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[THR] Worried I may have infection<<

Discussion in 'Hip Replacement Recovery Area' started by Jws., Apr 6, 2018.

  1. Josephine

    Josephine FORUM ADMIN, NURSE DIRECTOR Administrator

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    Well, I am flattered! But I doubt you'd ever get me in a long haul flight! Not my kind of thing!

    As for your pain sites, these are they, yes?
    jeff.jpg

    I'd say that the blue one is probably one of these

    Psoas tendinitis
    psoas pain small.JPG Psoas.jpg


    Lateral femoral cutaneous nerve entrapment
    lateral cutaneous femoral nerve.JPG


    And the red is very likely caused by the muscle called Pes Anserine

    pes anserine.jpg

    I think this is highly unlikely. Much more likely that you have tendinitis.

    Tell me, are you taking any pain meds for this?
    Are you engaged in much exercising or PT?
     
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  2. Jws.

    Jws. junior member
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    @Josephine Well I am back. Been depressed a lot since this hip hasn't really healed so I haven't posted. It is now going on EIGHT months post-op and I can't get this hip RIGHT. My PT (which is also my OS's wife) says that the pain is coming now from my rectus muscle and my psoas. My OS says rectus as well (can't tell because he says only about 3-6 words during the consults...and his wife says he suggest a cortisone shot in rectus.

    So I was not getting any real answers from the 5-6 OS I got opinions from (i.e tendinitis, psoas, etc. rest, shots in psoas and trochanteric bursa, etc. )...

    I had to do something instead of mulling around in my "head" and getting more conflicted and depressed. Started walking 1-2 miles every other day was fine, gait was fine, no pain). Three hours later pain - getting out of car again, first few steps painful and limping.

    I then decided I had to lose the weight gained during the 6 months and started to walk more at the track. I started walking 4-5 miles a day for the last few weeks. Some days were exhilarating. Actually no pain during the walk, no limping and no pain later on just some soreness. lost some weight and last couple of days groin pain came back and so did limp.

    PT says to walk 3-4 miles but not enough to cause groin pain. OTHER articles I read say to REST or risk chronic tendinitis.

    Josephine, my PT does really deep massage on my psoas groin when I go there and after it hurts like hell the whole day but I have to admit the next day it feels better. Am I risking chronic tendinitis by letting her be so aggressive??

    I NEED A PLAN FROM SOMEONE WHO I TRUST?

    Given it's almost 8 months post op, shouldn't I have been healed and not be going on this merry go round of pain no pain. I have not had a time yet of any duration where I felt confident this hip has healed.

    Please help. Any similar stories or input from all would be appreciated. No meds!
    Thank you..
     
  3. Josephine

    Josephine FORUM ADMIN, NURSE DIRECTOR Administrator

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    It shouldn't.
    Well I'm in the rest category! Once you have a tendinitis, activity is NOT going to make it better!
    Lacking a definitive reason for the pain, that's not an easy question to answer.

    Back in August, I asked you these two questions:
     
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  4. Jws.

    Jws. junior member
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    @Josephine...
    1. First to answer your questions. Once in awhile an Advil.

    2. Am doing PT stretching twice a week and walking 1-1½ hours (4-6 miles a day) per day and stretching before and after (crossing my legs sitting, runners lunge, sitting hands dropping down as far as can go so I can tie my shoes, etc. )

    Finally, I got some answers from another top OS (would have been my second choice here) disappointing but it is what it is..

    To restate my main problem would be able to walk 3-6 miles in morning, gait fine, no limping no pain, stretch and then get in car, go to work. After sitting for an hour or even 20 minutes.

    Then everything goes to hell

    All of a sudden my right hip area LOCKS up like a metal bar is placed there, can't walk, limping, like total effort to move the hip like it's a separate entity, depressing as hell, like fighting to move it forward. (even if I walked only one mile vs 3 miles..same result so it's not overuse.)

    So finally got some direct answers from this OS - here it is

    I told him about above and he said lay on table and see. He tried moving my operative hip (right) around and he said "there is definitely something wrong here after 8 months, your hip has absolutely no ROM."

    He said that he believes I am locked up due to scar tissue. He says the reason in the morning you can walk is the scar tissue releases but than later in the day it tightens up. He says he gives Advil 6 x a day post op to his patients during first two weeks and uses a dual mobility cup so the ROM is increased.

