Slipped Cup, Metal Debris - Birdie
How it began
3-20-06 Left hip resurface. Unremarkable surgery, no problems at all recovery progressed very well. Almost pain free, incision healing well.
4-18-06 Was walking slowly down stairs at 4 weeks post-op and heard loud "pop", felt intense pain, like an arrow piercing my thigh from the inside of my thigh outward. Xrays taken the next day showed no detectable problem. Pain quotient was now much higher than before the episode. I was convinced something serious happened at that point.
I wrote to surfacehippy…. Sun Apr 23, 2006 5:32 am
Does anyone know how to tell the difference between pain being generated by unhappy muscles and pain generated by something going wrong with the operation? I'm pretty sure that what I'm feeling is just normal post-op healing, but it's not getting much better and it's been 5 weeks.
I still experience pain when I put weight on the leg - not just when I move it, and that's what kinda has me concerned. The incision is healed and looks great, there's no swelling, but this other pain has me a tad anxious. Last time (first hip resurface), I was virtually pain free at this point.
After 3 months, most pain was essentially gone, except for start-up pain and upon certain maneuvers. (standing up after bending over for a period of time, releasing weight after standing on operated leg, sitting for awhile with hip bent at less than 90 degrees)
I queried doctor and staff several times over course of year about discomfort and clunking. Was informed that Xrays were scrutinized and that everything looked normal.
Pain levels and movements that cause it remained consistent. Bothersome clunking. Not painful, just annoying. Xrays at 1 yr revealed nothing, but pain continued. Pain was considered to be in the range of normal for that stage of the healing process. However, I "knew" there was something not right. Therapy for 3 months, therapist suggested impingement of some sort, considering type of pain that showed no improvement after therapy. Pronounced clunking that worsened throughout year 2.
Checkup and xrays at 2.5 yrs (10-28-08) Pain continued, but not constant - only upon above-mentioned maneuvers. No real improvement over previous year. Bulge (5" x 3" ) developed along left pelvic bone about 6 weeks or so prior to appt. Soft and pliable. Xrays examined - angle of cup determined to be off about 15 degrees - cup has slipped. Bulge is likely the reaction to metal debris.
As of Nov 22, 2008 clunking continues to worsen,(about 50% of movements of any type, including turning over in bed, shifting weight without moving legs, etc) Bulge/mass/swelling growing, extending to crease between thigh and abdomen. Occasional stinging feeling in affected area, rare but occasional shooting pain down groin muscle area. Consistency of lump getting stiffer, less pliable. Pain in swollen area upon prolonged pressure, such as lying on stomach in bed.
Again, I wrote to surfacehippy, this time in response to someone saying that his acetabular cup had slipped but was not causing any symptoms at the time, and what should he do?
Fri Oct 31, 2008 8:36 pm
I don't know how you are doing at this time, but I would like to caution you to really pay attention to your body, and to not ignore your gut feelings. I just got back from a checkup with the doctor. Had my left hip resurfed 2 and 1/2 years ago. Exactly 4 weeks after the surgery, from which I was healing beautifully, I was slowly walking down the stairs, and I heard a loud POP, followed by a zing thru my leg that felt like an arrow went through it. Scared the bejeebers out of me. Went to the local ortho guy for an X-ray first thing the next day, sent the xray to my surgeon by email followed up by the hard copy. Nothing looked abnormal, everyone told me, and it was just your typical post-op feelings.
I just didn't feel they were right - I just KNEW something else had happened. From that day on, nothing felt the same. My mistake was that I didn't push it. I should have pressed it till I was satisfied. Well, I've experienced pain on and off, groin pain especially, start-up pain, and a strange residual pain that resulted from standing up after bending over. It clunked while walking, all the normal stuff. It really did take my first resurf a whole 3 years to heal to just about perfect, so I was waiting patiently for that healing to take place. But it wasn't.
