Revision THR Continuing thigh pain from failed osteointegration?<

[Jamie]

Sorry it took so long to get back to you! Here are some options for you for second opinions in the Houston, TX area:

Dr. Stefan Kreuzer
346-571-7500
Specializes in primary and hip revisions

Dr. Vasilios Matthews
713-581-8152
Specializes in primary and hip revisions

broken link removed: https://www.cuellarclinic.com/albert-d-cuellar-md.html
281-440-6960
Specializes in primary and hip revisions

broken link removed: https://www.jointreplacementassociates.com/terry-clyburn-md.html
713-363-7948
Specializes in primary and hip revisions

 

[TerryB_TX]

Thank you so much, @Jamie. I'm going to try to schedule them as quickly as possible. One of these, Dr. Kreuzer, was recommended to me independently by a local anesthesiologist who has had the opportunity to see many surgeons in practice. Really do appreciate your help!

 

[chalcedonian1]

@TerryB_TX Good luck with all your interviewing of revision surgeons, I think I wrote to you about this once before, these meetings/interviews will help you along mentally/emotionally in the process if you do need a revision. If you can, try to have someone come along with you to take notes for you (probably already said that too---sorry if so!). Like you, I didn't have much confidence in my ability to pick any surgeon the second time around and was extremely nervous about it. But for sure, I wanted to see surgeons who had nothing to do with my first surgeon.

To make it harder, none of the revision surgeons reared back in obvious horror when they saw my x-rays (that may be the brotherhood of surgeons kicking in), none had a demonstrable "aha" moment, none said "I know exactly what caused this". They did all tell me what they would do for a revision, but it took a bit of questioning to get a couple of them to opine on what they might have done differently, if anything, if they had been my first surgeon--that is how I got ANY information out of them, none would give an "official medical opinion" as to WHY, which I fully understand is basically impossible anyway just from xrays. So, to my disappointment, none said what the first surgeon "did wrong"--- probably as Josephine says, because we can't really know why this loosening happened.

Just persist politely in your questions. Honestly, I can tell you as one who just walked this walk, you will be able to sort this all out if you have to. You will get beyond the "why"-- I admit it took me a couple of months to figure out who, what and where, but I did finally, and I have put the "why"question in the back corner of my brain. I am just glad I took the time, did the research (Leave no stone unturned if you have the luxury of time here...)

I would guess you have seen my thread about NSAIDs (which started with Josephine's comment on your thread as to possible causes of loosening), so I am with you about not taking ibuprofen etc., after a revision (unless it is prescribed to purposely inhibit Heterotopic Ossification in the first place; but I don't seem to have that problem, just the opposite, so I doubt that is it---I will find out more tomorrow-- if I find out anything new or interesting will post on my thread). And BTW, none of the revision surgeons or my original surgeon asked me if I took NSAIDs in the first three months or so, interestingly, so I guess the literature is really quite conflicting and different surgeons place different importance on the results/potential conclusions. I did want to say that my internist put me on a regimen of Alleve for two months, maximum dose, with appropriate blood tests at the end--this was well into my second year of pain(s) without relief. The Alleve did help calm down some of my various leg pains, but it always came back in some manner; that was disappointing of course because it would have been a nice "cure" if it had worked permanently. I would swear things felt better, convince myself of it, and then, boom, for no apparent reason, my leg would get a sharp thigh pain when I stood up, got out of bed, or moved to the side, got into or out of my car, etc., etc. Those pains would subside after I started moving, but I never have been free of them when I go from a stationary position to one where I am moving.

In any event, I am glad you are sticking with this site, I hope you continue to get assistance and information here that helps in your search to find some answers, and always sorry to hear when someone else has some of the symptoms which indicate a loose component. Good luck and will follow your progress, too, after my surgery.

 

[Mojo333]

What do we do now and how can we maybe the best informed decision.
Its the only choice you have.
I will praying for you and for the best of all outcomes. (@chalcedonian1 must know I feel the same for her)

Sending all the good Mojo I can muster!