    He also agreed that I had trochanteric bursitis and gave me a cortisone shot yesterday to relieve the bursa.

    He says also I need to be tested for metallosis because I have chromium and poly combo? (he doubts it will be positive) I have the Depuy Gription 56mm acetabular component, 56/36 poly liner, Microport Monoblock PROFEMUR Z size 6 femoral component with a short vv8 neck and a 36+7 cobalt chrome head.

    As an aside I am a mass tort lawyer and have been involved in the hip litigation for 5 years now and I can't believe my primary OS at this point in time with all the data out there would use anything or combination that would cause metallosis. UNBELIEVABLE!

    He says that he can schedule me with a PT who specializes in "stretching" the scar tissue which "MAY " fix it somewhat in about two-three months or he can replace (which he doesn't advise doing now) the "ball" with a dual mobility cup.

    Josephine, I really need your thoughts here. He says he wouldn't have to mess with the femur just the cup and it would be slightly less rehab than a total revision. He also did mention possibly going in and cutting the scar tissue but at this point I wasn't listening too well.

    Josephine please get back to me as soon as you can or anyone else who has had any similar experience. I want to walk again.

    PS. I have no infection. Sed rate and c-reactive protein is low normal.

    Thank you.
     
  5. Josephine

    Josephine FORUM ADMIN, NURSE DIRECTOR Administrator

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    Not only is that unlikely it's a shot in the dark because hips generally don't develop adhesions (scar tissue).
    I totally agree it won't be positive because your hip is metal on poly. UNLESS, he used a metal ball on a metal stem (left image) and specially if he used a shim! (right image). I suggest you find out about this.

    MoM THR.JPG sleeves.JPG

    That's just ridiculous because as I said earlier, hips don't develop adhesions!
    I don't see why he wouldn't do it now. It would seem the obvious thing to do and of some priority too!

    Personally, I recommend you get a surgeon who specialises in revisions and I bet he'd revise it ASAP!
     
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  6. Horseshoe

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    Hi @Jws. had a glance at your thread and a couple of things jumped out at me.

    Had two thrs and pop in here sometimes to compare notes. I still experience occasional IT band pain and swelling after workouts. Possibly from increased offset, new hips stick out at the sides more than natural hips.

    Anyway, have an appointment this month with a Physical Medicine dr. Was not familiar with this particular medical field and thought I'd mention it here for others with soft tissue, muscle, tendon, issues. Is a Physiatrist, not Psychiatrist : )

    -You mentioned possible leg length difference, imagine that would cause alignment pain when walking but not when bike riding.

    -Groin pain, have any of your OSs x-rayed the cup for loosening and alignment? Screw pain -if any screws? Josephine is a wiz at reading xrays if you can post a recent one.

    -I also got a surprise Depuy metal head on poly -though a different model- on one hip and was not pleased about it either. Was supposed to be ceramic/poly like the first hip. Have concerns about trunnionosis as I am active. Had discussed implant type extensively beforehand, metal head possibility was never mentioned; thought they were no longer used -old inventory perhaps lol? I now get yearly blood tests for chromium, cobalt and SED rates to monitor.

    -Consulting a revision OS and PT, is better checks/balance when not from the same medical group, friends or relations. LA has many top notch surgeons and schools. UCLA, USC, also UCSD, etc.

    -Trust your gut if something doesn't feel right and hope you can get this resolved soon.
     
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    Last edited: Oct 13, 2018
  7. Jws.

    Jws. junior member
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    @Josephine most days can walk 1-5 miles no problem with gait, limp or pain..LIKE NORMAL... believe it or not, the walking evens out the pain ...than if I sit in office, car or anywhere for 15 minutes (unbelievable) to an hour...back to pain like groin, hip, thigh (like tightness and band around thigh) ..and limping and hard to walk.

    Frustrating as hell.. EIGHT MONTHS! like this. Had the Trochanteric bursa shot 4 days ago relieved much of the bursitis..

    Beginning of day walk, OK JUST FINE...after sitting the pain returns - AND THE REST OF THE DAY IS SHOT...with limping, pain and inability to walk, like the wind is forcing you back, like the hip takes effort to move.

