Mr Jit Balakumar

In November 2011 I had my appointment with Mr Jit Balakumar. Prior to this appointment he had me complete a 12 page hip questionnaire for me to return via email. This questionnaire allowed Mr Balakumar to learn about my family history of hip problems (which was minimal), my physical charasteristics such as height and weight, working status and demands of my job, while also looking at physical and psychological implications from my hip disorder. I found this to be beneficial as he was able to generate a better idea of who I was and my reasoning for getting him to review my hip even prior to meeting me. At my appointment Jit initially completed a physical assessment. He was pleased by my lumbo-pelvic control and stability around the pelvis. Based on the way I moved he was confident that I would be fine without needing any surgery in the near future. It was only when looking at my previous scans that his impression changed. He asked "do you ever limp?" and "does your fiance tell you that you are limping?" It was like he was shocked by the extent of my hip dysplasia on the imaging when compared to my functional biomechanics and movement patterns around the pelvis and hip.

I was referred for a relatively new form of MRI which allowed for better assessment of cartilage quality. The scan is called a dGEMRIC (Delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage). He informed me that this would provide data used to determine if joint preservation surgery would be beneficial or if there is high risk of early failure following PAO surgery due to intrinsic wear within the joint. My dGEMRIC scan showed some early thinning of the cartilage consistent with mechanical damage as a result of my hip dysplasia. It also showed mild trochanteric and iliopsoas bursitis and mild gluteus minimus and medius insertional tendinosis but no tear as of yet. The changes to the gluteal muscles and bursa are expected in ladies above the age of 50 and not commonly seen in a fit active 27year old.

After recieving my results Jit strongly recommended that I go ahead and have the Periacetabular osteotomy. He explained that despite currently having more than adequate control of my pelvis which allows me to be active and complete high level activities such as skiing with minimal consequence, all it would take is for the degenerative changes within my muscles to progress to a small tear and then I would be in a lot of strife! The concern is that it would lead to increased pain and altered biomechanics, eventually resulting in further wear within my hip joint. This would then make the PAO surgery usless as there is no point preserving a degenerative hip and my only option would be a total hip replacement. Plus any further muscular changes would make recovery from the PAO surgery much harder.

So after many years of deliberation I decided that it was time to bite the bullet and book in for my surgery! I chose to book in with Mr Jit Balakumar. This was a hard decision to make as I have a lot of respect for Mr David Young, being one of the Melbourne's top hip surgeons. I have DY to thank for my progress thus far with my hip. Without him I would still be living on constant anti-inflammatory medication and most likely would have had a lot more wear in my joint due to the irregular shaped femoral head. However I found Mr Balakumar a better fit for my needs. He was able to answer my questions relating the the PAO surgery making me feel (for the first time) confident to have this joint preservation surgery. Jit works at the Epworth Hospital and also at The Royal Childrens Hospital. He has completed many periacetabular osteotomy surgeries especially at the childrens hospital. His technique is also slightly different to Mr David Young which will hopefully allow me to commence weight bearing earlier... But I guess time will tell. Only 64 days to go!!

[A great article on this subject is Torin Cunningham, MD; Rebecca Jessel, BA; David Zurakowski, PhD; Michael B Millis,MD; Young-Jo Kim, M.D., Ph.D (2006) Delayed Gadolinium Enhanced MRI of Cartilage (dGEMRIC) as a Predictor of Early Failure after Bernese Periacetabular Osteotomy for Hip Dysplasia. Journal of Bone and Joint Surgery. Let me know if you have difficulty finding it and I can assist.]

All eyes on me

I think Surgeons are amazing individuals. They spend many years (approximately 6) studying medicine just to become an intern, and then they still need to progress through to resident, registrar and eventually they become a consultant. Due to their incredible intelligence, which makes them a perfect candidate to become a surgeon in the first place, they often lack the "people skills" which can make them appear arrogant and disinterested to us "lay" people. So when I think about it like this I can understand why the stereotypical surgeon can appear so intimidating.

For anyone who has not been to see a specialist I will try to fill you in on my experience of seeing a surgeon towards the start of my hip troubles. Time in these appointments is of the essence so everything that was done in his little office was done for a reason. The specialist initially looked at the reports and scans and then complete his own physical assessment. He then had a few questions which he expected a clear brief answer to. I'm not sure if his room had some certain force field but as soon as I walked into his office I found that my words did not follow me in.. Even when asked the simple question "do you have pain?" I found myself taking the longest approach to provide a very vague answer... saying something along the lines of "well I don't really get pain, you see I have pain but I would consider that my normal pain, so if you are asking if I get pain that is unbearable I would say no, but if you are asking if I have pain at all then my answer would be yes". You can appreciate why my specialists didn't ask me too many questions!!

