Thursday, 25 September 2008

Return of the One Hip Wonder!

After the encouraging progress since the 2nd stage operation I have suffered a set back and now once again no longer have a functioning hip joint!

By way of background here is an email I sent to the orthopaedic surgeon's secretary which explains all except what had had happened at the time. Read on to discover how I found out that the hip had dislocated (2 weeks ago!)  and how this might yet be sorted out.


You very kindly helped me contact Mr yyyyyy in the past during the run up to my recent 2 stage hip revision this year following on going post operative sepsis, for which I am most grateful.

I hope that you will be able to bring the following account to Mr yyyyy's attention and let me know if he thinks I should see him in a clinic before my next appointment which is scheduled for 24th October at 9:15 a.m.

On the evening of 11th September while sitting down I experienced a sensation about half way up the outside of my right thigh which was akin to a spasm or twitch. On standing my balance seemed to be affected. I thought nothing more of it at the time but over subsequent days became increasingly aware that things seemed different from before.

I am convinced now that I have a leg leg differential (LLD) of about minus 2 cms in my right leg. I am using an improvised heel raise inside my right shoe to compensate. If I walk bare foot I need to raise my right heel and and walk on the ball of my right foot. If I place my right foot flat on the floor I dip in height and my left knee bends to accommodate the difference in height.

(On Monday 15th September I collected 5 left shoes which have had the previous raised soles removed. If I was still using the previously raised shoes the difference would be even more pronounced.)

Prior to the "twang" that occurred on Thursday 11th Sept I was walking with my right foot pointed out by about 30 degrees. I notice now that my right foot points to the front.

It appears to me that something has changed and I do not think that I am imagining the difference. I am in no pain other than that associated with the gradual return of sensation along and around the incision line from the last operation. Although reducing there is still some swelling above the back of my right knee which I am able to massage to remove the feeling of hardness which gravity alone seems to create.

I am due to see Dr Kkkkkk, Rheumatologist at Hallamshire on Wednesday 24th September at 10:30 and will share with her my current concerns. I wonder if it would be appropriate in the circumstances to request an X-ray of my right hip to allow comparison with the most recent one, in advance of my next appointment with you in about 4 weeks time. Alternatively would you want me to see you sooner than planned, if that can be arranged?

Having had experience of LLD before I am not concerned about the fact of it and know that if necessary I can manage with raised soles in my right shoes but I do wonder if the fact of a sudden difference is attributable to a tightening up of ligaments and / or muscle ( which might explain the change in angle that my right foot now points) or if it is caused by some movement in or around the prosthesis which might warrant a more conservative approach to rest and weight bearing?

I hope you do not mind me raising this with you. I am happy to wait until my next appointment with you but want to avoid exacerbating any possible cause in the interim if that can or should be avoided.

Thank you.


Although the note was printed out,  the pressure of work meant the surgeon had not got around to looking at it before my out patient appointment with the Rheumatologist

So yesterday morning I caught a bus to the local hospital and arrived in time for my 10:30 appointment at which I shared the above email with the Rheumatologist along with copies of the 2 recent X-rays (which you can see in an earlier posting) and she agreed that a new X-ray was called for. She indicated that an X-Ray review meeting would be held later in the week and she would let me know what it showed. A follow up appointment was made for 4 months and I was given the X-Ray request form, after which I could return home.

I was seen by the radiographer inside 5 minutes and the first clue that I had as to what was going on was when, after the initial X-ray of both hips, 2 more were taken of the head of femur and acetabulum of my right hip. Conspiratorial whispers between the 2 radiographers aroused my fears that the hip joint had dislocated. When they said they were arranging for a wheel chair, to take me to see the doctor again, it was pretty clear what had happened. They could not confirm that the hip had dislocated as this was "best left to the doctor to explain".

5 minutes later I was staring at a very clear picture which showed the round head of femur isolated from and outside of the cup. It had popped out and up. To my eye it was about one and a half inches above the centre line of the socket and about an inch to the outside. (no wonder my balance was affected!) 

