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Dr. Muneeb Ali
Dr. Muneeb Ali, Doctor
Category: Medical
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Experience:  MBBS, MD.Currently working in Critical Care Medicine with 6 year experience in internal medicine
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This question regards XXXXX XXXXX yo father. He had a stroke, then

Customer Question

This question regards XXXXX XXXXX yo father. He had a stroke, then carotid artery surgery. One month later he fell & fractured his right hip & left shoulder. He is left handed. Due to missed diagnosis, there was an 11 day delay between fracture & surgery. The surgery was clinically succesful, but my father developed contracture of his right leg & neuropathy. He had months of inpatient rehab, but never was able to functionally ambulate. He now has contracture of his right leg & lost the ability to use his lower body-he cant' walk. He is bed and wheelchair bound and on methadone for uncontrolled right leg pain.

My questions:
1) what caused his contracture and neuropathy if the total right hip replacement was successful?
2) is loss of the ability to ambulate a risk of total hip replacement?
I need some good advice and medical insight on why my father can no longer walk. I need to show that the fall caused his fractures-that's easy, but how do I explain the outcome of his inability to walk?
Submitted: 4 years ago.
Category: Medical
Expert:  Dr. Stan replied 4 years ago.
Hello,

Welcome to Just Answer: Sorry about you father.

His stroke caused brain nerve injury, but more importantly the fall with possible nerve injuries at the hip and shoulder, or due to the hip surgery, has caused significant impairment in his ability to walk.

There is generally a need for months of physical therapy after stroke in order to re-gain sufficient strength to walk without good support. It is also likely that the second fall was due to another stroke that could not be prevented by the carotid surgery or other medications he was taking at the time.

It is possible that the delay in his diagnosis contributed to his poor outcome, but can be an issue of contention. The contractures and neuropathy are the complication of severe nerve damage at the hip and shoulder, either during the fall or during total hip replacement (for the hip nerve injury only) surgery.

It was a pleasure to assist you.

Please, allow me get credit for my time and effort in assisting you and press the ACCEPT button for this assist. I will be glad to answer additional questions until you are satisfied. Thank you so much.

A Positive Feedback and/or Bonus is welcomed and appreciated.

Please note that this answer is for information only. It cannot be substituted for the visit to or the recommendation of your doctor.


Customer: replied 4 years ago.

Thank you for your time, and I do indeed intend to accept your answer. However, I wanted to clarify a few issues so that we can be less general.

 

My father had a stroke the month prior to his fall, but it was mild. He had carotid artery surgery, recovered well, and was able to walk on a walker with supervision. (This was due to a partial left hip replacement the year prior). His speech was affected a bit, but that was the most serious repercussion.

 

A month after the carotid artery surgery, he was in the ER for a skin rash. He was left unattended sitting on the edge of the gurney with no safety rails or equipment. He became itchy and fell off the gurney, which resulted in his right hip fracture and left shoulder fracture. He was discharged without diagnosing these injuries. 11 days later he was brought in because he hadn't been able to walk since this fall and was in increasing pain. He had total right hip replacement surgery and his left arm was put in a sling. The orthopedic surgeon showed that the implant was in place-nothing was wrong surgically.

 

My dad went to inpatient rehab following the hip surgery, but was unable to do much walking because he is left handed and his left arm was in a sling and his right hip had been replaced. He was in rehab for 8 weeks the first time and the most he could walk was 25 feet with supervision and assistance. Since then, he has not been able to walk at all.

His right leg is permanently contracted up; he cannot extend it. His doctor calls it neuropathic pain and avascular necrosis. He is on methadone twice a day for the pain.

 

Questions:

1) what is avascular necrosis and how does that relate to these facts? Is it caused by the 11 day delay in surgical intervention?

2) Could this 11 day delay be the cause of his inability to walk now? I've heard that a delay in time to reduction can impair chances of successful recovery.

3) How does a contracture and neuropathy develop after surgery?

4) in this case, is it foreseeable that a total right hip replacement could result in this sad outcome?

Please help me get a handle on these issues. Thank you.

Melissa

Expert:  Dr. Stan replied 4 years ago.
Hello,

I would not be able to discuss and speculate on all issues you have outlined, so I letting another available expert help you.

Thank you so much, and God bless.
Customer: replied 4 years ago.

Ok, how does that work?

Thank you.

I will leave you positive feedback.

Expert:  Dr. Muneeb Ali replied 4 years ago.
Hi,
As Dr.Stan has opted out ill help you here in answering all your questions,

First of all im sorry to hear about your father and i hope i will be able to help with my answers

1) what is avascular necrosis and how does that relate to these facts? Is it caused by the 11 day delay in surgical intervention?

Avascular necrosis is basically the death of the head of the thigh bone (femur) due to loss of blood supply to that area. this occurs because the head of the femur is highly vascular and needs constant blood supply to stay healthy. in case of frature of this area the blood supply is cut off and the bone starts to die. This condition is a surgical emergency in the sense that if timely intervention is nor made the head of the femur dies and leads to several problems later on. Now the delay in your fathers diagnosis definitely caused the bone to die, maybe if he had been doagnosed earlier then he could have avoided the total hip replacement and gone for some other modality but regardless at such an age the therapy most surgeons opt for is THR. but maybe the other complications could have been avoided.

