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THR Metal, illiopsoas, or both?? My story

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Thaks for replying. We are a bit diffeernt for sure. I have not hat a ct scan. My injections were into the illiopsoas tendon sheath and they did help greatly, but not for very long. I have the oversized cup and when I raise my leg, you can hear the tendon snapping over it. I can't do a straight leg raise without pain right there. I could not do one after my scope (before replacement) either and I suspect that I developed tendonitis with that recovery (I recovered quickly and was extremely active on it). I personally think that the THR made that worse becuae of the oversized cup.. I don't want to get rid of something I have to have either and I am not looking for it to take away every bit of pain I have. But if it took care of the pain I feel when doing that straight leg lift, it would be worth it...becuae you use that motion in every step you take. I can't really swim because of it. I am not looking to get back to competetive sports, but I am looking to be able to walk long distances and do certain exercises without paying so dearly for it. I think that if I had a regular sized ball and cup, I would be out of the woods as far as that pain goes by now. I have done every kind of stretch, therapy for that thing known to man and it just will not come around. We are not going to revise the hip at this point because the metal ions are down and the hip is in good position...this is the lesser more noninvasive thing to do.

Let me ask you a few questions if I may....did you have yours done arthroscopically? How long after your replacement was it done? How was the recovery...ie..how long before you could walk with a normal gait, etc...?
 
Hi MarkC,

I see you have a DePuy Pinnacle like I do. I have an over-sized cup like you, which may be one of the factors causing impingement. I still think I'm impinging, and it looks like it on my CT scans, so I don't want to be discouraging. My initial results were great! To answer your questions:

1) I did not have the Psoas release done arthroscopically. I had way too much scar tissue from the THR for that. My Dr. also wanted to go in SLOWLY so he could look at other potential sources of pain. I also had my lat fem cut nerve entrapped in scar tissue, and the areas he cleaned up are much improved.

Note: My Dr. used the same incision as the Anterior THR to go in. I know he had a difficult time isolating and getting to the Psoas. I don't know if this is common.

2) My Psoas release was done about 16 months after the first surgery. After 3-4 months, it became clear my pain wasn't normal recovery. I did do very well the first few months of my THR, except for the numbness and pain from the nerve damage.

3) My recovery from the Psoas release was easy-peesy. I was pain free for about a month. They kept me in the hospital overnight, but I was feeling great by the next day, and ditched the cane within a week. I had some PT to strengthen the muscles compensating for the Psoas, and I can't tell the difference in strength except when I get in a car. I still grab my bad leg when I get in, but I'm still having pain too.

I was of the same mind set as you when I had it done: Do the non-invasive thing first. If you decide to go with a Psoas release, I'd caution you to let it heal before pushing too hard. I think that's one of the reasons mine wasn't more successful.

On the other hand, make sure other causes are ruled out, which is very hard to do early on. The damage caused by malpostioned implants, aseptic loosening, and other causes of pain are hard to pinpoint, because enough time hasn't passed to get good results from bone scans and other tests. I'm of the opinion that often radiologists don't take enough time to study scans, and our Dr's only look at the write up and not the films.

It may be helpful for you to go to my thread "Pain after 2 years" and look at my Pelvis CT scans. You can see where the mid muscle is missing (or loose in there somewhere). I'm not a Dr. so I don't know if the muscle changes are from the initial replacement or Psoas release.

To sum up: it worked great, for a little while. I believe I'm still impinging on the cup and that I have a neuroma or other source of pain that persists from the lat fem cut nerve. I think the prosthesis is loose and/or damaged too, but am having a hard time getting STRONG evidence this is the case. Hopefully, your case is much more simple.
 
that is a big help. We are doing mine arthroscopically. I will definately take it slow after it is done (learned my lesson about that). The Dr. doing it is an arthroscopic expert (that is all he does) and he is confident that it will be a huge help and that it will be an easy recovery. I do not know if it is all of my pain...as a matter of fact, I think it probably won't be, but if that particular pain eventually goes away, I'll take it. I was worried about losing all my strength in walking, but he said that would not happen. As it is now, I can't do the leg lift without pain anyway so not sure what the strength I have now is actually worth (ha ha ha). It has been 2 years since my replacement this June and although I could live with it the way it is and just not do much (and pay for it when I do) I figured that I would take a chance on beng able to swim down the road and actually lift that leg without the pain. I know there are no guarentees, but this seems like a gamble worth taking.
 
