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'messed up hips' - dual impingements, bilaterally- surgery in June

grumpy231

new member
Joined
Mar 31, 2024
Messages
9
Age
40
Country
New Zealand New Zealand
Gender
Female
Hey all
I've had a very long journey to get this point, and i'm on the home stretch till my first surgery, but am struggling. I've just found this site and It's reassuring being able to read others posts about their journeys and know that I'm not alone.

I have been diagnosed with: ischiofemoral impingement, femoroacetabular impingement (socket too deep), labral tear, trochanteric bursitis, deep gluteal syndrome (trapped/stuck sciatic nerve in glute area), and also a problem with femoral version, (although this is just within the limit of not having to operate on, although apparently it will be making the other things worse) I have all of this in both hips. I also have inflammation in my si joint on one side, and a fusion has been reccommended, but we hope that once the hips are sorted, this will improve.

I have laparoscopic surgery booked in june and october (one hip each time) and i'm struggling with pain and mobility with 3 months to go. I nearly cried when they said it would be a 6 month wait for the first surgery, and i'm terrified that there will be some reason it will have be delayed for another 6 months. I'm not even sure how I will physically manage another 3 months.

I cannot go for a walk, and cannot even walk in the pool now, though can swim...when our small local pool is open.

It's been a fight to get diagnosed after being told for 6 years that I just need to 'do pilates' and the eventually being referred around a selection of specialists with a 6 month wait time each.

In the last year I have also been diagnosed with insulin dependent diabetes and have been struggling with not being able to 'pop out for a walk' ( or even hang out the washing) to improve my blood sugar.

I feel broken, and i'm trying to give myself permission to be 'broken'. I keep thinking am I really in this much pain? , and then do too much and end up dry retching (which is apparently my bodies cut out switch). I doubt myself because of all the previous doubt from doctors, and because I cannot see this (ie not a visible problem), and feel too young to be clinging on to a shopping trolley at the supermarket with barely anything in it.

I feel stupid having to choose either to do chores and be non functional for days, or recline in bed and be dysfunctional anyway.

Apologies for the rant. Has anyone else here got the ischiofemoral impingement? I've heard its reasonably rare.

T
 
@grumpy231 It is important to feel that you can express your feelings to others who have shared some of the same experiences. I felt the same way when I began my journey and this forum greatly helps us to mentally cope with life's curballs.

Sorry you are having a rough go of it. I can understand how the contributing problems you indicated can make your condition more difficult to deal with. There are a few people on this forum who have some experiences with ischiofemoral impingement aleviation @Krista if you enter into the search bar top right.

It's ok to rant... that is what we are here for too:)

:welome:
 
HIP Pre-Op Information and Guidlines

If you are at the stage where you have joint pain but don't know for sure if you are ready to have surgery, these links may help:
Score Chart: How bad is my arthritic hip?
Choosing a surgeon and a prosthesis
BMI Calculator - What to do if your surgeon says you're too heavy for joint replacement surgery
Longevity of implants and revisions: How long will my new joint last?

If you are at the stage where you are planning to have surgery but are looking for information so you can be better prepared for what is to come, take a look at these links:
Recovery Aids: A comprehensive list for hospital and home
Recliner Chairs: Things you need to know if buying one for your recovery
Pre-Op Interviews: What's involved?

And if you want to picture what your life might be like with a replaced hip, take a look at the posts and threads from other BoneSmarties provided in this link:
Stories of amazing hip recoveries
 
To Grumpy231
So sorry to hear you are in this situation and one so young . Your thread reads like a mirror image to some of my symptoms, although some of my symptoms actually appeared after my THRs . It’s tough I know as I too had back surgery at 40+45 years old and was robbed of my life years following. I digress slightly!

Eventually I regained better mobility and was able to sit and travel more comfortably by the age of 60! Only then to be confronted with two major gyney
Surgeries . Those out of way and having a better quality of life , I then had a blunt force trauma at 70 years old ( fell on my the back of my pelvis on a chest of heavy draws).
And since then life has been really miserable. As a result of the fall I had hip impingement for about six months followed by two hip surgeries . SI joint pain,
In fact was worse than sciatica as the whole of my buttock and perineal area felt like ground glass cutting into flesh and many nights i could not go to bed but was roaming around the house in pain with no way of being comfortable either to sit or lay on my front or back . Not much mobility , limping pain etc;

I too have deep gluteal pain problem now and wonder if I have trapped nerve in buttock from the fall . I have had quite a few cortisone injections since then mainly in SI joint , which incidently enabled me to get through hip surgeries as one has to lay on back for recovery , and would have been impossible without the injection . I am shortly to have another one for gluteal pain, but it will be in SI joint again .

