Last Round of Injections

Today's view of his right hip. There is no more socket or ball of the femur.

Noah was approved for hip replacement last summer, but after the new surgeon told him that "worse case you lose your leg," Noah quickly opted out. Fast forward to now and the pain has gotten pretty bad, so much so that I got him a cane at Christmas that he uses daily to help ease the burden on his leg. 

He's finally to the point where he knows he needs the replacement. We made an appointment with his old orthopedic surgeon at Phoenix Children's Hospital to see if he could get one last round of cortisol injections (he has to be injection-free for at least 3 months pre-replacement). After the routine x-rays, the surgeon came in and basically told us that this continues to be one of the worst hips he has ever seen. He informed us that Noah is now at end-stage osteoarthritis (stage 4) where there's no more cartilage present between his bones. So when the bones of the joint come in contact with each other they painfully rub against each other during movement. This results in severe pain with loss of movement and function. The surgeon approved him for the last round of injections but told us it most likely won't be very effective. It's pretty discouraging considering all that he's been through since the age of 4, but hopefully a hip replacement later this summer will bring him better mobility and comfort. 

He gets his last round of injections Wednesday, April 6th. 

Upcoming Summer 2016

Periacetabular Osteotomy (PAO) for Acetabular Dysplasia

That huge title is part of the surgery that Noah will facing this next summer, 2016.  Recent MRI results showed pretty much what the surgeon thought... the hip socket is too flat, the femoral head is too big and there are grooves in the bones where there shouldn't be.  Without this corrective surgery, Noah would develop severe hip problems in his 20s, most likely resulting in the need for a hip replacement.  With this corrective surgery, the outlook is good, and it wouldn't be until about his 50s that he might need a hip replacement. 

Figure 1 shows a normal hip.  Figure 2 shows a hip similar to Noah's.  (Note: These are not Noah's x-rays.)

The surgery itself would be in two parts.  The first is the PAO portion.  This is most commonly used to treat acetabular dysplasia or a "shallow hip socket."  A dysplastic hip has incomplete or inadequate coverage of the femoral head.  The dysplastic hip is more "dish shaped." 

Because of the inadequate coverage of the femoral head in a dysplastic hip, the weight across the hip is distributed on a smaller surface area resulting in excessive load along the rim of the hip socket. Over time, this increased load along the rim of the socket will lead to degeneration of joint cartilage and formation of osteoarthritis. Patients with this condition frequently seek medical attention due to activity-related hip pain (discomfort in the groin or side of the hip). Prolonged sitting or walking can also increase these symptoms and a sensation of catching or popping may also occur. As these symptoms continue to increase, a slight limp may be noticed and more strenuous activities may become difficult.  Noah already has a slight limp again, partly because his left leg is 1 cm longer than the right leg.

In case you didn't know, "Periacetabular” means around the acetabulum (hip socket). “Osteotomy” means to cut bone. Therefore, PAO means to cut the bone around the acetabulum and reposition the hip socket. At surgery, controlled cuts are made to loosen the acetabulum from the pelvis, and the acetabulum is repositioned.  An incision is made across the front of the hip joint to allow exposure of the hip and surrounding pelvis. The use of x-ray during surgery helps direct the bony cuts and confirm the correct reorientation of the socket. The acetabulum is fixed in the new position with three or four screws. In most uncomplicated cases the surgery takes two to three hours.  However, Noah's bones don't like to do that they are supposed to do, so he needs part two of the corrective surgery.

Part two deals with his femur.  Occasionally (approximately 1 out of 20 cases) there is also a deformity of the femur that must be corrected at the time of surgery by a proximal femoral osteotomy (PFO). This involves cutting and repositioning the upper portion of the femur bone. If this is indicated, a second incision is made along the outside of the hip and the femur is repositioned and fixed with a metal plate and screws.  All together, the surgery is estimated to take about four hours. 