 

[TerryB_TX]

@chalcedonian1 , your posts continue to be so valuable to me. Through your thread I've seen you progress from where I am now. I know I'll reach the same destination that you have. But, my mind works much like yours, and so I'll need to travel your same path. I am just now at the point that I'm accepting that a second surgery is inevitable.

All I'm really looking for is some assurance that the second time will be different. I'm still trying to figure out what went wrong. I'm a typical engineer with a 40 year career of data-based planning, troubleshooting, and problem solving. However, I'm recognizing that when dealing with the complexities and mysteries of the human body, I will never have all the answers I look for. My daughter, who is a medical provider herself, reminds often that there are so many things we still don't know about how the body works.

I understand having a cemented stem is one way to improve the odds, so I'll have that discussion with the revision surgeons. I know you are moving forward with an un-cemented stem. I'd prefer the same for a number of reasons. For one, I've started reacting allergically over the last year to medical adhesives, antibiotics, and other meds to which I've never reacted before. It's as if my body has become hyper-sensitive. I'm just afraid of introducing any new foreign substance into my body.

While awaiting my appointments, I'm putting together my list of questions. I will definitely take your advice on approaching the revision surgeons in the way you suggested... "What, if anything, might you have done differently?" I may also try to bring my wife along on some of these interviews, but she gets a bit squeamish when the details of the procedure are discussed. And, like you I suspect, I need to get into the details.

I was taking Celebrex for much of the period following my surgery. I don't recall if I started within the critical first 3 or 4 months PO, but I certainly won't be taking any NSAIDS this time around.

I'll continue to follow your progress. I learn so much from your posts and the posts of all the contributors to your thread. I'm also thinking of you, praying for you, and looking forward to news of a successful outcome.

 

[TerryB_TX]

@Jamie - I've got appointments with three revision specialists set up between July 12 and July 17. I'll be seeing Drs. Kreuzer, Clyburn, and Goytia. Dr. Goytia is in Dr. Matthews' practice and does the revisions for the group. Dr. Matthews no longer does revisions except those for whom he's done the original surgery. I'll add Dr. Cuellar depending on how the first three go. I'll feed back to you how these interviews go.

I've stopped the ibuprofen as the prescribed 2-month course ran out. I tried going without any pain or anti-inflammatory meds just as a test. That lasted only a few days before the hip pain and psoas tendonitis came roaring back. I'm now taking 3,000 mg/day Tylenol plus the occasional tramadol (left over from a prescription for another issue). Thigh pain is more intense than ever, mainly when I get up in the morning or after sitting too long. I'm anxious to move forward more quickly because I'm worried that I may be doing damage walking about with a loose stem.

 

[Jaycey]

@TerryB_TX glad you have appointments coming up. Please update us when you can! Hope all goes well!

 

[TerryB_TX]

Thank you, @Jaycey. I'll continue to post with updates.

 

[Jamie]

Thanks. It's true that walking with a loose stem can result in increased remodeling of the bone, but you should be okay in this short period of time. Just try to stay off the hip as much as possible until you get some of those opinions. Thanks for volunteering to provide feedback. You guys are our BEST resources when it comes to surgeon referrals.

 

[TerryB_TX]

BoneSmarties... I'm putting together a list of questions to ask the revision specialists at my upcoming appointments. From you experiences, do you have any suggested additions?

Background

Posterior Left THR 5/1/2017 - now 14 ½ month PO
Slight scoliosis pre-existing
Minimal at home PT first month – glut/quad isometrics, heel slides, quad extensions, adductor/abductor while lying on back. At 1 Mo PO added some elliptical, bicycle, swimming​

Three types of continuing pain

Thigh pain when getting up out of bed or chair, lessens with walking – pain getting much worse, more persistent
Pain under glutes, increases with walking/leaning forward while seated, getting worse
Groin pain with hip flexion, getting in and out of car, putting on pants, shoes
Treated at 1 year post-op with ibuprofen 2,400 mg/day for 2½ month (now stopped), pain improved but returning​

Findings from THR OS follow-up, 1 year post-op

Fibrous fixation of femoral stem (loose stem?)
Psoas tendonitis, possible tendon impingement on cup​

