Acetabular Placement Question

[JohnS]

BILL,
Hang in there.  I believe you have a right to be concerned and ask questions, especially when you feel you are behind the recovery curve and information is hard to get.  If I can get a copy of my x-rays on CD after my post-op 12/4, I'll send you a copy to add to the others you've been getting.  I know they won't answer any specific questions for you, but you have several for reference.
Good  luck my fellow hippy.
JohnS

[woodway2]

Stevel
Sorry, I've been looking on the web for the xray that I once found with angles marked out on it, but I can't find it. The study that is on Pat's surface hippy is http://www.surfacehippy.info/metalionstudy.php. It was this study that alerted me to the angle issue. I do know that my cup angle is not as high as the 3 outliers in
this study.
nancy/woodway

[stevel]

Nancy,

Thanks for the reference.  Those are steep angles!  It appears that the acetabular socket angle is measured from the horizontal, so a steep angle is over 55 degrees. 

[B.I.L.L.]

My cup angle is similar to the ones in those study pics.  I"ll let you know what the Dr. says when I see him.  I have made a lot of progress in the last few days. I'm off the cane for quite a bit during the day now but still using it on longer walks. I feel the last few days have been a turning point and really hope the steep angle will not be a big issue but we will see... Thanks everyone for all your pm's. Any info on steep angles I get I will let you know.  Thanks again, Bill   

[B.I.L.L.]

Got a message from my Dr. on my cell phone (he's never sent an e-mail, always a call on my cell with a restricted #, I was in the shower and missed the call). Anyway he said yes the angle is much steeper than he prefers, "It thought it looked ok after surgery but the last x-rays show the cup angle being very steep"   "We can wait an see if there are problems 6 months down the road" F-that, if its wrong I'd rather not waste another 6 months wondering. I'm not 100% sure there are x-rays from right after surgery, I got the impression the x-rays at 6 1/2 weeks are the only post op x-rays.  I have an appointment with him to get new x-rays and I will have my digital camera with me and post them here when I get them, as well as get 3 or 4 other doctors opinions.  Awesome huh ??   Right about now I wish I still had the original eguipment.....  If you are new in here and haven't had surgery yet,  LISTEN TO PAT AND USE ONE OF THE DOCTORS ON HER LIST.  Thats all I got, later, Bill.

Oh I do have one question, I can't seem to find exactly what are the downsides to high metal ions in the blood ?  Does it lead to loosening of the components ?  General health issues or what ?  Just curious. I googled metalosis and all it has is some lame video that shows some guy turning into the terminator.  What do the metal ions actually do ?
I'm gonna have to weigh my options, thanks. 

[Bionic]

I'm so sorry to hear about this.  I guess there's little consolation in knowing you were right all along. 

I suggest you get a guru's opinion on what to do.  You've given this doctor his chance, and he's blown it.

Find one of the renown resurfacing docs, send him your x-ray, and tell him your story.  He might recommend operating again, in which case the metal ion issue will go away, and, more importantly, you'll have an overall more successful outcome.

Do not wait.

[John C]

Hi Bill,
I would be very surprised if x-rays were not taken right after surgery. I think that it would be valuable to call ahead and make sure that these are available at your appointment, so that they can be compared to the new x-rays. Whoever you talk to in the future, it will be critical to know whether the cup is still where it was originally placed, or whether it has moved. From there, just get some opinions from Drs that you have a lot of trust in.
For what it is worth, I have had three different procedures done on my hip over the years. One that was done earlier this year, was a total disaster. It was after that event that I went to Dr. Gross, and his surgery has put me back on the positive track. I now look back on the previous experience with the other Dr. as an unfortunate side trip, not a dead end.
I am sure that you will find a way to feel that you are on track.

John

[obxpelican]

Hey Bill,

Sorry that you were right about the diagnosis.

This is my opinion, take it for what it is, I am not medically trained, but if you're having pain to me it's obvious that it's an impingment issue or something related to how your cup is seated.  I would get those x-rays (the originals), ask for them on a CD if possible, tell them that you are getting a 2nd opinion. 

As far as the metal ion issue, Dr. Gross has a good whitepaper on it.  http://www.grossortho.com/forms/MetalIonWhitePaper.pdf

I'm sorry that it did not turn out correctly, but that does not mean you won't be perfect soon.  Be the best patient advocate for yourself.  Find a doctor with experience that lives close to you and get a 2nd look. 


