Rehabilitation begins

After the appointment with my specialist I was given the all clear to start some physiotherapy. Despite knowing that physio is often associated with pain I was eager to get started. One of my previous physiotherapy clients asked if I was going to be selling tickets to watch my physiotherapy sessions.. she explained that there would be quite a few people who would happily put their hands up and volunteer to help with treatment as payback for my bony elbows and strong thumbs!

My first physiotherapy session was focused around improving the hip extension range of motion. I was then able to start some very gentle exercise bike and basic pilates reformer exercises. My next physiotherapy appointment is tomorrow and now that my scar has healed nicely I will be jumping in the hydrotherapy pool to start some water based exercises. I am very excited to be getting in the water to exercise as it will offer a low impact environment to wake up my muscles. Its amazing how quickly muscles waste away.. As a result of only 3 weeks of not using my left leg my thigh is now 2cm smaller than my right thigh and it feels much more jelly-like.

I have swapped cards with my brothers girlfriend for an automatic so now I have a small amount of independence back. This will allow me to get to and from physiotherapy sessions and it means that I am no longer under house arrest. I have been granted a short term disabled permit which will allow me to have better access when I do go out. Although I know that I have had major surgery I feel guilty parking in disabled parking spots. When i have been out and about I have had people ask me why am I using crutches as I look fine. I guess I do look fine as I don't have a brace or plaster. When I tell them I have had hip surgery they often say- oh but your so young and you don't look like you needed surgery. I think I need to come up with a good story to tell because having surgery to correct congenital hip dysplasia isn't very exciting. But I guess the old line of "don't judge a book by it's cover" very much applies here.

Post op appointment

With almost 2 weeks since the surgery I was due to see my surgeon for a post op review. Being unable to drive my mum took me to The Avenue Clinic to see Jit and as per usual he greeted me with a big smile. He informed me that he was very happy with my surgery and that things could not have gone any better. Showing me the post-operative Xrays he explained how my acetabulum (hip socket) now fully covered my femoral head (hip ball), increasing the surface area of the hip joint and reducing the load through the weight-bearing area. He had used 4 steel screws to hold the acetabulum in its new position and over time my body will fill in the gap with new bone securing the loose section of bone in its new place, then the screws will be removed.

I asked Jit what he thought about the condition of my cartilage within the hip joint. As suspected there appeared to be damage along the rim of the socket - where my labrum had previously been removed. The continued pressure on this area had caused small cysts under the cartilage which most likely will eventually lead to further wear within the joint. Despite these changes Jit was optimistic as the cartilage which is now repositioned into the weight-bearing zone is smooth and intact. He hopes that I will never need a hip replacement, however it is more likely that my hip will eventually deteriorate due to the changes within the joint, but I am hoping I make it to at least 50 before needing a new hip... which is much better than being 30 and getting a new hip which was on the cards prior to this preservation surgery.

At the post operative appointment Jit removed the dressing from the would revealing the scar for the first time. Once it had been cleaned up (as i don't really do blood - even if it has dried!!) I took a good look at my newest scar. It is approximately 10 cm long starting at my iliac crest (the bone you feel when you place your hands on your hips) and running diagonally down along my bikini line. Although 10cm sounds long, I am amazed by how small it actually is - especially considering what he did within that incision during surgery. I have been using Bio-oil twice every day on my scar and it is starting to heal nicely.

I was told to start increasing my weight bearing and to use pain as my guide. The goal is to reduce to one forearm crutch in a few weeks time and aim to be able to stop using gait aids by the time I go back to see him again in a month (making it the 6 week mark). Prior to my next surgery I will have further imaging done and hopefully will see the formation of new bone. He wants me to start physiotherapy and once the scar has fully healed I can jump in the hydro pool for rehab.

Learning to relax

It is lovely to be at home recovering, and although my routine hardly differs from when I was in hospital it is very nice to laze on my own couch watching the pile of DVDs which I have borrowed, rather than being in a hospital bed watching the small TV. Let me tell you, day time television does not quite do it for me!! I have had friends and family visit me over the past 4 days which is a welcomed distraction from the long days on the couch.

Usually being very active and not one to sit down all day I am still trying to get used to "relaxing" and not having to cross things off my to-do list. I know that the change of pace is needed to allow me to focus on healing, however it does take a while to break old habits... just don't tell my surgeon that I have vacuumed the house while on crutches! I never thought that being on crutches would make even simple tasks much more complex. In particular I find carrying objects extremely difficult as my hands are needed to propel me on crutches. I have overcome this by using a bag which I load in one spot before moving to where I need to take the items. As you can imagine this slows me down a lot and there is nothing more frustrating to sitting down at the table for lunch and unloading my bag to find that I have forgotten to put the cutlery in. Back up on one leg to hobble to the kitchen for cutlery I go.

