Revision THR Looks like maybe a revision will be needed...

[Josephine]

How the surgeon will be able to remove the femoral implant without breaking/shattering/doing harm to the femur is actually quite frightening to me.

The companies have designed special beefy extractors for this. Large clamps that fit around the top of the stem and with a sliding hammer the surgeons can use to extract it! It usually succeeds and you won't know a thing about it!

The original surgeon said "there is nothing I did or did not do"

Hmmm ... well maybe, maybe not.

If the science is that one simply cannot prove why implants have failed (@Josephine posted several reasons to me as why they do fail

I doubt I ever said that. I more likely said that if things fail. Because it is an absolute fact that implants do not fail. The problem is more generally due to some error of surgical expertise.

 

[chalcedonian1]

@Josephine
Thank you for the information on the beefy extractors -- I am better for the info! And yes, I should not conflate "implants failing" with "implants loosening". Good correction.

I believe you said to me earlier on that implants loosen because of improper site preparation prior to implantation, which I think you are also saying here with "error of surgical expertise". I would have to go back to some of your other postings for the others (might have been infection and improper placement), but my memory could be wrong. My point generally is that doctors so far haven't offered possible reasons why the bone growth was not as fulsome as expected and then the femoral implant loosened (other than infection, which was ruled out). You are the only one in this medical field who has said improper site preparation and surgical error etc. are possible reasons. I am not asking for proof positive, just would like to hear some honest possibilities from surgeons on this prior implant work. The surgeon I chose originally had over 30 years of expertise, came highly recommended and told me at 4 months looking at my Xray that the implant looked perfect, "textbook". How did it all go wrong from there? Am I really asking for too much of them to posit, based on their expertise and what they have seen in their practices?

Re: the surgeon's comment about whether I could have done something or not to cause the implant to loosen, "Hmmm ... well maybe, maybe not." Could you please explain that comment? I am not sure I understand. Do you mean my body did not make enough bone to grow around the implant? or are you saying there are things one can do to avoid this problem??? Thank you!

 

[Josephine]

I am not asking for proof positive, just would like to hear some honest possibilities from surgeons on this prior implant work.

Well, surgeons tend not to think in minutiae which is what they would consider this. I doubt you'd find any surgeon who would 'fess up to it!

Do you mean my body did not make enough bone to grow around the implant?

Not exactly. Did you read this Cemented and uncemented hips? It clearly describes how the bone and the implant interact and bond.

or are you saying there are things one can do to avoid this problem???

Not so far as I know!

 

[chalcedonian1]

@Josephine Thank you for your response.
I said: The original surgeon said "there is nothing I did or did not do"
You replied: "Hmmm ... well maybe, maybe not. "
So what is the "maybe" here you are referring to? So what could I have done, or not have done, to have prevented a loose implant (as opposed to what the surgeon could have done or not done)????

Yes, I have read these articles, they are great and very informative. I just don't understand why any surgeon would think something like, say, improper surgical prep of the area is "minutiae"!!! And my implant looked great supposedly in the 4th month, and the surgeon stops seeing patients at that point.

I wrote:" or are you saying there are things one can do to avoid this problem???"
You wrote: "Not so far as I know!"

Sorry but i am just trying to square your comments quoted in my last message with this response in your last message. Sorry if I am being dense, but I am confused! Thank you!

 

[Josephine]

I just don't understand why any surgeon would think something like, say, improper surgical prep of the area is "minutiae"!!!

But it is to HIM ! It's just a part of the surgical procedure much the same as putting on the drapes or dislocating the joint. He wouldn't comment on any of those either.

As for the "Not so far as I know!" it means just that. If I don't know something I say so.

 

[chalcedonian1]

@Josephine I was finally able to read the Xrays and post them, I hope I have done this correctly. The first xray was about a month after the THR in 2015. The other x-rays are from a month ago, December 2017, and are consistent with all the symptoms of a loose femoral implant. I would be very appreciative if you could give me your observations when you have a moment. Thank you so much!

 

[chalcedonian1]

@zinnia I hope you are doing a little better each day! Thinking of you and I look forward to your regular posts, they are inspiring indeed.

