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Which Surgery do I choose??

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Jo
Now I know why my hip MRI only showed mild o/a. As far as my knee showing mild arthritis also, no x-ray has been taken, it adds more suspense to my upcoming scope. Now I will not be as surprised if there is more arthritis than is shown.
Thanks again
Judy
 
I'm guessing in the UK you've had more experience with resurfacing?

Not actually. I haven't ever worked anywhere that did it and most of the surgeons I did work with were somewhat chary about the procedure. But has to be said, that was pre-1995!


How do they rectify the abnormal femoral neck angle pictured in B and C above? My xray looks just like B and I imagine shaving the femoral head down and preserving that horribly abnormal shaft may get rid of the pain, but not do much to solve the abnormal angles and, thus, abnormal ROM, etc.

That's one of the things the aforementioned surgeons were chary about. How do you do it and preserve the stability of the joint?


Lastly, could you shed some light on stress shielding? I understand the process, but cannot get it in my head how it can be entirely avoided with the introduction of any implanted device used to support a person's weight. I see on a few forums that people claim that resurfacing has "eliminated stress shielding". How? There's still metal that's unnaturally re-distributing your bodyweight. Isn't that one of the theories to explain the femoral neck fracture seen in some studies?

You got that right, Dave. It IS a potential problem all round.

broken link removed: https://www.eorthopod.com/public/patient_education/9912/femoral_neck_fracture_after_hip_joint_resurfacing.html is very informative though it admits there were some issues it did not address. IMO those issues were of a minor nature.

For those that don't know about stress shielding it basically works from the fact that bone grows and adapts according the loading that is placed upon it. In other words, leg bones are stronger and thicker than arm bones and people who are confined to bed for prolonged periods lose a lot of bone mass. As do astronauts who spend extended periods in space.

This is one of the reasons that when someone has a fractured leg bone fixed with a plate and screws, the plate will be removed as soon as the healing is complete. Because the loading that should travel in an organized way down the shaft is rerouted along the metal plate instead and so the bone loses strength. This is known as stress shielding meaning the plate is shielding the bone from the stresses it needs to stay healthy and strong.

A famous (and very old) quote is Wolff’s Law (1869): “bone adapts (remodels) in response to the mechanical loads placed on it”


Now in the hip, the loading normally goes from the top of the femur down through the front of the neck and down the shaft. But in a THR you can see how the loading is redirected through the entire stem of the prosthesis and only transfers to the femoral shaft at the base of the stem.

[Bonesmart.org] Which Surgery do I choose??


This results in three things
1. the bypassed bone loses mass and strength
2. the bone at the base of the stem has unnatural loading which can cause an overgrowth of bone mass. This can (apparently) result in aches and pains.
3. the loading in the femoral prosthesis stem can cause failure in the form of a breakage, especially at the bottom 5-10cm of the stem where the leverage is greatest.

In resurfacing, the article linked above has defined the probems very well in that the femoral prosthesis can exacerbate stress shielding if set at even a small variant angle and possibly result in resorption and fracture.

I think that's about the limit of my knowledge on the matter!
 
OOps - Sorry Josephine - I love to share - but wasn't sure how that worked here - so here are a couple that I found on FAI -

broken link removed: https://www.hipfai.com/

broken link removed: https://www.orthopaedia.com/display/Main/Femoroacetabular+impingement

https://www.ajronline.org/cgi/content/full/188/6/1540

broken link removed: https://www.hss.edu/conditions_Hip-Mobility-Arthroscopy-Patient's-Guide-Femoro-Acetabular-Impingement.asp

Again they really just focus on the issues with impingement but they really helped me understand what was going on and how it wasn't really my fault it was happening (I kept feeling like it was from not doing something or from overdoing things). It has also helped me see the long term issues - but... I am going to have a blast and get my life back when all is said and done!

Orthos are great with their explanations but I always feel like I have more questions becuase when they are talking about things after you have found out that something unexpected is going to happen you are really not as focused as you should be! What did we do before Internet!

Enjoy the Day!

Marianne
 
Hi

I am new to this forum. I have dysplasia, I had surgery for CDH as a child and had an arthroscopy 12 weeks ago to repair a torn labrum and debride cartilage. I have had even more pain and instability after the scope, and am now waiting to see a surgeon regarding a PAO ( osteotomy). The most used methods on adults seems to be the Ganz approach. I am surprised at 27, if your cartilage is reasonably healthy, that you would even consider a repacement or resurfacing, when you have the option of keeping you own bone. You will have far fewer restrictions post op with a PAO than any type of replacement, and may never need any further surgery,whereas once you have had a replacement the chance of needing a revision at your age is pretty high.If you do need a replacement later after having an osteotomy your sockets would be much better postitioned for a replacement cup also. I don't wish to confuse you further, but I ahve been researching this for a long time now, and just wanted you to know I understand exactley how you are feeling as I have considered all the options too. I am older than you, 39, and on the borderline as PAOs are usually only done up to early forties as the complications of non-union etc increase as you get older, but have come up with the decision to have a PAO and preserve my natural hip for as long as possible. I have been helped in making this choice by another message board specifically for women with dysplasia, that has lots of help and support from women gone through both osteotomies and resufacing / THR. I will post the link in a separate post below , as I am not sure whether posting rules allow other boards to be mentioned, if not Josephine is welcome to delete that thread if necessary. I hope this helps, and urge you to visit this site before making your final decision.
Good luck in making the right choice for you
Kate
 
Not a long post at all! You have info to pass on, it doesn't come in sound bites!

