Jane, Slipped Cup, Metal Debris

Failed BHR & Surgeon Experience
By Jane

(Update follows)
August 02, 2008

I am 18 months post LBHR and I am posting today with the hope that I can spare anyone contemplating the resurfacing procedure the consequences of choosing a surgeon with insufficient experience. I chose a surgeon who had only recently trained in England , I was his 7th resurfacing procedure. I justified the decision because he was local and had a stellar reputation. I foolishly reasoned that he would not take on a procedure that was beyond his competency. At four weeks I was complaining of snapping, popping and instability in my surgical hip. Those symptoms have persisted with the same periodic reassurance from my surgeon that the x-rays showed that the "prosthesis is in good position without any evidence of loosening or wear".

It was my good fortune to have had Vicky Marlow pick-up on a posting I made on this site earlier this month when I recounted a second opinion from a local orthopedist suggesting that the cup was malpostioned and that I would need conversion to a total hip. Vicky quickly facilitated the expert opinions of resurfacing surgeons who independently concurred that the acetabular component was indeed in the wrong place and that I was at risk for impingement, edge loading and the subsequent shedding of metal ions into the hip capsule and the blood stream.

In less than a week, I was seen by Dr. Su in NY. I am scheduled for either a revision or conversion pending the outcome of cobalt/chromium blood levels results.

I want to stress the importance of heeding the advice of Vicky, Pat and the surgeons who have made this website such an invaluable resource. I wish that I had appreciated the extreme technical skill required to exact the positioning of resurfacing hardware as well as the expertise necessary for immediate
recognition of the symptoms and radiographic evidence of a failed procedure BEFORE I signed that consent form.

My heartfelt thanks to Vicky and everyone who contributes to Surface Hippy. I will never again minimize the value of experience.


LBHR Chronology  for  Jane

Fall 05  onset of hip instability

9-06 bone on bone dx with THR recommendation

2-06-07  LBHR post –op activity included: standing leg flexion, abduction and extension exercises (unchanged since immediate post-op), recumbant bike, walking  1.5 miles

4-04, 06-07  cautiously hiked ½ mile with walking sticks. (authorized by surgeon’s PA)

4-07-07 noticed  “snapping” in operative hip

4-10-07 snapping, clunking, popping felt in several areas, often with each step, some burning sensation

4-11-07 xrays & appt with surgeon  “greater trochanteric bursitis & hip inflammation” advised to take Celebrex and “eliminate activities that are painful

5-02-07 pain dissipated but snapping etc continues xrays & appt with surgeon  “…has no symptoms related to the joint replacemnt, I detect no clinical problems…..no radiographic problems”  . PT ordered at patient request

5-09  Physical therapy consisted of heat, ultrasound, stationary bike, and ice. I stopped  PT as it began to aggravate my symptoms.

5-23-07 pain-free snapping continues    xrays & appt with surgeon.  “xrays look fine….I don’t think its anything serious. Over the next few months the snapping, popping  and clunking continued.  On ocassion there was a grinding senation.   No specific activity seemed to make it worse or better.  I was unable to walk more than a mile or two as the hip felt fatigued, unstable and loose with prolonged weight bearing.    I did pilates,   I tried water exercise and deep tissue massage with no improvement.

9-19-07 xrays & appt with surgeon  “prosthesis is in good position without any evidence of loosening or wear”  advised to work more on strengthening and eliminate any  stretching.

12-07 my personal trainer feels  that my hip is unstable and refers me to a Doctor of Physical Therapy  (DPT)

12-20-07 Evaluation from DPT,  goal to  eliminate alignment and strength variables.   Program includes private PT twice a week and daily 45 minute home exercise program.

2-6-08 ONE YEAR appt and xrays.   Clunking is virtually gone but snapping & popping        continues with feeling of instability, fatigue and pain with  prolonged weightbearing. I now have the left sided sensation of ‘sitting on rocks”.   OS dismisses  DPTs assesment which includes “significant indications of incongruency of femoral head and acetabulum”.  Although I do not complain of localized pain,  OS prescribes Celebrex with  re-evauation in one month ; then a cortisone injection for greater trochanteric bursitis/IT band tendinitis and schedule for iliopsoas injection and iliopsoas release if not resolved conservatively.

3-6-08   One month of decreased activity and Celebrex, snapping and popping remains the same.  I return to my physical therapy regimen and decide to seek a second opinion.

3-9-08   Appt with sports-med non-operating orthopedist whom I saw pre-op.  He advised continuation of  PT and muscle strengthening and if problem not reseolved, seek opinion from another surgeon.

4-08   Continued PT and home exercise. Walking limited to 30 minutes a day. While out of town, I walked 2 miles and rested for 30 minutes.  I then attempted the return walk and my hip felt sore and unstable, after one mile had  to summon a car ride due to pain.

5-24-08  DPT writes letter to consulting surgeon.

