml of my own blood, but I did not receive a transfusion. I ended up getting three bags of IV fluid (3 liters) before they unplugged me, which was enough to make me puffy but not to the point where I felt like my eyes were bulging, like last time. I felt a quart low or so; the first few days after surgery my blood pressure was low (90s over 50s) but eventually came up to 110 over 70 or so.

Even though I wasn't using the IV the last two days, the nurses still wanted to keep it in for quick access should the need arise, so I ended up having it in until the morning we left.

Dr. Mayo said that normally after re-opening an incision he would excise the scar tissue before suturing it up again, but he decided not to. Perhaps my skin was damaged somewhat by using steroid creams for months on the dermatitis. In case my skin was reacting to the kind of suture he used last time, he used nylon, the ends of which are hiding under the tape. So maybe I'll end up with a killer Frankenstein-style scar.

(You can see the effects of the dermatitis in the brown, pigmented splotchy area near the visible drain hole in the picture to the left.)

Dr. Mayo had me on a hip CPM this time, which I liked much better than the knee CPM. It was much easier to get in and out of, and it didn't rub my heel (last time I got an especially nasty pressure sore on the heal, in part because of the rubbing). My hip felt tight as the machine approached 90˚ but it was not painful.

In addition to radiation therapy I'm on Meloxicam, in pill form once a day after breakfast. It can have some nasty side effects and needs to be used carefully in conjunction with anti-coagulants like Fragmin. I'm eager to get off both. I've been having headaches the last few days and am wondering if the Meloxicam might be to blame.

Krista and I both really enjoyed seeing our old friends from last time: Kim, Stephanie, Pat, Margie, and many others. Thankfully I was a lot less work than last time, and we didn't have to share so many awkward and uncomfortable moments.

And of course Dr. Mayo and his new PA Renee were excellent. Dr. Mayo is careful and meticulous, two excellent attributes in a surgeon, which is why surgery was 5.5 hours (incision to suture completion, according to my chart). We always enjoy talking to them. Again, everybody in the hospital had good things to say about Dr. Mayo.

Thursday morning both Renee and Dr. Mayo came by to check on me one last time and gave the thumbs-up to go home, and by 11 am, after a stop at the hospital pharmacy, we were on the road.

Day 1 radiation therapy

[Flashback to the day of surgery, to fill in details on radiation therapy for those interested]

The morning of surgery, after checking into surgery pre-admission and changing into the lovely gown, we waited for radiation therapy to call. Finally about 7:30 they were available so a couple of nurses wheeled me and Krista down to radiation therapy--the long way. Neither nurse was sure how to get there with all the construction and rearranging that's been going on, with misleading signs thrown in for good measure. 

After 20 or 30 minutes we finally arrived. The radiation tech was clear, concise and assured us that we're in good hands because she's been doing this 20 years. She briefly showed us the plan on a computer monitor and then wheeled me into a large, open room with a concrete floor, various machines, and green laser beams criss-crossing in places. The machine they were using on me was much less intimidating than a CT or MRI machine, but way more dangerous.

Seeing a sizable chunk of lead on the platform I'd be lying on, I chuckled, and the tech said she'd explain that.

She told me that I would be receiving a single dose of radiation, a blend of five kinds of photons, X of something else and Y of something else, 700 centiGray's worth (absorbed, I think).

Next I get up on the platform while the tech and her assistant graciously give me the room while I employed the lead cup in the fashion they described (though I suppose they were watching on camera). They return, propping up my knees with a slab of foam, hooking my feet together with a rubber loop so I don't slip out of position, and then they line me up under their laser crosshairs. Satisfied with my position, they tell me to hold still and depart the room to run the machine.

First the machine does some calibration, taking a quick image from above and then one from below to make sure they align properly. Then the actual radiation bath began, bathing my front and then the rear. I think this stage was only a couple of minutes. While this is happening I could see these metal shapes inside the emitter head (or whatever it's called) shifting themselves into the shape that I saw on the computer monitor earlier.

And that was it. I freed myself from the lead prison (let's hope it worked) and then was wheeled back to the fifth floor for surgery.

