THR VSlowLife's Pre-op Questions

[VSlowLife]

Thank you everyone, for helping me. Truly, thank you!
Yes, Jamie, I was bone on bone in 2012, by MRI. Yes, 2012, and it has not been easy. My local OS, who is excellent, refused to do a THR because of my lumbar fusion. I did not understand at the time, because he would not elaborate, but I understand now. Its because my pelvis becomes stiffer with a lower lumbar fusion, and moves at a different angle, and there is up to a 30% chance of dislocation, if the acetabulum is not placed at the right angle to compensate for this. In 2012 they did not have the technology they have now.
Undaunted, because I was only 55, I went to the Hospital for Special Surgery in NYC. They are the number one orthopedic hospital in the USA. Mayo Clinic is second.
That excellent OS told me I should wait until I am 65, for hip surgery, because I was likely to need a revision surgery, in my life time. He said often times revisions did not go well. He advised me to just try steroid injections, in my hip, which I did, with HSS interventional radiologists. My supervisor at work, told me his dad did not do well when he needed to replace the first hip instrumentation in his early 80s. So I took the OS at his word and followed his directions.
The first steroid shot helped for only 3 months, the second not at all. I was told by my excellent HSS OS, that was it, because any more could cause bone necrosis or maybe it it’s called a vascular something?
I was still undaunted, and went to an NYU OS and a reconstruction OS at Mt. Sinai Hospital, also in NYC. Not an easy trip for me. I was told the same thing, but the reconstruction OS at Mt. Sinai had some computer to exam my MRI, that HSS did not use on their MRI image and he was able to tell me I had a cam impingement on the femoral head. No wonder I could not cross my leg!
By 2014, my left hip started complaining and that hip was nearly devoid of cartilage. I was in shock to say the least. Boy did I cry about that. I was still being told to wait to get a hip replacement, they did not care that I needed a walker to manage the trip into the city, or that I could not work.
I had thought it was the hip replacement appliances which wore out over time, and was hoping with time, the manufacturers may come up with something that was more durable.
I do not think I am going to make it to 65 for surgery.
This SuperCap surgeon was an undergraduate physics major, so he understands angles, in weird bodies, like mine, I am hoping. He takes a CT of your pelvis, etc., and the computer models how things should fit and work. A Mako computer assists him to get where he needs to be and insert the appliances. It sounds so space age to me.
I was wondering if I should try steroid injections in my trochanter bursitis, to help me feel a little more comfortable, before I see this surgeon. I have an appointment at the end of next month. There are not too many SuperCap surgeons in the USA. I met someone in my village, who had this done and was thrilled with the result. She is in her 70s. I am grateful for everyone’s responses. So far it sounds like this is not a 100% likely good response and it delays surgery for 3 months.
I am thinking of scheduling a second hip surgery, too, after the first one. I so appreciate everyone who shares their experiences, because it helps us newbies make better decisions.

 

[Jamie]

The first steroid shot helped for only 3 months, the second not at all. I was told by my excellent HSS OS, that was it, because any more could cause bone necrosis or maybe it it’s called a vascular something?

It's called avascular necrosis and it means your bones have areas that die back. Usually it occurs with long-term use of steroids like prednisone. If the second shot didn't work for you, it's probably not advisable to continue with them.

I do not think I am going to make it to 65 for surgery.

While I don't know medical details of your specific case, I do not feel that you must be sentenced to years of pain in order to wait for a hip replacement. A good surgeon will know how to make adjustments for any issues with your spine and how to lessen any risk for dislocation. Your case is the first I've heard of where multiple surgeons told someone to wait when they were in obvious pain. This seems really strange to me, especially coming from HSS. The only surgeon I'm acquainted with from there is Dr. Della Valle. By any chance was he someone you saw? If not and you wanted to get another opinion, I would trust his advice completely. If you choose to see him, be sure and tell him I sent you. We've chatted a couple of times about different patients' situations and I've found him to be attentive and helpful for our members.

I was wondering if I should try steroid injections in my trochanter bursitis, to help me feel a little more comfortable, before I see this surgeon.

I wouldn't recommend doing anything to make things better before getting an opinion from a surgeon. You want him to see you as you really are, not at a time where you're getting temporary relief from any symptoms you could describe or show to him.

 

[Ptarmigan]

Again, I have to chime in here with @Jamie .
(Perhaps you aren’t yet aware of all Jamie does to help us out here at BoneSmart, but one wonderful thing she’s working on is the surgeon database, and as a result, I imagine she’s consulted and/or reviewed references for more surgeons than most of us put together.)

