THR redo coming up. A few questions please?

[Willa]

Hello, and many thanks for this web site. I am currently getting ready for a THR revision/repair and wonder if anyone could comment on a few issues I’m thinking about.

History: 62 yr/female. avg weight/height, very active before surgery.
THR 4/2004, w/ Biomet M2AM and taperlock stem. Both Biomet rough
surface/cementless.

1YR; surgeon and I both agree= doing ok but not as well as expected.

2 YR; still 1 step ahead and 2 steps back, pain meds increased, possible slight hairline separation at pelvis cup/stem still looks good (x-rays). Advised surgery in future is a distinct possibility.

3-4 YR. Same issues of pain and mobility, worsening of both. Current x-rays show loosening areas around stem and cup. Cup has 2 of the 3 screws (that were put in at surgery to hold it in place till bone growth/adhesion got started) broken(sheared) and the cup rotated about the thickness of the screws.

Now; scheduled for Monday 1- bone scan and 2- aspiration of the hip. Both to check for infection as the cause of loosening, or to rule out infection and look to rejection as cause.

?’s
1- Almost seems like the implant(s) never really got the bone growth adhesion going good. Despite a good report at 8 weeks and then at 1 year, pain and mobility were still a problem despite PT and ramping up of pain meds. Is this possible? Or does this really always occur in 6 to 8 weeks? I was weight bearing right after surgery and very active the first year and a half, all with surgeon’s ok.

2- Anyone have any direct experience with these particular implant joints? I’m very surprised the screws would shear off as they did.

3- How do some of you handle the time factors involved? i.e.- surgeon says should move quick on this, asap and no longer than a few months. Obviously I would like to get the process started and have confidence in my surgeon; but I would also like a second opinion. I’ve found that scheduling a second opinion (which would be out of town) with any number of the surgeons I’d consider to use almost impossible time wise. Some of the surgeons can't even schedule me for 2 to 3 months. Am I wrong to limit a second opinion to someone I would consider doing the revised THR?

4- Reviewing my hospital file I saw the implant manufacturer had a rep attend my surgery. Is this a fairly normal practice?

Sorry to be so long winded with this, and thanks again for this web site.

 

[Josephine]

Not long winded at all, Willa - you should see some of MY posts!! Welcome to BoneSmart.

First thing that shouted out of that very excellent history you gave is - don't just get a another opinion, get another surgeon!! Sounds like the prostheses were loose from the very beginning.

The vast proportion of failures in joint replacement have nothing to do with the prosthesis but everything to do with poor technique! If the prosthesis was to blame, why would countless thousands be okay and only the odd few have problems? I am very familiar with the Bioment cementless hip and its record it excellent.

Take my recommendation and get someone else to do this revision for you. Given that this has been building over such a long time period, I would think another few weeks/months would be worth the wait to find someone else.

 

[Willa]

Thank you for the welcome and the comments.

I don't really know how many of this particular implants my surgeon has put in. He has quoted alot of numbers, but I always got the feeling it was either about all the different products or maybe the whole practice. According to him Biomet is the best product out there. But my husband is a retired engineer/contractor and I am very aware of the manufacturing-wholesaler-professional-end user chain of product developement and marketing.

In your experience, how often is the loosening the result of infection? Same question regarding rejection of the metal by the body. I got the impression that my surgeon considered those 2 things the ONLY reasons for the loosening?

If my implant(s) were loose from the beginning, would that explain how the screws were sheared?

thanks again for the discussion

 

[Laurie]

Josephine and Willa, Am interested in this discussion as I had a biomet metal on metal hip (the one marketed by Mary Lou Retton) put in (right THR) on Aug 26 and am doing great with it. Of course my surgeon thinks they are great as well and cited that they were used successfully for about 15 years in Europe before coming to US 4 or so years ago.
In any case, I am reassured by Joesephine's comments that it is usually the surgeon and not the protheses that cause the problems. Keeping my fingers crossed that my hip continues to heal with no problems. Willa, my best to you as you go through this trying time.

Laurie

 

[Willa]

Thank you Laurie for the support. Is your surgeon perhaps a revision specialist? We live in the midwest and are trying to get appointments at Mayo and Cleveland Clinic.

Good luck Laurie with your recovery.

 

[UTdave]

Willa,

You hit the nail on the head with the revision specialist comment. That should be your next stop.

I shouldn't blather about things I don't know all about, but. . . Why did you end up with a screw in the cup? The whole point of these rough surfaced implants is that they are "press fit" and should be tight enough without any additional fixation and your own bone grows into them. This raises a second point which is your age and sex - both risk factors for osteoporosis. This may make a non-cemented option difficult. Anywho, sounds like a revision specialist is the way to go - although this is just a non-expert blathering.

 

[Willa]

Hi, UTdave. Surgeon said screws were to hold cup in place during bone growth/adhesion, that's all I know at this time regarding screws. Except that only 2 are visible on xrays, 1 sheared and the other still solid but now acting as a pivot point, 3rd screw is not showing due to implant metal clouding it I guess.

