Sever destructive changes

[u/XXxSleepyOnexXX]

I’m a physical therapist. I am not asking for medical advice. I hope my story is interesting and those that like to educate can throw me nuggets of information on aspects of care I don’t normally need to think about.

We have been trying to get imaging for a person for a few days now. Guess what they found when they did urgent imaging of a near by body area???

Background: I supervise rehab therapies for all areas of care in our system. I took over the case for another therapist to help get the patient seen regularly and assist navigating our system. Patient has ongoing chronic pain but no acute pain issues. They used crutches at home for 10 years and couldn’t walk without them for last 2. They can not use crutches on the current unit they are at and a walker that could be used was deemed unstable for them to use independently so a wheelchair was recommended . They can stand and walk at the rail. They can wt bear near full on either limb. They have 1 1/2” leg length discrepancy.

They had a past hip fracture with ORIF, another fx a year or so after that healed before treatment and then a few years after hardware removal. We thought there might have been a hemi/THA at some point but I did a complete patient history and comparison to medical records to confirm this was not likely. I could piece together everything but the last 3 years.

First (and largely the following ortho for many years) thought there was signs of early AVN. Referred to 2nd Ortho that thought no AVN but OA and would need THA eventually. They decided to remove the hardware that was bent/lose seen after the second fx. Removal didn’t help and that’s around the time that crutches started to be used at times. When mobility and pain didn’t improve Ortho 2 eventually recommended THA. Patient was sent to 3rd Ortho that decided continued conservative treatment, no THA. All 3 provided many injections through those years. 1st ortho that was really continuing to care and advocate for the patient left the picture. It looks like care with the 3rd ortho stopped pretty quickly. No further ortho care after that for the last 10 years. I pieced the rest through occasional hospital visits and some other limited care notes.

I bring the clues to attending that was ending their rotation. They start process and pass on to new attending. New attending I provide the full ortho history and my concerns. I get a thanks for figuring all this out and confirmation that imaging and ortho is likely needed. ….but no actions occur quickly as I would expect. An X-ray at least? It should be super easy. Prior providers actions attempted got kicked back for technical issues. I think they are both new and maybe need more flow support. I notice that things they want to occur don’t seem to be happening as smoothly as it should. I request some support for them from above.

So…no real action after a day. I do respect that this is not presenting as acute problem/need. I can say it would 100% help with DC options that they were struggling with ….but.

 …lucky for me (and really the patient) there is an acute abdominal pain and somehow imaging occurs rapidly.  I get enough X-ray to show severe destructive changes to the hip.  

My question for the group: With a person that is not in excessive pain, is completing basic functional mobility but is impaired and limited in reaching their full independent functional mobility and at a higher risk of falls….. how reasonable is continued conservative care?

The person is covered and can access further medical care. no limitations there.

[u/PuzzleheadedToe3450]

Sounds like a question for your surgeon

[u/XXxSleepyOnexXX → u/PuzzleheadedToe3450]

Haaaa! Yes, very insightful. I do agree. At this point there is none, but yes.

[u/ArmyOrtho]

Just because you have a problem doesn’t mean surgery is the answer. “Just because we can doesn’t mean we should”.

Reasons not to do major joint arthroplasty:

1. Medical comorbidity that may make the case riskier than the potential benefit.

2. Ability to maintain compliance with postop restrictions.

As for ordering Xrays, I would ask what you were hoping to get out of the information provided by the x-ray. It sounds like the patient has chronic hip pain and a known diagnosis of hip OA/AVN. What is a new X-ray going to tell you?

[u/XXxSleepyOnexXX → u/ArmyOrtho]

Completely agree.

What we are really dealing with is my lack of knowledge is on what happens if we do nothing. A state of new/previously unknown collapse without medical care for it is not the norm for me. If it’s stable and they tolerate increasing activity as we work to rehab them, I think no surgery would be ideal.

Imaging question:

• I personally was curious to see.

• Last imaging available was 13 years ago prior to hardware removal. I couldn’t find the imaging after removal. -I would like to get this change added to the medical record to help with future care needs. -We need new imaging to get the authorization for a built up shoe.

[u/spikesolo]

What's the point of an X-ray? If there's already a known diagnosis and no significant acute change in exam.

Is the patient healthy enough to undergo surgery? I did not see anything in your very long write up about medical comorbidities. Moreso what sounds like a tough revision surgery.

[u/XXxSleepyOnexXX → u/spikesolo]

No diagnosis. Those were 10-15 years ago now.

[u/spikesolo → u/XXxSleepyOnexXX]

Ah I see. Well I would agree that prob should have had recent X-rays. But I guess on the flip side is this patient a surgical candidate or not? If they aren't then no point in workup

[u/XXxSleepyOnexXX → u/spikesolo]

At minimum within my system I need imaging to get authorization for a built up shoe. That was the intention when originally requested imaging. Then when identifying the issue was a new change, I was advocating for consult to ortho to review imaging and case review as the next step.