2) Could this 11 day delay be the cause of his inability to walk now? I've heard that a delay in time to reduction can impair chances of successful recovery.

As i have already mentioned this can cause the delay in healing process specially at an age that your father is. This can cause delay in healing after surgery, increased rate of infections etc.

3) How does a contracture and neuropathy develop after surgery?

A contracture is basically hardening of the muscles which occurs due to fibrosis of the tendons and the muscle. the fibrous tissue is basically a type of tissue that is stronger and less elastic than other types of tissues and once this muscle forms then it is difficult to break down or in the region where it is formed that region is difficult to move. this occurs due to less movement or rather decreased activity of the area after a stroke or an injury for that matter. in your fathers case it proabably occured because he had a stroke previously and the THR combined with that stroke impaired his ability to properly uindergo physical therapy. The pain from the surgery plus the previous stroke both combined in such a way that he could not exercise his muscles, leading to the formation of contractures.

Now the neuropathy can have developed due to several regions, it could have occured due to damage to the nerve during surgery, sometimes during surgery the sciatic nerve can be nicked or damage and once it heals it leads to improper relay of signals which causes neuropathy. Another cause be the contracture itself which can have caused the nerve to become entrapped at some location in the leg leading to the development of the neuropathy.

4) in this case, is it foreseeable that a total right hip replacement could result in this sad outcome?

Well this is a very difficult question to answer, because your fathers case is not a simple case. now the stroke combined with the THr definitely has impaired his ability to ambulate properly but there was no way of knowing this before the surgery. unfortunately everything that could go wrong has gone wrong in your fathers case. there is always the risk of complications like this of occuring in a THR and they did in your fathers case. In THR contractures can form alongwith infections due to inability of the patient to undergo proper rehabilitation as was the case with your father.


Right now the best thing you can do is get a Nerve Conduction Study to determine the cause of the neuropathy and if its entrapement then this can be relieved by releasing the nerve from where it is entrapped. the second thing which can improve your fathers symptoms is that of physical therapy alongwith Devices known as continuous passive motion machines which are very popular, especially following surgery of joints. Continuous passive motion machines (CPM) are specifically adjusted to each individual's need. The joint is mechanically moved through the patient's tolerable motion. CPM machines have been proved to accelerate the return motion process, allowing patients more function in less time.

Another option is Casting or splinting which are techniques are used to provide a constant stretch to the soft tissues surrounding a joint. It is most effective when used to increase motion of a joint from prolonged immobilization. It is also popular for treating contractures resulting from an increase in muscle tone from nerve injury. After an initial holding cast is applied for seven to 10 days, a series of positional casts are applied at weekly intervals. Before the application of each new cast, the joint is moved as much as can be tolerated by the patient, and measured by a goniometer. When as much motion as possible is obtained after stretching, another final cast is applied to maintain the newly acquired motion.

Lastly surgery can be done to release the contracture as well.

i hope this answers all your questions

If I have been helpful,

BONUSES and POSITIVE FEEDBACK is always appreciated

Please feel free to ask me follow up questions, also note that this is NOT a substitute for a visit to the doctor.

Customer: replied 4 years ago.

Thank you so much for your thorough answer. I will accept and leave positive feed back. I do have one last question:

I guess what I am trying to get at, and you seem to have addressed this, is whether my dad's outcome is a foreseeable result of the fracture AND the surgery?

I know this is not a common outcome, but does it happen more frequently than I think it does? In other words, this is not a random, freak result.

It appears the THR went well-surgically, but the fact that his left shoulder was fractured at the same time (he's left handed) his right hip was fractured appeared to impair his rehabilitation since he could not weight bear on either side with any confidence. Also, would his right side weakness from his stroke contribute to poor rehab?

 

thanks so much for your time.

Expert:  Dr. Muneeb Ali replied 4 years ago.
Well to answer your question the development of contractures occurs frequently in those patients who have undergone THR who are unable to ambulate properly or have some underlying conditions which inable them to participate in the exercises properly.

So this also answers your second question, YES his stroke and left shoulder fracture contributed to his recovery in a poor way resulting in him developing fractures. Now whether this was forseeable or not is a hard question, If i was in the place of your physician, the only thing i would have ensured was that your father was put on an extra special physical therapy regimen with strict and frequent followups alongwith early interventions to prevent the development of contractures. If he was not able to participate properly in the exercises the physical therapist should or would have picked up on it and altered the physical therapy in such a way that this could be preveneted butthen again i wasnt there and cannot assess what exactly was the condition of your father at that time.

I hope this answers your question

If I have been helpful,

BONUSES and POSITIVE FEEDBACK is always appreciated

Please feel free to ask me follow up questions, also note that this is NOT a substitute for a visit to the doctor.

Dr. Muneeb Ali, Doctor
Category: Medical
Satisfied Customers: 1354
Experience: MBBS, MD.Currently working in Critical Care Medicine with 6 year experience in internal medicine
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MBBS, MD.Currently working in Critical Care Medicine with 6 year experience in internal medicine