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[THR] Worried I may have infection<<

SaraK

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I'm saying I think your understanding of central compartment is incorrect. Josephine might be able to straighten out medical side but I don't believe they invaded the capsule. They stretched (distracted) the hip to put things in better alignment but the psoas is located outside the capsule. I asked my surgeon whether NSAIDs were necessary to prevent HO and he said they weren't because they wouldn't actually be working that close to the bones/joint. The amount of stretching of hip wasn't that great so I didn't have any time on crutches or brace - just a cane for first couple days as stiffness leads to instability. I did read about 6 weeks on crutches but my surgeon said that was for other arthroscopies where they were needing to get into the joint.
 

Layla

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:wave:Wishing you the best result through whichever solution you've decided on.
It's been a long journey and it will be nice to see you once again enjoying a pain free life.
Hopefully it's finally within your reach. :fingersx:
@Jws.
 

SaraK

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If you're truly wanting all surgeons we've had experience with on psoas release, wherever located, I have contact info on mine now. Was in St. Louis but went back to Montana. He's at Great Falls Clinic Specialty Center in Great Falls, Montana. Will start seeing patients 7/15 (not sure if he'll still require referral from revisionist before will see post THR). Phone no is 406-454-2171. Med degree from Univ of Wash, residency at Wash U in STL, Fellowship in sports med at Mayo.
 

Josephine

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lws, I asked you previously, would you, do you go into this much research, detail and worry if you need to have a root canal or a crown done? This surgery really is of a similar ilk and really doesn't warrant all this angst. It's a relatively minor procedure and is about 90% successful.
 
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Jws.

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@Josephine , @Harryn1 , @SaraK Went to Chicago to interview Dr. Benjamin Domb at American Hip Institute. He wants to to do a "lengthening" Psoas release at the Lesser Trochanter.

He has done over 2000 "native hips" tenotomies and over 200 tenotomies after THA.
He gave me the choice of either having the cut done at the central compartment or the lesser trochanter. He has done many at both places . He does not "cut" all the way (total release ) at the lesser trochanter he just cuts the tendon and repairs the muscle.

He agrees with me that doing the cut at the lesser trochanter has less risk of infection and less risk of dislocation (because you are not going in or near capsule (even though he admits both the left and central compartment cuts have minimal risk of either infection or dislocation).

He wants me in a brace for two weeks after surgery so I don't flex the psoas while its healing.

He says the main risks are the regular suspects (PE, Infection,etc ) and cutting the femoral nerve, and (which he has never done) etc.

He said I will not be worse off than before the surgery, it is relatively easy 30 minute procedure. He did mention the things that are not under his control that could make the surgery unsuccessful:
1. Rotational problem of implant that he can not see in CT or when he goes in (anteversion ,etc) rotation of stem causing problem (i.e .anteversion.)
2. Excessive scar tissue
3. Loosening of implant not seen on xray therefore unlikely
4. not the right diagnosis
5. extremely prone to scar tissue buildup, scars build back up and tighten area again.
6. weakness in leg that makes me unhappy . (has never seen it that significant..slight weakness)

He says he does not agree that if you have groin pain that you necessarily have to go into the "central compartment" because it is NEAR the groin pain, a significant release at the left tendon should loosen all the way up to the central compartment and relieve the groin pain as well.

However, the one caveat is before he releases the lesser trochanter (tendon only - not muscle part) that he will (Lysix ) look with the arthroscope all the way from the lesser trochanter up to the central compartment and REMOVE any and all scar tissue that may be impinging the tendon from the central compartment to the left and make sure its mobile before releasing at left.
6. Weakness in leg that makes me unhappy .(has never seen it that significant..slight weakness)

He looked at the CT and confirmed that the cup is well seated and there is bone coverage at the rim.

Please all comments would be appreciated. Especially from psoas release and tenotomy patients or anyone.

In addition if anyone knows of Dr. Benjamin Domb, please give me your thoughts bad or good. Or any other psoas release arthroscopic surgeons that you know of anywhere that are good?


You guys are the best Thank you Jeffrey
 
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Jws.

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Josephine, SaraK, Harryn1
Just received this info that is contrary to Dr. Domb's info......
Dr. Chien Wen is saying to release at the central compartment and ONLY release at the Lesser Trochanter if the release at the central compartment doesn't work?
I am confused ..

Chien-Wen Liew Denise Pinto Chenier thanks, a psoas release can be performed at the LT or within the central compartment. The central compartment means that the psoas is cut within the muscle fibres, and at the edge of the cup. In general, this is preferred, as the strength of the unit is maintained, as the tendon still functions.

The psoas tendon runs within the muscular unit and then becomes tendon only close down the bottom near the LT. This means that releasing the psoas off the LT is the more drastic measure, and should be reserved only for those who have had the central compartment released, which fails.