The other tricky component to an appointment is making sure you leave with all the information that you need and therefore before going to the specialist appointment I made a mental note of what I wanted to find out. However on this occasion I still left the appointment only to get to the car park to think "darn I forgot to ask..." Plus that's not even going into my thoughts on trying to ask questions in a smart way so that I don't sound "dumb" to my surgeon!

So now that you know the goings on in my head during an average specialist appointment I hope you can appreciate how petrified I was when I attended my first joint clinic. After seeing the initial specialist and being told that I have a very "unique hip" I was invited to attend a group style consultation at the Frankston Hospital. This is when many surgeons would be in the one place at the same time providing a great opportunity to discuss my case.

When I walked into the room there was about 30 people sitting and staring at me. From the looks of it most appeared to be surgeons (older men, some who I recognised from my orthopaedic physiotherapy placement at the hospital the previous year) and there was also some other individuals who I assumed to be surgeons in training and other allied health professionals including physiotherapists. I was asked to strip down to my underwear and complete different tasks such as walking, mini squats, standing on one leg etc so that they could look at my biomechanics. They also took me through a hip range of motion assessment. While standing there, still in my underwear, the surgeons talked amongst themselves about what they would do if they were my specialist. They spoke about me as if I was not in the room with comments like "She should never run again, this hip is the worst I have seen for her age". From this session the general consensus was to do nothing and wait until I was older to get a new hip.

Many years later in 2011 I attended my second joint clinic under care of David Young at Melbourne orthopaedic group where a group of 12 of Australia's best hip surgeons and a "guru" from overseas were invited to discuss my management. I was much more prepared for what to expect but despite this and the fact that I understood more of the surgeons' conversation I still felt that I was not included in the decision making process and I had very little time to ask questions or part take in the session.

It was not long after this session when I met Mr Jit Balakumar while he was presenting a lecture for the Australian Physiotherapy Association about hip dysplasia. During this session I found out that Jit was an orthopaedic surgeon with extensive expertise in lower limb surgery and that he specialises in joint preservation surgeries of the hip including the Peri-acetabular osteotomy. I thought to myself it couldn't hurt going to meet him for another opinion. So I booked my appointment for November 2011.

After all these years of appointments with specialists and also due to the fact that I am now much older (and therefore wiser?!?) I no longer find the specialist appointments as intimidating instead I find them very interesting.

My top hints for if you ever have to see a specialist:

1. Write down notes before you go, include any questions that you want to ask

2. Try not to feel rushed or pressured. Remember you are the surgeons priority while in that room so feel free to ask questions even if you think they will sound dumb.

3. Ask for a copy of the report which the specialist will send to your referring doctor. This can help you keep track of what was said and decided in the appointment allowing you to stay in control of your health management.

Imaging

Here is an AP (anterior-posterior = meaning taken from in front)  Xray of my Pelvis taken prior to my arthroscopic surgery. Both hips are dysplastic (dysplasia = abnormal development) with the Left hip (on the right side of the Xray) changes being more marked.

The close up of the left hip has the Centre-Edge Angle measured on it. The angle is formed by a line drawn from centre of femoral head to outer edge of the acetabular roof, and a vertical line drawn through centre of femoral head;
- angles greater than 25 deg are considered normal
- less than 20 deg indicates severe dysplasia (where the socket is too shallow or deformed reducing the surface in which the femoral head articulates)
My Left hip Centre Edge Angle  is measured at 13 degrees indicating severe developmental dysplasia of the hip (DDH).

The image above is a CT scan showing a 3 dimensional image of my left hip prior to having the arthroscopic removal of the cam impingement on the femoral head. The image shows a lack of an anterior wall of the acetabulum (socket) which has allowed my femoral head to grow abnormally.

This image is a lateral view of the 3D CT whish again shows a lack of anterior acetabular wall.

The Periacetabular osteotomy surgery will cut the socket out and rotate it so that it sits in a better position providing improved coverage of the femoral head - reducing the wear and tear occuring in the socket and hopefully preserving the joint.

Surgery again!

