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THR Worried I may have infection<<

Josephine

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And I edited it again!
I don't think you can see psoas impingement or tendinitis on a x-ray
And you are right, such soft tissue conditions cannot be seen on xray and so far as I can see, your hips are perfectly fine. However, that doesn't preclude any soft tissue issues.

As regards your numbered questions above
1. Some say minimal risk of dislocation if "nicked " by acetabulum. Others say there is risk of dislocation.. Which is correct if anyone has info or knows?
Depends who the 'some' are! I've never heard of such a problem.
2. Most Os say the recovery and arthroscopic surgery are relatively simple ?
Yes, they should be
3. Most say it will relieve your groin pain (THANK God) but you will have weakness for 6-12 months in operative leg but not significant. Will be able to drive, just won't be able to lift your leg up to your hip for awhile but you will be able to walk up steps, uphill, etc..
Here you are referring to what: cortisone shots or psoas release?
4. risk of infection-minimal
Of course - it will be carried out in the same sterile conditions as any major operation.
5. Since I have very little discomfort walking uphill, or even on steps, but do have slight pain1-2 getting in car and restricted ROM (main problem), is it my psoas?
Who knows?
My question here is my thighs and calves and muscles were strong as heck prior to the surgery. I have read that very strong guys after THR, because of the difficulty the OS has in dislocating the hip during THR, have a much longer recovery period sometimes as much as 18 months. Could this be the case.
Not in my experience.
6. In addition for the last two days I have taken 1 Advil, and two Tylenol and it has significantly reduced my pain and increased my ability to walk (no limp) and slight to no groin pain. Does the Advil reduce the inflammation therapeutically (like cortisone) and if you take it for a significant period of time could you reduce the psoas inflammation so that it would resolve?
You might but you run a greatly increased risk of these issues
Medications: acetaminophen (Tylenol, paracetamol) and NSAIDs, differences and dangers
NSAIDs Diclofenac. ibuprofen increase risk of heart problems: new study
I think you'd get the same result if you just took the Tylenol, which, I trust, is 1,000mg per dose.

You've repeatedly said "some say" and "I have read" but you don't tell me where you get this information from and neither do you give me links to where you read it. Therefore, as they say in court, it's hearsay and not real evidence.
 
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Jws.

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@Josephine ..ok counselor...no more hearsay...

1. I have talked to two OS's here in La. Top docs, one who does a lot of arthroscopic surgeries, and when I asked him about releases he's done and if he has dislocations after he said he has done many and in fact he did "a guy last week and two weeks after he dislocated". I said "Why" and he said " it generally doesn't happen, it happens to thin women and to people whose hip and pelvic geography make them susceptible" ???

I had another consult with a top OS in Pasadena and he said he's done two and "one he cut too much and it dislocated, the other was fine" (what a charmer he was!!)

I understand that it is a possibility. My thoughts on "dislocations' because of tenotomies are the more experienced the OS who does tons of these (there is none that I found who do a lot - it's a 4% post-THR problem) the better off I will be because they understand the "amount to cut and how to cut without a problem".

I have read in articles that the central compartment cuts near the acetabulum are the safest and leave the most muscle 40% tendon 60% muscle, second choice would be by the lesser trochanter 60% tendon, 40% muscle. Thereby the central compartment cut by the acetabulum would have the lesser debilitating results regarding muscle weakness in the leg.

Jo, your thoughts?

What is your opinion regarding dislocations re: Arthroscopic psoas tenotomies
It’s been a year and I am thoroughly miserable!

I have read your posts and you are definitely a direct, no nonsense totally empathetic informed "maven" and I really trust your opinion....give me some of your "mavenly guidance" It is truly needed. I'm a little bit adrift here

In addition:
Jo, I am want to post the following so that I don't have to review each post for psoas tendon release. Is that ok and do I post in a completely new thread or here as a reply.

"I am 13 months post op total hip replacement and need an arthroscopic "Psoas release" or "tenotomy". I have unfortunately been tagged with psoas impingement and it has been really difficult for these thirteen months. I have seen most of the best Orthos in LA and they do not do Arthroscopic work or this type of surgery.

