Some amazing new surgery, or a sign of the times?

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From an upcoming, much longer post, detailing my second visit to The Washington University in St. Louis. Where I took a course by Shirley Sahrmann and the physical therapy department. You can read about my first visit here. 

In discussing structural factors affecting movement, we really honed in on the hip. During our lab portion Shirley recognized one girl -who had a back pain history- walking a bit funky. She told the girl to point her toes in a bit, and see how that felt. The girl walks around the room, “That feels better.”

Shirley, “Of course it does. You have anteverted hips. Who told you to walk with your feet straight?”

Girl, “My last therapist.”

Shirley puts her up on a table prone, lets her legs fall out, and sure enough they went out significantly.

This girl had been, for god knows how long, forcing her hips into a range of motion she doesn’t structurally have. She’s not going to loosen anything up by keeping her feet straight, she’s only going to jam her hip bones together. Does she look pigeon toed / a little weird with her toes in? Yep. Will that help save her from a hip replacement? Yup.

(I’ll get to how a therapist of all people gave her this suggestion, and a therapist, of all people, continually followed this suggestion. To me, (I believe) the only non-therapist in the crowd, this was…disturbing.)

In the last decade discoveries of structural abnormalities of the hip have sky rocketed. To the point I don’t think we can even say what normal is anymore. What we can deduce from these findings is some people are better suited for certain activities than others.

If you have anteverted hips, it’s going to be extremely hard for you to play most sports without significantly risking blowing out your knee(s), destroying your hips, or wrenching your spine. If you have a shallow hip socket, it’s going to be harder for you to do anything too dynamic as you’re at greater risk of dislocating your hip joint. If you have a large femoral head, it’s going to be hard for you to ever safely squat butt to heels, like an olympic lifter, as you’re going to have to significantly round your lower back to get that low. You can’t get the flexion from your hips -the femoral head is too large, so it hits the acetabulum; you end up having to get the flexion from your spine.

It can suck if you end up with something like the above and yearn to be an NFL athlete, but that’s the way it is. Your body is first concerned with survival, then reproduction; not to be optimally put together to dunk a basketball, throw a baseball, or cut on a dime.

People always reference how athletically gifted professional athletes are. While true, we should also acknowledge how structurally suited they are for their sports. You can’t be an olympic weightlifter if you don’t have hips allowing you to fully squat. Furthermore, many athletes who are genetically advantaged for one sport are genetically disadvantaged for another, sometimes due to basic structural differences. If you’re a swimmer, it pays to have a long torso and short legs, like Michael Phelps. If you’re a sprinter, it pays to have a short torso and long legs, like Usain Bolt. Michael Phelps isn’t much of an athlete once you put him on a track; Usain Bolt isn’t much of an athlete once you put him in a pool. (How much of these variations are acquired through adolescence versus given at birth, I don’t know. Nobody knows. I don’t think anyone even has the slightest clue.)

In the grand scheme of life, these are minor issues. Most aren’t concerned with this level of physical performance or these types of ranges of motion past the age of 18 anyways. It’s no different than 99% of us who realize they aren’t tall enough to make the NBA. Stop the activity, modify the activity, or pick something different and move on.

At least that seemed rationale to me.

Shirley started talking about a 15 year old boy who was having difficulty abducting his hips. He discovered this because he had trouble playing basketball. Think a defensive position and shuffling side to side.

The boy also had trouble flexing his hips past 90 degrees.

So, he goes to the doctor with “mild hip pain and stiffness.” When X-Rays were done they discovered the head of his femurs were larger than “normal.” The doctors surmised these large femoral heads were clunking against his acetabulum, giving him pain. They think they can correct this with surgery.

For this procedure, a “femoral-acetabular osteoplasty,” they:

• Cut a ton of tissue to get to the hip joint. It’s not like a knee surgery where there’s not much covering it.
• I don’t know a ton about this, but I believe if it’s open surgery they don’t dislocate the hip, but you have to deal with all the issues open surgery come with.
• If it’s not open surgery, then the hip is surgically dislocated.
• Shave down the femoral neck.
• Shave down the femoral head.
• Shave down parts of the acetabulum. (This boy had some small fractures.)
• Reorient the above structures.

That was the first hip. Post-op the 15 year old was on crutches for ~6 weeks, then he went in and got all the above done again on the other side, after which he was in a wheel chair for a while. 8 months later he was playing basketball again. Shirley closed this story out with, “This is truly some of the marvels of modern surgery.”

I heard all the above, saw the pictures, and was fucking horrified. I don’t consider this a marvel of surgery, a consider this a profound example of a cultural issue. The only reason I can fathom putting your son through a surgery like this is they love basketball / sports, they (or the parents) believe the kid can make it to the NBA, and or they’re worried about their son’s hips as he gets older.

Regarding the last option, if this kid doesn’t flex his hips past 90 degrees and limits how much and often he abducts them, he should be fine. How many people flex their hips past 90 degrees on a regular basis? Most adults I know -other than sitting- don’t flex their hips ever. Why can’t this kid merely make sure to sit in a chair where his hips are below 90 degrees? Same thing with abducting them: Just avoid significant abduction. Is this really crucial for his life between the ages of 18 and 80? No.

