Open FAI Surgery, Torbay Hospital

[Carolan]

I?ve been reading some all your posts with interest over the past couple of weeks and hope that you may all be able to offer some advice / reassurance about open fai surgery.

My consultant is Dr Lofthouse at Torbay and I have open fai surgery scheduled for Thursday 25th June. I have really struggled to get consultant appointments at the hospital and don?t really know what is wrong with me or what the operation entails. Could anyone shed any light ?

To briefly summarise :-
- I?m 28 and I have always had ?bad? hips, which click and get stuck in positions which take a while (sometimes minutes, sometimes hours) to straighten out again.
- In December last year, both of my hips were sore and I quite violently sneezed and my hips stuck and I was unable to straighten. My partner took me to A&E who gave me pain relief and sent me on my way.
- My GP referred me to for x-rays and then to Torbay and I first saw Dr. Lofthouse in late January who request an MRI scan with a dye injection in the hip.
- The MRI scan was in early March and I then received a letter stating my next appointment with Dr. Lofthouse for 15th June. A few telephone calls got this changed to late March with another doctor.
- At the appointment with the other doctor, the words impingement and tear were used but this was all I picked up on. I was told that he would write to me after speaking to Dr. Lofthouse who would probably recommend surgery. I never received a letter.
- I then had a pre-assessment appointment mid May and, after reading the nurses notes upside down, found out I was having open fai surgery but no-one has told me why.
- I had a phone call last week asking if 25th June would be an OK date for my surgery. I have said yes as I can?t put up with the constant pain much longer. It doesn?t look like Dr. Lofthouse can fit me in for an appointment before the operation.

Could anyone offer any advice on the surgery, how to prepare for it, recovery times afterwards ? anything really that might help.

Thank you all in advance and sorry for such a lengthy first post. I?ve read that a couple of you have had surgery in Torbay and it would be reassuring to chat with someone in a similar position.

Carolan

[Kiwi]

Hi Carolan,
Open FAI surgery is a major hip op. I don't know how much you know about FAI but basically it is where your hip bones have too much bone on them so it causes too much friction in the joint. The friction leads to cartilage damage, pain and locking, popping etc.
The impingement can be either on the head of the femur (ball part of the joint), the acetabulum (socket part of the joint) or both.

In open FAI surgery they make an incision down the side of your hip, cut off a segment of the greater trochanter (bony part on the side of your thigh) and dislocate your hip. This way they can visualise the entire joint and remove all of your impinging bone and deal with any labral/cartilage tears. When they are done, they relocate your hip, check your ROM with x-rays and screw your greater trochanter back together.
It is pretty major surgery with a tough recovery. You should have a look at the Yahoo! Group Femoroacetabular_Impingement...there is a lot of info there.

Some surgeons are able to treat FAI with arthroscopy. This negates the need to dislocate the hip and remove the greater trochanter. Have you any other specialists in your area that you can see for a second opinion?

I Don't mean to scare you, but it is pretty bad if your surgeon doesn't give you the time to explain the procedure and the risks involved.

Good luck to you, I hope everything goes well!

You can contact me through my webpage www.jessmcb.com if you want to ask me questions directly :-)

Jess

[Rayray]

In the UK there are just two surgeons who perform the very major repairs via arthroscopy. One treats privately only and so is out of the question for most people and the other has an exceptionally long waiting list - I know as I was on it and it took over a year to get a first appointment. By the time he would have seen me and advised me whether or not I could have had surgery my time for the open option would have run out. His private appointments cost nearly £2000. You also need to remember that if anyone is in bad pain from FAI they are causing more damage daily and need surgery asap. The other factor is that despite others assurances open surgery does give the best view of the joint and so a full repair for extensive damage is more certain this way. The two surgeons in the UK would agree with this and I have seen other posts where even they have said something like there is a 70% chance of a satisfactory outcome.

Mr Ashworth at Torbay does do arthroscopc repairs for some cases depending on the severity and positioning of the impingement. When he saw me he confirmed that he did not believe that either of the two arthroscopic experts could fix mine because the impingement was so large - he said that he had observed the private surgeon in action and was very impressed with what he could do but he still felt that the impingement was too large to fix arthroscopically. If Carolan has been told she needs Open surgery then I suspect that the repair is too difficult with an arthroscope as the Torbay surgeons will work together to some extent.

It is unfortunate that our options are more limited in the UK but it is a fact that we are all stuck on waiting lists for months before we are seen and longer for surgery. Arthroscopy is a very new surgery here with NICE still looking at the stats. They are also looking at the Open stats but there is a much longer history of these.

As I have said before my surgeon told me he didn't believe that anyone in the world could repair my hip with an arthroscope including the two UK experts or the guy frequently quoted on this forum in Aus. He himself does arthroscopies as well as open surgeries. He has massive experience of Open surgery and now knows which hips can be saved with Open surgery and which can't. When he gets in there he assesses the damage and makes a decision - from my xrays I was 50/50 resurfacing. If it were down to many surgeons I would have had both hips resurfaced due to my age and pain. When he got in there there was NO arthritis just a badly deformed hip and a large labral tear. The result, at least on the right hip, is that I may never need this hip replaced as he has repaired it before arthritis has started although I know I can never say never BUT he has given me the best possible chance.