However, I have some misgivings about your statement "and may never need any further surgery". Upon what evidence do you make such a claim? I'd be interested to know. I do know the Ganz is akin to the Chirarie I mentioned.



As for the link, no problem at all. But I have never been able to suss out that kind of message board. There's a Buddy Holly one that I would dearly love to take part in if I only knew how!
 
Josephine...

The article/item you have posted was not written by Dr. Vail, as I can tell. It appears to be a layman's interpretation of what he thinks Dr. Vail has written, and "Matt" completely misunderstands bone loading and "notching".

"Notching" was a problem in the early days of the new Metal on Metal iteration of resurfacing. The high-speed devices that prepared the femoral neck for the implant occasionally touched a part of the bone they should not have, creating a tiny, unseen notch, fracture, weak point in the femoral neck.

When the notched femoral neck was loaded or torqued, after surgery, the stem would push through the notch, which was the weakest point in the bone. Notching is no longer a significant cause of resurfacing failure, because surgeons are aware the possible problem and avoid it.

There is an additiional problem with the nature of the quote about "stress shielding" As written in BoneSmart, it seems to suggest that the problem is in the femoral component of a resurfacing device. In fact the problem is in the longer stem of a THR...and virtually elimated with proper installation of resurfacing device.

That demonstrated fact was part of the appeal letter than convinced my insurance company to cover my resurfacing when the surgery was still investigation.

From what I've been told by others, I have some question whether this not will ever appear in the BoneSmart forum. But I hold out hope.

Regards,
Alan
LBHR 15Dec04 Dr. De Smet

Not actually. I haven't ever worked anywhere that did it and most of the surgeons I did work with were somewhat chary about the procedure. But has to be said, that was pre-1995!




That's one of the things the aforementioned surgeons were chary about. How do you do it and preserve the stability of the joint?




You got that right, Dave. It IS a potential problem all round.

broken link removed: https://www.eorthopod.com/public/patient_education/9912/femoral_neck_fracture_after_hip_joint_resurfacing.html is very informative though it admits there were some issues it did not address. IMO those issues were of a minor nature.

For those that don't know about stress shielding it basically works from the fact that bone grows and adapts according the loading that is placed upon it. In other words, leg bones are stronger and thicker than arm bones and people who are confined to bed for prolonged periods lose a lot of bone mass. As do astronauts who spend extended periods in space.

This is one of the reasons that when someone has a fractured leg bone fixed with a plate and screws, the plate will be removed as soon as the healing is complete. Because the loading that should travel in an organized way down the shaft is rerouted along the metal plate instead and so the bone loses strength. This is known as stress shielding meaning the plate is shielding the bone from the stresses it needs to stay healthy and strong.

A famous (and very old) quote is Wolff’s Law (1869): “bone adapts (remodels) in response to the mechanical loads placed on it”


Now in the hip, the loading normally goes from the top of the femur down through the front of the neck and down the shaft. But in a THR you can see how the loading is redirected through the entire stem of the prosthesis and only transfers to the femoral shaft at the base of the stem.

[Bonesmart.org] Which Surgery do I choose??


This results in three things
1. the bypassed bone loses mass and strength
2. the bone at the base of the stem has unnatural loading which can cause an overgrowth of bone mass. This can (apparently) result in aches and pains.
3. the loading in the femoral prosthesis stem can cause failure in the form of a breakage, especially at the bottom 5-10cm of the stem where the leverage is greatest.

In resurfacing, the article linked above has defined the probems very well in that the femoral prosthesis can exacerbate stress shielding if set at even a small variant angle and possibly result in resorption and fracture.

I think that's about the limit of my knowledge on the matter!
 
Alan,

"The article/item you have posted was not written by Dr. Vail, as I can tell. It appears to be a layman's interpretation of what he thinks Dr. Vail has written, and "Matt" completely misunderstands bone loading and "notching"."

Agreed. Though still an interesting article.

"There is an additiional problem with the nature of the quote about "stress shielding" As written in BoneSmart, it seems to suggest that the problem is in the femoral component of a resurfacing device. In fact the problem is in the longer stem of a THR...and virtually elimated with proper installation of resurfacing device."

It seems to anyone who puts devices into bones that the problem is with any device that gets put into bone - as Josephine mentions using the example of a screw/plate in a long-bone fracture. I'm not sure what you're referring to about the problem being THR or resurfacing. It seems a problem for both to a greater or lesser degree, as the phrase 'virtually eliminated' suggests. Remember in the 50's when science was going to virtually eliminate hunger?

"That demonstrated fact was part of the appeal letter than convinced my insurance company to cover my resurfacing when the surgery was still investigation."