I am just 62, so the discussion about waiting for surgery to avoid the need for revision came up with my primary when he was writing my referral to the OS. He pointed out that the risk of revision is real, but there is no way to be certain if I will ever need one. So, instead, he talked to me about what I could do to prolong the life of my new hip (weight loss, low impact activities, commitment to life long exercise, anti-inflammatory eating). And he pointed out that a sleep-deprived, sedentary life with chronic pain and inflammation was by definition unhealthy, so there were other real risks associated with delay.

What troubles me about your story is that the first surgeon - superb technician or no - could not have guaranteed you wouldn’t need a revision if you wait until you’re 65 - no one can. But, just as my primary pointed out, waiting did guarantee you continued pain and limitation. Now it appears, you have joint problems that are adding up instead of being treated as they arise.

I hope this new surgeon will provide you with a plan for treatment that is convincing enough to allow you to commit. Ideally, the surgeon will welcome your case, with all its particulars, instead of looking sideways at it and planting doubt in your mind. I can see from your posts you are risk-averse. I am, too. So, I have shared my PCP’s point of view, because I found it to be very helpful when weighing one type of risk against another.

 

[VSlowLife]

Thank you, Jamie. So it is called avascular necrosis. It’s a reality check on the limits of treatments.

I will look into Dr. Della Valle, thank you.

You have an excellent point that the surgeon should see the real extent of my pain. Ugh! This snail life is no fun.

I was very surprised, too, because the surgeon I saw, Dr. Howard A. Rose, had done six THR on the members in a neighboring lake community, so he came very well recommended. I met some of them by coincidence at a yard sale. I never asked their ages. My dentist who had a PhD in dental carries and worked as a professor at NYU was told the same thing. He left private dentistry for a less active, executive position. He had slightly better luck than I did with the first steroid shot. We would compare notes.

I was so disappointed. I expected my hip would get replaced, I would go through rehab and PT and get back to work. My aunt had a replacement due to a fracture in her 70s, and my great grandmother at 90, and they survived, so I had expectations based on them.

I have an appointment with NYU this time because they are leading the research on spinal fused THR patients. Their spinal fusion surgeon noticed the dislocation rates in his patients, and was able to do a study with colleagues and publish it in 2017, and it helped me understand why the first OS in 2010, who told me he would do my THR when I cried “uncle” back in 2012, called me back and said no, he could not take me as a THR patient because of my lumbar fusion. Sad but painfully true. I have to respect a doctor who know’s his own limits. Then I knew I needed to go to the hip God’s at HSS.

 

[Jamie]

Here is a link to his web page so you can take a look.

https://www.hss.edu/physicians_gonzalez-della-valle-alejandro.asp

 

[VSlowLife]

Ptarmigan, you hit the nail on the head. Oh you are good! I am not able to be as active and the weight is difficult to control. I have gone from a BMI of 22 to 26, and I am reading that surgeons have BMI preferences. I once was in great shape, ( former clinical dietitian in a hospital setting) and this “life style” is not healthy. I joined Weight Watchers this year, to try to bring it down to at least a 25 BMI, before surgery. I wanted some company on this weight loss journey, too.

I am enjoying the folks I have met, and this is how I found the surgeon I am seeing, by word of mouth from a former patient. This surgeon has unique skill sets, which none of my other doctors had. So he is intriguing to say the least.

I thought about you thinking I am risk adverse. I have seen many things working in a hospital, this is true. I am careful because of what I have witnessed and experienced.

My experience tells me, excellent hip surgeons are risk adverse, too. I had no choice but to respect their opinions. They have more patients, than they can shake a stick at. They triage patients, not just local patients, but patients from around the world. Who would give them the best surgical outcomes? My experience is that good doctors take great pride in their patients’ outcomes.

My excellent, local surgeon knew he would have trouble giving me a hip that would not dislocate, back in 2012. I respect him for that to this day. He is a gifted surgeon. It was not easy to hear, from three doctors, “You need to retire.”
About every 6 months I would do an online professional, medical journal search, to see if there was anything new, that might help my HSS surgeon say yes, to taking me as a THR patient, before the age of 65, or anyone else I had seen. Science changes so quickly in 6 months time, it is hard for the doctors to keep up. Spinal fused patients are not their largest population of patients. If they had unsuccessful surgeries with fused patients, in the past, they stay away from them. Their reputations are important.
I am more hopeful, this NYU surgeon may say yes to me, now that I have learned how his particular SuperCap surgery is coordinated with the CT computer model, to replicate my pelvis and hip in @ 3 D model, to get the right angle placement, which would limit frequent hip dislocations, due to my unique, un-instrumented, L5-S1 biomorphic protein, fusion. Plus he has an excellent spine surgeon colleague to consult with, who is published on this subject. If they tell me, hip surgery for lumbar fused patients is still in it’s infancy, as some doctors have reported, I may be out of luck, again.