I think what I am trying to say is that our surgeons in the UK do have good knowledge of Open debridements and some have good knowledge of arthroscopic procedures. What we don't have is the choice to go from surgeon to surgeon as basically there is only the one who can be seen on the NHS and he is inundated.

Yes it is major surgery Carolan and a long recovery but it will give you a very good chance of saving your hip from needing a resurfacing. My humble opinion is that it is your best option with the resources available.

It is bad that you haven't seen your surgeon yet to go through the details but this looks like it wasn't intentional as you fell through the net and this can happen anywhere (especially under the NHS!) - you will get a chance when you see him shortly.

Good luck Carolan - it will be fine (I know I have been there!!!).

[oscarsmum]

Rayray, I didn't realise that you actually don't have any Arthritis! Thats fantastic news!
So you are hoping that this surgery will be all that you will need- thats brilliant!

I didn't have the guts to ask the question. I still think I will face a THR in the long run- I already have arthritic cysts and cartilage delamination, the PAO is hopefully to slow down the damage, but I have been told that it can't make an abnormal hip completely normal. The long term question I saved for next time, how long does he estimate that I will get out of it-think it will be wait and see though!

Kate

[Rayray]

Yes Kate. I think that Mr Norton was as surprised as me. All my x-ray results over the last five years have shown ?arthritis?. When he got in there ? no arthritis! I think the lack of joint space was down to the massive head of femur I had which appeared to fill the joint space mimicking arthritis ? he removed 1 cm from all around the head of femur. I also had a large Pincer impingement so this all looked odd on x-ray I guess. I was surprised when I was told I had arthritis in the first place as there is no family history. I know I am very lucky as I have had this damage a long time BUT perhaps my joints are super arthritis resistant? I did have a very large labral tear but the cartilage was intact! I think I may be the exception to the rule on long term damage causing arthritis ? it didn?t in my case. Still quite amazed and I will further discuss this with Mr Norton next week.

I am sorry that you have got arthritis and hope that the PAO slows it for many years to come.

[Rayray]

One other thing I should have said. If Mr Norton or Mr Fern find cysts they will not do FAI repair but will resurface as with FAI, cysts have shown to have a poor short term outcome. I guess with PAO it is different and it at least gives you some time before THR if cysts have developed.

My pain on the right was clearly from the FAI itself, the tear and of course the trapped nerve. Will be interesting to see what the left is like although I suspect the sharp pain I get when I walk is from the tear.

[Spam1]

I have an acetabular cyst for definite on my right and my labrum was too badly damaged to be repaired so had to be replaced with a ligamentum teres graft and think I have a cyst on my left too ... so not so sure the cyst rule applies for Mr Fern!

[oscarsmum]

I thought that the cysts developed in a dysplastic hip because all the weight was concentrated in that one place, but once the PAO is performed and the weight is distributed more evenly through the socket then the cysts aren't considered a problem. I am not sure, but I think I have read that they can actually improve after the PAO- but don't quote me on that one!

How did the exams go Sam?
Did the hips hold up?

Kate xx

[Rayray]

The following is taken from the article on the Cornwall Hip site. I think I over simplified as labral cysts are okay, it is bone cysts which are not. Also this article applies to pure CAM and Pincer FAI and specifically excludes Dysplasia.

?Surgical intervention has been shown to be successful
at treating painful symptoms and stopping radiographical
progression of osteoarthritic changes in the short to
medium term if articular cartilage degeneration is minimal
and acetabular dysplasia is not a feature?.

It then states:

?Labral cysts are simply dealt with by sharp dissection but
intra-osseous bone cysts are more problematic. Noninflammatory
subchondral cysts are usually found in the
anterolateral acetabular quadrant (Bredella and Stoller,
2005) and are in the authors? experience always associated
with acetabular articular cartilage separation from
the labrum and debonding from the subchondral bone
surface (Figure 4). The authors consider this finding
preoperatively to be highly significant as a predictor of
the severity of articular cartilage injury and of a risk of an
unsatisfactory outcome, although some patients have
had a good result in the mid term.?

?Anterior subchondral and paralabral cysts indicate full
thickness chondral damage and a risk of a poor outcome with
impingement surgery?.

I am not sure if this clarifies the Cornwall view on FAI but I think it does. It also sounds like PAO cases are entirely different and should not be compared to standard FAI.

[oscarsmum]

Well that didn't make an awful lot of sense to me so its a good jub Im not a surgeon ,lol.
I know mine are sub-chondral bone cysts ( was initially told they might be malignant-that was years ago and the first consultant I saw-scared me to death I can tell you) but have since been told that they wouldn't cause pain, but are more of a side effect of the dysplasia. I don't think either of the other two consultants thought they were a problem, other than they indicated cartilage damage.
Clear as mud to me
Kate xx