independent

Saturday 19 April 2014

Getting hip to beating pain

MARIE CROWE dons her scrubs to witness the surgery that is saving Irish sporting careers



12.30

Clare hurler Conor McGrath is lying on a hospital bed at Whitfield Clinic. He's dressed in his Cratloe GAA T-shirt and NUI Galway shorts. The 21-year-old is about to be prepped for hip surgery but he's feeling very calm.

He undergoes a few quick tests before it's time to go into theatre to see the anaesthetist. When he leaves, I talk to surgeon Patrick Carton about what lies ahead. He's a very confident, dedicated man who left a top job in the NHS in Northern Ireland to move to Waterford to focus on pioneering this type of hip surgery.

A Christmas card from the Kilkenny hurlers sits on his desk. The front of the card is decorated with pictures of the current All- Ireland-winning team. It's no surprise the doctor received a personalised card from the team – he's carried out successful hip operations on several of their most prominent players.

Mr Carton is a busy man, operating regularly on the hips of sports stars who are all striving to play at 100 per cent fitness. Just a few days before Christmas he has allowed me to sit in on one such operation. Conor McGrath, inter-county hurler with Clare and dual player with Cratloe. For the surgeon, it's operation number 259 for 2012.

According to Mr Carton, the hip is the underlying problem for many other injuries like groin, back and hamstring and it's only recently that many athletes are being properly diagnosed. Many of his patients will have had groin operations and been fine for six months because of rest but the pain returns when full-on exercise resumes.

Others will have been regularly attending physiotherapists or had frequent rest periods and yet their injuries have persisted. And some will have even quit sport altogether but the pain won't have gone away.

The condition is called 'impingement' and is caused by repetitive abnormal contact between the ball of the hip and the socket. As a result of this contact, the shape of the ball changes from round to flat and the damage is usually done when these athletes are in their early teens and engaging in high volumes of sport.

This is what happened with McGrath. When he was a teenager, he played hurling and football for the club and hurling for the county as well as both sports with his school. He was training or playing nearly every day of the week.

In his case the damage was obvious from the X-ray and the MRI scan: the ball of his hip joint was clearly flattened and there was visible bruising on the socket and the cartilage on the hip was torn. No wonder he wasn't feeling right.

This problem is most commonly associated with sports that involve a lot of twisting and turning such as hurling, football, rugby and soccer but can also be seen in runners, dancers, boxers, martial arts practitioners and many other sports people.

The condition is often hard to diagnose because the symptoms are vague. Most athletes who present themselves to Mr Carton will have complained of progressive stiffness and tightness around the hips and also some lower back pain. More often than not the stiffness occurs after exertion, and usually it takes a while for it to ease.

Pain may eventually develop in the groin and around the hip and also the hamstrings can get tight and clicking can occur. For McGrath, it was constant stiffness that raised the alarm bells. He never felt much pain during training or games but afterwards he knew something wasn't right. His movement felt restricted, even while walking, and it all seemed to stem from his hip.

Kilkenny hurler Richie Power's symptoms were a whole lot worse. He could barely pick up the ball or get in and out of the car. He was close to quitting the game before undergoing the operation. McGrath's team-mate Darach Honan suffered badly with his hips too as he went from being the key man for Clare in their under 21 All-Ireland victory to being sidelined for the seniors. But now, thanks to the operation, his career is back on track.

In fact, hip operations are getting so common that it's nearly a weekly occurrence to hear reports of high-profile sports stars having the procedure. In the last couple of months Karl Lacey, Alan Brogan and Eoghan O'Gara have all reportedly gone for surgery. As have Leinster rugby players Seán O'Brien, Dave Kearney and Rhys Ruddock. Many of these players, like McGrath, have barely entered their 20s.

But that's the nature of the condition. It affects mostly young athletes, males in particular, and worryingly it's a progressive condition that can lead to degenerative arthritis of the hips.

So when the 2012 season finished, McGrath decided to get his problem sorted. Clare had performed well in the championship and had big plans for 2013. McGrath wanted to be as fit as he could be for the new season. Every extra bit counts when you are playing at the top level and he wants that edge. The team physiotherapist screened him and sent him to Barrington's Hospital in Limerick for an MRI and from there he went to Whitfield Clinic in Waterford to Mr Carton for further examination and an operation was scheduled.

