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[THR] broken drill bit and infection 25 years later

Discussion in 'Hip Replacement Recovery Area' started by lulu57, Aug 31, 2012.

  1. lulu57

    lulu57 New Member

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    hi. I had an oestoid oesteoma removed from neck of femur 25 years ago. i fractured femur post op and a pin and plate were put in, as well as a broken drill bit. a year later hardware was removed except for drill bit. 25 yrs on, pain has returned with activity and site is painful to touch. On xray theres a black shadow round drill bit and raised thicker bone. im having scan for possible infection. anyone heard of this and whether its wise to remove bit to treat infection? or any other info. i realise its not hip replacement but having hard time finding any info.
     
  2. Poppet

    Poppet Honourary Moderator

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    Hi Lulu,

    Welcome to our BoneSmart family, I am sorry to read of your issue, especially after all these years..

    I am going to tag Jo to come and have a chat. Jo is our very own resident Orthopaedic nurse of 50+ years and very experienced and knowledgeable.. I could ask lots of questions, but I know that Jo will zero straight in on the important questions and answers for you, once again welcome :)

    Josephine;
     
  3. Josephine

    Josephine Forum Admin and Mother Hen Administrator

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    That's a most unfortunate situation for you. Would you happen to have any xrays you can post for me to see? It would give me a better idea of the situation and what this black shadow is.
     
  4. lulu57

    lulu57 New Member

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    hi thanks so much for taking the time. hope these work... Josephine;
     

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  5. Josephine

    Josephine Forum Admin and Mother Hen Administrator

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    Thanks - excellent pics. I'd say there is nothing untoward there except for a bit of metal reaction. There are two aspects to this. One is that drills aren't made of as pure and inert metals as implants so it's quite likely that ultimately, a piece of a drill bit will cause a reaction. On the other hand, it's amazing how the human body does tolerate all sorts of foreign bodies like bullets, pellets and other bits and pieces! That this has co-existed with your body all this time is a testament to your body's good health!

    So what is the dark shadow and bump? Most likely a condition called osteolysis which is where the bone dies back from the foreign body and the bump is your body's compensatory reaction. to understand how that happens you need to understand how bone grows. Bone grows from within out and is in a constant state of development. Internally there are special bone cells called osteoblasts which produce new bone cells like queen bees. At the same time the opposite cells on the outside, osteoclasts, are consuming the old bone cells as they work their way to the outside of the bone. It's called 'remodelling'. I think what's happening is that the presence of the drill bit fragment has interrupted the flow of the bone growth and this osteolysis has occurred. In a reaction, the remodelling has been interrupted and so the bump has developed.

    Such ossifications can be painful and cause tenderness in the adjacent tissues. The treatment would be to remove the foreign body, excavate the cavity is has created and possibly put in some bone graft to help it close up. I think they should have removed the bit when they took out the pin and plate but we weren't that careful about such things back then. But I don't see any evidence of infection there.

    Of course, I could be totally wrong about this but I have seen one or two such cases in the dim and distant past! :wink:
     
  6. lulu57

    lulu57 New Member

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    thanks so much for your timely reply. its reassuring on one level but i would do anything to avoid surgery on my leg again. I was blessed up til now it seems.
     
  7. Josephine

    Josephine Forum Admin and Mother Hen Administrator

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    I doubt it would be a major operation. Smallish incision to have a look around, excavate the cavity and the drill fragment and scoop in some bone graft, close up - about 30-40 minutes tops!
     
  8. lulu57

    lulu57 New Member

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    laughing!
     
  9. Josephine

    Josephine Forum Admin and Mother Hen Administrator

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    Encouragingly I hope!
     
  10. lulu57

    lulu57 New Member

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    An update. I had a bone scan. There was some uptake in the area suggesting foreign body reaction. X-rays one year apart reveal little change round drill bit. Ortho believes its likely source of pain, but is not 100%. he believes surgery would be difficult and risky because they'd have to come in from the furthest side and remove a section of bone with risk of fracture during surgery or after, as well as usual surgical risks. Then crutches for two months. He's a man of few words as they all seem to be. I was left with no sense of his advice. He suggested pain might just go away or I put up with it.

    The complicating factor at mo is that I've been out of action for last five months due to broken hand and ligament injuries after bike fall (hence stilted typing...woe is me). So leg pain has not been such an issue unless I walk fast. And it will be some months before I hit the tennis court again... I'm no athlete but not ready to be put out to pasture.

    But I am afraid of the risk, sounds too like a rerun of the osteoma removal.

    Still looking for anyone with any experience of such a thing?
     
  11. lulu57

    lulu57 New Member

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    Also want to underline that he's not fully sure this drill bit is cause, never having come across this before.
     
  12. Jamie

    Jamie Administrator

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    Lulu....have you sought other opinions on your situation? It would seem that might be a good idea. I would suggest a larger hosptial in a major city or a university town. You would want to talk with someone who had dealt with a similar situation on numerous occasions.
     