First hip surgery left me pretty bad and I am nearly five years on now and am finally getting a third opinion relating to not being able to use my leg , I can walk ok now on it now ( Took a few years though and was also hampered by 2nd hip surgery) but can not lift my leg or do straight leg raise and is very uncomfortable turning in bed .
The radiologist has suggested I may have ischiofemoral impingement as my quadratus muscle shows some damage in muscle belly. This apparently could be giving me the problem in my hip and leg but I am sceptical of that one since it was only immediately following the surgery that I had the excruciating pain in groin and muscle spasm in thigh, that has left me in this mess. We shall see what the next Doc says? Like you I need some help and quickly. Seven years is a long time to be so imobile , I should be very active if not for the problems so I share your frustration and pain.
Might I ask how you received your diagnosis of sciatic nerve entrapment? Did u have an mri? I have had mris but only thing reported was the muscle damage although I know that can impact the sciatic nerve all be it no one has been suggestive of this. And to be honest this gluteal pain is my worst problem both hips come a close second really .
As you may well know gluteal pain is a beast not allowing one to either sit or even lay in bed in comfort. Finding the cause is crucial as otherwise no help. Just hoping I can get some answers soon as like you it’s miserable and depressing when most people around us are getting on and enjoying their lives. Our time is too precious to be hanging around for help and seemingly being fobbed off by uninterested physicians .
You didn’t mention how you came to be in such dyar straights, did you fall or have an accident , sport's injury?

Sending you a big velvety hug and hope things work out for you, and yes … you are allowed a rant and a moan …. We don’t mind one bit , we have all done it!
 
Grumpy321
Forgot to add that my spine has deteriorated fiollowing the fall unsurprisingly! Facet joint arthritis, some spinal stenosis and L 5 slipped backwards , can’t remember the name of that one?
 
Thankyou very much for you replies @Vanna and @Axx72

I've had steroid injections as part of this journey, and they made a massive difference, but alas, only for a fortnight! They did help with diagnosis though.

The possibility of an ischiofemoral impingement was initially picked up on an MRI. There is also a specific set of x rays that they can do to help diagnose IFI, but I don't know what they are sorry. I have also had a PET CT which showed the si joint inflammation and the IFI.

They also have done 3d mapping of my hip socket which was a CT scan which they sent off for processing.
Its interesting, but also a bit creepy as when I feel a crunch, I know exactly where its coming from...

I agree, gluteal pain is horrible, and quality of life limiting. It also makes me very grumpy!

My journey started with years of going to GP, physio, chiropractor and symptoms getting worse. All of this while dealing with other health problems, which are now known and better managed.
In the end I decided to try and rule out periformis syndrome ( the old name for deep gluteal syndrome) because my Mum was diagnosed with it a few years ago. She got to the point where she was using a walker and dragging her leg, but is back to normal now - its pretty amazing. Our symptoms were similar, and it is known to be hereditary.
I finally managed to get the magic referral to Mums specialist/surgeon, and then the appointment 6 months later. The specialist (neurosurgeon who lists periformis syndrome as one of his specialties) was great, and sent me off for scans. He said that periformis syndrome/ deep gluteal syndrome is not really able to be seen on scans, but it is a diagnosis of exclusion. He ordered the MRI of my pelvis/glute nerves, and the PET CT.

My results unexpectedly showed the SI joint inflammation, and also the possibility of the Ischiofemoral impingement. He basically said, look, I don't know anything about hips, I need to refer you to an orthopedic surgeon specialising in hips. So the referral went through, wait another 6 months, see hip specialist.
Hip ortho basically said, yes it could be IFI. There is only one person in the country who deals with it.
He organised steroid injections to make sure that it was not just referred from the SI joint, and then sent referral to the long distance hip specialist. Also referral back to the neurosurgeon regarding SI joint.
The far away hip specialist requested more in depth MRI's with lots of measurements and xrays and then was on leave, so it was about an 8 month wait to see him.
Finally had the appointment with the long distance hip specialist.
I had to travel a fair distance to see him and was not in good shape from all the sitting and travelling.
I saw his registrar first, who did the 'lovely' exam where they test all the hip range of motion etc.
I must have gone quite white and was trying not to dry retch from the pain which apparently was a first for him, but he was very kind. then he asked all the questions.
Then the hip ortho came in and they had a 'technical chat' discussing MRI measurements and physical exam results.