MarkC,

I don't think the surgery is that big of risk and it does help some people. I don't feel weaker from it, and it sounds like that's the important part. Since you have someone skilled at arthroscopic surgery, they'll disturb less tissue, so scarring won't be the problem for you I had. I wish I had surgeons with more training locally, but no one does arthroscopic hips.

So good luck to you and keep me posted on how you do.
 
thanks, well, it is a double edge sword. This fellow Chad Mather III has done a fellowship with one of the leading hip scopers and he is Dukes hip scoper now. He wants to get at my left hip in a bad way. That is a decision that I don't even want to think about..but he really believes that he can buy jme years by reshaping the femoral head. I have the 2mm space necessary to become a candidate...sooooo....I will think on that one for a while.

Many reconstruction Docs don't think a ton of these new scope proceedures for FAI so it is hard to know what to do about that.

I am glad that he is there and can do the tendon with the scope...should make it easier for me. I just hate that I had to put it off, but my thyroid is causing me major grief. I need to get that under control.

I will report back when I have had it done for sure. Thanks, Mark
 
Hi MarKC,

Now you are making me nervous. The guy that muked up my Anterior was from a S. Carolina fellowshiip (very good one), and his instructor was trained by Joel Matta - Anterior guru.

Even so, he lacked one important thing - EXPERIENCE!

I had a huge hard sell on being one of the first Anterior Hips at my local hospital. Needless to say, I wish I had the experienced guy with the Anterior Lateral approach do my hip. Don't be the first or earliest to have medical procedures and don't get a guy fresh out of his fellowship. He can set bones for awhile.

I think you'll be OK with the Psoas release - but I'd let Jo advise on all the other work he wants to do. I'm starting to be a believer in bigger incisions with larger areas of visualization. I had a colonectomy fail that was initially performed laproscopically, but when the ends came apart, I had open surgery anyway. That's another surgery horror story.

I haven't read all your thread, but do agree with some of what you've been told about not wasting time with scoping because you'll need a THR anyway. You are talking about your good hip? Mine has mild arthritis, but no pain. No one is getting near my good hip until I have major pain. And I'll wait for a THR from an experienced guy.

But you have a MoM replacement, correct? From everything I've read, the MoM will have to go, but I'm not sure how soon. It isn't just the DePuy ASR causing problems from what I've read. I am becoming a believer in what your Dr. quoted you:

"He said that based on his experience, when it is chronic like this, it rarely gets better."

I'm hearing the same thing. I have good days and bad days. We aren't the same as before surgery. Lot's of people do have good success with THRs, but I have a ton of arthritis in multiple areas, so "better than before" may be my good. It sounds like we both have hardware issues that will end up with revisions sooner or later, but our Dr's want to wait for later right now. Perhaps with good reason, as you are on the young side for hip replacements.

Other things I've done that help with pain are: Lidoderm patches - these seems to help with some of the local nerve pain; Gabapentin is probably my best drug, but I get kinda tired and stupid on it. Swimming is good when I hurt and don't feel like I can walk very far, and sometimes a nap when I need to escape. Anything that distracts me from focusing on the pain too. I started volunteering at a local senior center when I recovered enough to start doing things. Seniors are good teachers on coping with pain. Those of us who have progressive arthritis will need to learn ways to cope, because we aren't young anymore dammit, despite what our minds tell us, and those nasty osteolytes (?) will keep spreading! :tantrum2:
 
I don't know about the MoM dfeal. I think that just depends. If metal levels stay down, may stay in there forever....I know some people have them and have had them for a long time. I can only hope for the best there and take what comes.

