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[REVISION THR] 8wks post op - more pain than before<<

Pumpkln

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AMR1879,
Sorry to hear of your continuing challenges, glad to hear you have two second opinions coming up. A fresh set of eyes will be able to give you an independent opinion.

I am going to tag @Josephine , to take a look at your x-ray.
 
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Mojo333

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@AMR1879 :hi:
I was glad to see you back on the forum, then very sick at heart as I read you still have no resolution for this ongoing hip saga.:sad:
I do so hope one of the doctors have some answers AND a solution.:beg:
Your precious little boy is no doubt getting big and it is so unfair to all of you that you are still searching for answers for mommy's new bad hip.
Hugs and good mojo for upcoming appointments:console2:.
 

GrannyC

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I, too, am glad to see you post but so disappointed you have not been able to find a solution for your pain. It doesn’t seem fair that you have had to endure so much. I’m encouraged though that you continue to search for answers. I just feel certain there is a doctor out there that will know what the problem is. You just need to keep looking until you find him/her. Sending healing thoughts and prayers your way... :praying::prayer::roseshwr:
 

Josephine

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Apparently the bulge that was pointed out to me in the xray, at the end of the stem is nothing to be concerned about.
Well I disagree. I think it's of major importance. In fact, I think I've discovered the cause of your problems. Your stem is loose!

Look at this version of your xray

AMR marked.jpeg


1. is the bulge you spoke of. If you look closely and carefully where I have put the dashed line, you can see that the bone is hollowed out in the inside of the bone where the tip of the stem has been knocking against it. It's called remodelling. A less common result of remodelling is that the bone has been encouraged to over develop from within out.

2. here is pointing out the great gaps between the implant and the bone which is part of the problem because your stem is toggling.

When a stem toggles, it is usually fixed loosely in the centre of the stem and the top and bottom toggles back and forth as the patient walks. The problem is that bone really doesn't like something hard knocking against it and it reacts in two ways
a) it causes the bone to die back from the upper part of the stem, enlarging the gap between the stem and the bone instead of filling up new bone as it should
b) it also causes the bone to wear away at the tip, a process known as remodelling. In your case, it has also caused the bone to overgrow externally resulting in the bulge.
toggling.JPG


I hope you can understand this. Please feel free to tag me if you have any questions.
 

Krista

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@AMR1879, this is very difficult news, and I am so sorry for you. You've already had a revision to replace a loose stem. And now that replaced stem is loose. You need the best possible orthopedic surgeon/revisionist to help you, and I hope one of those that you are seeing soon will fit the bill. Your poor femur has been battered up and down by the implant.
 

clodaghcov

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@AMR1879 Hi what a time you are having, I've not much experience in loose stems but I can add a few ideas about infections. When I had infections I felt so ill and was in so much pain and I'm sure you felt the same, it really is unforgiving pain.

Blood tests are a complete mystery. I am in the middle of this at the moment over the last 6 months my CRP has gone from 400 and gradually reduces but still a 14 and my ESR has been the same still at 21. I have a spacer in and am still on IV daily. I feel really well, but of course worried like you. But I don't think I have infection.

My GP is convinced I have an auto immune disease. I have seen a Rheumatologist and he is also nearly 100% sure of this. Soon all the results will be back so we will know. This could be the answer to the quirky results. He also commented how well I was and was interested in the vast amount of supplements I am taking!!

I so hope you have answers soon. It is so stressful waiting all the time. Hugsxxx
 
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AMR1879

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My GP is convinced i have auto immune, i have seen a Rheumatologist he is also nearly 100% sure of this, soon all the results will be back so we will know
Before they opened you back up, did they do a hip aspiration? Or When they went in to put the spacer in, did they do cultures and all that? And if so, did they grow anything? I am so sorry you are enduring the whole process of ridding your joint of infection, and even more so if you actually aren’t infected and have an autoimmune issue and didn’t have to have the spacer put in! Ugh.... I too am exploring the auto immune route.

I’m 99.9% certain I’m not dealing with an infection. All my aspirations and cultures came back clear. And now after reading Josephine’s post, I’m more certain is isn’t.

@Josephine I completely understand your post and I have been thinking about it all day long and I’m still trying to come to terms with it. I highly respect your opinion....you were right the first time around also. How can these doctors not see what you see??!! Thanks for taking the time to respond.

I have an appointment with an Ortho Surg at the Rothman Institue in Philadelphia at the end of the month. He hasn’t seen this xray because it was just taken Tues. But when he does, hopefully he will see what you see.

These last two days my thigh has been more painful than ever! I found wrapping it tightly with a bandage is helpful, I guess it’s acting like a splint? I’m hoping it’s the weather and it will stop being so finicky very soon! The pain I’ve been having for over a year hasn’t been this intense; it will happen out of the blue when I take a step and it feels like my femur is going to break and then it goes away and I can walk normally. So now I carry a crutch and keep it wrapped so I don’t have to crawl to a wall or chair for support (yup, that happened recently).