They explained the list of things going on, which related to which thing, and what they would need to do in surgery. The hip ortho explained that they could see inflammation in my quadratus femoris muscles, and also the top of the hamstrings - which related to the IFI. They could also see that my trocanters are reasonably large which was not helping. I also have trouble bringing my leg forward and up, and this (well usually pain, but in me physically unable to do) they said relates to the IFI. They discussed the angles measured in the MRI and decided that a hip 3d analysis was needed to better understand the FAI. (and the later results of that showed that my hip sockets are too deep, which they will reduce, but the ball is ok, it also showed that I have femoral version( weird hip angles!), but was not not quite bad enough to need treatment thankfully)
They could see both the labral tears on MRI, but said that they would inspect and repair as appropriate while they were in there as MRI's are not always accruate for labrum tears, so they would play that by ear.

The specialist said essentially that I have so much going on, and so much inflammation, and also because I have had to do so much sitting and not much moving, that freeing up the sciatic nerve through the gluteal space ( especially with my mums history) will really be needed. Although he could point out specific symptoms, and scan results and evidence that point to each separate diagnosis that there is a lot of overlap, and for things to get to this level of pain and dysfunction, it suggests that the deep gluteal syndrome will be there. There are hints on the scan that there will be adhesions, but in his experience by the time the hip as a unit has got to this point, it will be there. And he also warned that the IFI surgery causes a lot of groin pain post surgery because the ligament that attaches to the trocanter, gets really annoyed.

The funny thing about this last part of the journey, is that he mostly only sees sportspeople. There were young people hopping and limping all over the place, so I felt a bit more at home:)
He also lists the recovery and physio phases for some of his surgeries on his website. Because he sees sports people, they include phases for getting back to running, and triathlons etc. Which my husband and I find hilarious. I'd be happy with going for a walk!

I have not had any injuries specifically - my socket depth and trocanter size are definitely the way I was made. and probably the femoral version too. I did have a lot of trouble with a very very lax pelvis when I was pregnant with my kids, and was on crutches for the second one. This probably won't have helped.

I have recently got a Tens unit for the glute pain which is helping significantly. Its just unfortunate that its a difficult area to attach to!

Thanks for the hugs and the opportunity to rant. I'm off to the tens unit again...

T







 
And what a saga.

What stands out for me, in addition to the prolonged pain you've been going through on long journey of to a treatment plan, is how health system norms vary across the world.

I'm impressed with the number of consultants and advanced scanning techniques being assembled in order to make accurate diagnoses.

May all this time lead to a successful surgery!
 
And what a saga.

What stands out for me, in addition to the prolonged pain you've been going through on long journey of to a treatment plan, is how health system norms vary across the world.

I'm impressed with the number of consultants and advanced scanning techniques being assembled in order to make accurate diagnoses.

May all this time lead to a successful surgery!
Thanks for the reply @mendogal. The caveat with my journey has been that I am very lucky to have private health insurance, and that finally once in that system, because my care has taken so long, that i have not gone over any of the maximums for each year. I have also had to do a lot of chasing up, following up and advocating for myself including asserting that 'no this in my head, there is a repeatable pattern of cause and effect causing dysfunction...' My other main gripe is that my GP's and physios etc knew for years that I had pain in my glutes. and not once did anyone tell me that glute pain can be referred from the hips. To me that is pretty basic.
A saga is a good description...:)

Thankyou for best wishes for surgery. Its a bit unsettling really as all the other surgeries I have had, ( mainly removing organs, its surprising how many you an do without!) the specialists have said - this may help but we can't promise anything. This ortho has said actually we should get a really good reduction in pain once healed. Obviously with the usual caveats of course, but I've never had that before.
Im also curious to see what recovery is like from this compared to more...squishy surgeries if that makes sense. Ive never had anything 'structural' before. Obviously the physio is one of gthe key differences, but it will be positive in that I will make progress, compared to the last 6 years of going backwards all the time.
 
And what a saga.