Chuck

Got a message from my Dr. on my cell phone (he's never sent an e-mail, always a call on my cell with a restricted #, I was in the shower and missed the call). Anyway he said yes the angle is much steeper than he prefers, "It thought it looked ok after surgery but the last x-rays show the cup angle being very steep"   "We can wait an see if there are problems 6 months down the road" F-that, if its wrong I'd rather not waste another 6 months wondering. I'm not 100% sure there are x-rays from right after surgery, I got the impression the x-rays at 6 1/2 weeks are the only post op x-rays.  I have an appointment with him to get new x-rays and I will have my digital camera with me and post them here when I get them, as well as get 3 or 4 other doctors opinions.  Awesome huh ??   Right about now I wish I still had the original eguipment.....  If you are new in here and haven't had surgery yet,  LISTEN TO PAT AND USE ONE OF THE DOCTORS ON HER LIST.  Thats all I got, later, Bill.

Oh I do have one question, I can't seem to find exactly what are the downsides to high metal ions in the blood ?  Does it lead to loosening of the components ?  General health issues or what ?  Just curious. I googled metalosis and all it has is some lame video that shows some guy turning into the terminator.  What do the metal ions actually do ?
I'm gonna have to weigh my options, thanks. 

[Pat Walter]

Hi Bill

Proper placement of the acetabular cup is one of the most difficult problems in resurfacing.  You are correct in encouraging people to use the really experineced surgeons.

The high metal ions can cause a number of problems from pseudo tumors, to metallosis which  is high wear if the bearing with the generation of lots of metal wear particles. It is usually a result of sub-optimal component positioning.

You can get fluid build up making it seem like an allergic reaction or just pain.  I saw videos of surgeries removing hip resurfacing devices which had the allergic reaction. There was an ugly mess of dark black tissue all around many areas of the hip.  Some called them pseudo tumors.  The surgoen would not want to leave that kind of tissue in your body and would do a revision if they suspected such problems.  Very high levels on metal ions in the blood will usually make the surgeon suspicious.  There are not many very good reliable blood test developed yet to test metal ions.  That seems to be one of the biggest problems.  

I have a handful of stories of people with metal allergies requiring revisions here  http://www.surfacehippy.info/hipresurfacingproblems.php

I would guess you surgeon would try a blood test if he suspected problems if he can find a lab that can do a decent job of it.  People have problems and don't have pain.  Dr. De Smet and other surgeons were talking about it at the LA resurfacing conference.  Only the blood test tells them there is a problem.  Dr. De Smet said the only way to have peace of mind is to know you used a really good surgeon who placed the acetabular cup properly. Years ago patients thought the femur neck fractures were going to be the big problem, now it has turned out to be loose or improperly placed acetabular cups.

Normally they take x-rays right after surgery so they can see the placement of the hip device.

Wish I could help you more, but don't know what else to say at this point.  See what your surgeon has to say.

Pat

[B.I.L.L.]

Thanks for the encouraging words you guys !  My appt. is next thursday the 11th.  I keep you guys up to date and will post the X-Rays when I get them. 

[woodway2]

Hi BILL
Well....sorry to hear your news but it is good that your doctor called you and is giving you some attention.
Here are some thoughts....It sounds like you are recovering well but slowly. My surgery was Sep 19 07 and I was not really physically confident until Christmas. Now my hip is great. Some of the discussion around metal ions at the course Pat went to in LA were because of me, as my surgeon was there delivering a paper and asked a few colleagues their opinions. Everyone had a different take on the angle and metal ion issue. The only surgeon who said he would redo the surgery based on the ions and xrays and not based on pain, said he would do it only if the angle was 70 degrees or more. My angle as measured by my doctor is 59 degrees.
Can you find out what your angle is?
RE: the metal ions. Pat is right, nobody knows much about this. I went to Dr. Gross's link and the problem I have with it is the same problem I have with all the "don't worry about the ions" articles. These papers never talk about those of us who have high ions - the outliers. It is hard to get accurate tests, and very confusing as all over the world different units of measurement are used. I am hoping that 10 times tiny is still tiny. The lack of information is because all that is known about metal in the body is from industrial applications, ie inhaled metals. And so most of the problems are lung related.
So maybe there is no problem. Wouldn't that be nice. I'm in denial right now......next test for me is in Jan.
best,
Nancy

[stevel]

I read an article where Dr. DeSmet's comparied the BHR device to the Conserve Plus device.  At the end of the article, he summarizes the problems with sockets placed greater than 50 degrees for the BHR device.