@Josephine I met with Surgeon No. 3 on Wednesday (please see my x-rays above posted last week if you can). Being somewhat younger he seems to have a bit less experience than Surgeon #2 on paper, but he was the most informative one yet. He did his internship and residency with the most well-known hip surgeon in the Boston area (who no longer does revisions unfortunately), and is leaving his current hospital where he has been for about 10 years, to join this "famous" doctor's practice at the beginning of April. He does about 450+ operations a year and 40% of them last year were revisions. He answered every question I asked, he even was able to get past the "fraternity of surgeons" and gave me an on-the-spot opinion, with appropriate caveats, from looking at my x-rays.

While he acknowledged that hindsight is easy, he said he believes my implant is the wrong size, wrong fit; he thinks it is too small and therefore not matched up/fitted properly into/within my femur. Had he done the original surgery, he would have used a bigger and longer implant, and would do so for my revision. (He said he uses a different manufacturer, but I do not know if that is of any consequence, he uses the manufacturer he is most comfortable with and that is fine with me, I believe it will also be ceramic and titanium. He will look at the cup and acetablular components to make sure all is well there, and that the new femoral components fit with what is already existing--I am hoping that things match up well so that he doesn't have to pull out the other hardware).

He would not do a cemented implant for the revision (same for Drs. 1 &2), he believes that unless the patient is elderly, it is better to use uncemented with “non-virgin" bone (virgin bone meaning bone that has never been drilled out for a femoral implant).

So long as I schedule the revision surgery within the next few months, he thinks I should be OK re: risking future fracturing, but if I start to feel more intense pain, I should get an Xray right away to see if I need immediate surgery. So far, so good, I am in pain when I walk, some pain is way worse than at other times, but if I can do so, I need to get my life prepared for what lies ahead; to do that I can use the two months or so before surgery!

@Josephine I am also very curious about your opinion on my X-rays if you have the time to opine, thank you!

So far: Surgeon #2 is the most experienced and the surgery would be at Mass General Hospital--he is mentioned by name on Bonesmart a number of times in various older postings and the Bonesmart members who posted about him seemed to like him, but they stopped posting after their surgeries unfortunately. I intend to see this surgeon one more time, and hope that my second visit is better and more informative than my first visit with him; Surgeon #3 appears to be a bit less experienced but more forthcoming with information. He trained at Mass General Hospital with the most renowned surgeon in Boston (who left Mass General to go to a smaller local hospital), and Surgeon #4, whom I see next week, is with the New England Baptist Hospital, an orthopedic hospital which surprisingly does not do as many revision surgeries as one might think.

Thanks everyone again for all their support as I continue fact finding and research. I need a mind set where I have hope that a surgeon can turn this around for me, where the "mystery" of why my implant loosened is discussed and addressed as best as possible, and that there can be a more painless existence to look forward to, eventually! Before I met Surgeon #3, I felt the first 2 surgeons were unwilling to posit what might have gone wrong, and in the meantime, @Josephine is saying on this site that there are indeed reasons in many cases for aseptic loosening, not all are mysteries. This is important because if it truly is a "mystery" as to why my bone did not implant fulsomely into the femoral stem the first time around, how can I be sure there is even a possibility of success in the future with my revision? All surgery comes with risk of course. I am willing to assume that risk so long as I know I have done all I can to (i) find the best surgeon to do this work, and (ii) have the revision implant fit better, if indeed that is the original problem here.

 

[Layla]

Hi @chalcedonian1
My heart goes out to you as you're living something many of us fear.
Thankfully there are many wonderful stories here of successful revisions.
I'm hoping that those stories in addition to the support and encouragement you
receive here will help you along your journey.
Prayers for your comfort and peace of mind as you move forward!

 

[Josephine]

Even as your image was loading, I found myself going "Oooh! What a good example of a loose stem!"

This is important because if it truly is a "mystery" as to why my bone did not implant fulsomely into the femoral stem the first time around

Your stem did not bond with the bone for the very reasons this surgeon cited

he believes my implant is the wrong size, wrong fit; he thinks it is too small and therefore not fitted properly into my femur.

I agree with him 100%. You can see in the xrays the big wide gap around the stem. It's huge! And in the right hand image,the stem is not even aligned correctly along the shaft of the femur. What a mess! (I think the cup is loose too, btw!)