Four tattoos and ectopic bone

Monday I had a CT scheduled for the radiation oncologist to use for targeting the radiation treatment he'll administer on surgery day. (This single dose of radiation is to suppress additional ectopic bone from forming after this next surgery.)

But the lingering dermatitis on my skin has been threatening the April 26 surgery date. It finally started to go away, so I stopped using the steroid cream, but the dermatitis returned so I'm back to using the steroid cream twice a day. The big question around here the last month or so has been, will it clear up enough for surgery?

Monday before my CT appointment Dr. Mayo carved out a few minutes from his schedule to take a look at my skin. I definitely did not want to absorb the extra x-rays for a CT if we weren't going ahead with surgery on the 26th. But thankfully it has cleared up enough for him to cut. He thought surgery was scheduled for the following Wednesday two days later, but was relieved that he'd have another week to think about how to get at all the ectopic bone. He's hoping to get it all through the PAO incision, but that may not be possible, so he might have to make yet another incision. I'm glad that in a situation like this that's not cut-and-dry he has three decades of experience to draw from.

So I went ahead and did pre-op with Dr Mayo's new nurse Renee and then had the targeting CT done.

The targeting CT gives the radiation oncologist the information he needs in order to plan how to administer the radiation. The tech marked the outside of both hips with crosshairs, plus another in the center near my waistline, and another near my belly button. Then she gave me four tattoos in the center of each crosshair--just a dot made by needle prick. She next taped BBs on each crosshair so the reference points would show up on the CT. Once that was done it took another five minutes or so to get the CT.

So everything's in place. The insurance company pre-approved the surgery. I won't need to bank any blood this time, nor do they have me taking iron. I also won't need to shower with that nasty hex-something-or-ever stuff the night before and morning of. I'll be on a CPM machine at the hospital, will leave on crutches, wearing TED hose and two more weeks of Fragmin to minimize the possibility of clotting and stroke, but when I return home I'll sleep in my own bed instead of a rented hospital bed, and won't need a CPM machine at home. I don't know yet whether I'll need a commode or shower chair again. I'll be on a no-straight-leg-lifting restriction for four weeks, and then I can resume PT.

I'm skipping the epidural, as wonderful as it was last time, in favor of PCA in hope that I'll be able to get back on my feet sooner, which will help the swelling to subside quicker and keep my bowels moving, unlike last time. I'm guessing it'll hurt more than the perfect epidural I had before.

Krista will stay with me for the three or four days I'll be in the hospital. We'll try to update the blog as things progress.

Thanks for your prayers!

[update: added photo]

I'm all screwed up

Three appointments this week: CT scan, consultation with the radiation oncologist, and an appointment with Dr. Mayo.

The CT scan was so Dr. Mayo could see how extensive the ectopic bone formation is. The consultation with the radiation oncologist was to prepare me for getting zapped around the time of the surgery to prevent new bone growth. And the appointment with Dr. Mayo was for him to analyze the CT scan to decide how he wants to go about harvesting all the extra bone. ("Harvesting" is an appropriate word considering I'm what they call a "bone farmer.")

I also brought home some pictures. First is an x-ray (taken probably in January) that shows some of the ectopic bone. All nine screws and five of the seven suture pins are visible. If you mouse over the image you'll see the ectopic bone highlighted in red, the small suture pins in green, and the screws that Dr. Mayo is going to remove in blue.

The other picture is a slice from the CT scan which shows a chunk of bone blocking the front of my hip. Mouse over to see the ectopic bone shaded red.

There are more images, but they're harder to read. The CT scan shows the extent of the ectopic bone much better than x-rays, and it turns out it's more extensive than was evident from the x-rays. It's going to take some doing to get at all the bone. Dr. Mayo is hopeful he can get at it through the front PAO incision, but it's possible he might need to go back in through the SDH incision (including slicing the trochanter again, etc.) or even a posterior incision, and possibly open the hip capsule.

So instead of this being a shorter surgery scheduled in the afternoon to fill out the day's surgery docket, this will have to be the main surgery for the day.