In a way it was nice to know and to understand the cause of what I had been experiencing but also a surprise - as I had always imagined dislocation would have been associated with a sudden movement, possibly some noise but most definitely a  lot of pain. Needless to say the image was also quite a blow as I imagined that some degree of surgery would be needed to put this right.

The rheumatologist spoke to the orthopaedic surgeon from another room as her phone was not working so I had to rely on her report of the discussion. The surgeon had said I was to go to a ward at his hospital and they would "pop it back". It sounded like this would be a manipulation and not require surgery at all. The rheumatologist could not confirm this but did agree it was possible.

A taxi was booked to take me home to prepare to get into the other hospital. I had taken a bus to the rheumatology clinic but they were reluctant for me to return home by bus with a dislocated hip - not surprising I suppose. A taxi was arranged. I rang a neighbour who agreed to take me in, I gathered overnight stuff together in an bag and decided not to have any food or drink in case a general anaesthetic would be required. I then rang my wife to leave a message but as it happened she was just finishing a morning clinic and was due to do admin in the afternoon so instead she caught a bus home and I told the neighbour his help would not be required - this time.

When we arrived on the ward suggested by the surgeon we waited about 45 minutes for a bed and eventually a nurse arrived to say that she had tried to contact me by phone so had left a message to say to go to a different ward. She escorted me to that ward and as I was being directed to a bed in one of the bays I mentioned that I had previously tested positive for MRSA colonisation but had the required 2 clear swabs yet understood I should let them know nonetheless. They checked the notes and found that their records only showed the positive test on arrival for the 2nd stage operation, a couple of months before, and they had no knowledge of the clear swabs.  I was told that I would have to wait for a side room to become available. When one did I was just settled in when I was told that I would need to move back to a 6 bed bay as the room was now required for a trauma patient being transferred from another district.

A couple of hours later the surgeon and some of his team appeared and we discussed the plan to manipulate the joint back into place under anaesthetic first thing on the next morning's operating list. We discussed what would happen if this did not succeed and I was pleased to hear that it did not require major reconstruction and in particular that the acetabulum cup would not be touched at all - so weight bearing should not be an issue. A nurse had indicated that the normal practice is to relocate the joint under anaesthetic and then to try to dislocate it again! That way the doctors understand how it could have occurred and can either take some remedial action later or advise on positions and movements to avoid.

The surgeon explained that if manipulation did not work and they felt that popping the existing head of femur back in place would not be sufficient to stop it dislocating again they could always unscrew the current head of femur and screw in place a slightly larger one which of course should be more resistant to popping out. I expect that there must be some trade off between size of ball and weight or degree of movement that is possible but will explore that later if and when I have some direct experience.

Prior to travelling from home to the hospital I "googled" the words dislocation, hip and revision and found an article published in 2002  by the Mayo clinic where over 1200 of their patients, who had revisions, were followed up after dislocation. About 7% dislocated of which 12 had surgery straight away (of these about half remained stable after 2 years and half had become unstable). The remainder of the 112 or so who had dislocated were initially treated by manipulation and of these a percentage later required surgery some later required further manipulation to redress a subsequent dislocation. The summary of the article mentioned that in 2002 not enough was known about the reasons for dislocation other than the generalisation that patients with revisions had more scarring and greater stretching of ligaments etc and that as these settled down after surgery the movement of the soft tissue could cause the joint to dislocate.

In our discussion with the surgeon he confirmed that in my case it was probably scar tissue breaking down that may have caused the movement. I wanted to know for future reference if I could have done anything to avoid it happening or could watch for certain signs that it might happen again in the future and he confirmed I had probably not done anything to bring this about. In a way this was comforting as I would hate to think I had been at all reckless.

As it happens my wife, the surgeon and I were all thinking it was unlikely that manipulation 2 weeks after the event would work and if it did the joint would probably pop straight out again - but this was left unsaid at the time although as you will hear our unspoken doubts were in fact confirmed.

