"Distended Anterior Capsule", "Displaced Iliofemoral Ligament"

[jsblock11]

I'm just over a year post-op from hip resurfacing (BHR metal on metal implant), and had an issue with a bone spur that broke off and I'm preparing for an arthroscopic procedure to remove that loose body. In the pre-op MRI I had done, the report says that:

"Persistent effusion with synovitis/debris in the right hip joint, distending the anterior capsule and displacing the Iliofemoral ligament"

My surgeon has not given me a good description of what this actually means, and if it is a problem that can be fixed via surgical or non-surgical treatment. In my non-medical brain, I'm reading that the iliofemoral ligament is displaced, so I'd like to know how I can get in back in place

Hoping that maybe @Josephine or others that may have experienced this before can shed some light. I'm going to get a 2nd opinion as well.

 

[Jaycey]

@jsblock11 As you already guessed, Jo is best placed to comment on this diagnosis. She should be along soon since you already tagged her.

 

[Josephine]

This shows you what and where the i/f ligament is. As you can see, it's an extremely board, flat and strong ligament which, along with the pubofemoral ligament and the joint capsule, provides a strong barrier to prevent the joint from dislocating.

However, your scan report says there is "persistent effusion with synovitis/debris in the right hip joint, distending the anterior capsule and displacing the iliofemoral ligament". The key issue here is the bony fragment you referred to in your post. This could well cause irritation and inflammation which would result in the development of free fluid, known as an effusion. If this is excessive, it can make the joint swell which in turn, would cause the ligaments around the joint, and the joint capsule, to become extended and swollen. This happens in all joints that get an effusion. This is the 'displacement' that was referred to. Once the free fluid is released, the pressure on the ligaments and capsule will be released and that problem will be resolved, in part at least.

However, I am more concerned about the metal on metal hip you have. Has this been investigated for any MoM issues? I think this needs to be looked into before you undergo any other surgery. Here are some articles for you to study

Metal-on-Metal Hip Replacements: Solving The Uncertainties Dec 2011
Metal on Metal ion levels: safe upper limits for MoM hip resurfacings set by scientists
Metal-on-Metal issues and DePuy recall: regulation of joint prostheses in Australia
Metal on Metal warning (old but ongoing news) (thread in hip pre-op forum)
Metallosis: what is it?

 

[jsblock11]

Hi @Josephine , thanks for the reply! That makes sense and hopefully removing the fragment will help resolve that issue. Last fall, when my symptoms of stiffness/fullness/pressure (on top of the existing symptoms from the fragment breaking off) first started, I did an MRI and Chromium/Cobalt Serum tests, as well as blood tests for infection. Initially in those tests my results were in a "gray area" for my surgeon at 3.9 Chromium, 2.6 Cobalt, along with a fluid collection on my MRI measuring 4.1x1.2x5.8cm.

I decided to wait 4 months and re-test before deciding on either the scope to remove the fragment, or a revision to THR because of the possible adverse reaction to metal. The new test results show 3.8 Chromium, 1.9 Cobalt, and fluid collection size has reduced overall by about 50%. This, along with the stiffness/fullness/pressure symptoms improving and several confirmations by other surgeons that I have "perfect cup placement", has led me to believe that I should do the scope vs. the revision since my metal ions and fluid collection are still within safe limits and trending in a positive direction. The persistent pain I'm having is more of the same on and off, sharp catching/locking/popping/stabbing pain that started back last May when we think the bone spur broke off, and I'm hoping that the removing the relatively large fragment will alleviate this.

The only other thing we could think of to check for metal issues was possibly draining some fluid and testing for metallosis, but my surgeon did not think that was warranted since my symptoms and test results are trending positive. Any other insight appreciated!

 

[Josephine]

Sounds good to me!

 

[prairienut]

I am a total non-medical person and this is just me speculating but if if you ever needed your BHR revised to eliminate the metal bearing surfaces, could the "perfectly placed" acetabular component be left in place and just the liner be swapped for ceramic or highly cross-linked PE?

 

[jsblock11]

Hi @prairienut, unfortunately there is no liner option for the BHR cup so the method we were going to do if I did a THR revision was to use a dual mobility femoral component and leave the BHR cup in place, so a ceramic on poly inner bearing and poly on metal BHR cup outer bearing. The poly on metal bearing could be a concern, but the other option is to chip out the cup as well and do a full THR revision.

Fingers crossed that this last me 20 years or so and by then they'll have all this figured out that much better