I'll probably be in the hospital three or four days, which seems a breeze after almost two weeks last time. Although I had a perfect epidural last time, I'm going to forgo it this time in order to get back on my feet and moving quicker. Epidurals cause the blood vessels in the legs to open up, with the effect that blood washes down and pools in the legs, which made me pass out when sitting up. The sooner I'm up and moving, the better to help the swelling go down and to avoid another ileus.

Speaking of ileus, Dr. Mayo said that mine was the first true ileus he's seen in a decade. He thinks it was likely caused by having an epidural for so long (I think it was eight days, starting with the SDH and continuing to three days after the PAO).

Next up is another CT scan April 19th for the radiology oncologist to use to craft his radiation plan, followed by surgery on the 26th. For four weeks or so I'll be back on the no-straight-leg-lifting restriction, and then I can start physical therapy for real. I can't wait to get back on my bike! And Krista's probably ready for me to start driving again.

My dad's praying for a bone-eating enzyme to clean things up so I don't need radiation or surgery. That'd be nice!

Dermatitis gone, next steps toward surgery

Dr. Mayo sent me to a dermatologist to check on my dermatitis just in case. He prescribed the same treatment as Dr. Mayo--topical steroid cream a couple of times a day. I continued to do that and the dermatitis has finally cleared up.

Last week I had a follow-up appointment with Dr. Mayo. He's satisfied that my skin has cleared up enough to take the next step toward getting the ectopic bone out. He checked my range of motion: it's still around 50˚ flexion, 5-10˚ internal rotation. He doesn't see a point in continuing to see a physical therapist at this point until he cleans that ectopic bone out.

The next step is another CT scan to map out the ectopic bone, a month from now. I'll also have a consultation with the radiation therapy folks regarding the single, low-dose of radiation they'll give me at my next surgery. Then I meet with Dr. Mayo to see what the CT shows. Thankfully, all those appointments are scheduled for the same day.

Then a month or so after that--likely sometime in April--Dr. Mayo will go back in and remove the ectopic bone and most of the screws. I have nine screws in my right hip, and seven suture anchors. The anchors stay, but I think he can remove as many as five screws through the PAO incision; two will be replaced as he'll need them to secure a chunk of bone that he needs to remove and replace again. If he needs to reopen the SDH incision to get all the ectopic bone then he'll remove the two screws in my trochanter. So best case I end up with two screws remaining.

Keri located some more x-rays (intra-op from the PAO), but we have yet to find the digital photos for the SDH. Evidently the machine that handles those doesn't talk to Multicare's network, so a radiology person has to upload them manually. She's doing her best to track them down. I'm very curious to see them.

My hip feels pretty good, considering. The joint doesn't hurt, just the tight muscles, and of course my range of motion continues to be limited. I still can't drive comfortably. But some things that hurt before surgery don't hurt now, and my hip no longer aches when I lie in bed at night. It really is amazing to think that the body can sustain such trauma and heal so well. Of course it helps that the trauma was intentional and therapeutic.

I can't say enough good about Dr. Mayo. I'm very grateful to have such a capable, conscientious hip virtuoso working on my hip.

Week 8: full weight bearing, a speed bump

[Warning: long post]

Much has happened since my last post! Tuesday by chance we got to meet Terri, another of Dr. Mayo's PAO patients who has been super helpful. She was in for her pre-op appointment before having a PAO on her other hip--four months after a PAO on her other hip! She had the ideal recovery from her first PAO, the best recovery story I've read. She's recovering from PAO #2 as I write this, and so far it sounds like it's going as well as #1.

But I'm getting ahead of myself. An update on the last three weeks: relatively uneventful. My hip has felt solid the last few weeks, like the bone has fused enough for it not to flex when I move this way or that. I can roll onto my non-operated side in bed and lie on it for some time without too much discomfort. I can do just about everything myself, including getting in and out of the shower, getting all my clothes on (except for my right sock if it's tight). My right gluteus maximus is on vacation--it's just flat. My incisions have healed well; to the right is a picture from about a week ago. The pressure sores on my heels are basically healed.

Tuesday Krista drove me in for my eight-week follow-up appointment--eight weeks from my SDH, seven weeks from my PAO. It was good to see everyone in the office again.

