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Was the best choice made for my hip surgery?

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leftyman

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My unfortunate story started on November 24, 2008 getting Christmas decorations down from storage in the garage using a 6 foot step ladder. I ended up falling from the ladder onto the concrete slab and landed on my right hip, displacing the head of the femur.

I'm 61 yr. old, and have an above average activity level. I was in surgery the following morning. Also FYI, I'm a fairly muscular guy from the waist down.

My physical therapy ended March 1, 2009 and I felt I was on the road to a successful recovery (which I had worked very hard at). Since then, I have relapsed progressively into discomfort in the hip and thigh. I've researched my problems on the net to discover that I believe that the surgery chosen for me was not correct, based upon my age and level of activity!

I'd appreciate any feedback on this, or opinions. I'll submit details as to what procedure was done, following feedback/opinions
:sct:
 
Hi Lefty Welcome. Wow that is ONE story. Thats terrible you were doing so well. Im a knee so I wouldnt want to give an opinion but others will post soon. And Jo and Jamie are the best they will help you as well with advice. Good luck to you. I hope it gets straight soon and you can be back on your way. Sounds like you were doing very well...keep us posted...
 
Hi and Welcome
Well it is not possible to say if the right choice was made if we do not know what was done. Did you have a replacement???
I did last year, age 52 do to severe osteoarthritis and love my new hip.
judy
 
Welcome, Lefty! I doubt anyone but a doctor could answer your question properly and realistically! You could always check out another surrgeon or revision specialist for the answer you seek! Good luck and let us know how you are doing!!!
 
Thanks for your reply Judy,
Since you asked, I'll take some of the uncertainty out of what I'm asking. There are likely (3) options that should have been considered:
  1. Reattach the femur head mechanically, which I can share I didn't have done.
  2. Hemi-arthroplasty replacing the broke/displaced femur head with steel ball/shaft inserted inside the femur. The natural socket (acetabulum lined with cartilage) is not changed.
  3. Total hip replacement doing above #2, plus replacing the acetabulum with a steel/polyethylene lined socket.
My question is, should I have had the surgery for #2 or #3 ?? (I am scheduled for "revision" surgery on August 7, 2009)
jerre
 
Well, I can say right off the top of my head that it's at best uncommon for anyone to simply dislocate their hip in such a fall. Usually there is some damage to the femoral head as well. Thus, the hip can't simply be relocated and sewn up again. And in a patient of such a young age, a hemiarthroplasty would not be the surgery of choice - that's just the femoral part of a THR with no cup which is used for the elderly and frail. Quicker op and less likelihood of morbidity. They would take into account all the aspects of your case and make the best choice given the need for urgency. Thus a THR would be indicated.
 
Hi Lefty....welcome to the BoneSmart forum. I would only add to Jo's analysis the comment that I hope you have total faith and confidence in whoever is doing this revision for you. If it is the same doctor who did the original procedure on you, you might want to consider an opinion from a revision specialist. Your comments lead me to believe that the original surgery was not performed by a surgeon who specialized in revisions or difficult cases.

I'm still not clear on what procedure WAS actually done that is now not working.
 
Thanks folks for the responses, and thoughts.
On November 25, 2008, a hemi-arthroplasty was performed on my hip. ( A bipolar prosthesis was used) I am due to have revision surgery (THR) by a specialist surgeon on August 7, 2009. The specialist surgeon who I have alot of confidence in, is not the one who did the original hemi. (The surgeons are from a very large orthopedic practice in our area.) When I complained to the original surgeon about my continued discomfort in the hip and thigh, she ordered xrays of my lower spine to assess if there was any evidence of disc problems. The xrays led her to believe that an MRI of the lower back would disclose any problems. The MRI did show some disc compression, but I've always had lower back pain. The xrays and MRI were done in April. Soooo, we went the route of epidurals in the lower back on 2 occasions to see if the hip/thigh pain could be helped. I thought I had 2 chances for relief from the epidurals.....slim and none. As it turned out, it was none. Frankly, I had trouble "connecting the dots" with nerve problems in my back deciding to inflict pain in the area where I just had major surgery.