    Pain is like 1-2 if that but whole hip goes in lock down ..tight as heck.. Have been doing PT with OS's wife's studio so she directly communicates with him. Go to sleep next day can walk again (strange tissues must have less swelling??)..then sit down...can't walk again..

    Something in the sitting (as little as 15-20 minutes causes the whole pain and lock down scenario again) but can't walk it off until next day. Must hobble through the day! Went to see second best guy in LA, he put me on table and said (was in last post) "there is something definitely wrong here. For eight months your ROM is terrible in right hip".

    Sent me for CT scan for HO and metallosis blood test, found out today BOTH NORMAL!
    His suggestion is to have his "special" PT stretch the built up scar tissue that he thinks is holding ROM back (Josephine replied to my last post that she doesn't buy that AT ALL! That hips don't build up scar tissue like that to create that much restriction in ROM).
    I am now at a loss.

    I hate this new hip. My life is all centered on this thing and docs and PT and ups and downs and ... Want to have my retirement with my wife and grandkids.. Prior to surgery spun every night 1½ hours.. Better pre-surgery than now (no BONE ON BONE)..Made horrible mistake having this surgery but can't go back . Have to figure out how to fix it.
    Don't really want revision with brand new rehab, much higher risk of dislocation, infection etc...

    Please, need some help, referrals, whatever. I am a really young 70, in great health otherwise and this is not how I want to end my later years!!

    ANY HELP WOULD BE APPRECIATED!
    @Josephine..new pain at TR1F (acute and sharp on getting up, turning or twisting to right side-(right side of hip)- started yesterday)....

    Doesn't feel like Tranchoteric Bursa - hopefully not cause I want the cortisone shot in bursa that i have had 4 days ago to still be working?

    But this TR1F on side of hip is like a 4-5 when getting up ..after stretching and walkin a little better but sharp painful whenever (4-6) i turn or make any movement to the right...never had this before? could you tell me what you think this is?...thanks josephine and anybody else..
     
    Last edited: Oct 16, 2018
  8. Layla

    Layla FORUM ADVISOR Forum Advisor

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    I'm sorry. I sense your frustration and don't blame you.
    I hope Josephine has some advice and you're able to formulate a plan that brings you relief.
    Wishing you comfort as you seek answers.
    @Jws.
     
  9. Jws.

    Jws. junior member
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    thank you
     
  10. SaraK

    SaraK post-grad

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    @jws - Your symptoms sound very similar to mine - no pain in walking but it then impacts the ability to raise the leg to get in car, etc. and affects ROM. I also stiffen up if I sit for very long - and more if I've walked much that day or the day before. I compare myself to the evolutionary poster - starting hunched over but standing a little more erect with every step.

    I finally got an OS that's listening and he's thinking the psoas tendon is rubbing against the acetabular cup. Could that be what your surgeon is referring to as "scar tissue"? I'm early in the process now but, assuming the sed rate, CRP and metallosis tests come back normal (which he expects they will), he's planning a cortisone injection into the psoas tendon. If it is the psoas tendon rubbing, that should provide some relief (and hopefully lasting relief so that nothing else is needed). If injection(s) don't work, he may recommend surgery to "release" the tendon but said that's the last resort. He said some of the other conservative treatments for this is rest (i.e., eliminate anything that irritates the psoas, including walking more than necessary), PT and NSAIDs, but I've already been doing that.
     
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  11. Jws.

    Jws. junior member
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    SaraK, Josephine

    I am now thinking that this is the exact problem or something like it that NONE of the OS's specifically identified.

    So about three months ago every time before "walking" when I would get up from the chair or out of the shower my operative leg "heel" of my foot would be "oddly" lifted up about 3 on its own -AUTOMATIC. (like it was pulled up when I got up) .

    I know my body and in all my 70 years my right heel would always be planted flat on the floor...

    The "heel lifting up" is obvious to ME, showed there was significant tightening on the tendon and besides pain in the groin for the first few steps this heel phenomenon showed that my tendons were too tight and pulling up at my heel and my groin area causing pain..The tendon is just too short.

    I told the OS's about it but they disregarded it. Yesterday I got my results of my latest CT scan and they were looking for "HO" bone calcification causing lack of ROM and my metallosis blood tests. Both tests NORMAL..

