June 23, 2011

Hi y'all,
This is really long, so I apologize in advance.
Here's the basic info about me: female, 4'11, 105 pounds, x-gymnast which caused osteoarthritis in my right hip, 43 years old when resurfaced to MoM Wright Conserve Plus size 40mm-46 socket. Cup placed at 45 degree angle. I chose a very
experienced orthopedic surgeon who has performed well over 1500 resurfacings.

Initial resurf surgery in May 2008: Recovery went well. First 10 days were uncomfortable but after that progress seemed to be steady. I did a mini sprint triathlon 4 months post surgery and felt great. I teach elementary PE and am always on my feet and I was also very dedicated the first year of recovery to stretch and strengthen daily. I continued to get stronger and more flexible for about 1 1/2 years. About this time I started making excuses for groin pain and
would limp for a few days after doing exercises like squats, lunges, etc even though I'd been doing them prior without a problem. I also began to have some ratcheting and clunking, but typically this happened when I was doing pilates
moves rotating my leg in a full rotation. I could hear and feel it click as it went around. I just figured that was part of having a metal hip. So, I blamed gymnastics and the overuse of my hip flexor, my shoes, my age, etc. It never dawned on my new hip could be the problem.

Fast forward to May 2011, now 46 (3 years post op)
My husband finally convinced me to go back to my OS and get my hip checked as the groin pain and clunking were now more consistent and I was having difficulty making it through the work day and sleeping. I figured, my OS would just tell me that I needed more physical therapy or something like that. He took x-rays and I described my symptoms of clunking, ratcheting and rotating pain around my hip area. Sometimes my quadricep hurt, other times my hamstring, then down the length of my femur, my groin or knee. It didn't make any sense since the pain was not pin pointed to one location.

My OS diagnosed me with metallosis which is when the metal devices rub and give off metal debris that gets into the tissue, bone, blood stream and will continue to cause damage until removed. So, I was given two choices. One was a total hip replacement and the other was to just remove the socket/cup and replace it with a cross linked polyethylene one. Both options have HUGE cons and I've been an emotional disaster for the past 5 weeks trying to figure out what to do. I did set a surgery date for July 5th since there was no question about the need to remove the MoM issue and I decided on the spot to do the socket revision.  Everyday after that I flipped back and forth from one surgery to the other in total confusion.

In a nutshell here's the pros/cons as I saw them:
Option 1
THR: This will last about 10+ years for active people in their 30s & 40s. (ages 55+ it should last more like 20 years) Pros: Longevity of the device depending on how active/inactive I choose to be. Cons: The restrictions and limitations make me question whether or not I would be able to continue my career as a PE teacher and live "my normal type of life" I am pretty flexible and fear dislocation may be more likely for me. Every time I considered THR I cried and grieved losing the real me. Don't get me wrong, I truly am thankful that this situation is only related to my hip and I don't have a terminal illness nor will I be confined to a wheelchair, but the reality is that it's very hard to accept a huge life change so I'm super sad, disappointed, worried, stressed, etc. 

Option 2
Revision: Put in a new socket and leave the metal femoral component alone. The cons for this is simply longevity. I do not want to be back in having another surgery in the next year or two. No one knows how long this may last. Pros: I
would retain my stability & mobility and not need to limit my activities or life style. Another con: I've worried a lot about keeping any metal in my body and also since I'm still a small female that this will simply fail again fairly soon.

Following this appt. I posted on the surface hippy site where I initially learned everything I possibly could 3 years ago. I had so many questions, worries, and concerns and didn't know where to turn to find unbiased answers.  Fortunately, I got in touch with Vicky Marlow who is such an angel!! She was a comforting listener who understood what I was going through when I felt like no one else understood. She provided me a way to get some expert opinions to find out what other Drs recommend and if my x-rays show any red flags for improper placement. It took a few weeks to get my metal levels tested and the results back (seemed like the longest weeks of my life--just waiting!) Then I sent her my x-rays from 2008 and 2011 along with my metal levels. Vicky forwarded the info to several Drs.  Again--more waiting... more worrying...more tears...more stressing...more prayer...
Meanwhile I'm reading everything I can find on line and freaking myself out with research studies and abstracts that I was applying to my situation. You wouldn't believe the things I was believing about metals in my body. More on this in a
minute...

Results came back from the other Drs. and all 5 agreed that I needed surgeryand recommended a total hip replacement. The x-rays however did not show that mydevice was misplaced. 4 Drs seemed a little surprised that my metal levels were
high when the placement looked ok, and the other thought my cup was too steep.  This info at first made me really question whether or not I really had 2 choices or if indeed I only had 1: a THR. Again more tears, more prayer, more grieving the active lifestyle I would lose, more sleepless nights.

