DO NOT WAIT

I am a retired 69 year old surgeon. For most of my life I had been super fit: competitive squash 5-6 times a week, heli-skiing, windsurfing, sailing, single handicap golf etc. I left it too late to have surgery and I find this is a common story (see Jimmy Connors, Jack Nicklaus, etc.) As there are now two options: BHR and THR, this has become important. Like most people, trouble started with discomfort in my right thigh on walking. Eventually I went to see an orthopaedic surgeon in Fiji. I was surprised when he examined me and then ordered hip X-rays. I had lost half the cartilage. The thickness on the outer half of my right hip. As a surgeon working a lot with bone, I knew that the glucosamine and chondroitin sulphate, needed for cartilage formation, are formed by the body. I deluded myself into believing that taking them orally would help – they had no effect. I also believed that a lot of walking would stimulate cartilage formation  – again deluding myself. Gradually the pain got worse, going from thigh to knee to leg to ankle. After 2 years I got a cane. This helped. Then I had to progressively increase to 200mg Celebrex a day, plus occasional Tylenol.

I am now a full time sailor going around the world with my wife. Maintenance and repairs are constant and require contortions of the hips into many awkward positions. Eventually I could no longer function in this life, so it was do something, or give up our life style. I was not afraid of surgery but I had never consciously realized that things could be so limiting that I had to get treatment. I started research and soon found BHR. Physiologically this was more logical and satisfying to me than a THR. I had excellent bone density, excellent muscle strength and I intended to live a physically active life for at least another 25 years!! A not unreasonable expectation as my mother died at 99!

I had been a surgeon in Dallas, so after due research, I found Kurt Rathjen and wrote to him. He replied personally saying he had learned BHR in England. He had installed 134 BHR and had 1 major infection. These were good enough statistics for me so I arranged to fly back to see Kurt and have surgery 1 week later.

Before leaving Malaysia, I had new X-rays taken of both hips, right knee, and both ankles ( a total cost of $85!). This was 3 years from my first X-ray showing trouble. I was appalled to find that I had no cartilage on the lateral side of the hip joint. It was not just bone on bone but disintegration and micro fractures of the femoral and acetabular surfaces. Kurt took further X-rays and this is when the bad news arrived.  I had developed large cysts in the femoral head and acetabulum. Presumably the micro fractures had allowed the joint synovial lining to be forced into the bone. The synovium then expanded to form the synovial cysts.

Kurt and I discussed the possibilities. One (unrealistic) possibility would be to scrape out the cysts, insert cancellous bone grafts, wait for 3 months forming new bone, almost non-weight bearing, then have a BHR. Obviously stupid. Secondly, I could have a BHR, ignoring the cysts. However, as the cysts were so large, there would be a significant risk of femoral neck fractures and neither Kurt nor I were interested in taking the risk. This  meant a THR was the only sensible option. One advantage of the BHR is the very large femoral head and an acetabular cup that covers 80% of this head. This decreases the chance of dislocation. The standard THR has been a small femoral head and an acetabular cup that covers 50% of the cup and thus a higher chance of dislocation. I was delighted to find that Kurt uses a prosthesis that is similar to the BHR with a metal head and acetabulam. Over long term metal on metal would be more durable if lubricated. Think of a car or boat engine with constant motion for thousands of hours, working beautifully if well lubricated. Fortunately, your body physiology means you do not have to change the oil every 100 hours!

So I had the THR, and expect it will me 25+ years.  However, as yet, I am not sure that I will be able to reach the level of activity possible with a BHR.

The moral of the story is: Get yearly X-rays. Once the cartilage is almost gone, or sooner, get surgery. Do not wait until disintegration occurs and cysts develop. Although a BHR is a relatively new procedure, it is physiologically and theoretically more sound than a THR- if the majority of the femoral head and neck are normal healthy bone. Conceptually, it really irked me that Kurt had to remove all the good normal bone of my femoral head, neck and shaft. Also if there is a problem with a BHR you can still have a THR. The reverse is not true. DO NOT WAIT. I wasted a year and a half – progressively limiting activities of going ashore to explore, or go for walks, visit restaurants etc. We went to Flores to see the Komodo dragons. Instead of going for a 5-10K walk with the guide, I was limited to an slow, brief half hour only seeing the dragons around the camp (wild but indolent). If I had been having yearly X-rays, I would have been able to have a BHR before cysts appeared.

Modern surgery is safe in a good center and will get you back to a normal life. Some surgeons use  minimalist exposure techniques with less muscle disruption resulting in a reputedly faster recovery. I had the standard approach but I am writing this 11 days post operatively and I am pain free all the time except for muscle ache during the three times daily exercise periods. I can see that within another week I will be pain free. Then mental discipline will have to take over in order to restrict activities. I have a non-cemented femoral stem and acetabular cup; in my opinion the only way to go. Progressively, over time, scar tissue will develop and adhere to the roughened outer surface of the prosthesis. By 6-8 weeks this starts to become significant. Over further time, the strength of the adhesion becomes stronger and stronger. If the periosteum of the femur was preserved at the time of bone removal, there is a good chance of developing bone adhesion to the prosthesis. This is more likely in a younger patient than myself. However, all joints of the body – normal or abnormal – are protected by the strength of the muscles around them. Prior to the onset of symptoms, I had enormous leg strength, balance and agility. All of this was lost by waiting so long. Beforehand I used to be able to jump from uneven rock to uneven rock along a seashore – even if slippery – knowing I would never fall. My muscle strength and balance meant I could always recover if I made an error. I wonder if I will ever get back to that again?