    After eight months now post surgery I have ruled out HO, metallosis, no infection, xray shows hip in fine, no loosening, cortisone shot in trochanteric bursa (no more pain), basically everything.

    Therefore, funnily enough, my wife and I figured out only yesterday that since a shortened psoas is NOT effected by walking (and I walk 5 miles a day) but is effected by what you described, up stairs, getting in and out of car, etc...this could actually be my problem.

    I don't know that PT can stretch it significantly enough but I read that you can have a shot of cortisone in the psoas tendon as a conservative treatment. The dilemma is I asked the last "good" OS that question (the one who said scarring was the problem) and he said 25% chance the psoas tendon "communicates" with the hip joint and he wouldn't take the chance right now (8-9 months out) for risk of infection...

    @Josephine - is he right in that statement?

    There was one other OS who said if I checked out my infection chemistries (sed and crp) to come back and he would give me the shot.

    I really need Josephine to tell me the risks of a cortisone shot there in psoas tendon and if it's a problem? Has anyone else had a shot in psoas that helped them?

    Sara , are you going to try a shot in the psoas?

    I would like to know also is a psoas tendonotomy a risky surgery 8-9 months post op. I can't keep living in this chronic pain EVERY DAY. I have to do something and don't want revision with all its problems.

    Thank you
     
  12. SaraK

    SaraK post-grad

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    The plan my new doc set out was, assuming infection and metallosis tests come back normal, we would proceed with a cortisone shot in psoas tendon (I'm a couple of months further post op but not sure whether that makes a difference). Hopefully nothing more required. If it helps but not long term, will try another injection. Surgery is last resort but injection is last "conservative" treatment option left for me. Would most likely be beyond the 1 year point though given time frame set out by doc.

    Sounded like surgery most likely arthroscopic. Some risk of infection with any surgery (or injection for that matter). I haven't discussed recovery time with him - trying not to get the cart too far in front of the horse.
     
  13. Harryn1

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    Hi @Jws . I had a guided cortisone shot into my psoas at 6 weeks post op, and it seemed to do did the trick. (And, thank God, no, it did not cause infection - I understand the risk to be minimal presuming, of course that proper infection control protocols are observed)

    Following the shot, I totally rested for 3 weeks. no exercise at all.

    5 miles a day is a lot of distance you’re putting in, kudos to you - but maybe maybe its worth quitting the long walks for a while to see if you get relief?

    Ps. Are you still spinning, and if so, I am interested to know if you can do so pain free.

    Pps. Sorry you’re suffering _ i hope you find the answer. Strength to you.
     
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  14. Josephine

    Josephine FORUM ADMIN, NURSE DIRECTOR Administrator

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    I would think it highly unlikely.
    Since the injection is done under the usual sterile conditions, I can never see why surgeons feel it necessary to show angst about this because there really shouldn't be any such risk.
    A psoas release can be done arthroscopically or via a very small incision as you can see here. However, the outcome is by no means certain.

    psoas release.JPG
     
  15. Jws.

    Jws. junior member
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    Josephine, SaraK, Harryn1

    As you all know, I have been in considerable pain now for 9 months post op. Have seen the best OS's in LA (maybe 8-9) all have guessed various daignoses. (from psoas tendinitis, to "it takes time to heal", Trochanteric bursitis, LLD, too much scar tissue, contraction etc.)

    So this week I saw the grandfather of all great OS's (77 yr.o 1,000's of THRs) here in LA. (I went to him as he wrote the most conclusive article on psoas tendinitis and as I indicated in my last post that I thought psoas tendinitis was the closest diagnosis that matched my symptoms)

    i.e. "cliff notes " on my routine and symptoms- (ruled out infection,metallosis, heterotopic ossification, loosening,etc)
    1. on awakening , could walk normal for 3-5 miles , gait fine, no limp, no pain, beautiful , perfect.
    2. If I then sit down in office or in car or anywhere for 15 minutes or more, I would have weblike pain in groin on standing, my right hip would lock up, pain in right side and would limp for rest of the day until I would lay down on couch and go to sleep (no pain) and wake up to same routine.

