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]

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.