[obxpelican]

Nancy,

I think Bill's problem is two fold , one is the possible ion issue, but the major problem is that is that he is having pain down the right side of his leg.  The pain that Bill was having was the major concern.  The angle issue was found because he was investigating the possible reason why.  The ion issue came up post-pain.


Chuck

Hi BILL
Well....sorry to hear your news but it is good that your doctor called you and is giving you some attention.
Here are some thoughts....It sounds like you are recovering well but slowly. My surgery was Sep 19 07 and I was not really physically confident until Christmas. Now my hip is great. Some of the discussion around metal ions at the course Pat went to in LA were because of me, as my surgeon was there delivering a paper and asked a few colleagues their opinions. Everyone had a different take on the angle and metal ion issue. The only surgeon who said he would redo the surgery based on the ions and xrays and not based on pain, said he would do it only if the angle was 70 degrees or more. My angle as measured by my doctor is 59 degrees.
Can you find out what your angle is?
RE: the metal ions. Pat is right, nobody knows much about this. I went to Dr. Gross's link and the problem I have with it is the same problem I have with all the "don't worry about the ions" articles. These papers never talk about those of us who have high ions - the outliers. It is hard to get accurate tests, and very confusing as all over the world different units of measurement are used. I am hoping that 10 times tiny is still tiny. The lack of information is because all that is known about metal in the body is from industrial applications, ie inhaled metals. And so most of the problems are lung related.
So maybe there is no problem. Wouldn't that be nice. I'm in denial right now......next test for me is in Jan.
best,
Nancy

[Pat Walter]

Hi Nancy

Your message is right on. One reason I have not written an article about the metal ion issue discussed at the hip resurfacing meeting is - there seems to be no concrete information.  THere is a lot of thought about metal ions and the possible problems - but few studies.  There are also no good blood tests developed that give good consistent results.  Not many labs do the blood tests and from what I understand the ones that do don't do it the same way. There is no industry standard.  The final concern is that the doctors and researchers just don't know what to make of the results of the blood tests.  There are no guidlines for what are HIGH ion levels.

The researchers and doctors need to do much more study about the metal ion issue.  Some suspect it could be a big problem, yet they have very little evidence to go on.  Dr. De Smet will opt to do a revision if he finds the metal ions are very high from the blood tests he gets overseas.  I saw the inside of the hip showing the ugly black tissue around a hip with an allergic reaction.  It was downright ugly.  The surgeon had to remove all the black tissue.  I am assuming it could cause a lot of problems or even become cancer -  no one said what would happen long term except it should not be left inside a person.

So the above would have been my article - no one seems to know much about metal ions and what to do about them if they exists and if they cause problems.  I think this was a complication that no one was thinking much about early on and now it is becoming more of a concern.  The cups placed at wrong angles seem to be much of the cause of the problem according to the discussions.  Again, there are no medical studies indicating that yet.

We are all pioneers with a new type of hip replacement.  On the whole, I think all the resurfacing surgeons are very optimistic about the proceedure, but understand they have not yet learned everything about hip resurfacing and metal ions.

Pat

[woodway2]

Hi BILL and Pat -
Thanks for that answer Pat. BILL, I got the impression your recovery had turned a corner. Sorry if it is not going as well as I thought. I do hope this resolves well for you. I forgot to mention something  re: the ions.  that in most normal resurfacers the levels are much reduced after the wear in period of up to 3 years. So my own plan, as my hip feels great, is to wait out the 3 years and see if the metal levels reduce, and if not, address the issue again. Perhaps ask for a biopsy if that's possible to check for the black tissue.
I have an appointment with my doc in early Feb after he has shown my rays at a resurfacing conference in January.
One interesting thing - When I was at the height of my anxiety I sent a lot of emails around. One was forwarded to the researchers at BHR in England. I received a note saying they would be interested in sending for my blood and xrays to look at and test for themselves with their own equipment. But when I wrote to say OK, I never heard from them.

[B.I.L.L.]