    I described this to Dr Dorr and he took a long look at xrays (for awhile) and said (like "Colombo you have "Trochanteric Impingement". He went on to show me in the xray the left natural hip and the space there on top and then he showed me the implanted hip done by my OS and said it was too small, that it was not clearing the trochanteric bone on sitting and I needed a new cup liner (which gave more space) and when he went in he would see if that "cleared the Trochanteric bone. If not he would have to shave the bone as well.

    He said all the reason no other os had picked this up diagnosis was that it was a "clinical"diagnosis AND YOU HAD TO HAVE DONE TENS OF THOUSANDS OF HIPS to see this.

    He said that when I sit now the muscles or nerves get impinged and it takes until the next day for the muscles to stop being inflamed.

    He said he didn't think conservative treatment would fix the problem (he did say cortisone shot in hip capsule (infection?) may relieve the pain for awhile but didn't think it would resolve it . He also said time may make it "bearable" but he doubted that as well.

    He said that the surgery to replace the liner was quick and would not deal with any other parts (except the shaving of the trochanteric bone if necessary) but he would have to open the capsule to get to the liner so no arthroscopic .

    So here are my issues and fears now:
    1. is he right?
    2. do I take this info back to my original OS and confront him and have him fix it as he is "technically " a terrific surgeon but does too many and got his wrong?
    3. they will be cutting the tissue, muscles around the implant so isn't his basically the same recovery as a revision?
    4. do I go to another one of the top OS's I saw who is younger but does 100's of these per month who uses the dual capacity ball which is safer for dislocation and gives full range of motion? (this OS doesn't use the dual ball)
    5. IS THERE A MORE CONSERVATIVE APPROACH THAN REVISION TO TREAT THIS?

    6. I met Dr.Dorr's PA and she was kind enough to give me the number of a recent patient of his that had a similar problem and would like me to call him?
    7. As an aside, the nurse told me that the PA does all of Dr. Dorr's "closings" and this scared me a bit. She has been doing it for 17 years with him. Is this a general practice ? and should I not be concerned if a PA is doing the closing?
    8. I am really "gun shy " now that if I ok this and go into another surgery that I could wind up much worse than I am now!!!! And really regret some kind of catastrophic result.

    Josephine, please, need your kind wisdom here. Or anyone else's thoughts would be appreciated as well.

    (btw..he absolutely said it wasn't my psoas!)
     
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  16. SaraK

    SaraK post-grad

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    I looked it up and it almost sounds like the opposite of psoas impingement - instead of the cup being too prominent anteriorly, it's too prominent on the side of the trochanter.

    My 2 cents? I'd go with the surgeon that's diagnosing this and is more an expert on this issue (but might see if I could get a second opinion specifically asking another surgeon whether the diagnosis is reasonable/fits the symptoms). If my psoas impingement requires surgery, I'll certainly have it done by the OS that diagnosed it.

    Have you done any additional research to see if your symptoms fit the condition as described in medical articles? Or if the treatment protocol looks like what those articles indicate? I wouldn't use that research as the end all/be all but I think it could allay some of your concerns.

    Maybe Josephine or others can provide more assurance from the medical side.
     
  17. Knitquilt

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    I think it’s common practice for the OR nurse to do the closing. My surgeon’s nurse said OS doctors leave surturing to the nurses who take time to insure the eventual scar looks good.
     
  18. Josephine

    Josephine FORUM ADMIN, NURSE DIRECTOR Administrator

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    Never heard of that before!
    I totally disagree. I also disagree with the 'risk of infection' since the injection should be done under aseptic (sterile) conditions.
    Oh gosh - no way is it 'quick'! He's giving you a line there. There would be very little difference between that surgery and the original hip replacement.
    Far be it for me to criticise a surgeon who has done 'thousands' if THRs, but I don't think he is!
    Well I certainly wouldn't go back to him for another surgery since he was the one that messed it up in the first place! If you took your car to a mechanic who made a mess of a repair, would you go back to him again>
    Exactly!
    I don't think this is anything to do with the implants.
    I really can't say.
    I wouldn't. SHE thinks he had a 'similar problem' but it's highly unlikely he did.
    Not at all! I used to close up for surgeons from time to time. It's not that difficult and often they make a better job of it than the surgeon!
     
  19. Jws.

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    @Josephine
    Your response really made me apprehensive and honestly a little lost.

    The Os rx "Trochanteric Impingement" .
    You said "I never heard of that before"
    maybe I didn't explain it correctly....so I am including a short abstract of the physicians who did the study...