That sent me on another quest. I decided to make an appt. with a OS who does not live in the resurfacing world to try to get another opinion. I chose an OS at University of Washington who went to college with a friend of mine and did a THR
for him. He totally trusts him, so I made an appt. and fortunately got an appt. because I was a friend of a friend. Anyway, I was able to send him my x-rays and blood test results and he was kind enough to review my information and answer
many of my questions via email since my appt with him wasn't until June 29 (just a few days before my surgery date) He recommended THR and shared some concerns, restrictions, the fact that I may never be pain free, and that I'd need to make modifications to my life style to lengthen the life of the THR device.

Last Thursday evening, I sent a super long email to both the UW OS and my OS asking lots of questions, both responded on Friday morning. I cried after reading the sobering reality from the UW OS and my Drs email said to come in
that afternoon and he'd stay as long as I needed to answer my questions. I ended up leaving work early (complete emotional mess) spent the afternoon in prayer and met my husband and my OS at 4:00. We were there for about 2 hours and I left finally feeling at peace with one of the surgery options. It won't make sense to most people, but I know it's the right decision for me. And I was to the point where I had to choose which Dr to trust and move forward. Even though all the other Drs recommended a THR I was having a very hard time accepting that inevitable new lifestyle.

I'm choosing to have a socket revision to poly and keep my resurf. After answering all my questions and concerns (& I had a zillion) the final question came down to "What hip do you really want?" He was willing to do either surgery, but I needed to decide quality or quantity. I could have a restricted hip that will last longer or a more durable/mobile hip that will last a shorter time. So, I've decided to go with the surgery that continues to allow me to be me... for how long, I don't know, but the alternative of a modified me wasn't appealing---at least not yet since I still feel pretty young. I decided to
cancel my appt with the UW OS and move forward with the hip that I really want.  I sometimes worry that I'm ignoring good solid recommendations and simply going with the OS that said what I really wanted to hear, but after meeting with him for so long, I do totally trust that he wants to give me the hip that I want. He doesn't make any more $ on a THR vs. resurfacing and in fact the resurfacing is so much more difficult and time consuming in terms of patient care and follow
up. He shared that there is no benefit for the OS who performs hip resurfacings, the benefit is 100% to the patient in getting the hip they really want.

If you're hanging in there reading this, I will share some more of my main concerns and how my OS responded from his 30+ years of experience and over 1500 resurfacings. I didn't write anything down and I was a total emotional mess, so
I will try to relay his answers as accurately as I can remember.

Rule of thumb: The larger the ball, the more stability and mobility, but the socket will wear faster & have a shorter life span. The smaller the ball, the less stable but also less wear on the socket so it will last longer. Everyone must choose what is best for them.

For me, even with a THR I would have chosen the largest ball possible for stability, reducing the longevity of the socket, so it made sense just to keep my femoral component ( 40 mm) and put in a new cup which is exactly the same cup
they'd be putting in for a THR. I'll be getting a 50mm cup. They'll need to take out about 4mm of bone in my pelvis to make room since my current cup is 46.  The poly needs to be thicker because it wears more than metal. However, in
future surgeries, they will only need to replace the plastic liner in the cup as it wears out leaving the metal backing that is ingrown to my bone alone.

I did have worries about the future and what would happen if I ran out of options or surgeries. What if I get a THR now at age 46, then a second in 10 years, then possibly a third? Will I run out of options? What if I don't have enough bone left to do another one? My OS assured me that I would never be out of options and that he'd never leave me wheelchair bound. He said if we ran out of bone, we'd get some from somewhere else, and that he'd always be able to do
something. Basically, he said he never plans on running out of ideas to problem solve this.

I was very freaked out about metals in blood. Most internet searches send you to lawyers who are trying to capitalize on the recalled Depuy so they use the most shocking scare tactics possible to gain business basing info on concerns from
cobalt/chromium in miners, not from surgery. I read about hearing loss, vision damage, cardiac damage, nervous system, thyroid, etc. The more I read, the more I felt like a walking time bomb. How scary to think about something as minor as a hip when irreversible damage may be happening. My OS explained that I was in no danger. Obviously removing the MoM issue is necessary, but no damage has been done and I have nothing to worry about. He shared that only 6 surgical cases world wide have had issues and none were from resurfacing. A few were from THR where the metal head wore through the poly liner and was hitting the metal liner that was never designed to touch each other and some other factors like 1 guy was a chronic alcoholic and wouldn't have it removed. He also told me that Sweden has the only place where metal levels can be tested accurately. While my metal tests confirmed that I need to have a revision, my high numbers are not cause for concern. I can share my numbers but can't even begin to interpret them. I did the urine and blood tests through Quest Diagnostics. My insurance fortunately paid 100%, but I don't think that's typical. 