I am still taking pain meds daily however I am managing mainly on panadol with endone for night.  Overall my hip is feeling good. I still have a low level of constant pain with only occasional sharp twinges if I over do it. When I was trying to put a sock on my left foot I did not have the available hip flexion range and I was made aware of that when the pain stabbed me in the groin. Might be a while before trying to put my own socks on again!! If I spend too long in one position, such as in sitting, my hip tightens up and takes a while to get moving again. I have lost a small amount of extension range (ie I cannot fully straighten my hip as I would need for upright standing) however I am not pushing it yet as it is still early days.

When Sam married me he knew full and well that I was planning to have hip surgery less than 3 weeks after saying "I do", but I highly doubt that he realised exactly what that meant for him. Nothing kills romance in the "honeymoon phase" like helping your newly wed wife shave her legs so that she can wear shorts!! On a positive note Sam has re-joined me in our bed, no longer needing to sleep in his swag on our bedroom floor, as my fear of him knocking my left hip during the night has reduced. He has been the perfect husband since I have returned home. Although I can sometimes see the frustration in his eyes he never complains even when I ask him for the 100th time to grab something for me only seconds after he gets comfortable on the couch. Secretly I think he sometimes looks forward to going to work for a rest. I am one lucky girl to have him in my life.

I am booked in to see Jit for my post operative review in 2 days time. I am realy looking forward to speaking to him in more detail about how my surgery went and finding out about the next step in the rehabilitation process. I am hoping that the scar has healed nicely so that I can commence some gentle exercises, possibly some hydrotherapy and very light resistance exercise bike.

All in a week

I was hoping to be much more consistent with writing my posts now that I have had my surgery however I think I underestimated the impact that the surgery and the medications would have on my ability to concentrate. I cannot believe that it has been a week since I had the PAO surgery. Although at times while lying in the hospital bed in pain it felt like time was going backwards, the past week has gone by very fast and to be truthful I cant quite remember all of it!! Each day seemed to merge with the one before and time was measured by the frequency of specialist and nurse visits into my room rather than days and hours.

I know I have mentioned in previous posts about my fascination and astonishment with general anaesthetic, however I now have higher regard for the power that all "drugs" play on the mind and body especially in regards to their role following surgery. I am not one to take pills willy-nilly, however I do believe that they play a vital role when used correctly. Too often, as a physiotherapist I would see patients come to an appointment in a lot of pain and being scared to move due to this pain all because they don't like to expose their body to drugs. Unfortunately as a result they are further behind in their rehabilitation. While in hospital I made the decision to be guided by my medical team as they clearly knew a lot more about what was going on, plus after surgery who has the energy to make an informed decision about every detail. At times I do remember thinking to myself "I have no idea what I am taking or why I am taking this" as I was swallowing the tablets that the nurse handed to me. Usually being a bit of a control freak and needing to know every detail before making a decision I like to think that when in hospital and in the hands of professionals it is complete trust rather than personal negligence and lack of care.

My pain was always well controlled as I was progressed from the epidural delivery of Pethidine to oral forms of different analgesia. I was also required to take aspirin daily to reduce the chance of post operative clotting, and anti-inflammatory medications to help reduce the swelling from the trauma involved during surgery. The unfortunate part about any drug is the unwanted side effects that are often associated. Try to imagine yourself just having had major surgery where your pelvis had been cut and fixed with 4 large screws trying to sit down on a toilet. It simply is not an easy task to perform. Although you may not want to be too graphic when visualising this, you must admit that even the mechanics of sitting on a chair requires a lot from the hip joint, and this is without even going into the complex positioning needed to get the bowel in its ideal position to open effectively. Then to further complicate the issue, surgery also goes hand in hand with:

* Pain medications -  the primary reason for constipation following surgery 

* General anaesthetic - not only does it put you to sleep for surgery, but it in effect "paralyses" the muscles including those in the intestines which are needed to push food along the intestinal tract.

* Inactivity - getting up and walking are usually one of the triggers for bowel movement

* Changes to food and drink for surgery - fasting prior to surgery alters your body's normal routine of elimination and lack of fluid in the body results in hard dry stools.

So without going into too much detail I was also given medications to help relieve the pressure, allowing me to once again think about the many other aspects of my life rather than having to focus on the everything toileting and finally being able to give the nurse the answer she wanted to hear when she asked the daily question "Have you opened you bowels today?"

While studying to become a physiotherapist I undertook subjects in cardiothoracic physiotherapy, leaning about the increased risks of getting a chest infection or pneumonia after surgery due to the lack of things such as deep breathing, movement and the body's natural mechanics to prevent infection such as movement of cilia (little hairs that bring up "gunk" from the lungs).  Never working in a hospital I thought that the knowledge I had gained from these subjects was never going to be much use, but in the past week I was proved wrong. Without being told I was able to complete deep breathing exercises and coughing to help reduce the build up of sputum. The first time I coughed I let out a sigh.. the pain radiated from the left lower stomach down to my left knee. This did make me a little scared to cough again, however when I was prepared - slight curl forwards, hand over the scar to support the left hip and lower abdomen, then the cough caused only a small amount of bearable pain. Being a bit squeamish with phlegm I was not too impressed with the large amounts of sputum which I could move after only a small time between deep breathing exercises.