What stands out for me, in addition to the prolonged pain you've been going through on long journey of to a treatment plan, is how health system norms vary across the world.

I'm impressed with the number of consultants and advanced scanning techniques being assembled in order to make accurate diagnoses.

May all this time lead to a successful surgery!
Thanks for the reply @mendogal. The caveat with my journey has been that I am very lucky to have private health insurance, and that finally once in that system, because my care has taken so long, that i have not gone over any of the maximums for each year. I have also had to do a lot of chasing up, following up and advocating for myself including asserting that 'no this in my head, there is a repeatable pattern of cause and effect causing dysfunction...' My other main gripe is that my GP's and physios etc knew for years that I had pain in my glutes. and not once did anyone tell me that glute pain can be referred from the hips. To me that is pretty basic.
A saga is a good description...:)

Thankyou for best wishes for surgery. Its a bit unsettling really as all the other surgeries I have had, ( mainly removing organs, its surprising how many you an do without!) the specialists have said - this may help but we can't promise anything. This ortho has said actually we should get a really good reduction in pain once healed. Obviously with the usual caveats of course, but I've never had that before.
Im also curious to see what recovery is like from this compared to more...squishy surgeries if that makes sense. Ive never had anything 'structural' before. Obviously the physio is one of gthe key differences, but it will be positive in that I will make progress, compared to the last 6 years of going backwards all the time.
I'm also grateful medical technology has improved so much - even from the beginning to this point of my journey, the hip joint 3d mapping took my by surprise, and I understand that its not used very much yet, but I am very glad of it!
 
Interesting information for me Grumpy
Could you tell me please where you had cortisone injection , was it in the quadratus femoris space or in the muscle belly ? And was it done by ultrasound and was it painful?
As I mentioned I think? I was offered one but I declined particularly as when I got to the clinic it wasn’t t the same radiologist that had diagnosed it on mri and who was supposed to do it . And quite honestly I had no confidence in him, looking like a frail old man who I had difficulty hearing or understanding any thing he said considering his foreign accent and the fact he was wearing a mask and wouldn’t speak up .
( At one point he said I wasnt listening !)
It took me all my time not to rip his mask off and tell him “I am listening “ if you would speak up I might have a chance of hearing and understanding you!!! ….. The conversation I had with him convinced me he wasn’t the right man for the job so thanked him for his time and politely left although I felt like saying a lot more .
The injection would have been by ultrasound . I believe following my THR I too had some ante version in the prosthesis whatever it’s called as I recall my 2nd consultant measuring the distance of my
Joint whilst viewing my mri scan. But I didn't take on board the significance of this . So it is possible I do believe that my groin pain and buttock pain could be related to the quadratus femoral impingement but as yet has to be confirmed .
Otherwise I could have 2 things going on ? The deep gluteal problem in isolation and the psoas tendon problem in the groin as a result of my THR
I have my appointment booked now to see a consultant on the 23rd of April who it seems does arthroscopy of hips so I’m hopeful he can sort this hip problem out as well as my other hip with the torn gluteus medius tendon. This was torn by excessive physio in clinic instructed by an over enthusiastic physiotherapist following my 2nd hip surgery …. Oh the joy!!!
I’m wondering did your consultant say that if your surgery goes ahead will it cure trapped nerve in gluteal area? Problems are very complex, shaving the lesser trocanther to Free the space in the groin which in turn should eliminate pain in groin and enable one to move and lift the leg without pain…… but will it cure the deep glute pain ? … I think the concept is, from what I researched is that once the femoral space is enlarged , the QF muscle
Will not then be squashed which is causing the buttock pain , however I have also read that the sciatic nerve could be compressed
also and if tethersd to the muscle that could lead to more surgery …. I mean ? There are so many implications and as u say caveats to this .
I have researched and seen many scans on the internet of this problem and I’ve found it very Informative in understanding what could be going on with us but as u say till they get in there who knows? .
So keep us posted and if u could answer my queries above I should b most grateful. By the way I do have my own thread going on here if u feel u would be interested in reading . I must say it all can get a bit much when “ a girl has so much say !” But am so grateful that we sufferers can come together on here and know we are not alone in our suffering.
Oh dear this is another long one isn’t it?
 