When arriving at Glenferrie Private hospital for my surgery I was not as nervous as I had been for my first hip surgery.. I think that going through the surgery process previously made me feel more at ease as I knew that I would first be admitted by the nurse who would put tags on my wrist and right ankle (which unfortunately reminded me a lot of TV shows when they show a body at the morgue!!) and make me drink a disgusting mix of fizzy stuff, then the anaesthetist would visit and ask me multiple times if I had any allergies to medications and finally just prior to being wheeled in DY would pop in and say G'day and reassure me that I was in good hands. A big arrow was drawn with red texta on my left leg pointing up to my hip. I jokingly asked if this was to make sure that DY operated on the correct hip and I got a very serious "yes it is" reply! I had invited a colleague from work who was my physiotherapist to view the surgery as I believed that it would be a great opportunity for him to learn from DY. The staff assured me that I would be all set up to "preserve my dignity" before he would be allowed into the room.

I was 2nd on the surgery list for the day so luckily the wait was not too long until they rolled me into the operating theatre. This was the first time I had been conscious in an operating theatre as previously I had been knocked out in the anaesthetics room. I was asked to shimmy across onto a narrow cold table, and I tell you this is no easy task to do while wearing a backless gown with no underwear!! While lying there I could see trays of sterilised equipment to each side with scary looking tools sitting ready to be used and in front was 4 computer screens which would be used by DY to navigate his tools while performing the arthroscope. Both of my ankles were strapped into separate boots which were attached to the end of the bed and the anaesthetist put a drip into my right arm. There seemed to be a dozen people in the theatre all busy getting something ready for the surgery when I remember the world going fuzzy.

When I think about it- general anaesthetic amazes me with its ability to bring about a reversible loss of consciousness, but despite this I really dislike the feeling I get when coming out of the sleep like state. It's almost like my mind is fighting to get back control however the effect of the drug makes me feel confused and disorientated. After spending a bit of time in recovery I was wheeled to a private room where my mum and dad were waiting for me. I was instructed on how to use the PCA (Patient Controlled Analgesia) pump which would deliver a bolus of morphine when I pushed the button. I pressed down expecting to feel a wave of pain relief but instead I felt nothing. Despite knowing that there was a lockout time after each dose I continued to press the button more than 30 times in 12 minutes. The nurse sternly told me that I had to wait 9 minutes after each dose of morphine before the machine would deliver another dose and therefore I should try to press the button less. The tone of her voice made me feel like she was judging me, implying that because morphine is a strong drug  I couldn't be in that much pain. Thinking to myself "stop being so delicate" I stopped pushing the button as often but I lay very still being careful not to move my left leg. After a couple of hours the same nurse lent on the bed to perform my obs and she noticed that the bed felt wet. Thinking that I must have been too hot and sweating she arranged to change my gown. It was only then when we all realised what had happened.. my morphine drip which was controlled by the PCA button had come detached from my arm and my bed had been receiving my morphine doses. I felt relieved, I had in fact a high pain tolerance having gone 4 hours after surgery with no analgesia. They decided to remove the PCA machine and provide me with oral panadeine forte as needed.

Once my pain was better controlled I was able to move around the bed more. I spend most of the next 24 hours sleeping and this was only interrupted when I needed to call the nurse for the bed pan.  Despite begging the nurses to let me go to the toilet and telling that I was a physio therefore assuring them that I knew how to non weight bear with crutches, I had to wait until the physiotherapist came in to teach me. I have never been so happy to see a fellow physiotherapist. He spent 1 min with me to check that I was safe to move about without putting any weight through my left leg and then I was free to move about with my new best friends the crutches, which were to be used every time I got up for the next 2 weeks.

DY visited me in hospital prior to discharge and informed me that everything had gone great. He said that had taken off 30% of the width of my femoral head (the ball was reduced by about a third of its original size) which had been shown in the literature to be the maximum amount of bone to be safely taken without having a high risk of stress fractures following. He then reinforced the need for me to be compliant and not put ANY weight through my left leg for at least 2 weeks which is when I would have my follow up appointment with him. I was sent for final scans at Glenferrie Hospital to check the shape and the position of my femoral head within the cup and then was discharged.

As my boyfriend Sam would have told you I was not the best patient. Lying on the couch watching the Hills TV Series DVDs was fun for about the first day, however that was about all I could manage. I was surprised how much the surgery had taken out of me.. still needing to sleep every hour or so and only spending half an hour upright or sitting before needing to lie down again. The worst part of this whole surgery experience was that the analgesia had caused me to get "blocked up" (if you know what I mean) but after a few days of trying green leafy vegetables the laxatives worked a treat!!