Then I was transitioned to the specialist surgeon who ordered bloodwork to rule out infection (which came back negative), a bone scan (which was negative), and a CT scan which disclosed little or no cartilage was left in the acetabulum, thus the need for a THR. What happened to the cartilage from November '08 to June '09 ?? I know what I've gone through like most of you, but if there is a mindset out there that says "lets give him a hemi, and if it doesn't work, we'll do a revision to a THR" as a cavalier strategy, then I'll be having a serious discussion with such individuals. All of the information I've found on the net points to the fact that I should have had a THR, not a hemi.

Please let me know if you have any follow-up thoughts.
Thanks again,
jerre
 
So when you said 'displacing the head' you mean it was fractured? I see!! That changes things. I thought you meant dislocated it!

So, let me go through the options you've mentioned .......


It all depends upon the position of the fracture. It's all about the blood supply to the head, you see. The head gets its blood from two main sources; the bone and the joint capsule. (The ligamentum teres, though very active in childhood, it pretty much defunct by the age of 40) If the fracture is inside the capsule, then the head is completely devoid of a blood supply and will begin to die quite quickly. This is known as ischaemic necrosis.

[Bonesmart.org] Was the best choice made for my hip surgery?


Intracapsular fractures are also graded according to the degree of displacement and the difficulty factor in reducing them. Grade I is almost undisplaced whilst grade IV is irreducable and probably already in ischaemic necrosis.

[Bonesmart.org] Was the best choice made for my hip surgery?


If the fracture is outside the capsule, then the upper fragment still has a healthy blood supply and various methods of internal fixation like screws and pins can be used to secure the fracture until it heals. These usually heal extremely well.

1. Reattach the femur head mechanically, which I can share I didn't have done.


This is internal fixation with screws or a DHS appliance. In order to do this, the situation has to fit into certain parameters. First the head has to be relocated onto the neck and accurately enough for the blood supply to be
quickly re-established. If the head is grossly displaced from the neck, (grade 2-4) it is well nigh impossible to get it back into place and probably already has a degree of avsascular necrosis by the time they are seen in ER

However, even those with a healthy blood supply can be problematic in healing and require later revision to THR.

[Bonesmart.org] Was the best choice made for my hip surgery?
[Bonesmart.org] Was the best choice made for my hip surgery?

. screw fixation of NOF ......... Dynamic Hip Screw (DHS)

2. Hemi-arthroplasty replacing the broke/displaced femur head with steel ball/shaft inserted inside the femur. The natural socket (acetabulum lined with cartilage) is not changed.


Hemiarthroplasty is not the treatment of choice in the younger patient. It is normally used in the very elderly with a limited life expectancy. Patients who may live 10 or more years don't do well with it.




3. Total hip replacement doing above #2, plus replacing the acetabulum with a steel/polyethylene lined socket.

THR with whatever prosthesis is commonly in use in the OR where you were. Most younger patients who suffer a grade III or IV intracapsular fractured neck of femur will be given a THR.


As a matter of interest, what exactly did you have done?
 
Judles,
That's the same question I have for the Orthopedic practice. Since I have been transitioned to the Revision Specialist, I haven't had an audience with the surgeon who did my hemi. I do intend to find out who chose the hemi.
jerre
 
Surgeons rarely tell patients which grade of fracture. In your case, it seems obvious it was a Grade III or IV fracture which, if fixed with screws, would not heal thus necessitating further surgery. Therefore the viability of the femoral head is the governing factor.

I think that given your young age it would have made more sense to do a THR straight off but since this kind of injury obviously comes under theTrauma label, the surgery is often carried out by surgeons maybe less experienced and/or who would most certainly have no hip replacement experience and maybe even in an OR where the instrumentation is unavailable anyway.

Some hospitals in the UK will do them right off but the majority still do a hemi and revise it if there's any problems - which I've
personally always thought to be unacceptable. So don't know what the protocol is in the US. The medical fraternity at large still argues for both.

The intention of bi-polar design which you had, with its semi-captive articulating head, was supposed to provide an alternative 'best of both worlds' hemi but the outcomes were always dubious. They had a higher than average dislocation rate for one thing. Very few hospitals in the UK use them any more and haven't done for years.

[Bonesmart.org] Was the best choice made for my hip surgery?

 
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