To make a long story a lot shorter, I didn't listen to my inner voices. Therapy didn't help at all, the clunking got worse (almost constant), and I still ignored my voices, because all the checkups and x-rays I had didn't show any problems.
Fast forward to this week. At my appointment, I reiterated all the symptoms I'd been talking about for years, and showed the doc a new development - a lump/swelling/growth - whatever you want to call it running along my pelvic bone - about 4 - 5" long. Xrays revealed that my cup was now a full 15 degrees off where it should be, and it's possible that the clunking I was experiencing was the femoral head rubbing along the exposed edge. The swelling is probably a reaction to the metal debris, and that is NOT a good thing. So now, we don't know if the cup is fixed in its tilted position, or if it's still floating around. We don't know if the femoral head is damaged from the rubbing along the side of the cup. And we don't know if I've sustained tissue damage from the metal debris, or what it effects will be long-term. What I do know is that I have to have a revision, most likely to a THR, and that it all could have been avoided if I'd listened to my voices and been so much of a pain in the neck that it would've forced them to do more tests. I could have gotten it fixed before any more damage was done, not 2 years later, when lots of damage has been done. But now, I will most likely lose my resurf, have yet another operation with a much longer recovery time, and will always have that cleaver over my head about what the metal debris has done or will do to me in the future.
This is not a "pity me" message, or attempting to scare anyone. The only message here is to listen to yourself. You already know the cup is not in perfect position. It's very possible that you will have no problems whatsover, and I hope that comes true. But three suggestions: Make sure that the doctor measures the angle of your cup on every visit to check for further drifting. Also, really be aware of your clunking and your pain. It should decrease with time. If it doesn't, or especially if it regularly increases, get to the dr quick! Also, pay attention to any new swellings or lumps in the groin or hip area. They can be signals of real trouble.
I hope for your sake that nothing else happens. Just don't forget to pay attention. And act on your hunches.
Vicky read my response, and knowing that my metal debris problem was unusual and serious, contacted me and offered her help, which I accepted most gratefully.
Through Vicky’s magical connections, I was able to see Dr Su, who was concerned and intrigued by my case. This was the second of its type that he had seen in less than a year, and the similarities were striking. Vicky was able to get several opinions from well known doctors from all over, and all concluded that a revision was imminent and should be immediate. The debris pad was of concern to all, especially since there was no way of knowing its extent or just what it was doing to me. It was the thing that concerned me most also. I had visions of my entire gut lined with black sticky ooze, and my very active imagination painted scenarios that scared me silly. But Dr Su’s, quiet gentle demeanor gave me confidence and assurance that things would work out OK. We scheduled surgery for Dec 17th.
One of the more interesting things that happened was on my marathon testing day. To make sure that you are prepared for surgery, they do a battery of tests, cardiac work, bloodwork and for me, an MRI. Two of those things were quite different, in that the blood testing was specifically for heavy metals, which only 2 labs in the country are qualified to do, and Hospital for Special Surgery has access to. That was one of the reasons I chose HSS and Dr Su. I really wanted to see my “numbers” and nobody else around here knew how to do it. The second unusual thing was going for an MRI. Everyone knows that someone with as much metal in them as me should never go for an MRI. (I had 2 resurfs at the time). Here’s where HSS’s expertise came in again. HSS is one of the only hospitals around that has the specialty equipment and a technical crew specially trained to deal with patients with a lot of metal in them. (It has something to do with the ability to eliminate the “artifacts” as well as positioning , etc that enables them to get good pictures despite the metals. I don’t pretend to understand it – I’m just glad they could do it.) So I climbed into the machine, expecting a good nap (It was the end of a long day of testing, walking all around NYC in the rain, dragging a sore hip. I’d had MRI’s before and know how to sleep thru them.)