Outlook, as previously stated, does look promising.  Although, that's what we thought after the first, and then second, surgery years ago.  The hospitalization time is two to four days and full recovery takes four to six months. Most likely, he will be given a wheelchair again and then after a few weeks he will graduate to crutches or a walker for what they call "touchdown weight bearing."  The majority of patients experience major relief of pain and become quite active after recovery from surgery. While the PAO is an extremely effective hip preservation procedure, it may not create a completely normal hip. Even if the PAO is effective in adolescence or early adulthood, some patients are likely to require a total hip replacement surgery later in life.  Noah will then need more physical therapy after he's healed to help with joint healing.

Still interested in what Noah has to look forward to?  Check out http://hipdysplasia.org

Hip, Hip, No Hooray

Noah had another hip appointment this past week.  He currently is measuring 5'4" and 104 lbs.  He only has one more inch to go and we'll be the same height!  So strange that my kid will be bigger than me!

Dr. Karlen checked Noah's hip again and we pointed out the ball of the femur prominently sticking out of the socket.  He was kind of discouraged that the physical therapy hasn't done much in the way of strengthening the muscles, so he ordered a MRI of his hip.  Tomorrow we go for the MRI.  The actual procedure will take about an hour, but we have to show up two hours early for him to get a conscious sedation and then have a dye injected into his hip.  He's not too excited about that, but at least with the sedation he won't have to worry too much about not being able to move for an hour in the machine. 

Hopefully this form of x-ray will better allow Dr. Karlen to see what exactly is going on inside Noah's hip and from there we can better plan when his next surgery will be.  Poor kid has already gone through so much with this stinkin' joint! 

No More After Four

 

Noah had his fourth hip surgery today.  This surgery was to remove the hardware from the 2nd major corrective surgery he had several months ago. Despite some scheduling problems with the surgical team, everything else went well.  Noah's orthopedic surgeon, Dr. Judson Karlen, said the ball is in the socket where it should be and the bone looks to have healed very strong.  He even allowed Noah to keep the metal plate and three screws as souveniers again.  His recovery should be relatively quick and he hopefully won't ever have to have surgery on his hip again!

Noah's Hip: Looking Back

Four years ago we found out that Noah had hip dysplasia in his right hip. Even since he had learned to walk, he had a slight limp. Our family doctor reassured us he was fine, but when we switched to a pediatrician, he discovered it right away. His right leg was shorter than the left and after numerous x-rays with a pediatric othopediac specialist, it was determined that he would need surgery to correct it. So in October 2006, just 2 months after Alora was born, Noah underwent an almost 8-hour surgery at Primary Children's Hospital (Salt Lake City) where his femur was shortened, his hip socket carved out, and bone was grafted into place. He was left to recover in a full body "spica" cast for the next three months. A year later his hardware was removed and we thought all of his hip troubles were over.

We were wrong.

About two months ago, we took Noah back in for his yearly hip check-up and x-ray; this time with a new specialist here in Phoenix. We thought everything would be progressing as normal, but the specialist informed us his leg was not rotating properly in the socket. After more x-rays and a 3-D cat scan, it was determined he would need surgery again. This time, however, the surgery isn't supposed to be as complex and his recovery should be much easier. Poor Noah has to report this coming Tuesday, November 23rd for another hip surgery. His femur will once again be cut, turned the proper direction, and then secured in place with some plates and pins. Hopefully all will go well and his hip heals how it should.

One of the first things the pediatrician did was compare Noah's legs side by side. You can see the discrepancy in height.

He also stretched out Noah's legs to check the length. The discrepancy is again very noticeable.

Halloween was just a couple of weeks after his surgery. My mom customed-made Noah's pants as well as this cowboy costume. (Because of his full body cast, he was unable to wear normal pants.)

January 8, 2007: The removal of cast #2! Wa-hoo! Goodbye annoying cast, wearing diapers, and having the most horrific wheelchair!

August 8, 2007: The area where his hardware was removed.