The first step is a diagnostic injection to the psoas to determine if this is in fact the cause. If you have a good response from the injection, then there’s is a good chance of relief after psoas release.

It is most often caused by a cup which is to prominent anteriorly, or a bone spur anteriorly, or it can also sometimes become irritated in high inflammation environments.

The psoas bursa often communicates with the hip joint itself, so there is sometimes an infective cause that causes psoas symptoms but is actually infection coming from the joint and inflaming the psoas bursa.
 

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Josephine

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It all sounds pretty logical to me. Does it worry you?
 

SaraK

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I'm no medical expert and only know what I read and what my surgeon told me. He only graduated a few years ago and did a strong emphasis on hip arthroscopic during a fellowship at Mayo, so I tended to believe he was more up to date than some other surgeons on this procedure. He told me the release had been done at LT for some time but was switching to central compartment because it represented less weakness and fewer restrictions on the patient (I was told to do whatever I wanted from day 1 - including dancing and weightlifting - just so long as the pain level didn't go above 4). He said some weakness was typical but it wasn't significant but it was also reversible if you wanted to put in the PT work (which you can do on your own) over a few months.

He said you don't completely sever the tendon and the muscle remains attached to the tendon. His analogy was the effect of fileting a steak. What is left of tendon not as thick so it stretches more, lengthening the tendon about 1 to 1.5 inches. Over time, the tendon regenerates at this longer size. He also said there's less risk of nerve damage from the angle for CC.

So, while I can't tell you which is right, my surgeon agrees with the new doctor you quoted. The type of question I usually ask myself when getting conflicting info like this is "Why would the medical community be gravitating towards the newer CC procedure if the LT procedure was better?". It may be that the doctor advocating the LT approach does that approach because that's what he was trained in and has so much experience in - similar to the reason some surgeons still do the older long posterior approach to a THR rather than even a mini posterior. They both work and there is a learning curve associated with any switch in procedure.

I think you can go either way here and it's a question of which you trust for their skill and experience. Personally, I generally gravitate towards the newer approach as long as there is some favorable experience with the procedure generally and that surgeon in particular (I wouldn't want to be the surgeon's first CC patient).
 
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Jws.

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Josephine, SaraK, Harryn1, slinky. Well it's almost done...I have found the surgeon and will be scheduling my psoas release for on or about August 15th at Hospital for Special Surgery in New York.

He and his PA were terrific. They addressed all the issues I was concerned about.
1. He will be "lengthening" at the central compartment 'area" but will not be going into the compartment. (he just found that recently if in surgery they lift the leg up a certain way , the psoas becomes clearly visible and he can then avoid cutting the capsule)

2. He has never had a dislocation, nerve problem or infection out of 100 psoas releases. (knock on wood). He does about 10 THR psoas releases a year. 15 additional native hips psoas releases a year.

3. The surgery will take approximately 40 minutes.

4. He will also be doing a trochanteric bursectomy. (mine keeps coming back after shots)

5. He estimates that I will be on crutches for three days (I'm not clear on this. If you can help me here would appreciate it). He estimates that after 6 weeks I should be up and ready to go?

6. He indicates that 99% of his releases are successful.

7. He does say that the psoas tendon is "salamandering like" and can "reform " or grow back, unlikely but possible, if it does he will go back in. However , he says he will do some scraping of 'some' bone so even if it does grow back in there will be space. ( what bone?)

I can tell you that I am nervous and that I can't see that one little cut will resolve all the "pains" I am in presently: groin, gait, butt, etc. and it will magically go away. But if it happens I will be 'over the moon" with it. (it's the lawyer in me) After 16 months of continual pain each day since the surgery, I am so grateful for even getting to this point and finding the right surgeon for me.

That being said it certainly does not relieve the anxiety as I am one of the unfortunates as most of us are here who did not fly by this surgery with "forgotten hips" but suffered some complication which upended our lives.

I did not clear up a couple of post-op rehab questions which maybe Jo, Sara or slinky can help me with.

1. I am renting an apartment in NY for the surgery and it only has a tub/shower combination. The tub is about 1½ feet high. How am I going to lift my operating leg into the tub given the first week or so weakness? Will I still have the strength in that leg to lift it up and over the tub to shower.

2. Will I be able to sit given I will have the two holes by my groin area that will have to heal? Will it be uncomfortable to sleep as well like primary?

3. Will the two cuts they make for the arthroscope be non-issues just like any other two cuts healing?

4. Will the trochanteric bursectomy add additional time to the healing process and given the release works will the trochanteric bursectomy effect my gait, rehab or PT in any substantial way?

