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.

Kathryn,

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.

Regards

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".

Progress - so far

A visit to the Out Patient Clinic on 19th August allowed progress to be reviewed with the surgeon.

At a previous clinic I had turned up with a memory stick to see if I could download some recent X-rays. The surgeon had a new wide screen computer monitor and was indeed able to bring up a list of recent x-rays and to display them. I had been sent some old X-Rays that had been digitised some time ago and was familiar with the viewing software so I knew it could export images. The surgeon was happy to try but all we achieved was the creation of a folder on my memory stick.

Since then he had acquired the know how and almost before we sat down he asked for the memory stick so he could provide me with the files. He was disappointed when I said I had not brought it this time but would next time around.

Nonetheless, as before I took a couple of photos with a digital camera and reproduce these . In time I will replace these with clearer images that will be downloaded - but these are clear enough to see what I tried to describe before.


I still had a stitch that had not dissolved and the surgeon was quick and quite keen to remove it in an infection free manner. We then discussed the mechanics of the solution and he was able to confirm that the segments were solid metal and not hollow as I had thought. They were not screwed into each other but instead were mortised into place with a hammer that compressed the dovetail end section into a recess at the top of the piece below.

He was keen also to show off his handiwork so we looked at the X-rays. My wife and I were both pleased that he took this degree of pride in his work.

He was happy for me to try to walk with one walking stick or preferably a single crutch and to start driving. I was not yet to fully weight bear but if all went well would be able to do after the next Out Patient appointment which was booked for 2 months time.

Its "OK 4 GO" in T - 2 months ( and counting!)

Just got back from the follow up Orthopaedic Out Patient Clinic.

The questions were answered after a brief hands on exploration of the right thigh confirmed no apparent infection remained.

A 2nd stage Operation was still on, there would be no need for prophylactic anti biotics leading up to the operation as the joint would probably be cemented and or bone allograft with a cement collar at the junction with remaining bone above the knee. Progress after the operation would be normal ( all being well) and if cemented I would be weight bearing straight away although assisted with crutches/ walking stick(s) initially.

The operation will be scheduled within 2 months in preparation for which I had some blood taken to assess current inflammatory markers (CRP and ESR levels) and will be invited to another pre-op assessment.

The advice about weight bearing was interesting - I was still to work on the assumption of no more than 20% weight bearing. When I asked how can I tell the answer was blindingly self evident - in retrospect - "Stand on some scales with both feet then place the good foot on the ground and put pressure through the bad foot until 20% of the previous weight registers" - Of course - but why is this technique not known more widely e.g. by physiotherapists. Even armed with the knowledge of how to measure a percentage of weight bearing my muscle feedback mechanism is not that finely attuned yet to assess the difference between 10% and 20% so it still remains a very subjective (touchy feely) measurement.

We tried to export the X-Ray image to a memory stick and although the software allowed for this and the consultant was happy to give it a go we only succeeded in setting up an empty folder. Plan B was to take an image or two with a hand held digital camera. You can see the result. Both my wife and I realised that there was significantly more of my own femur in place than we had been told. It now appears that I have just under half of my own femur in place. The surgeon said that they also thought they had been more radical and that it is not easy to judge in the heat of battle (my phrase not his!). I expect one other reason for the inaccurate estimate is that I have relatively long legs for my height another is that they would not want to peel away more tissue than necessary just to get an accurate assessment.

Having said that the x-ray shows the metal rod fixed into the remaining bone and around which a cement version of the head of femur was constructed, so I assume it would have been possible to know how much of this rod had "disappeared" into my remaining length of bone. All academic really I suppose. The metal rod is the important thing here. The cement being formed into a temporary bone was more to store the slow release gentomycin to fight infection and to act as a spacer to stop leg length shortening. It did not matter that the junction between cement and bone was displaced as pressure would be through the rod not the cement.

Preparing for a "Mid Stage Review"

Tomorrow I see the surgeon in his follow up Out Patient Clinic. I will be travelling as a passenger in my own car - driven by my wife - and not the ambulance that was booked when I left the ward over 6 weeks ago.

I will be dropped off outside the main out patient entrance and will use crutches to "walk" the 100 yds or so to the ground floor clinic. I expect I will have an X-Ray on arrival and then wait to speak to the surgeon or one of his staff.

If I can I will try to take a digital camera image of any relevant X-Ray - if only so the physiotherapist has a "clear picture" of the extent of the remodelling in cement of my right femur.

I will go wanting answers to the following questions:

1. Is the 2nd stage still practicable?
2. If so what can be done to minimise the risk of infection next time e.g. prophylactic antibiotics and/or wait a further 2 -3 months to be sure the infection is out of the system?
3. Should the 2nd stage wait until my iron stores and haemoglobin levels have been boosted by the iron infusion course and EPO injections?
4. How will the bone graft be formed into a femur?
5. After the 2nd stage would the progress to full weight bearing be as for any other hip replacement?
6. What should the physiotherapist be aiming to achieve with me in the next few weeks / months?