Well, not this time. As soon as the rays neared the debris mass, I could feel it! I knew that was not normal. With all that metal debris in there, I could just imagine the metal attracting the magnetic waves, heating up the metal and cooking me from the inside out! But I am no wimp, and I continued to do yoga breathing and sang along with the music in the headphones to keep myself busy. But it stung – not severely, but enough to concern me. Finally, I ended up calling them to tell them that it kinda hurt and to ask what was going on, etc, and asked basically if I was becoming a microwaved piece of meat, because that’s what I felt like. They added pillows, and did everything they could to divert some of the rays and make me more comfortable. It happened again, this time a little more painfully and this time the entire radiology department came in to observe this woman with a strange and unusual debris mass (that they had been well informed of). They all took turns poking at me, feeling the mass, moving pillows around, scratching their heads and trying to give me assurance. They assured me that I was not being cooked and that they would not allow anything to happen. But they were almost through, and if I could stand it a little longer, we’d be done. I put on my stoic face and used every personal trick I could to divert myself, and I did get through it. By the way it felt tho, I was convinced that I could slice open my abdomen and find cooked meat in there. Thankfully, the residual aches went away by the next morning. And we were rewarded by excellent photos of my “mass.” It appeared that the debris was primarily located in a bursa sac, and not widespread at all. Thank goodness. But as Dr Su said, it was an impressive mass, one that he had never seen the likes of, and he was eagerly looking forward to operating and removing it while revising the hip. We ultimately decided on a ceramic/ceramic total hip. I grieved heavily for awhile about losing my resurf, but the experts convinced me that I needed to remove the potential for more debris from that hip, as I’d had enough exposure to those lovely heavy metals already. They would test my blood occasionally to see how my metal levels were after a certain time period, and hopefully they would go down steadily. I affectionately refer to them as my “sludge” levels.
(Birdie had a revision to a THR on December 17, 2008 by Dr. Edwin Su even though he was NOT the original doctor that implanted her (left resurfacing done on 3/20/08)) cup that failed.)
My surgery went flawlessly. Since I was a well seasoned hip surgery patient, this being my third, I knew what to expect, pretty much knew how hard to push myself and had an easy experience of it all. It turns out that the acetabular cup was attached only with fibrous tissue, and popped off with the first tap of the hammer. There was no bone in-growth, and no need to dig the cup out of my pelvis. This led to an easier recuperation for me, thankfully. However, I still marvel at how much abuse the fibrous tissue withstood. The cup did not move around much, if at all, and I was not in as much pain as I would have imagined with a floating cup.
Dr Su dug the debris laden fibrous tissue out of the pelvic area, producing some pretty sizable, impressive hunks of yucky stuff that he artfully arranged on a surgical tray and took pictures of. Some of the masses were 2 inches long and an inch thick! He sucked some out with a vacuum, and took movies of that. I guess he had quite the entourage of on-lookers during my surgery – everybody seemed to know about me, and some were actually disappointed afterwards that it wasn’t as bad as they thought it might be. (Sorry to disappoint ya, fellas.)
Update January 26, 2009
At 6 weeks, I wrote to Vicky…
I am so sorry that it has taken me this long to write you back. Everything has gone so wonderfully and quickly that I got back into life right away. This marks my 6 week anniversary, and I couldn't have asked for a better experience. Without a hitch - not even a little one (so far, anyway) I have a big honkin' scar down my hip/thigh that healed up very quickly, and no significant pain. I needed no PT, no further followup of any kind. I can walk without hardly a limp (altho he wants me to stay on crutches at least until I see him in another 10 days). But I have such trouble remembering to use it, especially around the house. I frequently find myself up or down half a flight of stairs before I realize what I'm doing. And it's been this way since my three week mark. This has even gone faster and easier than my other two hips. WOW!!! My only real reminder is that sometimes the groin/other muscles across the top/front of my thigh spasm upon shivering when cold (which I do easily) or if sitting in certain positions for too long. Then all it takes is some walking around or massage and it goes away. That's infrequent enough to be inconsequential.
I can't wait to stride into Dr Su's office next week, ask him the barrage of questions I have and I pray he hands me my wings so I can fly! I certainly am ready, but want to ensure the long-term integrity of this hip.