I need recommendations of Orthopedic Surgeons in LA, NY or anywhere who do "arthroscopic post hip replacement tenotomies" or just plain arthroscopic surgeries of the hip. Your help in finding these good docs would be greatly appreciated"
 

Josephine

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I said "Why" and he said " it generally doesn't happen, it happens to thin women and to people whose hip and pelvic geography make them susceptible" ???
the central compartment cuts near the acetabulum are the safest
What is your opinion regarding dislocations re: Arthroscopic psoas tenotomies
I really wish I could offer a learned opinion on all this but I cannot.
I have read your posts and you are definitely a direct, no nonsense totally empathetic informed "maven"
I had to Google 'maven'!
Jo, I am want to post the following
You posted it already!
 

Layla

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She is a maven @Jws.
Jo you're a maven :wink: Perfect title!

Wishing you only the best moving forward (Jws)
I hope you're able to make an informed decision soon affording you the ability to move forward in life.
 
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Jws.

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@Josephine Well I am back and I am miserable. I can't walk, I limp, my operative leg pulls inward, and now I have daily groin pain. I am depressed and I am becoming more and more home bound because I don't want to go out and walk and feel the emotional pain at 14 months post THR, not healed with no answer in sight. All the OS's are guessing and throwing out theories, (psoas, scar tissue, etc but no concrete answers. The best answers I get are on this sight from Jo and others.

The main prosthesis is intact, no loosening, no infection ,(blood ok) no HO, no hernia, no LLD,,etc. mainly soft tissue.

I was a happy guy. Never had depression like this. Can't get out of this funk. Really need help. It's getting worse not better.

Had psoas cortisone shot Friday, lasted two days at most. Best two days in the last 15 months. OS says that he believes it's lots of scar tissue, wants to give me 3-4 cortisone shots 6 weeks apart, says "chemically" the cortisone not only may resolve the inflammation but will "chemically" burn away the scar tissue that's obstructing my ROM .

I asked him about a psoas Release and he says it may work but he says that he does about 20 each year and one or two of them resulted in dislocation. Doesn't sound like great odds -5%. He also says that the weakness in the operative leg could be significant. He says even being conservative in the release dislocation all depends on your "pelvic chemistry and geography".

He gave me a PT to stretch the hell out of the psoas while on the cortisone and thinks the combo of multiple shots and stretching could be the answer. Otherwise he says he would go in arthroscopically clean up the scar tissue and do a conservative release. If that doesn't work he says I "bought" myself a revision where he would inset the cup deeper.

My other OS also recommended psoas shot. He does about 20 tenotomies a year as well and has had no dislocations. He is not "concerned " about dislocations (I AM!) but rather that the % of releases that work is less than the articles written and is only about 60% effective and that's what I should worry about.

My son who is a doc (internist-not ortho) says that I should try "LYSIS?" or clean up of the scar tissue arthroscopically and NO RELEASE first since they believe thats a contributing factor.

I am at a total loss. Psoas releases have possible dislocation and weakening risk, revision increases the risk of more complications than in a primary, infection, loosening ,etc. and would I not end up the same as now with psoas and scar problem?

As always, any help would be appreciated. The worse risk is living like this in emotional limbo and progressively limiting my life and unintentionally retreating from more and more activities and living because of the physical and emotional pain.. "a coward dies a thousand deaths a valiant dies but one!"

@Josephine Jo I copied your reply post below to say is it true that scar tissue formation in hip surgery is rare? Why is my OS so keyed up on it in my case?

jws said:
"I have an extreme amount of scar tissue and it seems to be impinging the joint. Anybody had a arthroscopic surgery to release tension in the psoas tendon? This may be a root cause of my issues."
Josephine said:
This sounds like a much more likely cause of your problem. Personally, I have never heard of adhesions ("scar tissue") in the hip. Just doesn't happen. But a surgical release of the psoas is much more likely to be successful.
 
