Seeking educated opinion/advice re: post Total Hip Revision problems

Posted by suzeeq @suzeeq, Wed, Mar 13 9:48pm

Patient with severe bi-lateral congenital hip dislocation and multiple THA replacement and revision surgeries is experiencing persistent left lower thoracic spine pain, inability to abduct or independently weight bear on left lower extremity following early 2018 left total hip revision. Pt has diligently done months of abductor muscle PT exercises to no avail.

Pt not given diagnosis but just treatment, including facet and trigger point injections to no avail. (Pt believes diagnosis should generally PRECEDE treatment)

Pt returned to Orthopod who referred him to "back class" and further PT and said: "Let me know in a few months how that works". After injectingmwrong area twice, PM&R doc did 2 trigger point injections in correct area, the first which helped somewhat and the second which resulted in increased pain and prolonged swelling. Pt SUSPECTS but does not KNOW that second injection in correct area may have been performed in an unnecessarily aggressive manner.

Pt returned to Orthopod who ordered CT w/o contrast to assess osteolysis. CT was of limited value due to artifact caused by hip prostheses hardware.

Orthopod then ordered MARS MRI.

MARS MRI showed no osteolysis inleft hip but DID DISCLOSE severe fatty atrophy of psoas, obturator, piriformis, gluteus minimus and gluteus medius muscles of left hip. All of these atrophied muscles are IN the hip area with nerves that TERMINATE in hip area.

Orthopod says this fatty atrophy is due to de-innervation or disuse of these muscles (De-innervaiton means there's a disturbance somewhere along the nerves which serve the affected muscles and that disturbance prevents/limits the neural signal from brain/spine from reaching the muscle, so the muscle isn't "fired" and thus atrophies causing muscle fibers to to be replaced by fatty tissue which can't do the work of muscles)

Orthopod seems particularly anxious to blame pt's T-spine pain, LLE weight bearing failure and abductor weakness problems on spine rather than hip.

PM&R Doc opines that hip weakness is cause of T-spine pain, LLE weight bearing failure and abductor weakness problems .

Patient has some spine scoliosis, no traumatic spine injury, no tingling, or radiating pain and no imaging study evidence of nerve root compression.

Patent SUSPECTS, but does not KNOW, that the nerves serving all or some of these currently atrophied muscles were forceably retracted and may have been damaged during last hip surgery as the surgical procedure required dislocation the hip to replace /repair broken hardware and fractured greater trochanter.

Patient has consistently and articulately reported his symptoms and functional problems to Ortho, Primary Care, PM&R practitioners for more than a year but has yet to receive effective treatment or be given a causal diagnosis on which practitioners agree.

Following recent MARS MRI "severe fatty atrophy" finding, Orthopod suggested referral to PM&R doc for nerve conduction study to diagnose existence, location & cause of nerve disruption causing muscle de-innervation and subsequent fatty atrophy of muscle. Instead PM&R has ordered another MRI. – this one LUMBAR and not MARS, so Pt anticipates that artifact of his hip hardware in the PM&R ordered MRI might prevent effective imaging of the the lumbar spine.

Also Pt. wonders whether the MRI will provide ANY useful information to diagnose existence, location & cause of nerve disruption causing current muscle de-innervation and fatty atrophy of muscle.

Patient is actively engaged with his care, follows all medical orders, is articulate and accurate in reporting symptoms and problems and persistent with with follow-up which he documents in writing. Pt maintains a polite tone with practitioners but is not unquestioningly deferential. Pt believes that some practitioners don't listen and/or take PT's questions personally, to wit: Primary care doc responsible for coordinating care between specialties, has repeatedly reacted impatiently telling Pt to "cut to the chase" when Pt. attempts to provide him with relevant info re treatemtnby and diagnosis disagreement between pt's other practitioners — Pt's PM&R doc did 2 trigger point injections in wrong areas and then claimed "I injected where you told me it was most painful" — Orthopod calls patient "agitated" and "hostile" in response to patient's calmly stated questions.

Patient is understandably concerned that he may not be receiving accurate diagnosis and properly targeted care.

Patient welcomes educated comments/advice from those with medical expertise and/or similarly situated patients.

many thanks in advance

Hi @suzeeq, welcome to Connect, on online community where patients and caregivers can get support from peers. As such we can share experiences, but not provide medical expertise. You have certainly provided a detailed report of the person who has had a total knee replacement. Is this a medical report? May I ask what your relationship is to the patient? Are you his spouse, caregiver and/or advocate?

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