An excellent PAO article

This article was written by a medical student and PAO patient. This is a great PAO primer if you are preparing for surgery or as reference for your friends and family so they can understand what you are talking about.

I’m over 40 … and my timing stinks

A new study was published which concludes that the outcome of PAO for patients over 40 is “not as good as” the outcome of total hip replacements. While it doesn’t say the outcome with PAO is “bad,” for an insurance company this is denial fodder worth its weight in gold.

Thanks guys, please kick me while I’m down.

As of November 1st, my insurance company, along with most others, has unilaterally decided not to pay for PAOs. This probably means that they WILL pay for some, if you make a really great case on appeal, but that by and large they consider this rare operation, which has helped women for 30 years, to be “investigational.” Not enough large studies have been done. Hmmm, how many is “enough”? There are quite a few small studies that I’ve read, but how can anyone do a large study when this surgery is so rare? This isn’t like diabetes or heart disease – run of the mill maladies which every Tom, Dick and Harry seems to have nowadays. And oh, by the way, Tom, Dick and Harry probably don’t have hip dysplasia because the vast majority of people with this condition are WOMEN. We all know what whiners women are … with their subjective complaints and all. Those women, they want special, expensive surgery for all their silly little problems … we big insurers need to let them know that we know what’s best for them!

Believe me, if I could have a total hip replacement or resurfacing instead of a PAO I’d be overjoyed. Recovery time for THR is short, and one is only in the hospital for a couple of days. I’d be walking and full weight bearing the day after surgery, and probably skating again within months. Not that THR is a cakewalk, but compared to PAO it’s “hip surgery lite.”

The problem is that my dysplasia is on the severe side, and it’s coupled with severe anteversion. THRs are not designed for people built like me. They, and their cousin the hip resurfacing, are designed for people whose hips are fairly normal in mechanical construction, with perhaps small abnormalities, but which are diseased or worn out. While there is a “dysplasia cap” available for hip resurfacing, again, it is not designed for severe cases. Two experts have now told me that my best course of action is PAO, based on the severity of my mechanical imbalance and the fact that my hip joint is basically healthy. Why would I remove and replace a healthy joint! Why would anyone do that? It seems obvious to me that correcting the structural imbalance, preserving the joint, and avoiding multiple revision surgeries is my best course of action. I’m seeking a third opinion. How many expert opinions do I need to override Aetna’s blanket policy?

I will add that I am not your typical 45 year old. I like to think that I am in better physical shape than most. I am not overweight. I am very muscular. I have exercised all my life. What about the over 40 patients in the new study? How many of them were like me? Is the only thing we have in common that we are "middle aged"? Yes, I am over 40, but my life isn’t over yet. I’m not ready to take up knitting or lawn bowling. MY PERFECTLY HEALTHY HIP JOINT SPACES DO NOT NEED TO BE REPLACED … that is not my problem, oh stupid insurance company flunkie reading my file. What I need is better femoral coverage. Isn’t the solution obvious?

Speak softly and carry a big stick

My new sidekick: A wooden cane that my grandparents brought back from Mexico 30 years ago. It was in my parents' basement so I borrowed it for a test run.

Some problems with carrying a cane:
1. It's hard to carry other things since you only have one hand free! I must get a backpack since I carry a lot of stuff most days.
2. It's unwieldy. I have already wacked two people with it and not on purpose. It falls down when I lean it up against things. It's easy to trip over if I leave it lying around.
3. It's heavy.
4. It attracts attention. OK, look, I know I could mitigate this issue by getting something plainer; my cane has intricate carvings painted in bright colors. But my grandfather used this cane for years and it has sentimental value. Plus I'm cheap. Why buy a cane when I already have one?

I now have some level of pain pretty much all the time. If I sit for long periods of time my hips start to ache. When I first get up, I'm too stiff to move for a few moments. I can still sleep but only on my back. This doesn't hurt my hips but it does hurt my back. I figure eventually it will hurt my hips too, it's just a matter of time. I can't lie on either of my sides.

Walking hurts, although after I get going it hurts less.

Skating hurts.

Standing, sitting and lying down all hurt most of the time.

It's a tolerable hurt right now -- a dull ache and not a sharp pain. I am not taking pain medications until I have to. I'm not big on meds. NSAIDS can cause kidney damage and I'd rather have some pain now than kidney disease later. If I have to start popping an Advil now and then I will, but I want to delay that as long as possible. I want to know how bad it is, not mask it.