For those still keeping up, thank you for the kind words and support. They do help and are appreciated immensely this is turning into quite the ordeal! I’ll continue to keep you updated.
 

KarriB

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Let us know how the appointment goes and what the dr says at the end of the month.
 
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AMR1879

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@Josephine I’m not sure if you are comfortable giving your opinion, but I would love some reassurance that waiting until the end of the month to address this is okay. I'll be mindful of my activity level and wrap it for support when needed.
 

Josephine

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I’m not sure if you are comfortable giving your opinion
You're not sure? My dear girl, I give my opinion freely and frequently all over this forum - haven't you noticed? :heehee:

Yes it will be more than okay to wait. Some people find themselves waiting months before they get it seen to.
 
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AMR1879

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Latest Update.... I had 2 different appointments these last few weeks. The first was with a physiatrist who did EMG/nerve testing and the second was with the ortho surgeon in Philadelphia.

The EMG/nerve testing was one of the most unpleasant experiences I have ever had—and I’ve had a lot of diagnostics done! And of course, the tests came back normal, which I pretty much assumed it would. But now I can check it off my list of diagnostic tests to try.

The Dr in Philly said all signs are pointing to my stem being loose :( and because the thigh pain has only gotten worse over time, he doesn’t think it’s going to “get better with time.” @Josephine looks like you are going to be right again!

The procedure he would do involves removing a portion of the femur in order to neatly remove the current stem and place in a much lighter titanium stem. Then he would put the femur back together and secure it in place with some wire—kind of like making a custom fit.

Having the surgery would give me an 80% chance of being a normal, active, 39 yr old again! But I could also end up in more pain than before or developing an infection. Both are worth the risk, I simply cannot live like this

He suggested I hold off on the surgery for as long as possible because going back in and working on the hip for a fourth time in 2 years isn’t ideal. I have been using a crutch because the pain has been relentless these last two weeks. When I walk, it feels like someone is stabbing me in the thigh with a knife.

If I wrap my thigh with a bandage tightly around the area that hurts, it gives me some relief when I walk (without a crutch) but wrapping it doesn’t work all the time. I'm getting nervous because it feels like I have gotten so much worse over the last 3 weeks. I feel like I am in pain more than I’m not, and it is wearing me down. I just can’t imagine having another surgery anytime soon, not to mention I’d have it done down there which is at least a 4½hr trip. But I also can’t imagine living this way forever either.
 

Josephine

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The Dr in Philly said all signs are pointing to my stem being loose :( and because the thigh pain has only gotten worse over time, he doesn’t think it’s going to “get better with time.” @Josephine looks like you are going to be right again!
Well of course!
The procedure he would do involves removing a portion of the femur in order to neatly remove the current stem and place in a much lighter titanium stem. Then he would put the femur back together and secure it in place with some wire
This is the usual way to remove an uncemented stem.
1. they excise a block of bone from the side of the femur, just below the stem
2. the bone block is carefully preserved
3. then by inserting a rod upwards into the medullary cavity through this hole, they can use a mallet on the end of the rod to get the prosthetic stem out
4. then they will insert a new stem, one that goes down past the window in the bone
5. the bone block is placed back where it came from
6. Dahl Miles cables are placed around the femur and the bone block
7. the bone block will heal back into place.
8. the cables may or may not be removed in due time​

Dall Miles femoral cables.JPG
Dall-Miles cables.JPG


Hope this helps.
 

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@AMR1879, it's hard to believe that your previous orthopedic surgeons could have missed the loosening, but glad your new ortho sees what seems very obvious from the x-ray and your symptoms. Yes, it would be horrible to keep on without revision, with the stabbing pain you are having, and the damage that is being done to your bone by the toggling of the stem implant. If it were me, I wouldn't want to wait very long, because of the pain, disability and the damage. Do you know if this second revision would be cemented, or would they hope that uncemented might work, even though two attempts have already failed? At any rate, offering my sympathies for your unfortunate situation times two.
 

Mojo333

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Oh my stars...:sad:
I hate to hear you are having to go through this again, but am glad you have definitive answers to your pain.

Having the surgery would give me an 80% chance of being a normal, active, 39 yr old again! But I could also end up in more pain than before or developing an infection. Both are worth the risk, I simply cannot live like this
Having the surgery would give me an 80% chance of being a normal, active, 39 yr old again! But I could also end up in more pain than before or developing an infection. Both are worth the risk, I simply cannot live like this
You certainly cannot and with those odds...80% sounds pretty good too me.
I know how anxious the thought of surgery must be.
Please do try to eat well, get that immune system cranking and be ever so mindful of being on that leg.(sorry that sounds so lame, I know you are probably constantly think of it)
Seen many xrays of that femer wrapped up here and folks doing well...so I do hope you don't have a long wait.
Please know we care, friend.:console2:
 

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@AMR1879 I am sorry that you are going through this - again. But, at least this doctor has diagnosed the issue and you have a plan for treatment.