Sam was great during these two weeks- making me food, keeping the house clean while still working. I do recall him saying at this time "I never realised how much you do around here!" I had always known how lucky I was to have Sam and my amazing family and friends for support but it was during these early days after the surgery when this hit home and I felt blessed to have so many people that were willing to help me out.

Meeting DY

I commenced workin as a physiotherapist in a private practice at the end of 2007 where I worked along side many talented physiotherapists. When talking to colleages about my hip I was encouraged to see Mr David Young (commonly referred to as DY) who is an orthopedic surgeon at Melbourne Orthopedic group. As frustrating as it was at the time I knew that I was going to see a good surgeon when it took 8 months to get in for my inital appointment (and that was even after having some strings pulled for me because I knew people!!) I was warned by his receptionist when making the appointment that My Young often runs over time so it would be a good idea to bring a book to the appointment just in case! Well lucky I did because I was called in to see him after a mere 4 hour wait. I was introduced to a David as he was rummaging through the papers on his desk, clearly looking for something important. He buzzes his receptionist "Do you know where Meghan's file is? The receptionist walks in as says "is it the one that your holding in your hand?" To be honest I was then a little concerned.. thinking to myself "and I am supposed to trust him with my hip!?!"

After discussing my history of pain and prior surgery to remove my labrum I informed Mr Young that the main reason I had come to see him was not because I was in a lot of pain but instead because I was concerned about my future and wanted to ensure that I was doing the right things to preserve my hip joint. Mr Young took one look at my hip Xray and I could see his eyes light up with interest. It is never a good sign when a specialist who has been in the field for longer than you have been alive says "wow" when looking at your imaging.

I was immediately sent across the road for a CT scan (thankfully no injection required!!). On my return I was ushered straight back in to see DY. It was like I had some how become "dodgy joint royalty" bypassing thoes lower than me with only slightly dodgy joints!! I spent over an hour with DY as he measured important angles on my imaging and taking photos of the scans on the light box so that he could use them in his presentations to his colleagues. I was told at this initial appointment that I had a perthes like hip where the femoral head (or ball of the joint) had softened due to lack of blood supply during a critial stage of growth which eventually led to a developmental deformity. How I saw it was instead of having a nice "ball" that fit within the acetabulum (cup or socket) I had a misformed and overgrown "footy" shaped femoral head which therefore did not fit very well. Mr Young went on to describe other changes in my hip including the very shallow socket that was facing the wrong way which my abnormally large misformed femoral head was trying to articulate with and how this was a recipe for a total hip replacement sooner rather than later in my life. I was also informed that if he had met me earlier there would have been NO WAY that he would of removed my labrum as this has been shown to speed up the formation of degenerative changes within the hip joint!!

He strongly encouraged me to consider having an arthroscopic surgery which would do a few things:

1. It would allow him to look at my joint more closely to see if there was any evidence of osteo-arthritis

2. He could address the Cam Impingement or footy shaped femoral head by shaving my bone down to make it more ball like

3. He would be able to see how I go with the surgery, ie do I follow instructions and do I respond well to general anaesthetic... he informed me that If I do well with this surgery I would be a candidate for the peri-acetabular osteotomy surgery.

When I left Melbourne Orthopedic Group that day I remember feeling drained. I was now very late for work.. only by 4 hours or so.. however the girls at work on reception were very accommodating and they rescheduled my whole afternoon. I got into my car to drive home and burst into tears. I realised that despite having minimal pain I did well and truely have a hip joint that was not ideal. I felt that I had done the wrong thing by having my previous surgery to have my labrum removed despite knowing that it had solved all of my pain problems that I had earlier.

After talking to my boyfriend and mum I decided to go ahead and have the arthroscopic surgery and I booked in to have it done in November 2009.

(PS I will try and get some photos of my scans of my hip joint to include in my blog so you can have a look at my "famous" or should i saw "infamous" left hip!!)

Physical Vs Emotional

Following my first surgery I thought life was great. I was partial weight bearing on crutches for less than a week and then I was able to progress back to my usual activities. My surgeon had taken out my labrum so now I had no sharp pain, and it was the first time in years that I could run and jump with minimal consequence. I still experienced a deep ache which was usually worse at night especially after a night on the town dancing with my girls while wearing high heels. But to tell you the truth the ache became "my normal" and there was no way that I was going to miss out on having fun with friends and enjoying life as a young lady who had her life ahead of her! I had been told now by 2 different specialists that I should be very careful with my hip and that it would be best to avoid high impact activity, but despite this I still managed to go snow skiing and participate in recreational sporting activities as I wished.