I am hoping that the pain will be tolerable through this skating season. I can then do something about it. I have an appointment with the periacetabular osteotomy guy Oct. 30 (I still can't believe the lead times for doctors). PAO does not sound promising, however. It sounds horribly painful with a long recovery time. A week in the hospital, and no weight bearing for months. The pain is akin to a broken pelvis, because that's what they do, break your pelvis. Hip replacement/resurfacing sounds less painful with a much shorter recovery time. However, the life span of those methods is limited (10 years? 20? who knows really) and the PAO may postpone the need for them -- or eliminate the need for them altogether.

When I read about the limitations post-surgery, PAO also sounds worse. I can't skate if I'm constantly thinking about what I can't do. I don't want to skate if my toes turn in and my extensions look like shit. I have worked all of my skating life to fight my lack of turnout and now I am at the point where my legline looks decent. To give all that up now just because I'm in some pain sounds silly. But if the pain increases it probably won't be so silly any more.

That's PAO though. Hip resurfacing will allow me some turnout; perhaps more than I have now. It's just the limited lifespan that worries me. I plan to live a long time and don't like the sound of 2 revisions in my future. But it seems multiple surgeries of some sort are inevitable. It's just a question of what. And when.

Possibly Cathartic, Probably Immature,

...and Definitely Angry.

This is an addendum to my post from earlier today regarding my recent hip problems. If you haven't yet, please read that post first.

I realized today that my hip deformity has caused physical and emotional problems for a long time, even though I had no idea that I had this defect until today. This evening while feeling sorry for myself I recalled some of these problems; it is not much comfort now to know the reason behind them but I feel I should list them here for posterity.

I remember in Kindergarten when we were being read to, all of us kids were told we must sit "Indian Style" for 30 minutes (Not such a PC term now, but I'm sure you all know the position I mean.) At age 5 I could only sit that way for a few seconds before my legs started to shake and hurt. My femurs naturally rotate inward, not outward, and so I could then (and still now) more easily sit with my upper legs together with my lower legs turned out in "W" position.

I remember being told that we MUST sit for the half hour reading period INDIAN STYLE, and I was corrected by teachers, publicly, over and over again for being unwilling to sit that way. (Somebody explain the mindset of these Kindergarten Nazi Bitches to me ... I am at a loss.) Sometimes it hurt so much that I would cry. I remember the teachers scolding me for being "a baby" and "disruptive." Nobody thought it was a medical problem; who ever heard of a 5 year old who couldn't sit "Indian Style"? They never told my parents or sent me to a doctor, just strongly suggested to me that I was a bad child. Needless to say, children being the savages that they are, I was picked on mercilessly for being such a loser. Perhaps that's the starting point of some of my more interesting personality quirks.

Kindergarten teachers of mine, if you were here right now you'd be appalled at the highly disruptive and disobedient gesture I'm making in your direction with my middle finger. That's right, this is my blog, and I can do that if I want to. Nyah nyah nyah.

So I didn't see a doctor for the x-rays that would have made it obvious that I needed corrective surgery which, at that young age, would have prevented so many problems I've had since. Problems such as being unable to ride horses, something I love to do, because I can't walk for weeks afterwards due to my stiff and sore hips. Problems such as being yelled at as a teenager by skating coaches because I couldn't do an Ina Bauer (obviously not trying hard enough, probably lazy and bratty to boot). Problems such as difficulty in my late 30's riding a bicycle for more than a mile because my hips hurt (I chalked it up to being out of shape at the time and never rode a bike again). Problems walking over the last 3 years that I attributed to arthritis and old age which have caused me to groan like an old man as I get up and walk stiff-legged after getting up out of my chair at work, which co-workers have found amusing; I did too until it got so bad I realized that it wasn't normal.

{Addendum -- 8/8/08 -- my research reveals that periacetabular osteotomy, the surgical procedure used on children and young adults, was pioneered in 1984, so unfortunately it would not have helped me as a Kindergartner in the late '60's. However, I still wish I'd known about this problem earlier.}

Now it appears I may be too old for that type of surgery, leaving me again with the double hip replacement scenario as my only option, along with a lifetime of memories of things I could never do, or can no longer do, or stopped doing a long time ago.

Yes, I'm feeling sorry for myself, but this is my blog and I can say whatever I want to. Nyah nyah nyah.