Questions

What could have caused loose stem?​

Use of NSAIDS 200 mg twice a day prescribed following surgery, continued for most of 6 months
stem size, stem fit – OS mentioned height as possible contributing factor
exercise, too much too soon, none in first month other than PT​

Could loose stem be causing psoas tendonitis issues as well?
Any indication of cup not properly integrated?
Is cup aligned as you would expect? Alignment described by OS’s NP as balancing of impingement risk versus dislocation risk. Agree?​

How is revision different from original surgery?
How is stem removed, risk of femur damage? What happens if?
How is fibrous tissue removed?
Is complete removal required for new bone growth?
If so, does that imply a larger stem will be needed?
Should cup be realigned to eliminate impingement? Or is psoas tenotomy preferred approach?
What might you do differently in revision?

Cemented vs uncemented?

If uncemented, how is bone growth encouraged in revision?
If cemented, what are risks?​

Post revision

Pain management – avoid NSAIDS (inhibit bone growth?), what do you think of Tramadol/Tylenol combo?
PT, Exercise, restrictions
How often do I see you for follow-up after surgery​

When could/should revision be done? What are risks of waiting?
Where is revision surgery done?
How does hospital perform on infections?
What are infection management procedures?

@Josephine, Am I missing anything obvious? I recognize I may not get answers to all my questions, but I figured there was no harm in asking.

 

[Josephine]

Terry, I'm commenting on your post here

Questions

What could have caused loose stem? - since nobody knows, you'll not get an answer for this!
Use of NSAIDS 200 mg twice a day prescribed following surgery, continued for most of 6 months - I don't see the purpose of this question. It's too long ago to make any difference now
stem size, stem fit – OS mentioned height as possible contributing factor - good question!
exercise, too much too soon, none in first month other than PT - irrelevant!
Could loose stem be causing psoas tendonitis issues as well? - irrelevant!
Any indication of cup not properly integrated? - you'll never get an answer to this!
Is cup aligned as you would expect? Alignment described by OS’s NP as balancing of impingement risk versus dislocation risk. Agree? - that's a matter of opinion so he'll not answer that directly either!​

How is revision different from original surgery? - I'll be interested to hear what he says!
How is stem removed, risk of femur damage? What happens if? - if what?
How is fibrous tissue removed?- same as it is during the primary op, with reamers
Is complete removal required for new bone growth? - complete removal of what?
If so, does that imply a larger stem will be needed? - not necessarily
Should cup be realigned to eliminate impingement? Or is psoas tenotomy preferred approach? - realignment is dictated by your anatomy. There are no alternatives
What might you do differently in revision? - that's one of those "how long is a piece of string" questions and you can't possibly expect an answer from him!

Cemented vs uncemented?

If uncemented, how is bone growth encouraged in revision? - same is in the previous surgery. But generally, uncemented devices are not used in a revision
If cemented, what are risks? - less than with an uncemented, much less​

Post revision

Pain management – avoid NSAIDS (inhibit bone growth?), what do you think of Tramadol/Tylenol combo? - again, I doubt he'll give you an answer to this
PT, Exercise, restrictions - or this​

Hope this gives you some information.

 

[TerryB_TX]

Thank you @Josephine. You've given me some good advice to help focus my discussions. You see that I'm still searching for the answer to what went wrong. I guess I need to give up on that since, as you've reiterated, nobody knows why loose stems happen. I'm not trying to be stubborn, I'm just still hoping there's something obvious that can be easily corrected to give me hope for a better outcome the second time around. Maybe time to get over that dream.

Use of NSAIDS 200 mg twice a day prescribed following surgery, continued for most of 6 months - I don't see the purpose of this question. It's too long ago to make any difference now

Things I plan to do different the second time include the avoidance of NSAIDS that could be inhibiting bone growth (if they recommend uncemented), and perhaps not overdoing PT and exercises. That's why I'm trying to get a feel for the surgeon's views. I know and trust your views and I want to benchmark the revision surgeon's views against yours to help make my choice of surgeon.

Is complete removal required for new bone growth? - complete removal of what?