I was visited by the friendly anaesthetist who had been present at the first and second stage operations and he confirmed that I would escape need for the tubes and lines that had been necessary before - as this was to be a closed procedure. It will not be many patients, I suspect who can claim that an anaesthetist has provided by far the greater degree of "continuity of care" but we greeted each other like long lost friends!

Shortly after this I was moved to a side ward again. One nurse holding the case notes had clarified that I had previously tested positive for MRSA colonisation and said it was her "eagle eyed" companion who had "spotted" this. I remember seeing a red sticker on the front of the case notes with the word "infection record" on it and had assumed this is how the fact would be drawn to the attention of staff. I was however surprised that someone could be congratulated for spotting this.

I have previously commented on the NHS being like a relay team with the best individuals but little training in handing over the baton. Well here are 2 examples. The fact that I was cleared of any colonisation was not reported back to the people who had initiated treatment so they had to assume I was not clear "because their records did not show this and they could not take my word for it" - fair enough. But, to add insult to injury, the mechanism for drawing attention to the fact someone posed an increased risk was not sufficiently clear for it to register without someone being congratulated for spotting it!

I am not going to raise this with the infection control coordinators as they seem to have enough to be getting on with after my last reflections on the difference between rhetoric and reality of infection control but at some stage in the future I will try to take this issue forward.

Being admitted as an emergency I had to wait till 12:40 the next morning for the junior doctor to see me and take a history including signing me up for medication. I had written this down for the rheumatologist so had that note with me which I handed over to the junior doctor along with recent blood test results. This saved a lot of time so I was able to get off to sleep about 1:00 a.m.

However I must admit it took a little while to get off to sleep as I  reflected on what I had  observed with a 100 year old lady in a bed opposite me while I was in the 6 bed bay. 

She needed hip surgery (probably following a fall and a fracture) . She had been seen in the morning and seemed fit enough for surgery but later in the day she was developing fluid on her lungs. She was receiving oxygen through a mask and had apparently been catheterised. In addition she had a cannula in one arm, connected to a line (probably saline) but through which she could have injections administered. She was obviously confused and distressed. She called out for nursing staff who, as is often the case were busy passing through on one round or another and could not easily stop to provide the comforting words ( and touch)  that she needed. My wife at one time spent some time with her and afterwards I and a fellow male opposite her would try to call for a nurse or try from our beds to calm her down. When nothing happened she would look from one of us to the other silently mouthing words we could not hear and stretching her arms out as it pleading with us to do something to help her.

I overheard a discussion between 2 doctors after one failed to get her consent to have another cannula fitted prior to contrast medium being injected before going for a scan. They had ascertained that she knew where she was and why she was in and therefore she was fit to give consent which she was withholding so they had to respect her wishes.

For the best part of an hour  she continued calling out saying in a most plaintiff manner "please help me" and looking around for anyone to respond. She became increasingly desperate and tried pulling lines out and rolling back the bed covers which seemed to be uncomfortable. What really got to me was that she must have lost touch with where she was and why she was there because she resorted to saying "please help me - I'll tell you anything you want to know just help me - I'll give you names and addresses if you want , yes I can give you names and addresses!" I'm sure she must have thought she was being tortured!

She was calmed down when a senior nurse spent a few minutes with her talking calmly and stroking her hair but a few minutes later deprived of this degree of human comfort she was again distressed. Her escalating anxiety was only suppressed after she had a shot of morphine administered through the cannula in her arm. It was interesting in a way to her gradually quieten down and then fall asleep. She lay asleep and at peace but in what looked like a very uncomfortable position. She was in this condition when 2 visitors arrived and were informed of her "progress" they were told she had refused the further cannula and in answer to a question was told it probably would not affect the operation to fix her hip which would probably proceed.