My worse fear is that I will wear out my acetabulum, like a friend of a friend did, or the bone cyst will collapse, before a surgeon says “Yes, I am confident I can do the type of surgery you need, this year.”

I am up late, trying to end a medicine which helps me sleep through pain. Discussed it with my pcp last week. It has some adverse side effects.

 

[VSlowLife]

Thank you, Jamie!! He has so many reviews on Vitals, which is one of my measuring tools for sizing up a surgeon.
Watched the video. I want to learn more about his robotic work and types of surgeries he performs. He may use the SuperCap type of approach, too!
Fading fast. It’s super late for me.

Thank you again.

 

[VSlowLife]

Hi Jamie,
I looked at Dr. Gonzalez Della Vella, and his Medicare rating for 30 day complications is quite excellent, on propublica.
He is a high volume hip surgeon.
I called his office and they referred me to his own website, because they could not tell me the kind of hip surgeries he performs. The cite is mostly completed, and so far lists anterior, posterior, and hip resurfacing for larger boned folks. There is nothing about a direct superior or SuperCap approach, or maybe HSS has another name for it?
I will see if I can find out.

 

[marieltha]

I have not had hip issues or arthritis so far (knock on wood), but have suffered from trochanteric bursitis.

I have had cortisone injections in the hip bursas, which is very different than having it in a joint. Each time, the relief lasted at least 3 months, sometimes longer.
Before I had my first partial knee replacement (April2018), my hip bursas were very inflamed and I received an injection in each hip bursa about 2 weeks before the surgery, as I was concerned the bursitis pain would impede my success using a walker.

I avoid repetitive motions when working out at a gym. When walking long distances, I stop frequently and stretch.

Since I had my two partial knee replacements, I have not suffered from the trochanteric hip bursitis.
I am still recovering from the second, as well as shoulder surgery, so I will monitor the hips as I become more active.

 

[VSlowLife]

Thank you, Marieltha, it’s good to know you had success with the steroid injections, and your partial knee replacements seemed to fix the trochanter bursitis. It’s great to hear everyone’s experiences. Maybe that is what I need, too, to fix my bursitis? Time will tell. So far it is only my right knee that has pain sometimes in the front, and I am thinking it’s coming from the hip.
It sounds like you are weathering all your procedures well! It hurts me just to walk 15 minutes on an indoor track. I look forward to the day I can take a long walk.

 

[VSlowLife]

Hi Jamie,
I did call HSS and asked the referral service for a surgeon who uses SuperCap or the direct superior approach. They could not tell me if any of their surgeons used that technique :-(

 

[Layla]

Hi @VSlowLife
Let's tag @Jamie to make sure she catches this.
Hope you have a great day!

 

[VSlowLife]

I do not know how to tag, Layla. Thank you!

 

[VSlowLife]

Hi all,
I know only a few people can answer this. What was your experience?
I am a bit taken aback this morning. According to an article from Feb. 2019, Hospital for Special Surgery research, my spinal fusion is considered a risk factor, for THR, right along with neuromuscular problems.
“.....Dr. Sculco. "We may find that precautions don't make sense for any of our patients, but we need to look at in a stepwise fashion." Risk factors include neuromuscular issues, such as stroke, Parkinson's disease and lumbar spine fusions.”
I was under the impression that as long as they could compensate for the change in angle and movement of the pelvis, as a result of the fusion, my THR post-op treatment and result should be as good as anyone else’s post -op treatment and result.

 

[Elf1]

@VSlowLife I've read most of your posts but my brain isn't always engaged totally. I have to ask, do you actually have an Orthopedic Surgeon that you are seeing? And, if so, what does he/she say about your lumbar fusion? And if you don't, I highly recommend you get one and talk to them and quit playing with Mr. Google and finding all these articles. Not trying to be mean/rude/unfriendly but sometimes the more research one does online, though well meant, the more scary it gets. I did this myself before finding this sight. Had myself scared witless. I'm case you don't remember some of our conversations I have had a lumbar spinal fusion at L5/S1 to stop my disc from sliding back and forth due to Spondylolithesis.