Where is the fact demonstrated? For which pt's, for which indications? I've said this before on this website - show me the evidence as I really want resurfacing to be right for me despite evidence to the contrary!
 
Not a long post at all! You have info to pass on, it doesn't come in sound bites!

However, I have some misgivings about your statement "and may never need any further surgery". Upon what evidence do you make such a claim? I'd be interested to know. I do know the Ganz is akin to the Chirarie I mentioned.



As for the link, no problem at all. But I have never been able to suss out that kind of message board. There's a Buddy Holly one that I would dearly love to take part in if I only knew how!

I will try to find some links to back up that statement, although it will not be today as I don't have time to go through all the info that I have. However, I did only say MAY not need any further surgery- that is definatley not a guarrantee, I don't think anyone would give that, for any surgery. I have read several articles that state that with the realignment of the joint to a better position it is hoped to slow down or prevent the progression of
arthritis and thus further surgery MAY not be necessary.I do know someone who had the Osteotomy almost 20 years ago and is still pain free, to me at the age of 39 if I can prevent having any sort of replacement for even ten years then it is worth a shot. If you do need to have a replacement following a PAO then the socket is often better placed for this to be carried out.Yes, it is a major operation, but so is a replacement, and 3-4 months on crutches plus a time for physio etc afterwards is, in my view, worth taking to have the chance to live a normal life, without the restrictions that you inevitably have with any sort of replacement. As I said, it is very much a personal choice and I respect that, but thought it would be helpful for the original poster to be able to read messages from people who have gone through both operations( sometimes a resurface on one hip and a PAO on the other).
Thanks
Kate
 
Thanks for the advice Kate. Afterall, that's why I'm here. The more advice the better!

As far as the PAO, I have talked to several people through forums, online, and in person, that have had the PAO done, and I have actually spoken to the surgeon here in WI that does them(he was the second specialist I saw), and have heard a common underlying complaint, that they were not completely pain free post-surgery. Because you ARE keeping your own bone you still have the parts that allow for more arthritis to continue to develop, which in turn can cause pain. In MY opinion, if I am going to go through MAJOR surgery on my hip/s I do NOT want to continue to have arthritic problems and go through all of this pain all over again, only to have a resurfacing or replacement later. Now don't get me wrong, I understand the importanct at my age of preserving as much bone as absolutely possible to deter future problems, which is why I am considering the resurfacing right now over losing the entire top of my femurs.... I've researched and researched these options and asked a ton of questions as well, and after speaking with a handful of ortho surgeons each that specialize in one thing(PAO, THR, and BHR) I think I've made an informed decision, and am comfortable with proceeding.... I almost cannot WAIT!
 
Good luck then Prinny!
Resurfacing is a great choice too. That is definatley the way I would go if I found out I was not a candidate for a PAO. I wish you all the best, and look forward to hearing that you are enjoying an uneventful and pain free recovery.
Kate
 
Well, that's the most important issue in my opinion - that it is an INFORMED opinion. What ever other people think of this or that procedure, whatever experiences others have had, it all comes down to YOUR choice. Hope it goes really really well for you. Keep us posted.
 
Josephine...

The article/item you have posted was not written by Dr. Vail, as I can tell. It appears to be a layman's interpretation of what he thinks Dr. Vail has written, and "Matt" completely misunderstands bone loading and "notching".

"Notching" was a problem in the early days of the new Metal on Metal iteration of resurfacing. The high-speed devices that prepared the femoral neck for the implant occasionally touched a part of the bone they should not have, creating a tiny, unseen notch, fracture, weak point in the femoral neck.

When the notched femoral neck was loaded or torqued, after surgery, the stem would push through the notch, which was the weakest point in the bone. Notching is no longer a significant cause of resurfacing failure, because surgeons are aware the possible problem and avoid it.

Somewhat tempted to use the phrase 'teaching your grandmother to suck eggs' here but

a) I never noted authorship of the article, just that it was 'interesting' which it is ...
b) your description of notching is a layman's perception and little to do with 'notching' as discussed by the professionals


There is an additiional problem with the nature of the quote about "stress shielding" As written in BoneSmart, it seems to suggest that the problem is in the femoral component of a resurfacing device. In fact the problem is in the longer stem of a THR...and virtually elimated with proper installation of resurfacing device.

That demonstrated fact was part of the appeal letter than convinced my insurance company to cover my resurfacing when the surgery was still investigation.

Again, a misconception - ANY device applied to bone creates stress shielding, that's why in trauma surgery, implants are always removed when healing is complete. And why trauma surgeons often use external fixation devices rather than internal plates.

See, this ol' ga does know what she's talking about!
[Bonesmart.org] Which Surgery do I choose??



From what I've been told by others, I have some question whether this not will ever appear in the BoneSmart forum. But I hold out hope.

Regards,
Alan
LBHR 15Dec04 Dr. De Smet

Curious to know what you mean by this ~ for a start either your sentence has a spelling or grammer error or my reading glasses need to be changed! Either way it lacks a degree of readability.

Plus who are these 'others' that know what topics I will and will not allow on here? Because they seem to know more than I do! You may feel free to pm me rather than derail this thread anymore.
 
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