Karen Bell: Bilateral PAO
Date of surgery:1st PAO: Dec 2011; 2nd PAO Dec 2013
Surgeon: William Jiranek, MD
Hospital: Virginia Commonwealth University Medical College of Virginia, Richmond VA
Prior to surgery
When did you first notice symptoms and what were they?
Starting at age 17, I was having what I perceived to be lower back pain, which was attributed to my excessive flexibility in high school gymnastics; I was told to quit, which I did.
What was your medical diagnosis (traumatic osteoarthritis, congenital hip problem, avascular necrosis, etc)?
Developmental dysplasia of the hips, due to trauma during birthing (no C-section; I was breach, mother's first pregnancy), diagnosed in October, 2011 at age 42. I had severe dysplasia on the right (Tonnis 1.5 arthritis), moderate dysplasia on the left (Tonnis 1.0 arthritis).
What forms of treatment did you seek before considering surgery (chiropractic, acupuncture, medications, bodywork, physical therapy, herbs, etc)?
I tried various different sports (other than ballet and gymnastics) in addition to massage therapy. My massage therapist always noted how tight my glute muscles were. I also always had lower back pain (which I now believe was due to muscle cramping) since age 17 and right leg pain since early 2000s. I had always lifted weights but began to focus more on hip strengthening, still at the stage of being undiagnosed. I lived on NSAIDS for years and heat packs day and night. I tried chiropractic therapy (not a good idea for dysplasia). Also, I did months of physical therapy (see below) which helped me to walk again but did not fix the problem.
How did you change your work habits, lifestyle to accommodate the hip problem?
I found my iliopsoas muscle weakness and inability to rotate the leg inward forced me to quit doing dressage and move to show jumping, tennis and running (I quit dressage after 20 years of training). In early 2010, I lifted a bale of hay and my "back went out." I was in the process of training for a ½ marathon. After 6 months of fruitless more visits to orthopedic surgeons, back injections, and months of physical therapy, my PT and I decided I needed to see a hip doctor. Once the x-rays came back, it was clear my riding/running/tennis days would be put on hold, possibly for years.
2005 clinic in Houston:
Note the lack of inward rotation of both feet, which should be parallel with the long axis of the horse. Also, legs are too far forward, a function of both proper saddle positioning on the horse and rider ability to move the leg back. Although not so obvious from the picture, I could not keep my knees forward (toward the head of the horse), in order to maintain inner thigh contact with the saddle.
How long an interval was it from the onset of hip problems until surgery?
42-17 = 25 years!
What factors, physical, emotional, financial, etc. influenced your final decision to have surgery?
The number one factor was that 1) my surgeon would do the same surgery in my position (ask this question when you are considering this surgery), and that 2) I would have a lower rate of infection compared to artificial hip and that 3) I can "pound" on my legs afterward and possibly never have to have another surgery. I also have a good support system and knew I would not have to do it alone, and that my job could be put on hold for months without worrying I would be fired. I did not work for 4 months; therefore, having job security was paramount. Also, a consideration for younger patients, you can still have children after a PAO.
What influenced your choice of surgeon?
He was the only one in the state and had good ratings from other doctors and did a PAO about 1-2 per month on average. He was not a novice at the surgery.
How long were you in the hospital?
Did you have any complications in the hospital?
I got a UTI (urinary tract infection) from the catheter
Anything else to say about your in-patient experience?
Yes, avoid hospitals, ha ha. I found the nurses and the occupational therapists had no idea what a PAO was and were asking me to do things (like reach for my toes) that were completely contraindicated. When the drain fell out and I was bleeding out old blood, the nurses were trying to stop it- also not what you want done. I demanded a resident show up at that point to explain to them and me what was going on.
Did you have any complications, especially unexpected difficulties, after you got home?
I could not lift my leg up; all hip flexor muscles failed, making walking dangerous. Pain management was also insufficient both in hospital and post-operatively. On second PAO, I had a better initial post-operative outcome (am now 4 weeks post-op) and better pain management.
What steps did you take toward recovery? (Physical therapy, chiropractic, acupuncture, medications, bodywork, herbs, etc.)
2 months of aquatic PT, 2 months of land PT - however, not all people will need this much PT. I went into the operation with a very weak leg, lots of atrophy and muscle pain. I was subsequently diagnosed with chronic muscle pain on the right side. I took gabapentin (Neurontin) which helped immensely after the narcotics (which only help the bone pain). Be careful about falling, even after the hip is healed. I suffered a couple of avulsion fractures in my upper limbs due to a fall because my leg did not lift up enough to avoid a hose on the ground.
How long did it take you to really feel recovered (6 months, one year, two years?)?
I am not yet recovered after 2 years on my right leg, which is still weak and flairs up with pain when I run. I do believe my left leg will recover within that period of time, however, because I only began having symptoms 8 months prior to the second PAO (compared to years of pain due to my right leg). Anything or any practitioners that you would highly recommend? Make sure your PT is competent to handle a PAO patient. Mine was diligent and called around town to find out information from other physical therapists on how to help me. I never push myself beyond manageable pain, no matter what a PT says. You have to be your own advocate both with your doctors and your therapists.
Did you return to riding professionally?
No, I gave up my equine business in 2009, and I have no intention of starting it again. I might ride recreationally sometime in the future.
Do you do other physical exercise (e.g., Yoga, Pilates, biking, swimming, etc.)? If so do you modify what you do in these activities?
I cross-train, just much less intensely. I was running 2 miles prior to my second PAO and playing tennis. At 44, even a healthy person will need to slow down the training and wait for muscles to recover.
How has the surgery impacted you professionally, physically, emotionally, spiritually, and financially? Is your life different now? Did you have any outcome, good or bad, that was different from what you expected? Any other thoughts to share?
I think you had better be prepared for the worst, the pain, and the time. Seek social services if and when the post-operative recovery is causing any mental strain (which I admit I did not do and should have). It's not an easy surgery to recover from, and even having done it once, I was amazed 2 years later at just how frustrating it is to walk and have your muscles function. There is plenty of data, however, showing good recovery especially for younger (under 40) patients in good physical condition, especially if no arthritis is present (PAO Research Paper).
I obviously elected to do it again, so I do think I will recover, just slower than someone who is younger and was not in chronic pain for as many years as me. I was told I had a 20% probability of needing hip replacement in 10 years on the right and 10% probability on the left.
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Submitted January 13, 2014