Bone-on-bone osteoarthritis leading to *positive* changes in blood supply?

[jd]

Hi everyone,

I emailed Dr Bose looking for his opinion on the suitability of my hip for resurfacing and one of his comments surprised me as I don't recall seeing anything on this topic in my research until now.

He stated that he thought the lack of bone on bone OA was a contraindication to hip resurfacing, as the blood supply to the femoral head changes as OA progresses and with spur formation, making it favorable for hip resurfacing.

He did say that overall he thought I would end up being a good candidate, but that I should wait it out with cortisone injections or any other non-op options until I get to bone-on-bone. This really surprised me as I had thought that letting it go too long could lead to AVN, cysts, etc.

Has anyone heard something similar before? Are there any studies on this?

I have also consulted with Dr Schmalzried (who likewise thought I should try to get by on injections for awhile, but gave a different reason -- the more obvious one relating to me being only 33 and the unknown lifetime of the implant) and am waiting to hear from Dr Gross and Dr De Smet.

Thanks to all!

[jss]

JD,

Condolences on the condition, but welcome.

I've read about this before and my understanding is this ... The femoral neck and head are supplied blood mostly by the medial and lateral femoral circumflex arteries. Some years ago a Dr Freeman hypothesized, and subsequently published, that by the time OA in the hip had become bone on bone, that a new blood supply to the femoral head and neck had developed; that supply being from the more distal portions of the femur.

If you've seen videos of a BHR surgery, you can imagine the difficulty in preserving tiny arteries in the neighborhood of the femoral neck and head.  So if Dr Freeman's theory is true, then it follows to reason that waiting until you're bone on bone could yield a better long term prognosis for BHR.

If you want to look up the actual work, here is a bibliography to Dr Freeman's theory.

Freeman MAR. Some anatomical and mechanical considerations relevant to the surface replacement of the femoral head. Clin Orthop 1978;134:19 – 24.

Good luck!

[chuckm]

I have heard about this too. In basic terms the femoral head develops new sources of blood supply as osteoarthritis develops. Before OA, arteries in the soft tissue along the neck bring blood from outside the bone to the head. As OA develops the head begins to receive some of its blood supply directly from within the bone inside the neck. All resurfacing surgeons try to preserve the soft tissue (blood supply) surrounding the neck although Dr. Bose says that probably doesn't matter as much in a patient with advance OA.
As far as I know these are all still just theories.

Chuckm

[Dannywayoflife]

I have heard Dr Boses theory on this. How bad is your arthritis? Have the surgeons suggested any other options?

[jd]

Many thanks to the three of you for your quick responses. This is the first I have heard of this theory, and if true, it at least makes intuitive sense so thank you for the explanation. I'll dig into it some more.

I wanted to keep the first post to the point, but now I'll give some background. I'm 33 years old. I was an active mountaineer and runner through most of the 2000s but developed severe chronic deep aching in both of my hips (right-side much worse) in late 2008 and was diagnosed with FAI (cam) -caused osteoarthritis.

I ended up having bilateral hip arthroscopies with Dr Sampson in SF mid-2009. The left hip was relatively straightforward (femoral neck resection to "fix" the cam FAI and labral repair). There was only minor articular cartilage damage and it's holding up reasonably well to this day (it's not a perfect hip, but I only have occasional and minor complaints about it). The right hip was much more severely damaged. There was a medium-sized area of articular cartilage which had delaminated, so that was removed and I got microfracture (in addition to resolving the underlying FAI). Other areas of articular cartilage had thinned at that point also.

The right hip also actually did very well until about 18 months ago (it was a *drastic* improvement from pre-surgery and I returned to full activity). About 18 months ago, what I call "museum sightseeing" started to end in a very acute stabbing pain deep inside my hip. While walking I would get intense sharp, but unpredictable pains from inside my right hip. Strangely, at this point I didn't get any chronic ache afterward. Fast-forward to the last 3-6 months and now the same thing happens far more frequently. I cannot hike more than a mile or so anymore without provoking this, and I do get a moderate-level chronic ache again, just like I did before the arthroscopy. The chronic ache comes and goes, but I am very concerned about the rapid deterioration in my condition.

I understand that the consensus is that regular repeat microfracture isn't really a workable solution, so I have been investigating a hip resurfacing as I wish to remain very active and I need the implant to last as long as absolutely possible given my age. To be fair, I am still relatively active (I do crossfit a few days a week, for example, and I scuba dive very regularly). However, I cannot hike, traveling is very difficult (as it tends to provoke the stabbing pains that cause me to almost collapse), and I am guessing that somewhere in the next couple of years I am going to have to further modify my activity to maintain my sanity.


Dr Schmalzried said that I was a clear candidate for hip resurfacing, but that he recommended trialling cortisone injections to see if I can buy more time. He didn't mention anything about blood supply, but just said that he was concerned about the implant lifetime and given my age recommended delaying. He was very clear though that he thought that fitness and strength level at the time of surgery was important, and he thought that I should have the surgery before I had to modify my activity-level further. One interesting point is that Dr Schmalzried hypothesized that the sharp acute pain could be cartilage on the edge of the microfracture area delaminating and getting caught on the femoral head.

Dr Bose is also suggesting waiting and trying to get by with steroid injections, but for a different stated reason.