  13. lulu57

    lulu57 New Member

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    Hi Jamie. It was the head of orthopaedics in a private Dublin hospital. I paid out of frustration with slowness of public system. I am waiting three months for appt at St Vincents university hospital. so yes, if I can get into system there should be more opinions available. I'm going back to GP too, hoping ortho is more articulate in his report writing. Mostly I got the feeling he put my problem in the difficult box and didn't want to engage for fear of failure...
     
  14. Josephine

    Josephine Forum Admin and Mother Hen Administrator

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    And I think he'd be quite right. There is a saying "If it ain't broke, don't fix it" so if he's not convinced the drill bit is responsible for the pain, he's dead right not to want to interfere with it. You wouldn't thank him for a broken leg and weeks of recovery in a cast.

    However, in my time I have scrubbed for more than a couple of broken drill/screw removals and they are not easy. But nowadays we have a special crown drill set developed especially for this situation. Only trouble is that hospitals don't usually have it in stock until they've had a case that needs it! And with the modern AO system of drills and screws, they just don't snap off like they used to 25 odd years ago. So it is very likely he's never come up against this before. These surgeries are far from straight forward, let me tell you. So failing in irrefutable evidence that it's the cause of the pain, I most certainly would leave it well alone...
     
  15. Poppet

    Poppet Honourary Moderator

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    Mmmmm! I agree with Jo, if they are not sure that the drill bit is causing the problem, I would seek other opinions to ensure I had a broad range of experienced surgeons examining your situation.

    Good luck, I hope you get some answers :)
     
  16. lulu57

    lulu57 New Member

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    thank you all for your support!
     
  17. lulu57

    lulu57 New Member

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    Hi all, here's an update in the hope of more information. I have been seen by a second surgeon in a public teaching hospital. He too was uncertain about all of it but has just done a procedure on me. He attempted an aspiration at the site but found nothing so no infection but he also injected a local anaesthetic into the area as a test to see if numbing the area deleted the pain hence demonstrating that it was the source. Well I have to tell you when he injected the area it caused the worst pain of my life. The surgeon was lucky he didn't get my knee in his face. He said at the time if this didn't get rid of the pain then there was nothing he could do for me surgically - he's nothing if not abrupt.

    More importantly afterwards, the pain along the length of my thigh was gone, though I still had shooting bone pain at the top of the femur and in the hip afterwards as well as a weakness in the leg 24hrs later. Walking was pain free. My question is - would one expect excruciating pain from the injection in and of itself or was it related to something going on in the area? I had no pain relief or sedative. I have to admit that the post op talk with the surgeon was not great because I was too upset. he had said he would try to recreate the pain I was feeling to then numb it so I was expecting pain but not to the extent i had. He was a bit short on kind words. And still reluctant to remove drillbit. I'll see him again in three weeks.

    Any notions would be gratefully read.
     
  18. lulu57

    lulu57 New Member

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    PS. Just found out that they injected a steroid at the same time.
     
  19. Josephine

    Josephine Forum Admin and Mother Hen Administrator

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    as they would, of course! Hello Lulu and good to hear from you. I have been wondering how things were progressing.

    The reason for the excruciating pain is easily explained: he injected an amount of fluid into an area where the tissues are sparse and tight. If it had been in or around your hip, then the tissues are large and easily expanded. In the knee they are not. I remember once having an injection in my wrist at the base of my thumb where the same restrictions apply - I passed out with the pain! I felt like it was draining my entire consciousness and then it did! So you have my sympathies. However, this has nothing to do with the result of the injection which was to demonstrate the cause of the pain and it seems it did not do this which is disconcerting for you.

    I am going to invite our knee surgeon, Orthodoc, to come and read this thread and see if he has any input to offer.
     
  20. Orthodoc

    Orthodoc Forum Advisor

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    Jo,

    Thanks for tagging me to check out Lulu's thread. Oh, and as you know, I am more of a general orthopaedist with a special interest in teaching knee replacement patients. I do still have a busy trauma practice, and I have seen many patients with drill bits or other retained hardware.

    Lulu, as you may know, it is not quite as common nowadays as it used to be, to have a retained drill. However, it is definitely not unheard of. When a drill bit or pin breaks within the the bone, the OS has to weigh the benefit of increased surgical dissection or disruption of bone versus the need to remove it.

    You have mentioned that you had a bone scan that indicated their was some uptake in the region of the drill bit. This was followed by an aspiration. Was the aspiration done under fluroscopic or CT guidance? Did he take you to the OR for the procedure? The x-rays (while not diagnostic and provide only a small field of view) seem to indicate that the drill bit is buried in the posterior femoral cortex. Again, while I can not be totally sure from those x-rays, the drill bit may be completely buried within the bone. That area of the bone is not particularly easy to access either percutaneously or even with a open procedure. I completely understand your other surgeons reticence to move forward with open surgical management.

    You wrote this previously... These comments reflect the reality of this type of surgery. However, I would not give up on trying to get out of pain. As long as you fully understand the potential risks of surgery, it is still not unreasonable to consider it.

    I wish you the best of luck.

    Orthodoc
     

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