Next, as I went over in “If we studied normal gait now, we’d have to revise everything,” there are loads of questions with this type of operation. Especially when it’s so new:

• How do we know this kid could be at risk for issues down the line? Do we have a sample of 75 year olds who we diagnosed with large femoral heads as 15 year olds, then observed them throughout their lifetimes?
• How many people who modify their activities, such as the range of motion they put their hip through, still have issues?
• What are the success rates of this surgery? Are those rates on a large sample size? How many other teenagers have had this done? How are these people doing 30 years later?
• In hip replacements, a smaller femoral head has actually been been shown to increase the rate of hip dislocation. Is the same true for this surgery? Are you (maybe) decreasing the kid’s hip pain by making the femoral head smaller, yet at the same time increasing the risk he dislocates his hip?
• In fact, if a larger femoral head has implications for decreasing hip dislocations, does the kid have a larger femoral head because his body is trying to make sure he doesn’t dislocate his hip while doing activities, like basketball?
• Say there is a risk of hip replacements later in life, is it better to take that risk than the guarantee of surgery now? Is a major surgery like this better when you’re a grown, mature adult, than it is when you’re 15? Is it easier to become temporarily handicapped as a 40 year old than it is a 15 year old?
• What are the chances he has this surgery and STILL needs a hip replacement down the road?

Does anyone think there is a good, solid answer for any of the questions above? I doubt it. My assumption is this kid is very much a lab experiment due to this surgery’s nascency.  What we fully know though is this kid has no chance of competitively playing many sports the way he is now. So, I’m forced to deduce sports are the motivation here. Money and fame? Shit, people will do a lot more than be put in a wheelchair for a while.

I don’t know anything else about this 15 year old, who was probably 16 by the time he played basketball again. I do know, by age 15, if you’re still having issues abducting your hips or playing defense, you’re not making the NBA. If the story on you is anything other than, “He destroys anyone he plays against, ESPN is looking at him, he has a ton of college offers already…” you’re not making the NBA.

I know the probability of a high school basketball player making the NBA is 3 out of 10,000. 3 / 10,000 = 0.0003%.When you’re 15-16, can’t play defense, have had two, MAJOR reconstructive surgeries, and missed an entire year of playing basketball, I’d wager that 0.0003% gets a lot smaller.

A recent study looking at elective surgeries examined four million operations over the course of three years. Of four million, about 28,000 didn’t go as planned. 28,000 / 4,000,000 = 0.007%.

3 / 10,000 = 0.0003% chance of making the NBA.

28,000 / 4,000,000 = 0.007% chance of this surgery not going well. (Considering how much more invasive this elective surgery is compared to others, along with how new it is, this number should probably be demonstrably higher.)

0.007 / 0.0003 = 23.

That is, there is a 23 times greater chance this surgery doesn’t go well than there is this kid making it to the NBA. Not to mention he has to do the surgery twice!

Part of this kid’s issue was a large femoral head and neck. This boy is only 15 and still growing. Who’s to say his femur isn’t going to grow right back? Shirley mentioned the genesis for a large femoral head can be playing sports growing up. The extra pounding causes the femoral heads to hypertrophy. Maybe the reason this kid has large femoral heads is because of the basketball he’s playing. Maybe he’s getting a surgery which will help him go back to an activity that caused his issue to begin with.

Actually, since he’s still growing, how do we know the rest of his hip isn’t going to grow to accommodate his femoral heads? When I was little I remember having a big gap in my front teeth. I was easily a candidate for braces. My dentist thought about things and concluded there was a good chance, once the rest of my teeth grew in, they’d push the front teeth together, thus closing the gap. So, after a while, my body would effectively do the job of braces. If not, then we could entertain braces. My teeth came in, pushed my gap together, and that was that. I have no doubt there are an inordinate amount of dentists who would have done the braces to begin with. Our bodies don’t grow in perfect proportion. Some things come in faster than others. Perhaps this 15 year old’s femoral heads have come in quicker than his acetabulum?

And why does nobody think of the psychological impact of doing this to a teenager? I was on crutches for two weeks in high school and I remember them vividly. You feel awful, lonely, and left out. Going around school on crutches is like wearing a Scarlet Letter. People constantly ask you what happened, want to play with your crutches, and generally act like the assholes that teenagers are. Lord knows how this goes over for a teen in a wheel chair. Because of this, you’re likely to rush your rehab. You simply don’t have the patience an older person has.

Oh, I should probably mention what I mean by chance the surgery “doesn’t go well.” By “doesn’t go well” I mean there is a 23 times greater chance he dies in surgery than makes the NBA. Not risk of infection, or surgical failure, or complications, strictly mortality. (Obviously, the chance of general error is greater than any one error alone.)

Sure, 0.007% chance of dying sounds small. 28,000 people dying doesn’t.

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