 

[chalcedonian1]

@Josephine Thank you for your rather amazing response. Amazing because neither my original surgeon nor the first revision surgeon said anything close to what you wrote, they simply said my femoral implant was loose and this was said with no indication about how large the gap is.

What do you see in the cup that makes you think it is loose? What are the physical symptoms of a loose cup, how would a loose cup feel to me ?? Not one of the revision surgeons has said anything about the cup looking loose!

Surgeon #3 did not specifically state that he thinks the cup is loose, but he did say when he goes in he checks out all hardware. He then gave me an example of a patient who tested negative for infection, he said he had a bad feeling about the cup, the femoral implant was clearly loose, he started the surgery, and checked out the cup, sure enough there was an infection hiding out there (he stated that simply because a needle aspiration comes from one part of the hip and tests negatively doesn't mean 100% there can't be an infection somewhere else, and I guess this patient may have had some other symptoms). I don't want to read into what he said as an implication about my cup in particular, I think he was saying this in the context of me asking a lot of questions.

(BTW, don't want to be confusing: the x-ray on the left in your last post was taken just a few weeks after the surgery in April 2015, the x-ray on the right is current (December 2017), and I posted a third x-ray "Screen Shot 2018-01-30 at 10.22.31 PM.png File size: 785.2 KB" which is also current (December 2017).)

I guess I would not expect the original surgeon to be as forthcoming as you are, for obvious reasons. I understand the medical profession delivers bad news rather matter-of-factly, but if there is such a large gap, or a loose cup, you'd think revision surgeon #2 would not want to prolong my mental agony, and would state that the gap is large and the implant was not big enough (Surgeon #2 didn't say that, he just said he would use an implant with a longer stem).

At this point I certainly don't want to assume anything, so I will ask the revision surgeon next week if he thinks the cup is loose as well as the femoral implant, and how it would be addressed. Seems like I need a whole new implant, not just the stem. But I am rather shocked no one has mentioned the cup specifically, or the idea of all new hardware, is this common that they wouldn't specifically say that, it is assumed when they start the surgery they pull out what is a wrong fit, or loose and/or what will not fit properly with a bigger stem??

@Josephine You were right yet again about the fit issue which you had alluded to in earlier posts to me without seeing the X-rays, and now you have alerted me to another possible issue with the cup. Your comments have hit the nail on the head so many times on this site for so many people, you are indeed a national treasure. Thank you again for your time and thoughtful responses to my questions in this post, sorry to bother you with them!

 

[MammaT]

Glad you are actively pursuing this @chalcedonian1. We have to advocate for ourselves. I think it is possible that can’t tell everything from X-rays-they get the best view when they can physically see things, so maybe that is part of why they don’t bring up everything. Also, doctors may think they have explained everything because they communicate in their terms, but it doesn’t mean the same thing to us (doctor speak). That’s why it’s good to double check understanding with them.

I would be asking the same questions you are, especially since Josephine thinks the cup possibly looks loose.

 

[chalcedonian1]

@MammaT Thank you for your response. Yes, you are right, we have to advocate for ourselves. When I am seeing a revision surgeon, I expect them to give me their best professional opinion about what has happened to my implant and what they would do to rectify my problem(s). If they have a theory about why bone did not bond with the stem, I want to hear that too. If they don't have a theory but @Josephine and one surgeon can look at the X-rays and say 'yes, the implant is too small and that is why I think the bone did not bond', does that automatically imply that the "doctor's doctor" (Surgeon #2), for example, was not able to see what they see on the same set of x-rays? I am going back to him to find out -- I don't understand why surgeons would say so little when asked direct questions., especially doctors of good repute who are known for complex revisions! If he has a valid reason for his approach to patients like me, then I want to hear that too.

Only one surgeon has said this is a "wrong fit", the other two said only they would put in a longer stem, which implies of course the stem wasn't long enough but it does not to me imply that this was a too small implant in many, or perhaps all, regards (width, depth, length, shape etc). I believe I have asked plenty of questions so that they could have explained to me what they mean if they meant any or all of those things.

And no one has mentioned the cup AT ALL. I am waiting for @Josephine to explain to me what she sees that gives her the sense the cup may be loose.