I have no way of knowing what will happen to this lady but cannot help thinking that the chances of her having a successful outcome and walking again free of pain are very slim. She is now bed bound and not exercising, her lungs are filling with fluid, because she is not having a scan the doctors might not be able to ascertain the extent of the problem so she will remain at risk under anaesthetic. 

The experience confirmed me in my desire not to have my life end like that - if I can avoid it. Not that I expect to be around till I'm 100! Three score and ten remains a very optimistic score for me but I am convinced that the discussion of NHS priorities needs to move beyond the emotional "saving of lives" and be replaced with "deaths deferred". Perhaps once that happens less  attention will be given to the length of life and more to the quality of one's death. The World Health Organisation's mantra of "adding life to years as well as years to life" and the trade off between "cure and care" sum up this need for a more mature discussion of what the NHS is and should be about.

Returning now to the procedure itself. I was wheeled to theatre reception area around 8:40 a.m. I was transferred to a trolley and wheeled into the anaesthetic room about 9:00. I had a single cannula inserted into the back of my right hand through which I was injected with a sedative. I remember the senior registrar introduce himself again and ask for muscle relaxant ( The surgeon was in London and I knew the Senior Registrar would be in charge but that he could call on the asssitance of another consultant if necessary). I guess a little while later the sedation kicked in or was augmented so I was unaware of what happened until recovering outside of theatre. The friendly anaesthetist informed me that it had not been successful and I then overheard a discussion between him and the senior registrar to the effect that I would be on the list next week for "surgical reduction".

I was back on the ward by 10:30, had been in theatre about 40 minutes (it was thought I would only be there for about 15 minutes) and by 11:30 was ready for food and drink which duly arrived at lunch time.

I was discharged at 4:30 p.m after speaking to the senior registrar who confirmed that it was not successful and that I would be asked to come in next week for an open procedure. My wife and I fired many questions at the guy who was confident that next week he would only need to make a small incision and would pop the joint back in and as a result I would not need tubes and lines, should be able to weight bear straight away as they would not reconstruct the socket at all and I  would probably be discharged home after a few days.  If necessary he would fit a larger ball to the end of the femur but that would not require any further cutting of tissue.

He confirmed also that the manipulation relies on brute strenght and that he and 3 others tried, including the consultant from an adjacent theatre and despite being drenched in sweat they could not relocate the joint. When he phoned his boss in London and told him the news his response was " I didnot think it would" - so we all thought the same but didnot say it - it was worth a try but the best chance of success is straight after dislocation while tendons etc are still loose - not 2 weeks later and after driving 300 miles from Cornwall, followed by climbing stairs, driving around town, getting on and off buses and ( no small feat in itself) walking from the hospital bus stop to the rheumatology department (up a steep hill and some distance away)

I have one more observation to make to round off this tale of woe. On the way out of the hospital , getting into a lift,  I passed a gentleman also using 2 elbow crutches but with a metal cage running on the outside of his right leg. In the lift we compared notes and he said that he has already had 5 operations since May this year. He originally came in for a minor operation on his knee (probably keyhole removal of debris from a cartilege - or similar exploratory examination) but his knee became infected so he has had repeat visits to theatre to clean it out and repair the damage to his knee. He explained that he cannot bend his knee now without using spanners to adjust nuts on the bars that are screwed into his leg in at least 8 places. I noticed a spring running on the outside of his knee which probably keeps the required tension while he gradually "undoes" his knee to bend it when sitting down. 

Despite my own problems 2 things help me retain both a sense of proportion and optimism (most of the time) - the first is "this too will pass" (a much more succint expression of Kipling's If you can treat those imposters of success and failure as the same) and "however bad you might think things are - there's always someone worse off than you". I guess I did not expect the second of these to be so well demonstrated getting into a lift on my way back home while I wait for "only" my 4th operation of the year! 

As a result of this latest chapter in the saga, I can retrace my steps (or should that be hops) and  once again am able to live down to the claim of being a "one hip wonder".

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