My OS was aware of my fusion, also aware that previous drags showed that I had a tilted pelvis. He did additional drags himself in various positions so that he could see how much bend I still had, etc. He did say that yes, there was a bit of a higher possibility of dislocation due to the fusion BUT, if he did his job right and took everything into account, there should be no problem. Today I'm a month out from surgery and feel pretty darn good. OA pain is gone, referred knee pain is gone and other than dealing with some muscle and tendon aches I'm awesome!

I know when I first came to this site I had asked the question about spine surgery and dislocation as like I said was scared witless. Had numerous hippies come on and tell me they have had both spinal fusion and hip replacement and some of them multiple of both and doing fine. Don't know if this helps you any of not, hopefully it at least helps put your mind at ease.

 

[Mojo333]

sometimes the more research one does online, though well meant, the more scary it gets

I agree.

Today I'm a month out from surgery and feel pretty darn good. OA pain is gone, referred knee pain is gone and other than dealing with some muscle and tendon aches I'm awesome!

Great to get the scoop from those who have been there, done that.

 

[VSlowLife]

Hi Elf, @Mojo333
First, I am glad your recovery is going well. I have been following your progress! May you continue to improve. You had told me your OS took some extra types of x-rays to plan your surgery, based on the fact that you have a lumbar fusion, not just the standard hip x-rays. I was glad to hear that. I am very interested in your recovery.
I think I had also read from you, that you thought you may be getting a duo-mobility cup.
So few people on this site have spoken about lumbar fusions in relationship to their surgeries, but you have.I am grateful you shared that. I know It is not common to have both issues. I expected that.
I have a medical background and was trained to read professional journal research. Now it helps me understand what the doctors have been telling me. It’s little consolation.
I have an appt at an excellent OS research hospital, because that is where the spinal surgeon and OSs who have published the latest research on this issue are located. My spine issues are more complex. Since Elf1 mentioned spondylolithesis, I have that in the adjacent vertebrae above my 12 year old, un-instrumented fusion, just as one example. So far I have just been told to keep my core strong and it’s working.
Meanwhile I am focused on losing some pre-surgical weight, and doing some of the things I have read here, that are important pre-surgical check list items, since I have a snail’s life.
As previously stated, I started seeing my local OS back in 2010, when I was first diagnosed. In 2012 I requested a THR. I was judged to be too much of a risk because of my spine, to my great disappointment. They did not know then, what they know now. Then I went to an OS, the same year, at The Hospital for Special Surgery, since they do complex cases and I was told to wait until I was 65. I have called the doctor at HSS annually, and have been told the same recording, “Wait.” I have seen other OSs, too, because pain is frustrating, when you have been told to wait. They all must play golf together, lol.
In 2014 I was already a couple of years bone on bone on the right side with a cam impingement and a labral tear. My left hip was nearly bone on bone with two labral tears.
My left hip is speaking up, too loudly at times, this year. The left is my “good” hip. I do not think I can wait until I am 65, which is why I am here. I feel more confident I will get a “Yes” from the next OS I see. I think both hips are bone on bone, now, which is why I read Mojo333’s recovery from bilateral surgery. Mojo333 and I have spoken about this.
Hope that answers your questions.

 

[Elf1]

@VSlowLife the OS and I had discussed the dual mobility cup but to my knowledge it was never used. You may want to look at my pre-op thread The Waiting Game towards the beginning and see who all had mentioned they had fusions. I know there were a few that had multiple fusions.

Question, it says you're from Mass but you seem to keep referencing NYC hospitals, why when Boston area has some of the best hospitals around? Just curious. Hubby is originally from New England and quite a bit of the family still live there and quite a lot of the family are in the medical field. That's what I'm basing my assumption on so you know where I'm coming from.

 

[VSlowLife]

Hi Elf1,
Thank you for your suggestion to look at the beginning of your pre op thread. I hope your recovery is continuing well and you are getting stronger everyday.
I had put in location as Northeast, perhaps that made the program choose Massachusetts?
I do live far from NYC, but I am willing to go where I feel best with the surgeon. I use trains because they are easier on my hip than driving. The handicapped section lets me put my bad leg at any angle I need, to feel better. For my surgery in May I stayed at a hotel near the hospital until I was well enough to get back on a train. They release you so quickly after surgery theses days.
Yes, Boston has great hospitals, and easy above ground trains, too.

 

[VSlowLife]

I am wondering if I would possibly sleep a bit better in a lifter recliner with “zero gravity? My hips are much worse, day and night, and my bed is not a comfortable place no matter how many pillows I use to help. I have done too much standing recently, and 15 mg of Meloxicam does not touch it, nor my current pain patches.