    Go to:
    Abstract
    While uncommon, trochanteric-pelvic impingement may lead to significant lateral hip pain. We defined “impingement distance” as the radiographic distance from the medial aspect of the greater trochanter and the corresponding lateral edge of the acetabular bone or component and compared this to the contralateral normal hip. We present two painful total hip replacement (THR) cases, each featuring a patient with severe lateral hip pain when walking and sitting. Both patients had diminished femoral offset and trochanteric-pelvic clearance, compared to the contralateral normal hip. The impingement distance was increased an average of 10 mm with the exchange to a longer femoral head. Both patients had immediate and complete pain relief with operative treatment to increase the impingement distance.

    Introduction
    Total hip replacement (THR) is one of the most popular orthopedic procedures performed in the United States today, and its utilization is predicted to rise over the next decade. While most patients are extremely satisfied with the pain relief THR achieves, a small percentage of patients experience persistent pain. In an otherwise clinically and radiographically stable implant, lateral hip pain is thought to be caused by trochanteric bursitis or the result of referred pain of spinal origin.

    We have dealt with several patients who had residual lateral hip pain due to what we believe was trochanteric-pelvic impingement. These patients shared many common findings. Their pain was severe, in fact, incapacitating. The pain was described as “deep” and accompanied by a “catching sensation.” The pain was always lateral and described as involving the trochanteric region, not localized to an exact point. All patients had spine MRI scanning and consultation with a spine expert to rule out referred pain.

    The gait of each patient was markedly antalgic. Passive hip range of motion in flexion was not painful, though forced abduction past 20° reproduced the patient's pain. Lateral pain was also present with flexion and external rotation of the hip joint. Muscle strength testing was not noticeably different as compared to the contralateral side.

    Radiographic examination revealed stable implants. Of note, however, the medial aspect of the greater trochanter was closer to the acetabular structures present on the contralateral non-operative hip. Shortening of the hip was also present. Metal suppression MRI scan was negative for trochanteric bursitis, fluid collection or abductor muscle tear. A diagnostic injection (lidocaine, marcaine, depomedral 10 cc cocktail) was given at the proximal tip of the greater trochanter and deep to the gluteus medius insertion, as this was thought to be the site of impingement.

    We hypothesized that symptoms were caused by trochanteric-pelvic impingement. We present a radiographic technique to measure relative impingement.


    Josephine, I really need for you to have heard of this as this fits my symptomology and really no one (9-10 OS's) came anywhere close to what is causing my groin pain, lateral pain and limp after sitting for half hour...when before sitting I can walk pain free 3-5 miles , with no limp whatsoever...(it seems sitting (office or car) throws my muscles into spasm the rest of the day.

    Secondly, I didn't quite understand - are you saying you disagree that a cortisone shot in the hip capsule or groin area or as they say above at the "tip of the trochanter and deep to the gluteus medius" would NOT relieve the pain on its own and there is no risk of infection under aseptic conditions 9 months out.

    Thirdly, I meant that the revision is less difficult because he is saying he doesn't have to cut the bone just change the liner or "ball" to open up some space so the implant can freely pass the trochanter when sitting. Isn't that true? As well as less risky..

    Lastly, if this isn't the answer or even a possibility, I am truly lost after nine months of searching os's and pm's on how to relieve and resolve this.

    Could it be as simple as a intra-articular shot of cortisone in the groin or "hip cavity" or gluteus medius or??? to solve this...

    Is this OS dx really not known ?(trochanteric impingement)?

    I am really tired, frustrated, depressed and scared that I can't find a resolution and will have to live like this the rest of my life...please help.

    All help would be appreciated. My life is not a life now, it's just about chasing doctors ...
     
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  20. Layla

    Layla FORUM ADVISOR Forum Advisor

    Member Since:
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    I'm sorry I can't be of any help to you. Your desperation comes across in your posts and it's heartbreaking.
    I feel for you as it's by the grace of God I'm not walking in your shoes currently. I hate that this is frightening, depressing, frustrating beyond measure, and that you don't know who to trust or believe with so many differing opinions. I'm praying for your comfort, peace of mind and clear direction as to which path you should take. It's all I can offer.
    @Jws.
     

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