As for OP, so far negative, bone density tests all good. OA is my problem. So far just 1 hip, other hip still looks good.

 

[Laurie]

Hi Willa, I am in northern NJ, real close to NYC so not near you. Bet you will find some good choices in your area, given the highly reputable hospitals you mentioned. I was wondering about the screws as well. Don't think I had any--if so think they would have shown up in the xrays of hip/prothesis at 6 wks. I too had oa of the right hip and no signs of it anywhere else. Your surgery sounded more complicated. Do you know why?

Please let us know how everything goes with your upcoming appts.
Take care,
Laurie

 

[Willa]

Complication wise-I assume my surgeon based the procedure on the extent of the deterioration of my ball and socket. My original xrays were quite clear with the damage to the joint. To me it seemed to make sense what he proposed and a local second opinion concurred at the time. Mondays tests will at least get the ball rolling and I will ramp up the search for revision specialists who can see me asap.

Have a good evening.

 

[Josephine]

I wouldn't go so far as to say the Biomet is the BEST product as they are all pretty much of a muchness IMO. But it is a good one and widely used. Fixing the shell of the cup with 2 screws is part of the design so nothing untoward there.

Loosening can occur without infection but infection almost always leads to loosening. I couldn't comment about rejection of the materials. It does happen but I believe it's pretty rare. Sounds to me like a bit of blather to cover up his lack of experience. Because the more I hear about this, the more I lean towards his NOT having used this one much before. Experienced surgeons (experienced in a particular prosthesis, that is) just don't need a rep present and I know of no other reason one would be there. Could be wrong, of course, but ....

And as for the broken screws, well they are pretty strong things and would have withstood the loose cup for quite a while until metal fatigue finally caused them to fail. Nothing significant in that whatsoever. Just common or garden bio-mechanics and metallurgy.

I knew a man once had a very old (circa 1940) plate in his lower leg. Though the fracture had healed, the poor quality metal had caused a reaction so the bone underneath had become extremely soft. In the end, the only thing that was holding his leg together was the plate which by then was about 28 yrs old! And he was a farm labourer! He did well once we took out the plate though. Happily metallurgy has been greatly refined since then.

 

[Willa]

Hello again, well had the bone scan and hip aspiration today. Only comments today- doc said fairly large amount of fluid, enough that alot of times this means an infection. Will have to wait on lab results and reading of bone scan to be sure I guess. Back to the surgeon in 3 days then.

Josephine, wanting to double check a few things, can you tell me how to find out how long biomet's M2Am/taperlock stem, both with the plasma applied bone growth coatings, have been available in the USA. I am having trouble verifying this info. I know my surgeon is one of the more experienced and respected here in the midwest USA and has done alot of THRs. If this particular system was not approved until 03 or 04 then you may be right about my being amoung his first patients to get this system. I did have a couple of people tell me today that nowdays products are changed so often that reps are in surgery alot.(yada yada)..I just don't know about this particular implant system. I plan to ask alot more questions at this next visit.

Thank you

 

[Josephine]

That prosthesis has been on the market for years, Willa. I remember using it when I was at the Royal National Orthopaedic Hospital in 1999 and it was well established then. Was more commonly called the broken link removed: https://www.hipforlife.co.uk/index.html at that time. Furlong was a surgeon at St Thomas' Hospital, London. It's reputation is pretty sound.

So the issue is not with the prosthesis being new but the surgeon never having used it before.

A surgeon I once worked with explained to me this way; a surgeon new to using any implant has an increase in poor outcomes (i.e. failures) during the time he is getting his expertise up to scratch. When he has achieved a high level of competence, his outcomes should be in the high>excellent level. However, if he changes the product he has been working with, his statistics will take a dive until he gets experienced in using the new item. Very tellingly, he added, "And if he hasn't got some pretty good evidence to justify the change, that's something he - and his patients - are going to have to live with for the rest of his life."

 

[Josephine]

Just had a pm from Willa's husband which is for all of you

hello, just wanted to drop a note. willa had talked about this forum and wanted me to post her thanks for the support and questions answered for her. she's abit under the weather these days as she had revision surgery alittle under 3 weeks ago. but touching base on this forum was on her mind so I told her I'd send a mesage.

I wasn't sure it'd be proper to bring her thread to the top, nor to post under her registration so hence this PM. she is doing good recovering here at home now and we realize what a long slow process it will be.

anyways, thanks again.
willa's significant other

 

[Jamie]

To Willa's dear significant other.....what a peach of a guy you are to make sure we learned that she had the surgery and is on the mend....even if it is going a bit slowly right now. Thanks for taking time to write to Jo and here's a big (((HUG))) for both of you!

 

[Willa]

thank you very much Jamie. and Josephine for posting this for me. take care to all, and I'll try to post some more in the next few days. 1st note- revision recovery is way way tougher than original THR.