Recovery of external rotator function after surgery

[Rn2md]

I understand that the external rotators are detached for access to the joint and then reattached afterwards, which affects their function.
Does anyone have any thoughts or personal experience with degree of recovery of external rotation after a posterior approach hip resurfacing?

[John C]

Here was my timeline with the external rotators. They were pretty non-functional for the first few days. Challenging to get then to function for the first six weeks. By six months they were working well, and allowing for sports like high level skiing which involve a lot of force and resistance for the rotators. I still saw improvement out to 18 months. I would say after that they settled in at about 95% of what they would be without ever having had surgery. That means that I almost never notice them during daily sports, but there are times when they remind me that something happened.

[jimbone]

Rnmd

Glad to see this topic posted as I am having some difficulty re establishing strength and ROM with these muscles.  I asked my surgeon at the 2&6 week check up about the muscles detached during the surgery- he indicated it was the periformis muscle that was detached and reconnected during closing.  I have struggled with clam shell exercises, side ways band walking, crossing my ankle over my knee and getting my sock on as well as tying my shoes/sneaker.  Additionally I have had a singular point of discomfort in the region of surgical detachment whenever that area is stretched, worked too hard or challenged to aggressively.  This all led me to think it is a periformis muscle problem, however, in speaking with my PT and having him do some functional testing ans well as hands on feedback/locating of the muscles firing during motion, he thinks it is the gluteus medius that is producing the discomfort, which makes some sense as that muscle is retracted out of the way during the surgery I had and could still be having difficulty reforming itself and learning to receive and respond to the neuropathway signals as well as general trauma.  I have seen a tremendous amount of improvement since surgery but there's still so far to go I can't tell if I am progressing adequately or how far I'll be able to get with this issue.   Frustrating but persevering anyway.  FWIW I am bilateral with surgeries on 7/16 & 9/18 and have been getting PT for both with the second PT course starting about 3 weeks after second surgery, so early Oct. this year.  Looking forward to further discussion and insight on this topic with forum members.  Also my surgery was done with a Direct Superior approach and carried 6 weeks of Posterior precautions.  I am getting better but too slowly for my preferences and that pace leaves me feeling anxious regarding eventual ultimate abilities.  Regardless- a world less OA pain and restriction for which I am eternally grateful just want to make the most out of this opportunity that I can.

[Rn2md]

John C-
Thanks very much for sharing your experience with this issue. It’s reassuring to know that 95% function can be achieved with bilateral. I also plan to use Dr Gross this March, for unilateral. So far I’m really impressed with everyone at his office. Speaking with him was also a pleasure.
Perhaps I could discuss your experiences by phone sometime too?

Jimbone-
So sorry to hear about those issues, but glad to hear that at least the pain is not a problem anymore. I was under the impression that the superior approach only detaches the Piriformis, which is then supposed to be reattached/repaired. I read that is felt by some to be the least disruptive of all the approaches, at least in theory. I read that Dr Pritchett uses that approach, but the others I read about all use the posterior approach.
I wonder if they all use the same basic technique for the repairs. It’s very difficult to know.

[jimbone]

Rn-

Yes Dr. Pritchett who did my surgeries does and did use the Direct Superior approach with me.  Not sure what you mean by "technique".  Surgical approach usually refers to location of incision but my understanding is that's because of the means/direction by which the surgeon accesses the hip joint capsule. Dr. Pritchett's website has a good description/diagrams of several surgical approaches I found informative and consoling to learn were aimed at minimizing tissue damage.  My recovery difficulties aren't anything outside of normal, even if it's really only been somewhat more challenging with the second procedure.  After all, that hip and leg had been my dominant one for several years, supporting and carrying the weaker left leg with more advanced OA.  Also, after the first hip was fixed, by about week 6 and feeling quite strong, the second hip began to deteriorate very quickly- it was in fact the only reason I still needed a cane and pain meds.  My thinking is it took the brunt of damage from aiding the worse leg and is having a more difficult/longer time recovering.  With that said I am seeing continuing and encouraging progress even in just this last week.  My adductors were impacted more strongly with the second hip and that seems to contribute to a weakness/balance in my rotator/glute which refers weakness and pain down the IT band.  it is a real challenge to stretch that glute/periformis.  I have taken to using a foam roller as well as a new stretch suggested by PT last week and have begun to see changes.  You're right, it is the periformis that is released and reattached, but the glutes are still in the way and get pulled/stretched pretty hard as well.  Depending on their restrictions going into surgery, the outcome after will vary.  The adductors seem to be letting go and stretching, the IT band relaxing and even the stubborn glute medius which provides me a very specific, sharp pain when stretched is now sort of drifting toward a more diffused, less sharp, duller ache when stretched and allowing a bit more stretch as well.  I never expected this recovery to be easy but I am truly fortunate that it is far from being the worse injury I've had to heal from or that others have had to get through.  Currently my goal is to be able to put my socks on and tie both my shoes by Jan. and do a challenging 5 mile trail with considerable elevation in a decent time  within 6 months.  By some of the supermen and women on here that makes me a complete slacker but we all need to run our own race.  From all I've read Dr. Gross is an exceptional surgeon with outstanding results and an army of satisfied patients.

[Rn2md]

The technique I was referring to was the one which a given surgeon uses to accomplish a repair of a detached or incised muscle/tendon. Of course the specific structures to be repaired may vary by surgical approach etc, but presumably a given surgeon will always do the required muscle and tendon repairs the same way.
For example, In his you tube videos, Dr. gross appears to utilize a small tunnel through bone to provide a new point of fixation for the detached external rotators.
Although I’ve seen other surgeons procedural videos as well, I haven’t been able to determine what specific repair technique they utilize. It could well be that there is a standard method and all use it.
My original thought was that if there were different techniques to accomplish muscle and tendon repair, then I wondered if it could be an important factor with respect to differences in rates and degrees of ultimate functional recovery. (Assuming Other important clinical, surgical, and hardware factors are equal of course)

Agreed, Dr. Pritchett website was very informative, and that’s in fact where I learned about the superior approach as it relates to the piriformis and other structures. I thought it characteristically spared the iliotibial band though.... He’s done some incredibly innovative work with the modifications on the Buechel Pappas cup to create an alternative bearing surface for hip resurfacing.

Well, despite the bumps in the road, the worst of it seems to be behind you. I wish you continued success in your recovery and in accomplishing your goals!👍💪

[blinky]

Two thoughts:

1) I am a same week bilat. Hip #1, the worse hip, came back more slowly but more completely than hip #2. I could do the front lift exercises pretty easily from day one, but the side lifts...no way. The ability returned over about six weeks, however, and by three months post op I could do them weighted. I noticed the changes and the unevenness in breaststroke swimming as well. When I first started running, I could tell the right hip external rotator was weak and had to take a step back and let it heal more before surging forward.

I still notice some unevenness. I ought to do some PT, like clamshells or even ab/adductor machine. (My overall recovery has been great, I run up to 13.1 miles and do all kinds of things,  but probably ought to commit myself to lifetime PT/PT awareness for best functioning. But hey, life gets in the way!)

2) Could you ask Dr P and Dr G these questions directly? Maybe add Dr Su? I know exactly what scene to which you are referring in Dr G's surgery video. Ask him about it. Ask him if he uses the same technique and how it is working. Ask Dr P the same thing.

Best of luck.

Dr Gross
bilat 11-15

[karlos.bell]

Hi yes my understanding it is done to preserve the Gluts which is more important.