Interesting information for me Grumpy
Could you tell me please where you had cortisone injection , was it in the quadratus femoris space or in the muscle belly ? And was it done by ultrasound and was it painful?
As I mentioned I think? I was offered one but I declined particularly as when I got to the clinic it wasn’t t the same radiologist that had diagnosed it on mri and who was supposed to do it . And quite honestly I had no confidence in him, looking like a frail old man who I had difficulty hearing or understanding any thing he said considering his foreign accent and the fact he was wearing a mask and wouldn’t speak up .
( At one point he said I wasnt listening !)
It took me all my time not to rip his mask off and tell him “I am listening “ if you would speak up I might have a chance of hearing and understanding you!!! ….. The conversation I had with him convinced me he wasn’t the right man for the job so thanked him for his time and politely left although I felt like saying a lot more .
The injection would have been by ultrasound . I believe following my THR I too had some ante version in the prosthesis whatever it’s called as I recall my 2nd consultant measuring the distance of my
Joint whilst viewing my mri scan. But I didn't take on board the significance of this . So it is possible I do believe that my groin pain and buttock pain could be related to the quadratus femoral impingement but as yet has to be confirmed .
Otherwise I could have 2 things going on ? The deep gluteal problem in isolation and the psoas tendon problem in the groin as a result of my THR
I have my appointment booked now to see a consultant on the 23rd of April who it seems does arthroscopy of hips so I’m hopeful he can sort this hip problem out as well as my other hip with the torn gluteus medius tendon. This was torn by excessive physio in clinic instructed by an over enthusiastic physiotherapist following my 2nd hip surgery …. Oh the joy!!!
I’m wondering did your consultant say that if your surgery goes ahead will it cure trapped nerve in gluteal area? Problems are very complex, shaving the lesser trocanther to Free the space in the groin which in turn should eliminate pain in groin and enable one to move and lift the leg without pain…… but will it cure the deep glute pain ? … I think the concept is, from what I researched is that once the femoral space is enlarged , the QF muscle
Will not then be squashed which is causing the buttock pain , however I have also read that the sciatic nerve could be compressed
also and if tethersd to the muscle that could lead to more surgery …. I mean ? There are so many implications and as u say caveats to this .
I have researched and seen many scans on the internet of this problem and I’ve found it very Informative in understanding what could be going on with us but as u say till they get in there who knows? .
So keep us posted and if u could answer my queries above I should b most grateful. By the way I do have my own thread going on here if u feel u would be interested in reading . I must say it all can get a bit much when “ a girl has so much say !” But am so grateful that we sufferers can come together on here and know we are not alone in our suffering.
Oh dear this is another long one isn’t it?
Thanks for your reply @Vanna

I initially had a steroid injection in the SI joint under CT

I later had the steroid injection into both quadratus femorus muscles (left and right) under CT. This was to help diagnose the Ischiofemoral impingement.
They tape a grid on your butt, and then do some scanning, and then put in a local pain reliever and then initially start putting in the needle, then scan again, then advance the needle and do the injection. The local pain reliever is a bit bitey but well worth it, and if you have had surgeries or procedures before then you should be OK.
Its just really weird lying on the table with your butt bare wizzing in and out of the machine:)
Unfortunately I had a steroid flare afterwards, so would only recommend getting one injection at a time.

They did both - separated by about 3 months, to help differentiate between the pain of my si joint and the IFI.
Turns out its a bit of both.

Im not sure what you mean by space, rather than muscle belly. For me there is not really any space in there, but I was told the injection went directly into the muscle.
I initially had the injections booked for being done under ultrasound, but the radiologist had a look and said nope, this need to be done under CT - lower risk, as there is a risk of hitting the sciatic nerve if its not done right.

I totally understand not going through with the procedure if you cant understand the person doing it, and if you don't have confidence in them. You feel vunerable enough having a normal scan, even without the being jabbed bit! I was lucky to have really kind people doing it (assistants etc included) who all communicated really well and didn't rush. They also said I could withdraw consent at any point, no problem which gave me confidence too.

My specialist said that he can free up a certain amount, obviously he cannot access at either end, past certain anatomical points, so he says he can help the bits he can get to , but it may not help entirely if other areas are affected that he cannot get to. Yes, there are multiple things going on in a very small area!
There is another variable to consider as well, there are quite a few different pathways that the sciatic verve can travel in the glute area. There are the more standard ones, and some of the rarer ones which take a different course are more likely to be trapped under or through eg the periformis muscle. I apparently have a more normal pathway, though apparently can be a bit tricky to identify on scans.