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SaraK

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I was told that the fact that my pain went away just from the "caine" med into the psoas tendon and then the degree of relief .got from the cortisone, even for just a short time, confirmed that the problem as with the psoas tendon. My doctor didn't recommend any further injections. He felt that if it only lasted for a few days/couple of weeks, it was unlikely to be successful in the long run. I didn't know if that was influenced by me being diabetic and having issues with the injections (I can see a 10 lb weight gain on my weight chart last year each time I got an injection). It certainly wasn't influenced by money because the doc that diagnosed me then referred me to the one that did the surgery. Financially unrelated practices.

I was told no one does a lot of the releases in any year so I'm not sure you'll ever find a high volume surgeon for this procedure. So it's a question of which doc you're more comfortable with and whether you Want to try a more conservative approach for a longer period. Whatever you do, I think you need to decide on a course and begin moving forward. That helped me get out of the funk from my psoas issue.

Wonder if Jo has any info on the dislocation issue. My surgeon went through the risks thoroughly and did not mention that as a risk. When I asked whether the original surgeon's work had been within normal standards, he said it was and indicated that if the cup placement is too far off, there is a much greater risk of dislocation in general (i.e. he was saying general risk and not risk caused by the release). I wonder if that was the issue with the patients the one surgeon had that dislocated. Can you not see that in the xrays?
 
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Josephine

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Had psoas cortisone shot Friday, lasted two days at most. Best two days in the last 15 months.
Yes, that's how it goes sometimes.
OS says that he believes it's lots of scar tissue
Don't believe him.
he does about 20 each year and one or two of them resulted in dislocation
If a tenotomy is done well, it shouldn't involve any risk of dislocation.
If that doesn't work he says I "bought" myself a revision where he would inset the cup deeper.
That sounds like a jolly good idea!
My other OS also recommended psoas shot. He does about 20 tenotomies a year as well and has had no dislocations.
That's how it should be.
He is not "concerned " about dislocations (I AM!) but rather that the % of releases that work is less than the articles written and is only about 60% effective and that's what I should worry about.
I quite agree with him.
The term lysis means arthroscopic or open division of adhesions
is it true that scar tissue formation in hip surgery is rare?
I wouldn't have said it if it wasn't true!
Why is my OS so keyed up on it in my case?
Good Lord, how should I know? I can't see into the man's mind! But it's my guess that he's blowing in the wind! What's wrong with the second surgeon, the one who said he'd do a revision. Sounds to me like he has something.
 
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@Jo @SaraK Well I am back again It is now 15 months of pain and terrible frustration and yes, at times very depressed and imprisoned. After 15 months THR and not more than one day of walking ok without a limp, groin pain and/or wooden leg and consults with at least 9 OS's or Pain Management Docs... it comes down to :

1. get a revision for what? (no one actually saw in the xray or ct scan the ball sticking out and impinging on the psoas or any other muscle) so my question is what will they revise if they are not going to adjust the ball and liner. 9 OS saw xrays and CT and only one mentioned impingement.

2. Psoas Release - possible dislocation risk, severe weakness in the leg (I bring it up and they say it is a definite risk even if fractional, or lengthening and a slight cut by acetabulum) and only 60% that it will work.
3. Aggressive PT.

So my last OS understood that I am done with this frightening nightmare, and not looking for anymore nightmares (dislocation, severe weakness in leg, etc) So his suggestion was to "conservatively" and aggressively stretch the hell out of the psoas and in between give three cortisone shots to the psoas tendon to aid it in loosening and freeing up. I have
now been in the most "aggressive PT since the operation and it is significantly uncomfortable. It really hurts a lot. He is really aggressive and I am a kid from the projects in the Bronx and a black belt and it hurts.

I end up in the last week out from work because of nauseating groin pain for two days after the therapy. However, I was with my wife last week shopping, bought a pair of shoes and for the first time in 15 months was able to lace them up. (so some progress)...but still groin pain and a limp.

Does anyone see or have a solution. I am tired and drained from the hip and its pain being the center of my life.

I am truly lost. I am thinking of not so aggressive PT but less but then I am being told that "I went 15 months without aggressive PT" and that's why I am in such a mess, that the scar tissue has to be broken up and the "capsule needs ROM and movement".