I am determined that when I choose the revision surgeon (as I have now second guessed my choice the first time around) and go in for the revision, I will know as much to the best of my ability in order to anticipate what will happen, why certain decisions would be made, etc. Once I have done this, I will have greater mental strength than now. But overall, it would be more than maddening to me if surgeons I am seeing are using "doctor speak" to obfuscate what they really might be thinking, positing, and/or observing (and possibly protecting the original surgeon, for all I know).

 

[Josephine]

What do you see in the cup that makes you think it is loose?

This space between the cup and the bone

What are the physical symptoms of a loose cup, how would a loose cup feel to me ??

Pain much like bone-on-bone pain

Surgeon #3 did not specifically state that he thinks the cup is loose, but he did say when he goes in he checks out all hardware.

He'd be a mega fool not to!

I will ask the revision surgeon next week if he thinks the cup is loose as well as the femoral implant, and how it would be addressed.

Once an implant is loose there is only one solution and that is revision.

the x-ray on the left in your last post was taken just a few weeks after the surgery in April 2015, the x-ray on the right is current (December 2017)

Oh! Like this then? Did he change the 2015 cup?

I posted a third x-ray "Screen Shot 2018-01-30 at 10.22.31 PM.png File size: 785.2 KB" which is also current (December 2017

Sorry, I got them all muddled up! The other 2017 xray must have been a lateral (side view) and this one is the AP (anterior-posterior or from front to back). It has the same black line around the stem as the cup if you look.

the other two said only they would put in a longer stem, which implies of course the stem wasn't long enough but it does not to me imply that this was a too small implant in many

It hardly matters what the old stem was. If they are going to revise it, they will start from scratch and choose one that is much better for you.

 

[chalcedonian1]

@Josephine Thank you for your responses. I understand that I need a hip revision, and that I have no other choice.

What surprises is that the surgeons have focused on the stem, never the cup etc. when looking at the X-rays, showing me where it is loose around the stem, pointing out the halo in the bone around the stem, discussing that the stem needs to be removed and replaced. If it is too difficult to tell from x-rays only that the cup is loose I would have hoped the surgeons' would say that. Of course I understand that the ball has to fit into the cup, so if a bigger ball is needed, the cup would need to be replaced to accommodate. But the surgeons have been less than forthcoming in their oral explanations to me when I am sitting there with them right in front of the x-rays.

I only want to be a very informed patient! I am in the process of choosing a new surgeon, and if one is more informative than the others (which is so far the case), it is not a level playing field among surgeons I am interviewing. I don't want to assume anything in this process. It makes no sense to me that a surgeon wouldn't talk to me about the WHOLE implant if the whole implant is affected, or the cup, if the cup might be loose. You might tell me it is a natural part of a revision to change out every piece of hardware if the new implant is larger, but no one has actually said that to me.

The most experienced surgeon is mentioned favorably by people a few years ago who were going in for revisions on this forum, with their first implant having been done by my original surgeon ironically! Too bad they never came back to say how the revision implants worked. But this doctor did not give me a very thorough explanation, nor did I leave his office feeling like he had come down from his 20,000 mile attitude; I just didn't feel confident with him and he made several stupid attempts at humor that fell completely flat, thereby causing him to be non-responsive to my questions (e.g. "my hip implant was not put in upside down or backwards" -- and "no one comes in here looking for a lower leg differential". REALLY????)

So I am going to see him again as he is so well known for doing complex revisions and has been touted by other doctors at the hospital as the "doctor's doctor". Perhaps he had an off day or was preoccupied when he saw me. The other hip revision surgeons I am seeing are somewhat less experienced than him and are at smaller hospitals, but that does not mean they don't have enough experience to do a great job, and there are some advantages to smaller hospitals.

This has been a very hard period of time for me, I just want to choose the right person for the revision so I can be mentally prepared, and have faith and trust that there is a good chance I will feel better with the new revised implant! Apparently the original surgeon was not the right choice as he botched my surgery by using too small an implant and God knows what else didn't go right. It makes me crazy to think about.

You asked me if the 2015 cup has been changed? NO, the entire implant is original, from March 2015, I have had nothing replaced or changed out since then. It looks like you have the x-ray dates correct now. I think it is easy to tell actually because there is one where there is no bone re-modelling in the stem (that's the 2015 x-ray a few weeks after surgery), while the other two x-rays show white patches of bone at the base of the femoral stem (those are current, December 2017).