It sounds like you have had a massive journey, and its great that your consultant appointment is coming up.
Happy to answer any questions, and I'm sure I'll be asking some round the site. the more info we can share, the better our outcomes will be - hopefully:)

I'm really curious myself to see what sort of an outcome I get.
My Mum was using a walker and dragging her foot, and 1 day post surgery, walker was gone and she was doing laps of the ward. Although hers was specifically a sciatic nerve trapped by the periformis muscle. She does have some residual nerve damage from it though, and cannot sit for long.
I realise I have a lot of other things going on, but it does illustrate how significant and dramatic relieving a trapped sciatic nerve can be. Fingers crossed for you @Vanna
 
Thank you for sharing so much detail about the procedure, @grumpy231. I'm sure it will be helpful to others who are dealing with this kind of impingement.

Are you still scheduled for surgery in June? If so, please give us the date and the procedure, so we can create a signature for your posts. Having that information in each post helps us give you timely and appropriate information.
 
Thank you for sharing so much detail about the procedure, @grumpy231. I'm sure it will be helpful to others who are dealing with this kind of impingement.

Are you still scheduled for surgery in June? If so, please give us the date and the procedure, so we can create a signature for your posts. Having that information in each post helps us give you timely and appropriate information.
Thankyou @benne68 I am hoping my story can help others.

My first surgery is the 25th June, and the procedures are:
arthroscopic hip femoral osteoplasty, acetabuloplasty, labral repair, endoscopic sciatic nerve release, lesser
trochanteric resection and ITB fenestration. Not sure how to summarise all that sorry--- maybe 'assorted endoscopic hip procedures...!'

My second is early october, doing all of the same on the other hip.
 
@grumpy231 I put your signature in as: Femoral osteoplasty & related hip procedures.

Please let us know if that's okay!
 
Hi @grumpy231, as it turns out I have IFI as well. Well, it's something that has been diagnosed as IFI but is really just the lesser trochanter squishing up my sciatic nerve, apparently. I've now had four sciatic nerve hydrodissections and PRP for nearby tendon tears, with limited success. I'd be very interested to hear where you're doing your surgery if it's in the US. It seems to be very hard to find doctors who are doing surgery for IFI.
 
@dxross If you look at the information under grumpy231's name on the left of her post you will see she is having her surgery in New Zealand. Please start your own thread so that we can assist you - and perhaps help you find a surgeon near you to help. To start your own thread go to the main listing for hip pre-op. At the top of the list on the right is an orange button "Post thread" click on that and you will be able to start your own.
 
Hi @grumpy231, as it turns out I have IFI as well. Well, it's something that has been diagnosed as IFI but is really just the lesser trochanter squishing up my sciatic nerve, apparently. I've now had four sciatic nerve hydrodissections and PRP for nearby tendon tears, with limited success. I'd be very interested to hear where you're doing your surgery if it's in the US. It seems to be very hard to find doctors who are doing surgery for IFI.
HI, and thanks team for sorting out the mix up:) Sorry I can't help out.

Its really interesting to hear of someone else with IFI, and yes that essentially seems to be what IFI is.
It does seem quite rare, and difficult to diagnose. I'll keep an eye out as im really interested in hearing your story if your share it. - Do you have it on both sides?

If you have no luck finding anyone, maybe look for some research papers. Some surgeons appear to be publishing papers for individual surgerys or very small groups.

FYI my specialist is going to approach from the back, and only remove half the trochanter, and also leave the ligament attached to the trochanter in place. He also warned me that the ligament will get very annoyed, and cause decent groin pain for a few weeks, so something to watch out for. I am aware that there are a quite a few variations for the surgery, so when you find a surgeon, maybe check his specific approach and ask why? I think mine is a newer approach, based on reduced risk and other learnings from some of those older papers.
Best of luck!
 

FYI my specialist is going to approach from the back, and only remove half the trochanter, and also leave the ligament attached to the trochanter in place. He also warned me that the ligament will get very annoyed, and cause decent groin pain for a few weeks, so something to watch out for. I am aware that there are a quite a few variations for the surgery, so when you find a surgeon, maybe check his specific approach and ask why? I think mine is a newer approach, based on reduced risk and other learnings from some of those older papers.
Best of luck!
Oops - assumed surgeon would be a male! - maybe check -their- approach! :)
 

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