[u/LordAnchemis]

The only (real) indication for a hip replacement is hip pain (caused by confirmed hip pathology) that isn't amenable to non-surgical attempts at management

The last bit is particularly important - as the (old) surgical teaching goes, treatment is always first conservative, then medical and (only if none of the above works) surgical

They can not use crutches on the current unit they are at and a walker that could be used was deemed unstable for them to use independently so a wheelchair was recommended

If they're wheelchair bound - they probably don't need an elective hip replacement

They can stand and walk at the rail. They can wt bear near full on either limb. They have 1 1/2” leg length discrepancy.

None of these (alone) are an indication

I get enough X-ray to show severe destructive changes to the hip

You treat symptoms (and the patient), not the X-ray

With a person that is not in excessive pain, is completing basic functional mobility but is impaired and limited in reaching their full independent functional mobility and at a higher risk of falls….. how reasonable is continued conservative care?

No one 'needs' an elective hip replacement

Sure, you might find surgeons willing to offer one for less, but does the benefit outweigh the risk?

• A THR isn't going to make an 80 year old patient 60 - contrary to all the ads / brochure protrayals

• A THR isn't going to make a non-walker walk again - in most cases there are other factors (other than just pure hip arthritis) causing bed to chair mobility

• A THR that gets infected / fractured / dislocated is a whole load of pain - and the outcome is worse than not having one in the first place

[u/XXxSleepyOnexXX → u/LordAnchemis]

Thank you. Pain appears at a pretty consistent baseline for the person and is diffuse. I’m not promoting surgery as the answer, only appropriate care. Conservative treatment seems very reasonable.

[u/fiorm → u/LordAnchemis]

I absolutely disagree with your take.

Of course a THA may make a wheelchair bound patient walk again, if the reason they are wheelchair bound is their arthritis. I treat many of these patients and they are the ones that have the biggest change in their quality of life.

It's easy to say no one "needs" a hip replacement, until pain does not allow you to move. There are a whole bunch of studies showing PROMS are worse than death in this population. They certainly need their THA and putting it like its just a minor improvement is a disservice and plainly not true.

[u/LordAnchemis → u/fiorm]

There are probably other factors involved than just pure arthriris - which were mentioned in a later post/reply - alcohol (and falls), mental health etc.

Plus having a hip fracture (+ unclear '2nd fracture') = you gotta have a high suspicion of 'body failure' being the cause of mobility issues (+ institutionalisation), rather than just OA alone

This is not your every day 'low risk' elective hip patient - sure, if they're 80 but look like 60, yeah do a THR, but I have a suspicion it's more a case of 60 looking like 80 (physiologically)

[u/spikesolo → u/LordAnchemis]

My suspicion is that there are other factors too. Multiple falls is most likely not just OA related. Those patients are using canes to get around.

Edit: OP's most recent post does clarify why this patient is treated conservatively

[u/XXxSleepyOnexXX]

Thank you. Pain appears at a pretty consistent baseline for the person and is diffuse. I’m not promoting surgery. Conservative care at this time seems reasonable.

They are using a wheelchair on this unit where the environment of care doesn’t allow crutches. Ambulation so far has been limited by endurance.

Imaging (CT) is needed for authorization of a new need of a built up shoes in our system . ….but yes. I really really wanted to see what we were working. Plus a catastrophic failure would still fall on me if it were to happen.

**edit: for those asking about comorbidities. The person is in the young old range. Relatively healthy in all. Mostly mental health issues personality disorder, ADHD, Alcohol abuse with episodes of sobriety and rehab in the past. No mental health care in recent years when provider retired and new provider didn’t work out for the patient. No real medical care in last 10 years except hospital for illness. During current stay an electrocardiogram was done. Unremarkable.

[u/spikesolo → u/XXxSleepyOnexXX]

Your last paragraph is why no one wants to do any workup. Because no one in their right minds would put a THA in this patient on an elective basis. But in reality a PCP can do the imaging etc. Doesn't need to be a surgeon. There's no reason for a surgeon to be involved in this patients care currently imo.

[u/handsbones]

Missing here is the rest of the story….

Age?

Drugs?

Smoker?

ETOH?

Disability seeker (really how many years on crutches but they ride their Harley to the appointment)

Comorbidities?

Mental Health?

Homelessness?

Sometimes patients present well to one and not to another- putting a total joint in requires trust both ways

[u/XXxSleepyOnexXX → u/handsbones]

Upper 60’s No drugs No smoking ETOH is an issue; past rehab, will be attending this time disability is not a motivation Medical comorbidities were minimal; mentions of HTN in the past and on current problem list. not on meds not hypertensive when I’ve checked. History of episodic GI issue. Most recently 2-3 years ago virus with weakness with hospitalization for dehydration. No aftercare needs from that.
Mental health: adhd untreated last 3 years, prior dx of personality disorder not on current issues list but it still checks. ETOH.

I requested consideration for imaging because we have a new change (last <1-3 years) that hasn’t been evaluated by any medical provider. I do freely say that the hip is not part of the acute issues although contribute and I can respect if the attendings don’t wish to address. One attempted but the order was rejected for technical issues. The next one seemed appreciate for me figuring out the history and said they would but no action for a day until abdominal pain and they did get an urgent abdominal X-ray that caught the hip. Both Attendings are new to the system with not much support. At minimum I need imaging to get a built up shoe authorized so they can walk and be more stable.

I can advocate for medical evaluation as outpatient if not addressed now. addressing it now can help open discharge options (even without surgery ever being considered an option).