I was referring to complete removal of the fibrous scar tissue. If surgeon wants to do uncemented, I assume all scar tissue would have to be reamed out so as to expose fresh bone to allow bone growth on new stem. This implies to me that a new stem would have to be larger than original since the reamed opening would have to go into existing bone (I think).

You're stating that cemented is lower risk than uncemented in revision surgery. I see from forum comments that some have had uncemented revisions, especially in US. I'll go back and reread the article on this topic.

How is stem removed, risk of femur damage? What happens if? - if what?

Trying to understand what might be done if femur is damaged/fractured in process of stem removal. This is probably very low risk and not worth pursuing.

Could loose stem be causing psoas tendonitis issues as well? - irrelevant!
Any indication of cup not properly integrated? - you'll never get an answer to this!
Is cup aligned as you would expect? Alignment described by OS’s NP as balancing of impingement risk versus dislocation risk. Agree? - that's a matter of opinion so he'll not answer that directly either!

I'm still concerned about impingement (if that's what's causing my psoas tendonitis) persisting after the revision. I'd like to know if the surgeon can address both the loose stem and the psoas issues in the single revision surgery.

Thank you for your insights and guidance. As I said, I view your advice as the gold standard by which I will judge the advice and recommendations of the revision surgeons I am interviewing.

 

[Josephine]

If surgeon wants to do uncemented, I assume all scar tissue would have to be reamed out so as to expose fresh bone to allow bone growth on new stem.

Wether it's cemented or not is also irrelevant. Both have to have the same preparation in the bone.

This implies to me that a new stem would have to be larger than original since the reamed opening would have to go into existing bone

He will use whatever device he deems necessary at the time. They actually don't ream out that much bone.

Trying to understand what might be done if femur is damaged/fractured in process of stem removal. This is probably very low risk and not worth pursuing.

No it's not. And it's rather like asking a driver what he might do if he had a crash in his car when he hadn't even started the engine yet!

I'm still concerned about impingement (if that's what's causing my psoas tendonitis) I'd like to know if the surgeon can address both the loose stem and the psoas issues in the single revision surgery.

Also irrelevant because no surgeon would not bother to get this right. I mean, think about it. Wouldn't you agree?

I'm not trying to be argumentative, just trying to give you an idea of how your questions might resonate with a surgeon.

 

[chalcedonian1]

@TerryB_TX Your questions are all ones that I asked my choices of revision surgeons, pretty much to no avail. It was maddening but it helped me give up the quest to figure out why this happened--even though it was mostly because I did not want to repeat mistakes from the first time around! And I would ask those same questions again, even knowing they will not say much, because it is part of the process I think of preparing for the revision. Did they think there had been malpractice? Well, they absolutely do not opine on that, unless it is fairly egregious. I gave them the caveat that all bets are off once they open me up, what they find is what they find no matter what they tell me in our meeting, that only helped a little to cajole something out of them. I got a number of hypotheses finally from them, and only when I asked the question that @Josephine says you will not get an answer to (her 'how long is a piece of string' comment). I believe they will talk about what they would do differently, all three at least did with me.

None of them said they were sure the cup was loose, one surgeon guessed it was, but yes, it was indeed loose. I guess people read x-rays differently. @Josephine felt the cup was loose from mine as well as the stem, and she was right.

I also found that all 3 revision surgeons I interviewed said they would likely NOT do a cemented hip as "I am too young", but would see how things looked when they opened me up. That was a surprise given what the BS forum reports happens on revisions outside the US, or at least, the NE part of the US. I pushed back but they held their ground. I do however now have three screws in my hip. Interested to hear what they say with you as you are younger than I am.

RE: NSAIDS--I will also be surprised if any of the revision surgeons align with this philosophy against NSAIDs (at least if just for a couple of weeks after surgery) as this has not been proven scientifically. In my case, the revision surgeon gave me a two week dose of Celebrex for inflammation and to also inhibit bone growth in the wrong areas. I told him I would prefer Tylenol, and he didn't push back too hard, but I could tell he didn't place much stock in the literature out there that is against NSAIDS, most especially as he only puts his patients on it for 2 weeks.