On a practical level I continue to gain in confidence and in the last week have not only managed to top up the bird feeders, have another steam shower, be driven to renal out patients for an iron infusion but have also managed to ascend the stairs to the converted loft on crutches which means no more "climbing" up the stairs by sitting down. I was even contemplating seeing if I could stand at the lathe long enough to finish off one of the two half completed bowls I started a couple of months ago.

I still notice that my right leg seems happier with my foot pointing out between 45 and 90 degrees. Great if I wanted to be a ballet dancer but otherwise not much use, although it would be the perfect angle for side footing a ball past a luckless goalkeeper diving full length to the left! Chance would be a fine thing!

X Rated X-Rays - not for those of a nervous disposition!

First the good news about continuing progress in terms of mobility. I have now progressed to regular use of crutches instead of the Zimmer Frame. I can now negotiate steps in the garden and have therefore been able to achieve one of the two targets I had not set myself for achievement until well after the 2nd stage operation - to be able to top up the feeders for the birds in our back garden. The other longer term target is to get back to wood turning. I will wait to hear what the surgeon says next week about weight bearing and might even be able to give this a try after the clinic appointment.

At that clinic I will try to take a digital camera image of the current state of my right thigh.

In preparation for that however I was playing about with transferring 94 X-ray images provided on CD by the local hospital in response to a request for personal information in connection with my thwarted PhD studies. (The new digital imaging archive service broke down in the middle of transferring my X-Ray library so I'm not sure how many more there are to incorporate into my lifelong electronic health record but I will find out when I request a further update after the 2nd stage operation.)

I have selected 2 images to illustrate the metamorphosis of my right hip. I begin with an image taken a couple of months before the initial hip revision operation.

It shows the extent of protrusion into the pelvic cavity of the cup placed there nearly 23 years previously. You might note that the left hip joint prosthesis looks altogether in a better state. X-Rays tend to show the view of the observer not the observed - hence the left side will appear on the right of the picture.

The operation to replace this initial prosthesis required the removal of the metal ball and spike and the cement that was used nearly a quarter of a century earlier to secure it in place.(Nowadays most hip replacements are cementless and use sterilised and pulverised bone removed from previous operations to pack the metal spike into the cavity otherwise filled with marrow.) This would be quite normal, however in my case - because of the extent of protrusion - the bone that surrounded the cup (or acetabulum) had to be remodelled with pulverised bone. Like mending a rusty car wing with plastic padding the bone needed to be kept in place until it could graft onto my own bone and a metal grid was used and kept in place with a number of screws. In theory once the bone had grafted successfully the metal cage and screws could be removed - this would not normally happen in practice and would be left in place along with the prosthesis.

So this is the same hip after the extensive remodelling 4 years ago. All of the metal has since been removed along with a lot of the femur and soft tissue that became infected. In time I hope a new metal prosthesis will be in place without the need for any additional metal work. ( We'll see!)

I should explain what the loop is that appears wrapped around the top of the metal head of femur. It is in fact some wire that was helping to keep the surrounding bone at the top of the femur in place! Apparently during the insertion of the metal spike some of the surrounding bone at the top of what was then left of my femur chipped and was cemented back in place and secured with the metal wire looped around. So in addition to the metal spike my right hip had 7 screws a metal mesh and some metal wire to keep various bits in place. All of this metal was removed in the operation to fillet my right thigh nearly 2 months ago.

Although not conclusive the 2 X-rays do point to a difference in the relative lengths of both legs. Slight leg leg differences are one of the risks associated with this type of surgery. My previous 3 operations had not caused me any problems but in the years leading up to the revision I had lost half an inch of length in my right leg (due to the protrusion into the pelvic cavity)and walked with a waddle until provided with a polystyrene wedge to place inside my right shoe. This low tech solution straightened my posture and allowed me to walk with the family without too much pain. It was a pity that it required a referral from rheumatologist to physiotherapist and then from physiotherapist to podiatrist a chain of referral that took 6 months.

After the revision I felt that my right leg was longer than the left. It took about 12 months before this was accepted and I had a prescription for up to 3 shoes a year to be fitted with a half inch wedge to be inserted into the soles to compensate. I will wait until the 2nd stage operation before getting these removed.

The latest X-Ray shows a few inches of femur above the right knee and a "rudely" fashioned femur made entirely of cement with a knob at the end to act as a spacer. (I hope to provide a picture of this in a week's time) As the swelling in my right leg recedes I am becoming aware of the limitations of the knob that was fashioned. When I stand and let my right leg swing free it twists out to between 45 and 90 degrees. When I sit down I have difficulty drawing my right knee toward ny left and when I do my thigh sticks out to the right while my lower leg is bent inwards. I am not complaining as this is both temporary ( I hope) and I was not expecting any kind of fashioning to have been possible.

All in all though now that I am able to get around the house and garden - and further afield as a passenger in a car - I am beginning to contemplate a return to what I have considered normality for the previous 3 years. I did not think that this would have been possible while I was a one hip wonder so I remain grateful for the "emergency" remodelling that the surgeon managed during the extended operation.