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Revised High Femoral Osteotomy

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  • Revised High Femoral Osteotomy

    Hi, I'm a triathlete, or I used to be! My last race was December 2004. In July 2005 I had a revision on an osteotomy that I had done end of 1994, which was necessitated by osteoarthritis in my right hip, probably brought about by a cycling accident. At the time it served its purpose and allowed me to continue racing and I managed to do a good 10 yrs racing including 4 ironmans and many long distance races. The extra lease of life it gave seemed to be finally over in 2004.

    The plan is to get a BHR done. Because the original osteotomy imposed some limits on my range of movement, like no external rotation, hyper flexion reduced to about 105 degrees and no abduction. I decided that I wanted this corrected before going ahead with a BHR and that is why I had the 2nd osteotomy to more or less undo the first. I am also planning on continuing racing, if not maintaining a fairly active lifestyle.

    So far the recovery has been going reasonably well. I have been back on my bike for about 9 weeks and I was off crutches back in December onto a walking stick and off that just before Christmas. At about 6 weeks back I had some sharp patellaro-femoral pain only when walking and the local physio taped up the patella and that seemed to stop it. My surgeon had some doubts and seemed to think it could be referred pain. After about week of being taped it seemed fine again. So I started to feel reasonably certain it was actual knee pain. Plus on the day I hobbled into the physio after taping I walked out.

    Last Sunday the knee pain returned. It wasn't serious just some short sharp tinges of pain in the knee while walking. I felt no pain while cycling. I don't know if it a coincidence but the problem started on a Sunday last time too. I do a group ride with a tri club and on the return leg the pace can pick up at times. While I think I have been progressively finding it easier to stay with the pack it makes me wonder if I am pushing too hard and this is causing some issues.

    Anyway on Monday, which is when I visit the physio I mentioned the twinges I'd experienced I also noticed that I had gained some more internal rotation. In my left leg I have about 27 degrees (internal rotation of the hip) at about 90d hip and knee flexion. In my right leg I was now getting 10d and previously I'd had none. I confirmed this in the surgeon's office yesterday too. Maybe this change has altered the joint alignment (of both hip and knee) and is causing either the referred pain in the knee or the knee pain (due to the fat pad being caught between the patella and femure).

    I walked out of physio after some exercises, massage and heat treatment feeling a lot better, looser, walking more correctly as I usually do. I went into work on Tuesday the next day and a had a short ride in the morning and felt a little discomfort in the hip but nothing unusual. It has been coming and going and generally improving. Though when I got off the bike at home I started to feel some knee pain again. For whatever reason I decided to throw my walking stick in the car - just in case. I parked at work and walked in from the car park feeling slightly more discomfort than usual.

    Progressively as the day went on the knee pain became more servere. I needed someone to drive my car closer to the building entrance and bring my stick. I later walked out carrying my laptop saying I didn't need any help. About halfway to the car it was complete agony. I had highly localised intense pain in my knee. Luckily someone offered to carry my laptop and encoraged me to hold their shoulder. I got to the car and drove home with shooting pains seeming to come from the knee and now the hip too. I rang my wife from the driveway and she brought out the crutches so I could get into the house. Two panadeine fortes and 30 minutes later things were settling down.

    I went in to see the surgeon yesterday with x-rays of the right hip and right knee, both are fine and dandy. I wondered if I had broken a screw or something but everything is looking good. The pictures more recently taken while full weight bearing show a nice gap between the head and the acetabulum where it had been previously bone on bone. Surgeon is not sure if this is due to an artefact or perhaps there has been some repair of the surface during the non weight bearing phase of recovery (or even over the years whilst in the old position). Anyway the pictures look good and he's happy but I am not as there is still quite a severe amount of pain - funny I don't like that! He did say before and said it again yesterday that episodes like this are not altogether unexpected and that when they occur I simply need to back off and revert to using either the crutches or the stick at these times.

    Here is a picture of my hip 1 month after surgery:

    My questions are what are the likely causes of such flare ups of pain? Also I had a go at taping the knee myself in the morning on the day from hell and it seemed to make no difference on this occasion, maybe I did it wrong, maybe it really is referred pain, how can you really tell?
    Cycotec Jesus is coming, look busy.

  • #2
    Very detailed post - however that hip is pretty arthritic and no wonder you are getting pain, whether it is felt in your groin, thigh or knee. I think some sort of full hip replacement procedure is the way to go, as you have suggested.


    • #3
      Thank you for your reply, and while it has been planned to happen further down the track, there is some time in between. I wish I could show you the latest x-rays whilst full weight bearing. We are currently about 9 months post op. As I alluded above there is a now a reasonable and even gap around between the head and the acetabulum. It had the surgeon a little puzzled too and wondering about artefacts and wondering if the BHR (hip resurfacing) would even be necessary. Because I have a dead uncle he is concerned about avuncular necrosis but I said he should worry about avascular necrosis more (a little joke you orthopods can share with the aneasthetist and theatre nurses, if it isn't already an old one, if I can think of it...). Jokes aside, we are trying to maximise the time between the osteotomy and the BHR to obviously rebuild a good solid blood supply to the head and the latest x-rays are encouraging. If I had the latest x-ray images I'd post them you might be surprised and perhaps with evidence be a little more convinced I am not merely talking wishfully. I am hoping for 5 years - that might be wishful thinking!

      All of that aside the pain since the operation has been very much on the improve and reaching better comfort levels than before the operation. In general this whole recovery has been faster than the last osteotomy. Of course they still hurt like f*ck and day 3 always makes you wonder why you did it. Well yesterday felt almost like day 3 again. I needed painkillers and was unable to work, my job is mostly thinking but that was impossible to do with any clarity. So given that there has been a big improvement and ignoring the picture above for the moment, because things have changed, assume for a moment that things have improved and on yesterdays x-rays remain so, any ideas on why the sudden knee pain? Which by the way does appear to be much better today though I don't dare walk on it again yet. Any possibilities in 3D out there? Any wild hypothesis entertained.
      Last edited by Slowman; 23-03-2006, 01:01 PM.
      Cycotec Jesus is coming, look busy.


      • #4
        The knee pain problem I experienced, whether referred or not, has never returned and generally everything is continuing to improve. The latest x-rays show an even 2mm gap all the way around between the head and the acetabulum surfaces. My surgeon has now postponed indfinitely the BHR procedure. The fact that there is now a healthy space between the joint surfaces is not without precedent. Apparently changes in gate have been known to bring about such results. I guess I couldn't be luckier with the way things are going. I will have the rod and screws in the x-ray above removed sometime in November after my first race back, which will just be a marathon mountain bike race. After the metal is out I might try some running but until then I'm happy not to push things.
        Cycotec Jesus is coming, look busy.