5-27-08   Appt with orthopedic surgeon,  retired chair of orthopedics. I received a thorough exam, passive and active ROM with demonstrable snapping and popping.   MD describes on xray “a bit of an offset of the femoral head………..iliopsoas and possible rectus irritaion……….either live with it or probably convert it to a traditional hip and hope that solves the problem.

7-2-08   Appt with  a second prof of orthopedic surgery.  I was examined by surgeon and his fellow.   He suspects that the acetabular cup is not properly seated and that there may be more than one factor contributing to the instability and continued popping and snapping.  He suggested a conversion to a THR when the symptoms are no longer tolerable.

Currently I am unable to walk more than one mile.  I cannot tolerate prolonged weight  bearing as eventually my hip feels fatigued, swollen, unstable and painful. I have been unable to return to working a full 8 hours if I am on my feet.  If  I am sedentary, I have no pain.  I can ride my bike without pain or snapping.  Standing with a weigh shift creates popping,  side-lying flexion and extension can reproduce as many as ten consecutive pops. When I roll over in bed, the hip pops.   I take anti-inflammatories around the clock.   With the exception of two recent incidents (following a first time dose of once- a- month Actonel) I have not had pain that required a narcotic.

January 14, 2009
Conclusion-  Jane’s Story
Unfortunately, I am no longer officially a “hippie”.  Nonetheless, I feel compelled to complete the story of my failed resurfacing and share the lessons learned from my experience. After seeing Dr. Su in July regarding persistent clunking, snapping and instability following a LBHR in February 2007.   He advised revision or conversion to THR as soon as possible by a surgeon experienced in revising MoM (metal on metal) prostheses.

Dr. Su pointed out that without a corroborative clinical picture, it could be difficult to confirm a malpositioned cup (my situation) by radiograph alone. Although the cross-table x-ray provided better evidence, the assumption a surgeon might incorrectly make in the absence of pain would be that placement was adequate.

Dr. Su believed that my resurfacing components were positioned so that the metal head and socket congruency was less than optimal which would lead to the generation of metallic debris..  He felt that it might be possible to save my resurfacing by repositioning the acetabular component only, but that I could remain at risk for metallosis as the ground work for metal reactivity (to be differentiated from metal sensitivity) had been laid as my hip capsule had likely bathed in the  metal debris for an extended period of time.  In addition, it was possible that the wear to the femoral head was extensive enough that it would not support a revision.  With this information in mind,   I elected to have the BHR removed and replaced with a ceramic THR on September 30, 2008.

I recovered in HSS for 3 days.  My surgery and subsequent hospital stay were without complication.  I received the legendary 5 star treatment during my stay and I have the same praise for the hospital and staff that has been posted before on this site.

Because the resurfacing cup had to be extracted from bone, I was restricted to 30% weight bearing with two crutches for 7 weeks post-op. 

I am now 11 weeks post-op and 100% weight bearing with all precautions and restrictions lifted.  I have no clunking, no pain and have virtually no untoward sensations to remind me of what I have experienced.

While in NYC, I had Cobalt and Chromium blood levels drawn.  It was explained to me that a normal level in a person without any metal in their body would be 0. A person with a properly positioned MoM prosthesis might expect to see levels in the 5-10 range. The levels drawn in July dropped significantly 3 days after I had the MoM components removed and replaced with a ceramic on ceramic (titanium backing and post) THR. Cobalt: from 136.5 ng/ml to 49 ng/ml Chromium: from >100 mcg/L to 59.9 mcg/L It is unknown what my immediate pre-op levels were but I would assume that they were much higher than they were 2 months earlier. As soon as the MoM factory” was removed, the systemic levels plunged. Although none of my renal studies indicated impaired kidney function, it was clear that my kidneys could not purge the blood stream of the metal ions as quickly as the shearing mechanism was generating them.

Ten weeks following my surgery my metal levels had dropped even lower. Cobalt: from 49 ng/ml to 8 ng/ml Chromium: from 59.9 mcg/L to 17 mcg/L Metal ion levels are a useful tool but not routinely done following resurfacing procedures.  Dr Su suggested that interval metal levels may become part of the post-op evaluation of a metal on metal prosthesis. It is patently possible for a poorly positioned implant to be shearing metal ions into the hip capsule while the patient remains pain free.  With a baseline level pre-op, a surgeon would have feedback long before a patient developed symptoms. It seems that if a surgeon is prepared to perform a MoM resurfacing procedure, it would be prudent to know how and where to have baseline and scheduled metal levels drawn and know the significance of the resulting information.

Thank you
I am forever grateful to the efforts of Vicky Marlow who stepped forward to guide me toward a diagnosis and treatment by an experienced and talented surgeon.  Vicky and the many surgeons whom she has personally interviewed, deserve great respect for the generous donation of their time and energy and for facilitating the dissemination of accurate information that otherwise might not be available to the vast majority of us.