Unfortunately, it does not surprise me that other doctors missed the loosening on the x-ray. I think that some doctors only go by what is written on the radiology report. If the radiology report states that nothing is found, then that is what the doctor relays to the patient. Not all doctors actually look at the images. Sad, but true (as I've had that happen to me in this journey twice now).

Even though the surgeon said that your chance is 80% of getting back to normal, to me those are pretty good odds - especially with what you are currently working with.

Please do not worry about traveling for surgery. I have had family members do this. Even though it may not be ideal or what we want (as we are always more comfortable at home), if the treatment is better and what you need, then I would do it. Is there anyway you can get a direct flight from where you are to Philly?

But, in the end, it is your decision and you will know when the time is right to pursue another surgery.

I wish you all the best. You know we will all be here to support you. :angel:
 

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Hello AMR1879, I just found your thread and am amazed at what you have endured. Let's hope this most recent OS gets the right action plan in place for you.

I had a THR at age 59. Now almost 10 years later, I am informed I have a loose stem and perhaps also a loose acetabular cup. I am scheduled for revision surgery on Jan. 3 at HSS in NYC, a two-hour drive.

I have mild to moderate pain when putting full weight on the loose side but usually not severe. I am using a pair of crutches until the surgery to avoid pain as much as possible and am mostly comfortable. I do get short stabs of pain when moving in certain ways, and I have learned to avoid those moves. I started feeling increased pain off and on early this year, but about 5 weeks ago, the morning after a particularly strenuous day (5 mile hike on level ground then some extreme gardening in the PM), the pain increased greatly. I've been on a cane and then crutches since then.

My theory is that the loosening was starting even back in April and it finally gave way 5 weeks ago. The surgeon at HSS suspects that the prosthesis used in my THR was too small, and that put me at much higher risk of loosening. Also, I have a 1.5 cm LLD which he will correct during surgery. I read with interest all the tests you underwent to rule out infection. I've had most of those tests as part of my pre-surgical workup including the hip aspiration (ouch!), and fortunately there are no indicators of infection. I worried about a high RBC and WBC count in my synovial fluid, but I have been told by the OS that is normal for THR hips.

I wish you all the best in your pursuit of getting back to normal levels of activity. Surgery is a daunting prospect and always has to be considered carefully and with full knowledge of risks and benefits. It sounds like the Philly OS has a good handle on your case and has a reasonable plan. It is reassuring that he is experienced in the area of revisions for young people.

I feel as you do -- I do not want to live with a loose prosthesis and the pain that goes with it. Good luck to you. I'll be watching your thread.
 
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AMR1879

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I am scheduled for revision surgery on Jan. 3 at HSS in NYC, a two-hour drive.
I was thinking about you today @prairienut i hope your revision went well!! Who did you use as HSS? (if you don’t mind me asking). Sending healing vibes your way.
 
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AMR1879

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So, is anyone familiar with metal sensitivities or allergies? I have never been tested but, I will be getting tested this week. It may be the answer to why both prostheses never achieved complete ingrowth. It could mean that my body is having an inflammatory reaction to the prosthesis and not letting it fully heal. That would explain my elevated inflammatory markers, since we know with 97.5% certainty (thanks to the alpha defensin test) that it isn’t infected.

After hearing this I began to think about whether or not I have had reactions to metal, and I felt so dumb. I absolutely have, at least externally. I often had reactions to necklaces or bracelets that were not pure gold, silver, or platinum. If I wore them for extended amount of time, I’d often end up getting a rash in the area touched by the metal.

Then I remembered. back in 2009 I got a small (about the size of a quarter) red tattoo above my inner ankle. From day one, it itched like crazy. I’d say it probably itched for at least a year until I basically scratched the tattoo off. I know that sounds strange but I would basically scratch off the scab until it slowly stopped itching. However, you can hardly see the tattoo now and you definitely don’t see the red in it anymore—strange, right?

Anyhow, I am eager to get tested and I am planning on seeing an allergist and a rheumatologist to definitively rule out any other inflammatory diseases.

I can’t help but wonder why I have never been tested, especially after the first hip failed. If this is actually the cause of my two unsuccessful THRs, it gives me hope that I have a very good chance of returning back to “normal” or at least close to it, because we will know which materials my body will not react to. However, I’m trying not to get my hopes up. I have learned the hard way that even something that may seem like the cause of my problem, usually isn’t.

@Josephine do you have any thoughts on this?
 

Mojo333

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:hi:I do so hope you get answers...I'm so sorry you have struggled all this time...and for something you could not possibly know.
No insight here, just :fingersx: for my Bonesmart friend.
Prayers for answers:praying:
 

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