So I have to thank you once again for your involvement in bringing me to this end. I am delighted with HSS, Dr Su and the entire procedure. I'm VERY thankful that there have no further complications, and I pray there never will be. I have it on my list to write my story for your website, and I promise I will do it eventually.”
Update April 10, 2009
Today, at 4 months post surgery, I’m back to my old self, hiking, walking around constantly, and I even found myself running upstairs today. 99% of the time, I forget that I even have a new hip – it feels that normal. Actually, it feels better than my second resurf ever did. Dr Su is a master at his craft, and I firmly believe that the skill of the surgeon has SO much to do with the success of one’s surgery. That, and the attitude of the patient. As for my attitude, well, I’m a little bit of a clown, a definite glass half full type of gal with a typical Type A, “get out of my way and let me at ‘em” personality. I knew I would recover fast and was anxious to try out my new hip as soon as I could. And I did. (a little too much, actually, but that’s a different story)
We’ve checked sludge levels twice so far, and they’re coming down nicely. I have an appointment in a few more weeks, when I will undergo another blood test. I hope and pray that this new hip will truly last me the rest of my life, and that the toxic metals in my system will not wreak havoc on my body in any way in the future. But I won’t know until it happens, and until then, I have a very full life to lead. I'm back to my old self, meetings 3 or 4 nights a week, sitewalks (climbing over rock walls, piles of downed trees, up dirt trails on mountainsides, etc) - nary a hitch. It's not 100%, but probably about 95%, and I'm doing lots of strengthening work at the gym. This little puppy is going to be STRONG!
So far, I have the happiest of endings, and am back in the world full strength. Places to go, people to see, things to do..... And it's great!”
As a quick timeline:
3-20-06 Left hip resurface
4-18-06 .Heard loud "pop", felt intense pain Xrays showed no detectable problem. Pain quotient much higher than before episode. Patient convinced something serious happened at that point. After 3 months, most pain gone, except for start-up pain and upon certain maneuvers. (standing up after bending over for a period of time, releasing weight after standing on operated leg, sitting for awhile with hip bent at less than 90 degrees)
Patient queried doctor and staff several times over course of year about discomfort and clunking. Was informed it was normal.
Pain levels and causes remained consistent. Xrays at 1 yr revealed nothing, but pain continued. Pain was considered to be in the range of normal for that stage of the healing process. However, patient "knew" there was something not right. Therapy for 3 months, therapist suggested impingment of some sort, considering type of pain that showed no improvement after therapy. Pronounced "clunking" that worsened throughout year 2.
Checkup and xrays at 2.5 yrs (10-28-08) Pain continued, but not constant - only upon above maneuvers. No real improvement over previous year. Bulge (5" x 3" ) developed along left pelvic bone about 6 weeks or so prior to appt. Soft and pliable. Xrays examined - angle of cup determined to be off about 15 degrees - cup has slipped. Bulge = reaction to metal debris.
As of Nov 22, Clunking continues to worsen,(about 50% of movements of any type, including turning over in bed, shifting weight without moving legs, etc) Bulge/mass/swelling growing, extending to crease between thigh and abdomen. Occasional stinging feeling in affected area, rare but occasional shooting pain down groin muscle area. Consistency of lump getting stiffer, less pliable. Pain in swollen area upon prolonged pressure, such as lying on stomach in bed.
LHR rev to THR scheduled for 12/17/08
**WARNING** Graphic photos from her surgery follow
A view into the hip joint. Note the metal-stained tissue at the inferior aspect of the joint.
A picture into the hip joint with the femoral head removed – this shows access into the front of the joint, also with metal stained tissue
This shows the femoral head and the indentation along the femoral neck where the bone has remodeled; note the metal stained tissue invading under the femoral cap
This shows the backsurface of the acetabular component, which shows no bone integration
Excised metal-stained tissue from the hip joint