I am glad that I have not been actively posting on here for the past week is because most of what I did write and save before publishing does not make much sense now when I read through it. The drugs that I was needing to take while in hospital were great for the pain however they played a role in changing the way my brain was able to work. I can now appreciate why people get addicted to these types of drugs. One afternoon while lying alone in my hospital room all of a sudden I felt as if my body was moving, almost like I was floating through the air. As silly as it may sound I was determined that what I felt was real and I think at the time I would have argued my case if anyone told me that I had not been flying around the hospital.  The only way I can describe the feeling was as if I had experienced an hallucination. This did frighten me enough to ask my nurse if I could possibly try to reduce the amount of strong medications that I was taking and see if my pain would still be controlled on less mind-altering drugs. The past few days I have felt like myself again, however I have been experiencing what I imagine to be withdrawal symptoms. Theses include vivid nightmares and night sweats as my body got used to not having the strong drugs in my system.

I was given the all clear yesterday from my team in hospital and was discharged. Oh how nice it feels to be home. The next time I go to hospital I am not going to forget to take my own pillow!! It is great to be able to spend time with my beautiful husband and my jessie - dog.

Over the past week I have been blessed to receive many messages of support from friends and family, and I had many loved ones make the effort to come and visit me in hospital. I was spoilt with gifts of flowers, lots of chocolate (especially for easter), and things to keep me occupied including magazines. It does make me feel very special when I think how people were willing to make time in their hectic lives to think about me and or visit me in hospital, even just to sit there and keep me company. Yes it would be nice to be rich, travel the world and have nice things, but at the end of the day I realise that the important things in life are good health and having people in my life to share my journey with.

Time for surgery.

It has been a very exciting and busy start to 2012 for me. I married the man of my dreams just under 3 weeks ago, then spent an amazing 2 weeks skiing at Whistler in Canada for our honeymoon (sort of a last hurrah before being out of action). All the excitement building up to our wedding which included a hens day, dress fittings and a kitchen tea provided enough of a distraction from my upcoming periacetabular osteotomy. With everything planned and ready to go the only thing I needed to do in preparation for surgery was to get a blood test so that they could determine my blood type and hold some units ready to be used if I lost a too much blood during the operation. I woke at 5:30am before my alarm at 6am on Thursday 5th April as the day had arrived. Following instruction I had not had anything to eat or drink since the night before. I was surprisingly calm however i could feel butterflies in my tummy during the drive to the epworth hospital.

Most people just had one parent or a partner with them while they waited for their surgery, but in true Bartle family form I had mum, dad and my husband with me. Due to a few delays in the surgeries prior to me I was not taken through until 4pm in the afternoon. By that stage I was so hungry that my nerves seemed to have dissappeared. My surgeon Jit along with my anesthetist came to chat to me prior to heading through to the theatre. The last thing I remember was sitting on the edge of my bed in a glamorous white hospital gown while the anesthetist explained the steps he was taking to put in the epidural. My medical team had decided to perform a spinal block via the epidural and a light anesthetic as this was to be a great way to control my pain post op. So what felt like 5seconds to me (despite in actual fact being over 2.5hours) I awoke in the recovery room.

Initially I was experiencing quite a lot of pain, but the nursing team were quick to get that under control with a bolus of pethadine in my epidural. My legs were both still numb from the spinal block. It is the strangest sensation when I was telling my foot to move but nothing happened. Luckily the sensation slowly returned so by the time I returned to my room (filled with my welcoming committee- family) I could wiggle my toes and ankles. The first night I has obs taken every half an hour (including blood pressure, oxygen saturation, heart rate and temp) so my sleep was very interrupted. My leg felt very heavy and I was very anxious to move my left leg however my pain was very well controlled. I have lines coming off me in every direction- an IV saline drip, my pathedibe epidural and a catheter (which I am stoked about as trying to sit on a pan with a sore hip is very challenging!!)

My surgeon came to speak to me in my room once he had finished surgery for the day at 11pm informing me that everything went fantastically and that he couldn't be happier with the position of my hip socket. He informed me that he had used 4 large steel screws to fix the bone segment into place. I'm looking forward to seeing some X-ray films. On instruction from my surgeon the physio visited to start me on a CPM (continuous passive motion) machine which is going to help the hip get moving. Prior to being put on the CPM I was assisted to standing where I could partially load my left foot- with majority of my weight to go through my right foot and through my arms into the crutches. I lasted about 30seconds before I started to feel gitty and I lied back down. The physio was happy I managed to stand up especially as my blood pressure is low from blood loss. I am currently lying in my hospital bed while the CPM machine does its magic. I am feeling very optimistic as I never imagined that I could feel this good only 24hours after surgery but I guess time will tell, especially when they take down the epidural.

My main focus at the moment is relaxing and preparing for another fun filled day of physio, meeting with my surgeon and seeing family /friends who plan to visit. But don't worry I'll keep u all posted about my progress :)

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.