Is my PT right? Do I really have to go through 3 times per week and hours at home of aggressive PT to make up for the "chronic condition" I let happen by not getting the 'needed PT ' I should have got during the first 5-6 months.

I'm lost guys. Sincerely I need your help on any of the issues here. Is there a light at the end of the tunnel?

Thanks Jeffrey, my life is all about my hip pain, not my wife, son and grandkids. This was to be my best golden years, instead it's a horror

Thank you
 

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Wow @jws I really feel for you with everything you have been and are going through. I wish you strength and comfort and a full recovery.

I definitely can’t offer any solutions, except to say I think aggressive PT is only gonna make it all much worse. No brainer.
 

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Hi jws.
I'm not sure your tags were successful so please let me tag @Josephine for you.

@SaraK also, as she is some time out from her release surgery and may give you hope that this could be a good option for you.
I guess if I were in your shoes I would try all non operative measures I could but..
then I am being told that "I WENT 15 MONTHS W/O Aggressive PT and that's why I am in such a mess, that the scar tissue has to be broken up and the "capsule needs ROM and movement".
I really don't believe this at all.
And it's causing you so much pain.
Hopefully Jo will be around and I DO send my heartfelt sympathies that this has been such a struggle.
 

Josephine

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Is my PT right? Do I really have to go through 3 times per week and hours at home of aggressive PT to make up for the "chronic condition" I let happen by not getting the 'needed PT ' I should have got during the first 5-6 months.
No she's not right! Hardly anyone in the UK does physio or exercises after a hip replacement. For the simple reason that hips very rarely develop adhesions. They can't because there is such a lot of soft tissue and padding in that area.

However, doing aggressive PT is a jolly good way of getting very similar problems! They are mixing up the cause and effect in your hip!
 

SaraK

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You're looking at the success rate of only one of the options and not asking what happens to the other 40% on that. I was told that some need to do a revision if the tenotomy doesn't do the job - that those were more likely to have a greater offset on the cup and tenotomy wasn't enough.

As for dislocation, how great a chance of dislocation? Is that one of the small risks? It wasn't even mentioned to me when going over other risks so I wonder if it's one of those possible but very unlikely items.

For aggressive PT, I certainly ask abou success rate and drop out rate. I had 3 PT that told me PT wasn't the answer once they suspected an impingement. One referred me to my surgeon.

If you want to try them PT first, that's your option. But this isn't all or none on any option. You can try them one after the other until you find the right one. The main thing is to do SOMETHING!
 
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Need to know about psoas release - the good, the bad and the ugly!
It looks like it's my last option. Thanks.

@Josephine @SaraK ..ty for responding...as always you hit on something I didn't think of was the other 40%....I don't remember if it was you who told me but I was told that if the release doesn't work at the central compartment I think they said they could go in again and try the release at the lesser trocanter. (I still don't know exactly where the "central compartment is?" )
My other concern is if I truly have a "psoas' issue.

I had the cortisone shot to the psoas and felt a hell of a lot looser , I could "bounce " around more easily..but don't recall if it took away my hip flexor catching, etc. I was so enjoying the "looseness' and more ROM , I forgot to test the sitting and getting up hip flexor pain, getting in the car pain,etc.

On the other hand , my symptoms do indicate Psoas, I have 1-3 pain always getting into my SUV, Definitely have "catching " pain in my hip flexor area every time I get up (7 months now), and most significantly have continuous 1-4 groin pain when sitting and now when I am lying down.

On the other hand (I sound like "fiddler on the roof")..I just went to UCLA and walked up and down 1400 steps (20 rows-70 low riser steps each) in the stadium with litttle groin pain during or after. In addition ,I can walk uphill with not much discomfort.

Prior to this new " aggressive" physical therapy" I was having no groin pain when I was lying down at all, and not the back pain I am having now. After this PT ,I am in pain at least three days after so this doesn't seem right.

I am scheduled to have another Psoas shot by Ultrasound. I am trying to get another OS who I know who does the shot by floroscopy . I read study that psoas shots that are done by floroscopy are 40% more effective and sometimes the fact that a shot is done by ultrasound, it is less likely to succeed.
As always in this hip nightmare , I have also read that both are equally successful as long as the OS who administers the shot is comfortable with either mode. thoughts?