@Josephine reassured me the surgeon I chose would look at the entire implant, not just the obvious loose stem and see how/if a new part would line up with existing ones. My surgeon told me he was going with a completely different manufacturer for the stem, and he would see if he then had to replace the cup--which he did, as he pulled it right out, scar tissue and all. There are computers used also which help with all the measuring and sizing of the new implant too. I believed I would come out with a whole new prosthesis unless the ball/cup was snug and fitting properly, which I felt was NOT the case given the pain I was in.

My only advice would be to prioritize questions because these meetings go by very quickly, and it would be good not to focus on less important issues (like how do they pull out the stem--if you look at my thread, @Josephine answered that question for me too--it is quite an instrument!). Also I was scared that the revision surgeon would wind up breaking my femur when he pulled the stem out, but he said sometimes it actually helps to do that, and I left it at that--I was fearful and very skeptical about the whole process, as you can see from my thread. I am now guardedly optimistic, can't know for sure for awhile if this one will work, healing has to take place first, but so far, so good and it does not feel like the first one as I have also reported.

 

[TerryB_TX]

I'm not trying to be argumentative, just trying to give you an idea of how your questions might resonate with a surgeon.

Not at all! This exchange is helpful. You're helping me focus on what's important in the limited time available.

 

[Layla]

Prayers going up Words are hard to come by. I read your thread and feel overwhelmed. I can only imagine how you must feel.
I'm sorry you have to experience this. So very sorry....
@TerryB_TX

 

[TerryB_TX]

That you for the comments, @chalcedonian1

My only advice would be to prioritize questions because these meetings go by very quickly, and it would be good not to focus on less important issues

Excellent advice. The issue of cemented versus uncemented seems like one of the important issues. Clearly no universal consensus on this. Same lack of consensus on NSAIDS, but no doubt less important.

From your and @Josephine's comments, I now have a better understanding that the revision surgery is a mission of discovery. The job of the surgeon is to consider all the symptoms, evaluate the entire prosthetic, and fix whatever he concludes needs fixing. Nobody is going to tell me ahead of time what's wrong based on x-rays alone. To that end, I'll mention the psoas tendonitis/impingement, just so they know it's still an ongoing problem and to be on the lookout for contributing factors.

@chalcedonian1, your contributions are especially appreciated because I know you are still in the very early stages of your own recovery. I wish you well and look forward to updates on your progress as you are able.

 

[TerryB_TX]

Thank you for your kind words and prayers @Layla . I think I had to whine just a little bit to get it out of my system. Now I'm embarrassed by my whining as I've read through the threads of others who have endured so much more with such courage, grace, and perseverance. They give me inspiration and hope. I've seen how you have supported them all along the way. You're a kind and caring person, grateful to have you on this forum.

#heterotopicossification

 

[Layla]

You are very kind. Thank you.

I don't view you expressing your concerns as whining and I'll guarantee others don't either. You've come to a safe place where you can seek advice / opinions, learn and vent. We'll support you through it all. It's heartbreaking to think of all that's going through your mind. The why's, how's and what if's. It's not what you signed up for. It feels unfair. I hate it for you.

Please feel comfortable to share no matter what. We'll uplift you with prayer and kind words of support and encouragement as you journey through revision and recovery. We'll be your loudest cheerleaders as you victoriously cross that finish line. And you will...

Wishing you the best as you begin your appts on Thursday and continue them next week.
Prayers for discernment as you seek answers and resolution. We're here, we care.
@TerryB_TX

 

[Josephine]

-I will also be surprised if any of the revision surgeons align with this philosophy against NSAIDs (at least if just for a couple of weeks after surgery) as this has not been proven scientifically.

Actually it has. There are many scientific articles on heterotopic ossification (overgrowth of bone) where the treatment is use of NSAIDs because it is the only med that will effectively reduce the bone growth.

You can read in this article this comment Heterotopic ossification prophylaxis – an updated review

A serious problem with the use of high-dose indomethacin and other NSAIDS for HO prophylaxis is that while new heterotopic bone may be prevented from forming, the formation of bone for healing the fracture site may also be impaired.

There is also this article Heterotopic ossification