I have not yet tried a cortisone injection, as I was concerned that it may cause more damage to the area. Obviously if the cartilage is damaged at this point, that is what it is and would be removed in the surgery regardless. I'm more concerned about weakening / damage to the bone and I know at least some of the surgeons (Dr Pritchett?) recommend against cortisone injections for this reason.

So, I am waiting for a call from Dr Gross to get his impressions, as well as an email from Dr De Smet. If they do not strongly recommend against it, I will go ahead and get a cortisone injection and see how long that buys me. I will also get their thoughts on the risk I am taking

Finally, I am also following up with Dr Sampson (and he has requested MRIs, so I will get a somewhat more detailed idea of the state of the cartilage).

Is there any way to evaluate the blood supply within the bone (vs outside) with an imaging technique?

Again, thanks to all. This is certainly a roller-coaster!

EDIT: Removed an incorrect "no longer" in one of the sentences.

[chuckm]

Ugh. That really sucks. You really need to fix those hips. Suppose resurfacing only lasts 20 years for you. Or even only 15 years. What's wrong with that? Then you revise to a total hip replacement by mini incision (or whatever technology brings by then) when you are in your fifties. And with the quality of total hip already that should be your last device. So two surgeries. That period where you do anything to keep from surgery is the worst. You're in pain and it is just continues to get worse.
Hope you can get fixed soon.

Chuckm

[Ljpviper]

I in a very similiar situation, read my other post. How is your joint space on the bad hip?

Larry

[jd]

Hi Larry,

I had indeed read your other post. Thanks for chiming in here.

My joint space is definitely reduced from normal, but far from "zero". I'll upload an x-ray for context when I get home today.

Chuck,

I think Dr Schmalzried is arguing that perhaps waiting makes the difference between an extra THR revision and not (ie., 1 surgery vs 2, or 2 surgeries vs 3). I pressed him a little on this as I figured at most I'd buy 2 years, and that'd be lucky. He didn't really want to speculate about lifetimes, returning to the idea that my probability of minimizing surgeries goes up if I'm older. As I mentioned above, he did finish by emphasizing that as soon as I feel like I'm losing substantial fitness due to the pain that the waiting should end and I should get it fixed. I'm hoping to understand this, as well as Dr Bose's concern when I speak to Dr Gross.

EDIT: I'm concerned that Dr Bose is worried about the reliability of the resurfacing regarding lack of bone-on-bone and blood supply changes. I started this topic because that concern really threw me off. I generally agree with your analysis that I would likely get by with 2 surgeries (a resurfacing and a THR).

-Joe

[Ljpviper]

Joe, I tried cortizone two weeks ago, didn't help.

Going for an MRI now, will post results when I get them later in the week.

Good luck dealing with the Drs. These microfractures don't seem to hold up well, once someone returns to a high activity level.

Larry

[jd]

Hi Larry,

I'm interested to hear how your MRI goes. I'm getting mine next week. Out of interest, did you have similar symptoms to me with *acute* sharp pains after certain activity, in addition to the chronic ache?

[chuckm]

Chuck,

I think Dr Schmalzried is arguing that perhaps waiting makes the difference between an extra THR revision and not (ie., 1 surgery vs 2, or 2 surgeries vs 3). I pressed him a little on this as I figured at most I'd buy 2 years, and that'd be lucky. He didn't really want to speculate about lifetimes, returning to the idea that my probability of minimizing surgeries goes up if I'm older. As I mentioned above, he did finish by emphasizing that as soon as I feel like I'm losing substantial fitness due to the pain that the waiting should end and I should get it fixed. I'm hoping to understand this, as well as Dr Bose's concern when I speak to Dr Gross.

EDIT: I'm concerned that Dr Bose is worried about the reliability of the resurfacing regarding lack of bone-on-bone and blood supply changes. I started this topic because that concern really threw me off. I generally agree with your analysis that I would likely get by with 2 surgeries (a resurfacing and a THR).

-Joe

If the blood supply issue is turns out to be true then you probably don't have much choice but to try and figure some way to get by while OA sets in. That sounds so not right but I guess that is something resurfacing can't get around at this time.
As far as multiple surgeries, I'm an optimist and just figure in another 15 years from now that joint replacement will have reached a whole new level.

good luck

Chuckm

[jd]

Larry,

I've attached an x-ray of my right (bad) hip for your interest -- I've definitely seen many that are worse, but it looks far from pristine to me.

JD

[Ljpviper]

Joe, yes I have chronic pain that is aggravated by sitting. I too remember the day my microfracture let go. I felt a weird burning pain, never went away.

Only time I am not in pain is when laying down.

My OS is also hesitant to do another microfracture.

We are gray area patients in the sence our bone structure was corrected(FAI), but the cartilege failed.

[jss]

JD,

There is an imaging technique called MRA (magnetic resonance angiography) that is used to look at blood vessels. They simply inject an intravenous dye, wait a half hour and then do an MRI on the area in question. An experienced doctor can tell a great deal from this test. I don't know how effective/informative it will be inside a bone. Your orthopedic guy would know.

Between achilles, plantar and spine, I can't count the number of steroid injections I've had. For those conditions the injections were a great reprieve from the pain. Most guys I've seen post about hip injections for OA echo Larry's outcome; little or no relief.

Good luck!

[Ljpviper]

JSS, you get your hip resurfacing a week from Monday, correct?

[jss]

Yes Larry. We fly out a week from Monday, and then Wednesday, Jan 7 is the day I get fixed (so to speak). Anxious to shed the pain. Thanks.