Chromium/creatine ratio is 112.5 reference range is <5.0 mcg/g cr
Chromium 41.5 ref range <2.0ng/mL
cobalt 98 mcg/L
chromium serum 98.5 ref range 1.4 or less mcg/L

I was also worried about the dead tissue and metal stained tissue that would need to be dealt with during the surgery. My OS said that he would remove all dead tissue, but the tissue that is metal stained and still alive will stay and
the metal will be absorbed back into my body and excreted and the tissue will eventually heal. The metal in my blood should be gone in 3-6 months as my body will not be fighting any additional new metal debris (as soon as my MoM is
removed) and can finally deal with ridding my body of what is currently there.

The cross linked polyethylene cup that I was concerned about is the same one that my OS uses in all THR and in revisions for failed MoM resurfacings. Long term studies are hard to get because the devices keep changing and improving.
This one has been around about 10 years and seems to be successful. Mine will be made by Stryker.

I was very worried about the fact that I am still a small female in the high risk for failure category and wondered if it's ridiculous to think I could replace the cup and have a successful result and keep all the benefits of resurfacing. My OS has been doing this revision on small females since 2007 and as of yet, none have failed. At this point if I understood him correctly, he is no longer doing MoM resurfacings on small female sizes 40-44 due to our high failure rate. Instead he is still doing resurfacings, but using metal on poly for people my size which is exactly what I'll be revised too. I can't remember exactly all the sizes, but because I'm a 40mm femoral component, I'll be a perfect match for the Stryker size 50 poly cup. At this point they only make certain sizes. (I think that's what I heard.)

At first, I thought that I had to remove ALL metal from my body and get a ceramic on ceramic THR because I believed that my immune system would continue to attack the metal femoral device that would stay if I chose the revision. I found out that as soon as the two articulating metal surfaces no longer produce debris, my body will begin to deal with what's there and slowly rid my body of the metals. My immune system will be able to get back to normal when it's no longer over loaded with metal debris.

I have also had itchy hives all over my body for the last several months that we believe may be another immune system response that should go away after my revision surgery. At first I didn't think it was related because it didn't make
sense that I would have a reaction after 3 years, but now it makes more sense that my body has more metals than it can tolerate, so it's letting me know that something needs to change. By the way, everyone can tolerate different amounts
of metals which is another reason the blood tests are so hard to understand or make a diagnosis with.

I was frustrated that my OS wasn't monitoring my progress over the past couple years by taking x-rays or checking my metal levels. After talking with him, I understood why. X-rays do not show any damage from rubbing together, in fact,
even when the device is taken out there is no visible damage to the devices.  X-rays do not show if someone has metallosis. The reason he knew I had metallosis was not from the x-ray, rather it was from my symptoms (groin pain
and clunking) combined with the time period of 3-4 years post surgery. He did not ask to have my metal levels checked because he knew I had metallosis and needed revision. When someone comes in about year 3 or 4 with these symptoms,
it's metallosis. When you make it past year 4, you're home free!! That said, he does monitor on a yearly basis people with poly sockets because the x-rays can reveal wear when a small ball is used. It will be much more difficult to monitor
the poly cup with a large ball since the socket is hidden behind it, but he'll do his best.

Sorry for the length of this. It's kind of therapeutic to work through all this swirling info and emotion that's been building up inside me. Good luck to everyone on whatever you decide to do. Through tons of prayer and tears, I'm finally peaceful and ready for surgery. 12 days and counting. I'll let you know how it goes.

(Vicky, if you'd like to post this on your "complications" section on your site, you are more than welcome. Thanks again for your invaluable help, support, understanding, and direction when I was at my lowest point and desperate for answers. You are so amazing and to go out of your way to help complete strangers through this emotional life altering decision is hard to comprehend. You are sacrificing so much of your personal time and energy to help others and I can't thank you enough. Words can't possible express my gratitude.

You are one of God's precious angels!!!)

Wendy (Mikayla)
Rt hip Conserve Plus May 2008
Revision to Stryker Poly Cup expected July 5, 2011
Dr. Pritchett