The release is not a big deal for me now. I don't think it willhurt and can only help. The Dr. I was talking about was talking about chronic tendonitits with that illiopsoas and he said that once it really sets in after years, very difficult for it to resolve itself..and I figure that is especially true with that big cup rubbing over it. I want to be able to swim down the road and that is difficult to do without bad pain later. Other than that, my THR is pretty good. It is definately the leg I lean on most.

My left is hurting me and there is a window of time where you can attempt these scopes. I have read stories of success and also stories of going down hill after them. I have had one go downhill myself but it should have never been scoped according to the Dr.'s I have seen since and my left is much better off than the right one was. That is the hardest decision. To think that you could give yourself an extra 10 years on your own hip is very tempting. Dr. Mather feels very confident based on the amount of space I have (minimum 2mm). I do have some arthritis there and there are no guarentees but it mighj be a chance worth taking. You just can't know for sure. These reshaping scopes are so new (with the latest techniques) that the older reconstruction gurus aren't sure about them. I think you have to take in the condition of the hip, age, and everything else.

The worse case scenerio is that you have too much space for the reconstruction guys to do a THR but not enough to try the reshaping, so you just have to suffer as it goes down hill, however long that takes.

I have found a few folks who have done it and it did work for them. I have also found many that seemed to go down hill after they tried it....but none regretted giving it a shot. Seems like the success depends on the person being a good candidate (the youner the better) and that is the judgement of the surgion. I know that Dr. Mather absolutely believes that he will be able to give me many years on it once it is done and I have rehabbed, but he of course says the same thing we all know (nothing is guarenteed). All I do know is that the left one is really bothering me now. When I get the release done, he is going to give me an injection into the left one so hopefully that will help me out.

But a decision will have to be made....whose advice do you take, the experienced reconstruction Doc, or the younger Doc that has actually done the procedure hundreds of times??

I was honestly hoping he was going to tell me that it was too far gone (like my right one was before that hack scoped it). But it is not nearly as bad as the right one was when I had it scoped and that has put the choice back on me. uuuggghhh

I am very active now, illiptical 4-5 times a week, weights, walking, swimming (that can be troublesome). I am 42 years old and not wanting to live a sedentary life. I do not believe it is good for you at any age, but especially not as young as I am. I am not holding onto dreams of grandure mind you, not thinking I am the bionic man, but I I do believe that I should fight for every bit of activity I can keep. What to do, what to do???

@Josephine:
 
Mark, I've said this before but I will say it again as I just heard it all repeated at a conference two days ago! Low ions are not a reliable indicator of MoM problems. I'm not trying to scare you but you do need to get it checked out with an MRI scan to be sure.

Three of the surgeons who spoke on Monday showed cases who were asymptomatic and had low blood ions yet MARS MRI showed abnormalities around the hip which, when opened up, proved to be pseudotumours. They expressed considerable alarm about this and urged those present to re-evaluate their criteria for exploration/revision.

Mark, this is hot off the press information and something you should seriously consider. You just never know and it would be much better to rule it out now, just in case.
 
I had all that testing done months ago..MRI was unremarkable..very little fluid at all...had it aspirated and there were no problems with it. We went down that road all the way to the end. No sign of pseudotumors or anything wrong. There was some inflammation but there had to be,,it hurt. Once all this testing was done, that is what caused us to look at the iliopsoas. I'm not saying that there is nothing wrong, but two reconstruction / revision specialists are saying that there is no evidence of aversion to metal. That is what I have to go by. Niether of them would consider a revision based on what they saw. We took every step you can take.
 
by the way Jo, I would love to sent you my mri (the one they did after metal ions were up) and also my latest one of my left hip. I wish I could post the findings, but I can't figure out how to do it. Maybe I could attatch the attatchments. I have them on line and saved on my computer.
 
:DOH: Oh you said before - so sorry (I'm getting old!).
 
Hi MarkC,

The one thing I'm worried about with you, is that you are only 2 years out and having the same pains as I am, but also getting ambivalent test results. I've been told you shouldn't be in pain this long if the replacement was good. There is very good documentation that MoM implants release more and more of the toxic metals the longer you have it. I wouldn't want to take the chance.