I have scheduled consults with three docs who have done many of these psoas releases, one in NY at HSS, one in Florida, and one in Colorado.

Sara, in response to your last reply , yes i am doing a lot of "analysis-paralysis" and "do something" response resonates with me. It has been now 15 months since the original operation and there has not been one day that I have not been in pain.

I have been depressed in ways I never was and my life spirit has been taken out of me. Everyday I wake up in fear of "how bad is today going to be" . and how do I get out of this nightmare. If you remember (and I know that's the past) I really didn't need the hip surgery, I was having some mild back pain, was not even close to bone on bone..(worst mistake of my life).

The truth is I am scared as hell to make the same mistake again (psoas release) and fall into another horrible mess with more severe consequences, (dislocation, weakness in the leg, or it doesn't work and I face a another revision with much more possibilities of downside).

I am worn out and emotionally drained. Sorry to be venting..
As always all thoughts and recommendations would be appreciated.
 
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SaraK

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Don't let the fact that you had this complication stop you from doing what you need to do to fix this. I'm guessing "central compartment" means the area near the acetabulum where my surgeon did the release. I doubt you need to go cross country to get this done, but that's up to you.
 
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@Josephine ,@SaraK Sorry I have been sick and have not posted for a week. When I posted last time I was very despondent, and I pm'd josephine with some questions. I just want to say that josephine took the time to give me the support and patient answers I needed with empathy and solid wisdom. It has been 15 months with this nightmare of a hip of mine and I can definitively tell you without Josephines guiding hand (And help from several others on this site) I would be a mess. Jo gives advice day in and day out selflessly and is my true voice of reason and compassion. I don't generally use forums as they generally have a lot of folks spouting a lot of mystic stories .
This site is the gold standard of a meaningful forum and @Josephine is the gold standard of leading this site with compassion,selflessness, and a truly special human being . It was important that I voiced this , I am sure all of you are aware of what I am saying but it's always nice to share every once in awhile.. bravo @Josephine!.

ok now to my hip, I have relistened to my recording of my OS and for the psoas and before the attempt at the release. His plan is to shoot the tendon with cortisone three or four times (spaced about a month) and have me do aggressive pt during that period. He feels that if you "splash" the cortisone over the psoas tendon chemically it will "soften" the tendon and let the physio stretch the tendon giving "possibly" the space necessary to have the tendon release from the hip . I don't know if that's possible but during that period I am going to interview four OS 's who do the release and see if I feel comfortable with them. Mark Phillipon of the Steadman group in Vail Colorado, two at HSS in NY , and one at Duke in NC and one in florida.

I only see these two possibilities (other than a complete revision) as the simplest remedy to my problem.
Any thoughts and suggestions would be appreciated? am I missing anything?...thanks as always...
 

Josephine

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His plan is to shoot the tendon with cortisone three or four times (spaced about a month) and have me do aggressive pt during that period. He feels that if you "splash" the cortisone over the psoas tendon chemically it will "soften" the tendon and let the physio stretch the tendon giving "possibly" the space necessary to have the tendon release from the hip .
Not sure that I can either see the logic in this nor the wisdom. Considering the tendinitis was originally caused by aggressive PT, it's a bit like sending the fox to go look after the chickens!
 
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@Josephine ...the tendinitis was not caused by aggressive pt...in fact during the firs 5-6 months there was very little hands on pt...he thinks that that's when the tendinitis became "chronic" and it now needs not "aggressive" but "hands on" pt to stretch the tendon while the cortisone is softening the tendon so it doesn't snap back..he thinks the hip has very little ROM....he says to try this first and then if necessary do a "careful" keyhole release..
 

Josephine

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.the tendinitis was not caused by aggressive pt
Okay, aggressive activity then
it now needs not "aggressive" but "hands on" pt to stretch the tendon while the cortisone is softening the tendon so it doesn't snap back
No I don't believe that. I think that is the pathway to hell. You will be making the entire situation much, much worse.
 

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