First they sent me off to get a bunch of x-rays next door. One x-ray required me to spread my legs a bit and turn my toes inward, to rotate my femur inward as much as possible, but I wasn't able to rotate it at all. I was hoping that was just due to muscle atrophy, since I've been very careful to observe Dr. Mayo's restrictions.

Then back to the office. Sara came in with the x-rays and slapped them up on the light box for us to look at. All those bone cuts have healed well. There remains a little gap where the top cut above the acetabulum was made but it will close up. The trochanter cut for the SDH seems to have healed perfectly. Nine screws of varying lengths and seven suture anchors are visible on the x-ray. (I'd put up pictures but for some inexplicable reason the IT department didn't allow an orthopedic surgeon's office to run DICOM software which would allow them to view the x-rays!)

Dr. Mayo also patiently answered a bunch of questions about the repairs he made. If I understand correctly, the labrum was torn pretty much all along the front of the acetabulum, which is why seven suture anchors were required to sew it back. He's confident that it has/will reattach itself to the acetabulum. I'm guessing this was caused by the thickened neck of the femur impinging on the retroverted acetabulum. He also trimmed down the neck of the femur to minimize impingement (see the illustration at the beginning of this post).

There was also an apparent lesion near the top of the femoral head. One doctor diagnosed it as osteochondritis dissecans. It looked like it might be a little divot. But what Dr. Mayo found was a small bump on the femoral head that also scored the surface of the acetabulum. He performed an OATS procedure, removing a 10 mm plug of bone and cartilage where the bump was, and transplanting a plug of bone and cartilage from the edge of the femoral head, where the cartilage is less crucial. The plug is press-fitted and the bone should fuse with the surrounding bone. That should stop the damage to the cartilage in the acetabulum.

Dr. Mayo expects my hip should last at least 10 years, maybe more, but he thinks I'll probably need a hip replacement someday. I would be very grateful for 10 more years; it would definitely be worth it.

But the x-ray showed some bad news too: ectopic bone has formed in front of my hip socket, where I was opened up, enough to severely limit my range of motion--Dr. Mayo estimates I have a range of motion of about 20˚ before the ectopic bone starts impeding movement. As I understand it the bone is not what we normally think of--like a solid chunk--but is rather bone cells interwoven with the muscles. Evidently when these cells are traumatized by something like surgery they can differentiate either into scar tissue or fibroblasts, or they can differentiate into bone.

The treatment is another two or three hour surgery. The approach would be the same as for the PAO, and would require detaching a couple of muscles again. Dr. Mayo would hack out (he prefers the term "morselize," borrowed from spinal docs) the ectopic bone from the surrounding tissues. Recovery would be much easier, since I would still be able to bear full weight, but I would again be restricted from lifting my leg straight up while those muscles re-anchor. While he's in there, Dr. Mayo would remove most of the screws. By my count four would stay: two to reattach one of the muscles he detaches by chiseling off a chunk of bone (because bone-to-bone heals better than muscle-to-bone); and the two in the trochanter, since those would not be accessible through the PAO incision.

Shortly before surgery I'd get a single dose of targeted radiation to the area, to preemptively inhibit the cells that would want to turn to bone after this surgery. Evidently I'd need another CT scan before then to help the radiology/oncology guys do their targeting.

Surgery would happen sometime after the four month mark. The bone needs that much time to mature in order to be able to differentiate it from the surrounding tissues. In the meantime, I'll stay busy with PT, limited by my range of motion. Dr. Mayo said there's no point in trying to force it; I'd just make it "angry."

Before these surgeries Dr. Mayo told me that the likelihood of this happening was increased because we were doing two surgeries close together, so it wasn't a total surprise. Had we known how everything was going to turn out we might have done the two surgeries six months apart, but then I would have had two long recoveries rather than one.

But all this ectopic bone is just a speed bump (no pun intended). The important part is that the repair appears to have been successful.

So now I'm trying out my new hip. I'm limping around the house with one crutch reasonably well, better the more weight I put on the crutch. Without the crutch all I can do is lurch around, almost hopping on my good leg. I have PT orders so I'll need to find a physical therapist and get busy.

I'm very grateful to God for how he's working in all this. And I couldn't be happier with the care Dr. Mayo and Sara give.