Honestly, I don't know why your surgeon gave you a Pinnacle MoM 2 years ago, because the ASR was in recall and your type of implant was in question then. I remember my surgeon and I discussing what type of implant I'd have and he mentioned the MoM problem to me 6 months before your surgery. I've heard lots about unethical practices between DePuy and Orthopods

And Lawyers are taking DePuy Pinnacle MoM recipients in anticipation that it will be recalled. I had attorneys soliciting me until they found out I was a ceramic/poly. There's enough documented problems with the MoM version that it's felt it's just a matter of time before it's recalled like the ASR. Jo has more up-to-date info on the status of the implant.

But the Psoas release will do nothing if that's not the problem, and I sacrificed a muscle in vain. So, in my experience:

1) Surgeons don't like doing revisions soon after the first without strong concrete evidence that the implant has failed, and MRIs and CAT scans don't always catch problems. There are horror stories of the Dr's not finding any problems with the MoM until they open you up, and

2) There's not a great way to really find out if the Psoas is the problem. You get the series of injections, but they can calm down other types of inflammation besides impingement.

I know I told you the Psoas release was an easy recovery - and it was. But it also didn't work. I'm just worried about you and wonder if you need another opinion.
 
I have had two opinions from two different highly regarded revision specialists. Niether one of them did the original replacement. I don't know what to say but that there is just no evidence that anything is wrong. Could they be wrong? Maybe so, but I really have nowhere else to turn. If I end up getting it revised later down the road, then that is just the way it will be. They both told me that if the metal ions started to move up that we may have to get it out and change out the parts. But neither would do it now with the evidence we have. I have read every review of MOM you can imagine (trust me on that...been consumed by it for 1 1/2 years). And don't worry about the lawsuits.....should it be recalled..I will be covered lets just leave it at that. I have made arrangements. But, you can't make a Dr. take out a hip replacement based on what you think might be happening. Mine have followed the protocal to the letter and they do not believe that the device is failing. I can also say that neither is in bed with depuy...quite the opposite in Dr. Kelley's case...he never liked the metal on metal replacements and never used them. Dr. Attarian did and has had to revise many, so he knows what he is looking for.

The reason my original OS put it in is becuase he has put in a ton of them and has a huge success rate. He chose it for me to be the most durable because I was so active. He was aware of the ASR and it's failures. He told me that the pennacle was not the same and that he believed in it. They were using them like crazy at Duke too (probably still are). We must remember that there are thousands of people with this very device that are fine. But again, should mine take a turn for the worse, I am ahead of that game.

My hip is better than it has been in the two years to be honest...les pain all around but still painful with that leg lift against resistance. Seems like to me that if the hip stays, it will be a problem until the tendon either magically gets loose (which ain't happening) or it releases itself (which can happen I think).

I am taking a shot at it...but I don't think it is a shot in the dark I am doing what I think will work based on all the evidence and symptoms combined. I don't know what will happen 1, 3 or 10 years from now....but two years with this front leg lift groinn pain tells me that it is not going away on its on any time soon. I could be wrong..I will have to live with that.
 
by the way, how much has that release weakened your leg as far as wakling, swimming, and other things like that. That is what I am most worried about. When I swim now, it aggrivates that tendon and it affects the tightness of the entire hip (pain radiates a bit..not as bad as it once did, but I don't push it as hard either).

Also, I will tell you this, Dr. Attarian had told me that if we had to revise it, he could take care of the tendon at the same time...as he anticipated that it was at least causing much of my pain even if the metal was causing some. In the beginning I really think he believed it was a combination and was suprised that all the tests came back like they did.

My luck, I will get this done...then have to have it revised down the road...oh well...two surgeries when it could have been one...I hope not, but that would be my luck. I just don't want to wait around a few years for that decision to be made.

Now, tell me something good.
 
At the meeting on Monday, it was largely confirmed that the issue invariably isn't with the bearing (between the ball and the cup liner) but in the trunion/ball interface - that's the taper on the stem where the ball is fitted.
[Bonesmart.org] Metal, illiopsoas, or both?? My story

​

It seems that when there is a metal ball on the trunion, then corrosion effects can occur in minute quantities but enough to cause these problems.There is plenty of evidence to confirm that but none released yet, it's still being researched. Soon as I can get any info, I will make sure it's posted in the forum.