I do experience groin pain, it comes and goes depending on my position, if I am walking, sitting or laying down. I am doing a lot of reclining now when I can, where my leg is stretched out in front of me because the whole hip and thigh tend to hurt less that way. My hip just does has never felt right, it doesn't feel stable now, and my quality of life is severely restricted. I don't want to be so inactive, very bad for me mentally, not to mention physically.

So can I assume that even though you might have gotten the dates on the x-rays confused, you still think this implant is a mess because the stem is not aligned correctly along the shaft of the femur, it is the wrong fit and therefore that is the likely reason that the bone did not bond with the implant, and the cup is possibly loose? I know it being "a mess" is hardly a technical term that a surgeon would use, but honestly it would have made me feel better to hear something more from the first 2 surgeons: it would mean to me that there is hope for a better future with a better fitting implant into which hopefully my bone would grow. Instead, two surgeons have treated the lack of bone implantation as a doggone mystery, and only said the stem needed to be longer, with the first surgeon saying he would give me a femoral stem that he uses for people over 70-75 yrs of age.

Thank you again @Josephine for all your kind responses.

 

[Mojo333]

I can only imagine how frustrated and upset all this has been for you.
I can only say that I hate it for you and sincerely hope you are able to find some peace in having confidence in the surgeon you must ultimately choose.
Thinking of you....

 

[chalcedonian1]

@Mojo333 Thank you for your empathetic comments! I am determined that, if I am so lucky as to have the chance (e.g.,that in the next couple of months I don't get so bad I have to go in as an emergency patient), I will make as informed a choice as I possibly can. There is risk attendant with all surgery, I understand that, and I also understand that there are no guarantees in life. But I would like to do all I can do to fall within the good odds this time, instead of the bad ones, and this starts with the surgeon. Hence all my questions!

 

[Josephine]

What surprises is that the surgeons have focused on the stem, never the cup etc. when looking at the X-rays,

It surprises me too.

Of course I understand that the ball has to fit into the cup, so if a bigger ball is needed, the cup would need to be replaced

Actually that's not quite how it works. The choice of ball and liner is what you are talking about so if I'm wrong and the cup is not loose, and they want to use a larger ball, that's no problem. They can just change the polythene insert But the long and short of this is that they don't decide on treating a loose stem and ignore the cup. They check out the entire device, all four parts of it. If you think about it, they'd be rather daft not to.

it is not a level playing field among surgeons

You got that right, my dear!

he first surgeon saying he would give me a femoral stem that he uses for people over 70-75 yrs of age.

I've never heard of such a thing! That's like a car mechanic saying he'll use a set of brake pads specially for a 10 year old car!! In my experience, we had a certain range of implants available in the theatre and they were used for all patients aged 20-90!

 

[chalcedonian1]

@Josephine Great analogy with car brakes but that is exactly what the OS said if his office were to do a revision. I am not using this office in any event.

Thanks so much for the detailed explanation of the components. And yes of course a revision surgeon would be daft to not think about how all the components align, but that has not yet been a source of discussion, nor has the cup. You said once before that there are details surgeons don't think to talk about, perhaps these are just too obvious...

However, since my OS may have been deficient in his surgical technique, one can understand my desire to understand as much as possible, and actually get thorough medical opinions about what has happened, perhaps why it has happened, and how they would rectify it through bigger implants, etc., if possible.

Once I decide on who will do the revision, I will then step back and try to build up a sense of trust and confidence in them, something I am sorely lacking right now, which I am sure you can sense.

 

[Mojo333]

I would be exactly how you are, so prayers for you to have someone you feel confident in to get this thing done so you can truly heal!

 

[chalcedonian1]

@Mojo333 Thank you so much! I guess I can say I have confidence in one important factor: I will have some good revision surgeons to choose from, which is not always the case for others on this forum, so I am lucky in this regard. As I learn and understand more, I am adjusted to the fact I am going to have revision surgery, as living this way is simply not tenable. I do not particularly fear the pain and rehab of the surgery, I will just have to get through it as everyone else here has and as I did 3 years ago --- my biggest fear really is to go through it all again to just result in a similar outcome. However @Josephine with her thorough and direct explanations, and others going through this such as @zinnia, are giving me the hope and encouragement I need. I am very grateful for everyone who has responded here!