Although it was not well known to many I really struggled with the diagnosis of my hip abnormality. It was like I had to "grieve" the loss of having a normal hip. I remember crying to my mum saying "who will want to come see me when I'm a physiotherapist?? .. I can't even look after myself!!" As hard as my brain tried to convince itself that I was fine by saying things such as " it could be much worse.. I could have cancer" or "what am I upset about? I am surrounded by good friends and family and I have almost finished my dream degree to become a physiotherapist, I'm not going to let a hip get me down!!". Reading this may appear silly to you especially if you have never dealt with an injury or pain but I believe that I needed to go through this "grieving process" for my hip so that I could come to terms with my perceived loss. It took a while but slowly I learnt to accept that my previous view of being a fit and active young adult who could do what ever she wanted had shifted to identifying myself as a healthy young adult who would need to preserve my hip.

As a physiotherapist now working with people who are often in pain I believe that my experience with an injury has really helped me understand the connection between the emotional and physical being. I'm not going to sit here and get all spiritual with you but I do believe that we cannot separate our physical and emotional selves... For example I could list all the anatomical differences with my hip (shallow hip socket, abnormal femoral head, tight superficial muscles such as iliopsoas, weak deep gluteals ... the list goes on) and try to seek treatment to "fix" these things. But even if they are fixed the treatment would be floored as it would have not addressed the other domain of my injury - how I identified myself, how I felt about having an abnormal hip. I am very fortunate to have so many wonderful people in my life who have assisted me to look after my "emotional health" while dealing with my physical problems. It was my mum who helped me realise that the experience of having a problematic hip has shaped who I am and I believe it has lead me to bacome someone who can not only help people physically with their injuries but hopefully also help them through their associated journeys and struggles.

The Start of my hip history

For those of you who are following my blog and want to know more about the surgery that I have planned for April next year, here is a link to a video on my surgeon's website which shows you what will be done:

http://www.jitbalakumar.com.au/hip-and-pelvis/periacetabular-osteotomy.html

My Hip history up until now...

As long as I can remember I have always been very active. From the age of 4 I did gymnastics and eventually competed at National level. I had a few usual injuries while growing up such as a broken arm (who knew that roller skating down a steep hill over a stick wouldn't end that well!?!) and rolled ankles. I would say that I had never had any hip problems until I was 18 however when looking back I have realised that throughout my childhood there were many indicators of my left hip dysplasia which went un noticed. My mum tells me stories of how difficult it was to put a nappy on me as my legs were like springs and as soon as she let go to hold the nappy my legs would recoil back in towards my body and she would have to start all over again! I remember dreading sitting on the floor in primary school because it was an effort to sit with my legs crossed and I would much prefer to sit with my left knee rolled in instead of out. As for gymnastics.. I was the least flexible gymnast going around!! My coaches would tell me to relax and they would sit on me in side splits to try and stretch me further but I insisted that I was not stopping them.. it felt like the bone was stopping me!!

When I was 18 and I had finished school, I moved to Bundoora to attend LaTrobe university to follow my dream of becomming a physiotherapist. Having only recently obtained my manual car licence I spent a lot of time driving and I would get a deep pain in my groin, but I thought that was normal. One day out of the blue I was walking between class and I felt a sharp catching pain deep in my left groin. The pain was so shap that it took my breath away. My friends did not know what had happened.. I had been walking along talking and then all of a sudden I was curled over in pain. After a few minutes the pain subsided and I was left with an ache in the left hip region. Thinking nothing of it I kept on with my day. This pain started to occur more frequently so I thought I better find out what was wrong!

Being a hot shot 1st year Uni student I diagnosed myself as having a hip muscle strain!! (mainly because thats the only thing I knew about the hip region at the time). My doctor who clearly knew a lot more than I did sent me for a hip and pelvis Xray which showed 2 abnormally looking hips with my left being much more abnormal than the right. She referred me to a specialist on the peninsula who took one look and me and my scans and told me I would eventually need a hip replacement but until then I should stop doing anything that hurt. "Hrrmmm" I thought... "But I get pain with mundane activities such as walking and sitting... and my pain isnt just a mere annoyance but it is aggony!!". Unsatisfied with the surgeons lack of empathy I sought a second opinion. I was sent to get an MRI (needle = me fainting = not a very nice experience) which showed the cause of my pain... a labral tear. Trusting the specialist's opinion I had a large portion of my left acetabular labrum removed and I had not more pain and everything went back to normal.. or so I thought!!! ...