5. Am I risking a new problem adding the "bursectomy" into the equation (the OS says its simple as well) but I can get a shot or live with it and have it done at another time. I just want to walk pain free again!

I am thrilled that I have made this decision, found the surgeon and can give up the research on finding out what my problem was (going to over 9 OS's), cortisone shots, xrays, uncaring doctors, etc. etc.. you all know the drill and have done this nightmarish journey as well.

I am afraid to get my hopes up as I will be really despondent if it doesn't work and truly "lost" as to what is causing my pain and where to go then ? (there goes that obsessing again)

For the time being I will bite the bullet and sometime this week schedule the surgery and leave it in the hands of the Gods that be.

I cannot thank you all enough for being there for me. You truly have been more than helpful, especially during times when I was at my lowest and I couldn't even post about..

Any tips on the recovery after this surgery would be greatly appreciated ..and again thanks for being there.
 
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SaraK

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I can't say as to the other questions, but there will be stiffness the first several days. For me, that melted away hour by hour but did take a few days to resolve. My cane was helpful during that time because the leg wasn't able to fully move or respond to commands. A little extra balance and stability and the ability to take a little weight off it was good. I went from being unable to lift it to reach a pedal one day to confidently driving the next (day 4).

I didn't have much pain. I took meds for the first day "just in case" but stopped that first evening - even though I'd gone out dancing that night. The incisions were not right at the crease so there was no pain sitting for me.

My house just has bath/shower combo so I had to learn to get in and out after THR. The key when you have trouble lifting the leg is not to lift the leg. Step in and out with the good leg (preferably holding onto a rail or cabinet or something for balance support standing on the bad leg) and bend the leg at knee so that the knee is at right angle and the foot is behind you. Easy peasy!

Glad you're getting this scheduled! The number of procedures he does each year sounds about right from what my surgeon said. Other arthroscopic lead to even more experience. I have heard of them creating a better trench for the psoas for issues with native hip. I thing they do this on the ilium near the joint.

Good luck - will be glad to hear how your recovery goes!
 
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Josephine, SaraK, Harryn1, fiveboysma, tiona

Ok ...scheduled psoas release for Aug 23rd. Talked to OS (really good, finally got one at HSS who knows what the hell he is talking about) and is empathetic and detailed oriented. Had second meeting with him and asked a bunch of questions mainly about his new technique.

He does it close to the central compartment to get to the groin pain but does not enter the capsule. He says that doing it this way there is little risk of infection, instability or dislocation. This was exactly what I was looking for versus the lesser trochanter, not close enough to cure the groin pain but also far away from capsule. No risk of infection or instability or through the capsule, theoretically risk of infection and instability.

He was doing it through lesser trochanter then found central compartment was closer to problem/groin pain and worked better but had the risk of the infection and the instability.

So what he did 5 years ago was during surgery he would raise the knee which would expose the psoas and go directly into the psoas that way. Ok enough of the logistics, nice guy, wrote many papers on psoas release, and I trust him.

The one upending remark he ended the conversation on was, he said that all his THR patients who got relief from the surgery were over the moon happy. I then asked him what about the other patients that didn't get relief - he said they either lived with it or got a revision - that was not what I wanted to hear!!

Notwithstanding, I am still nervous about the surgery so all the good stories or bad - info is always a good thing, would give me encouragement. Hopefully you'll stay with me until the day of the surgery. Thank you all

Jeffrey (hopefully, I get lucky and it works for me)
 

Layla

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We're rooting for you.
Even if we're not active on your thread, we're watching :unsure: waiting :bored:
and will let out a big cheer :yes!: when it's finally behind you. :happydance:
Wishing you comfort until the 23rd and all the best going forward!
@Jws.
 

CricketHip

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I just read through your thread. Glad you have found a solution together some relief.
Best wishes and will follow your recovery!
 

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@Jws. wishing you strength and comfort and all the best for the 23rd. May it relieve your pain. It sounds like you have confidence in this new surgeon, and you have certainly done your homework. Now leave the rest up to him and God.
 

SaraK

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Keeping my fingers crossed and wishing you a quick recovery!
 

Mojo333

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Best of luck @Jws. :tada:
Hopefully you will have the same stellar success as SaraK.:thumb:
 

Bumpa

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The Lancet have just published a great article on knee infections.

In the largest study of its kind, researchers from the Muscoskeletal Research Unit at the University of Bristol have identified the most important risk factors for developing severe infection after knee replacements.

The research, which follows work on hip replacement published last year, also showed that some patients are at higher risk of early infection, while others are more prone to late infection after knee replacement. The study analysed data from more than 670,000 primary hip replacement patients, with 3,659 requiring revision for infection.