I know we are causing you worry and anxiety and I am truly sorry for that. But it would be so easy for us(me) to say if your surgeons have checked it all out and are happy then it's fine. I am just trying to pass on to you very recent findings on this topic and finding that will not yet have seeped through into the general populace of surgeons out there. It really is a worry, isn't it?
 
Hey Jo, when do you think this info will be released..will it be years or are you thinking sooner than that. If that is the case with me, I would imagine at some point, revision will be done. Oh well, at least they won't have to mind the iliopsoas....and Depuy will pay and pay dearly if that is the case...you can take that to the bank.
 
In truth, I have no idea when. Some of these things can take an age to emerge.

Fact is that there are an awful lot of devices that are throwing up these issues, not just the two mentioned. Hence the recent announcement by the UK-JRI that all MoM hips should no longer be used. I'm not at all sure that it's any company at fault as all hip devices are modular and have trunions upon which to fit a ball but only the MoM ones are causing these issues. Some early guesses are being offered but nothing conclusive as yet.

In the early days the modular hip came out, in the early 1990s, the technology to identify these issues just wasn't available and with most of these complications like pseudotumours, we just had no idea what was causing them until the sciences evolved that would enable us to. It's easy to point fingers but DePuy were as ignorant as any of us and fact is, the entire profession and allied scientific community were in ignorance. I know ignorance is no defence in the eyes of the law but when such developments are made in good faith, it seems such a shame when things go wrong that somebody must be held to account.

(By 'us' I mean the professions!)
(These comments don't include the issue regarding ASR cups as that is a totally different issue.)
 
I agree hole heartedly. I think that some things just happen as we progress. It's knowing that they are happening at a higher rate than advertized and keeping that quiet that is the problem...if indeed it is. that is where depuy made a mistake with the AsR..however, in fairness, the recall somewhat owned that and I am not sure what else they could have done. I think if a hip fails because of design flaw, the designer has to come up with something because there is work that must be done to rectify it (if it can be). I also know that medicine is as much of an art as it is science and sometimes it is just no ones fault..things just don't work the way they are supposed to.

I do wonder how many people in the US are still getting the MOM hips...I don't even know if my original replacement surgeon uses them now. I would love to find out. They totally make sense in theory and I completely understood why we were going with it. I do not believe that my surgeon knew all this would come about. No doubt in my mind he absolutely believed it would be a life time hip..Come on...maybe it will be.....maybe,,

I can only hope that in my case, it continues to work the way it can, and if it does not, that I can get something that does and not have to mortgave the house to do it.
 
The ASR had a design flaw that crept under the radar of the government agencies such as HMRA but it was a loophole in the regulations that said a device didn't have to be rigorously investigated or tested if it was 'similar' to those already on the market. Trouble was, no-one ever got around to defining how 'similar' it had to be and therein lies the flaw.

As for the owning of problems, when such news breaks, it takes a long old while for it to become common knowledge and many surgeons continued using them in the belief that the number of failures was small and the majority were okay.

The news about MoM in general was broken by Tony Nargol, a surgeon who works in a hospital in Middlesborough, not far from where I live. But because he was a little surgeon in a provincial hospital, no-one accepted what he had to say. I believe he first raised the alarm as long ago as 2009. Indeed, the very next year, one of his colleagues in a neighbouring town was quoted in their local press as broken link removed: https://www.hartlepoolmail.co.uk/news/local/no-medical-risk-due-to-hip-ops-1-1002877 and saying there was nothing for patients to worry about. This was the reaction of the medical fraternity at large and it's taken till now for us to get together and seriously discuss this issue with some intent on getting to the bottom of it. It was as a result of the first meeting in December that the JRI-UK made the statement that MoM should no longer be used. I hope very soon to be putting together my notes and creating a report on Monday's meeting but it won't hold any breathtaking revelations. Too early for that yet.
 
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