1.30

When we go into the operating theatre, McGrath is under anaesthetic. It's strange to see him lying on the traction bed, motionless with cotton wool on his eyes. It's impossible not to stare. He looks much bigger than his 5' 11" frame because the bed is positioned at chest level.

I'm directed to a spot just a few feet away from the bed and told not to touch anything blue as it's a sterile area. The surgeon gets to work and I move around cautiously.

Most of the time there are about six people in the room, two doctors and four nurses. The anaesthetist never leaves McGrath's side, watching him, watching his monitor and listening to the beep of the machine.

The rest get to work on McGrath. Firstly, his hip and leg need to be separated. The hip has to be pulled out because it's such a tight joint and space is needed to get the medical instruments into the right area. If the hip isn't pulled out, damage can be done to the surface of the hip while trying to push the instruments in. Although it's a gentle movement the machine makes a cranking noise when the joint is being carefully separated but thankfully Adele is playing in the background so it's possible to block it out.

All the internal work is done in a really small space but it's magnified on a screen above the bed. A tray of instruments that looks like a tool kit is situated beside the doctor. A knife, drill, needle, scissors along with a lot of other instruments I don't recognise are laid out on the tray. The nurse hands over what is needed.

There are two incisions made on McGrath's leg, one for the camera and one for the instruments. Water is pumped to the area to keep the blood out and the picture clear. Every move made by the hands of Mr Carton can be seen on the screen.

To get at the hip bone, the labrum, which is the cartilage around the socket of the hip joint, must be peeled back off the bone and then repaired. McGrath's earlier X-ray and MRI showed that this cartilage was torn. In the process of getting at the hip bone, the tear is repaired by Mr Carton.

He inserts an electric knife to peel the cartilage back and leaves it suspended until he has the work done to the bone. What makes the surgery in Whitfield unique to others around the world is that the cartilage isn't cut down completely. Mr Carton leaves the end of it intact which makes it easier to reattach. He is pioneering this method and is developing necessary instruments to become more efficient at it. There is no one teaching him these procedures, in fact he is teaching others his methods and Whitfield is now recognised as an international teaching centre.

When he gets to the socket it's obvious that work is needed. It's not smooth and curved as it should be. Instead it looks rough, flat and damaged. Dr Carton shaves back the edge of the socket, the bit that's been causing the damage.

He also smoothes the head of the hip before returning to the cartilage. This is the trickiest bit. He has to sew the cartilage back using a needle and thread but first he must drill a hole in the bone to insert a small anchor to allow for stable reattachment.

When all the internal work is done, the traction is released and the hip goes back into the joint. Finally McGrath's wounds are stitched and bandaged.

2.48

The operation lasted exactly one hour and 18 minutes. At this stage McGrath is still recovering from the anaesthetic and will be for the next little while. When he wakes he'll be given a rehab programme that will see him through the next three months.

There are different levels of rehab for patients who undergo this operation but because McGrath is a young, fit athlete he will be on the most intense programme. He'll be on the exercise bike in 24 hours and on crutches for a few days, possibly a week. Then, when the wounds are healed, he'll be in the pool daily.

In seven weeks he'll have progressed to light running and in 12 weeks he'll be back playing. In between, he'll be building himself back up, doing conditioning work in the gym. Last season a Waterford inter-county hurler played the Munster final ten weeks after the surgery but Mr Carton is cautious that the rehab isn't rushed.

ST stephen's day

When I visit McGrath at his home just five days after the operation, he is walking without the aid of crutches and is relatively pain-free. He has already started his rehab programme and, all going to plan, he'll be lining out for Clare again during the middle of the National League.

"At the end of the day it's only three months mostly in the off season, it's far from the end of the world," he says. "It could be much worse I think, I could have a knee injury that can't be fixed. Hopefully now I'll be back playing and fit soon. I felt a bit stiff when I woke but as the hours passed my leg became less stiff and by now I'm fine to kind of jog around the house. There's not much pain it's not too bad at all."

McGrath is an amateur player striving for perfection on the playing field. Time will tell if he's any closer to getting there but for now it's another job done.

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