The study, published in The Lancet Infectious Diseases in April, conducted as part of the INFORM research programme funded by the National Institute for Health Research (NIHR) and the NIHR Bristol Biomedical Research Centre (BRC), considered the risk of infection following primary knee replacement. This study used data from the National Joint Registry (NJR) for England, Wales, Northern Ireland and the Isle of Man linked to the Hospital Episode Statistics database.

Knee replacement, used mainly to treat pain and disability caused by osteoarthritis, is a common procedure with around 110,000 operations performed annually in the UK. A rare but serious complication affecting about one per cent of patients is deep infection. This causes considerable distress and often requires long and protracted treatments including revision surgery.

This study showed the reason for surgery, the type of procedure performed and the type of prosthesis and its fixation, influenced the risk of needing revision surgery for infection. Surgery performed following trauma, inflammatory arthropathy or a history of previous infection in the operated joint were more likely to be revised for an infection. Cemented total knee replacements were more likely to be revised for infection compared to patients with an uncemented implant. Finally, the risk of revision was increased for patients with a posterior stabilised fixed-bearing implant or a constrained condylar (CC) implant compared to those with an unconstrained (or cruciate retaining) fixed-bearing implant. The experience of the surgeon and the size of the orthopaedic centre had no or only small effects on the risk of revision for infection.

Uniquely, the research identified that these important factors have a different effect depending on the post-operative period, with liver diseases or inflammatory arthropathy increasing the risk of revision for infection in the long-term but patients receiving a patellofemoral, unicondylar or uncemented total knee replacement had a lower risk of late revision for infection. This is an important factor to consider when conducting further research in this area, as just considering overall risk or short-term risk may mean important effects are missed entirely.

Michael Whitehouse, Reader and Consultant in Trauma and Orthopaedic Surgery in the Musculoskeletal Research Unit of the Bristol Medical School: Translational Health Sciences (THS), said: “This work has identified key patient and surgical characteristics which influence the risk of revision for infection following knee replacement, and specifically the risk of further surgery for infection two years or more after the initial operation. This information provides me with the strong evidence I need to discuss the risk of infection with my patients undergoing knee replacement and helps us identify strategies to minimise that risk for them.”

Dr Erik Lenguerrand, Research Fellow in the Musculoskeletal Research Unit, added: “These findings are consistent with the results of our infection after hip replacement study and could be applied to a wide range of patients undergoing different implant surgery. Most of the risk factors identified are generally associated with a complex initial knee replacement. This should be considered by surgeons when planning their surgery to minimise the risk for their patients. We now have strong evidence to develop new patient resources with better information to help them discuss with their surgeon and make decisions about their treatment.”

The researchers found the risk of revision for infection following primary knee replacement is affected by many different factors, but is mainly driven by patient and surgical factors. The possible issues identified in this study should be considered by clinicians when preparing patients for knee replacement surgery.

Further research should be carried out to find out if changes to the management of these conditions alters the risk of infection. It is equally important for clinicians to consider the issues that can’t be changed and the factors that show time-specific effects on the risk of prosthetic joint infection, to support patients appropriately in their decision making pre-operatively and after they have undergone knee replacement.

The research team will analyse further data from the NJR to look at the treatment of infection when it does occur to see what treatment has the best outcomes for patients.

Source: University of Bristol

Reference: Erik Lenguerrand, and others. Risk factors associated with revision for prosthetic joint infection (PJI) following knee replacement: an observational cohort study from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man; The Lancet Infectious Diseases
 
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Jws.

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@Josephine
Ok ...the date is set for aug 23rd. I will find out the time . I will be having a tenotomy(psoas release) FINALLY and a trochanteric bursectomy.
I am clear that the surgery will and should clear up my groin pain but how it will clear up my glute pain and make my walking effortless is a mystery to me. I can deduce that by loosening the psoas should give me more "room" but I don't see how that will loosen all the way to the glutes and stop the 'twisting" and "wooden leg" symptoms when I walk.
However there is a point where I have to let go and let it be to the powers that be. I have done my homework (boy have I done my homework, 14 months of researching, seeing docs good bad, arrogant and obnoxious, informed and "no clue", read every article ever written (it seems), etc.) and I have absolutely chosen the best surgeon for this surgery, the best hospital for this surgery (hss), and the rest is more of "casa ra sera.. whatever will be will be".

In our last meeting I asked my surgeon that he said '" most people who have success with this surgery are thrilled with the results" , I then asked what about the ones who don't have success, he replied .." they have a revision"...and the agony of consultations continues.
Thank you all for coming along with this journey..you have know idea how much your feedback has helped...
please stay with me until the end of the 9th inning..and say a small prayer (maybe a big prayer would be better)...you all are blessed. thank you from my heart. @SaraK, @Harryn1 , etc.etc.
 

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