Hey all, ok here we go.  My hip is working better and better everyday, the pain is subsiding even though it is still there, so I feel like I have definately turned a corner in that respect. I am off the cane as of the last 2-3 days but still have pain after walking for more than 20-30 minutes, even though it is not extreme pain it is enough to make me limp and head for the pain meds. My ROM is getting better as well.
I guess I really won't know until I have x-rays in hand and 2 or 3 opinions from other doctors what the call will be.  I am thinking ahead 3 to 6 months, do I want to be 6 months out and wondering ?, or in 6 months would I rather be 3 months out with a correctly placed cup ?  In the grand scheme of life I gotta think I'd rather know its right. 
My hip is going to get put through the ringer as far as use and wear and tear. I am a self employed poolman wich means I am on my feet and knees all day, carrying a heavy toolbox or equipment in and out of yards all day long, and getting in and out of the truck 30 plus times a day easy.  Plus I plan on surfing and riding my dirt bike until I no longer can, (hopefully a long time from now).  So its not like I'm going to be in an office and up and about a few times a day, I am on my feet from the minute I get up until I go to bed. So for me I am concerned with wear, and would be even if the cup was perfect, but I know its rubbing on the edge of the cup, because there is no way it can't be, no way.
   I won't have an exact number of what degree my angle is until I get the actual x-rays and measure it I supose, but I know from looking at the pics of the x-ray I do have that the angle is close to 67 degrees or more.  If straight up and down is 90 degrees, and 1/2 way is 45, mine looks to be 1/2 way between 45 and 90, maybe even a little more. If you figure where the very top of the ball is, the cup barely goes past that, like if you were to tug on my leg from the side, the cup would offer little if any resistance in that direction. I'm probably over explaining it, just picture the steepest x-ray youv'e seen browsing through all these sights, thats about where were at.  I know this is a long post so thanks for caring if your still tuned in at this point Ha Ha.
(Don't worry my spirits and sense of humor are still intact 8))

  So I meet with the doctor next thursday, here is my list of questions so far, feel free to give me any more, I'm all ears trust me.
Do you personally believe it should be redone ?
Have you ever done a cup revision before ? If so how many ? and why ?
If I do a revision is it a thicker cup due to bone loss when they pop out the old one, or is it the same cup just repositioned ?
How many muscles are cut to reach the cup/pelvis , will it be less than the original operation or will I truly be at square one rehab wise ?
Why in the world would you tell me the x-rays "Looked fine" until I brought it to your attention ?  Then tell me yes its steeper than I prefer ?  Is it really my job to know this stuff ?
Do you have other cups as steep as mine ? If so how are they doing ?
Can I have their phone numbers ?
Does Kaiser have a way to test my blood for metal ?
If a radically steep cup needs revision, isn't it better to do it ASAP ?
(according to Dr. DeSmet it is)
What would you do if it was YOUR HIP?

Then I guess I need to decide if I want him back in there at all, another Kaiser Dr.  or out of my pocket (wich I don't have, so not sure how that could work) for one of the more well known doctors ?

Anyway lots too think about, I gotta go try and make some money, talk to you guys later and thanks for reading this if you made it this far ha ha, Have a good day, Bill
   

[Bionic]

I would just tell this doctor that you want the problem fixed.  I wouldn't ask him for his opinion.  Maybe I'm cynical, but I think that since he made this mistake, he's bound to try to minimize it, even if it's at your expense.

The implants can probably be saved as long as you act quickly.  Six months from now they might have started to wear in an odd pattern which makes them harder to salvage.

Ask him what instruments or surgical guides he has to ensure that the reoriented cup will be correctly placed and you won't have this problem again.  Before you let him operate again, make sure you are satisfied that he won't screw it up.  If you're the least bit suspicious, or if he seems to be acting out of self interest rather than an interest in your health, say "thanks but no thanks" and try to find a doc who gives you better answers.

In theory, this corrective surgery should be cheaper than the first since no new implants will (probably) be needed.  Surgical time should be much shorter.

If you're satisfied that this doctor is qualified to repair this, you might want to talk with him about reducing his fee since you believe this condition was caused by his surgical error.

[Pat Walter]

Hi Bill and gang

This revision stuff is very serious business. If a surgeon did not place a acetabular cup properly the first time - there is no guarantee he will do it right the second time.

If the device is not properly place for either component - there is no guarantee it can be saved at all.  These are very difficult surgeries and the components are not easily changed.

I just want everyone to understand that.  If the femur cap has any placement problems - it can never be replaced, only a THR can be done.

What makes sense to us a laymen - does not make sense medically. Hip resurfacing is a difficult surgical skill and can't just be tweaked as you do an adjustable mechanical device.

Just wanted to add some input here.  I hope to have an indepth surgical video available soon and once you see it, you will reallize how much skill is required to place the components properly.  It is an art as much as a learned skill.

Pat

[stevel]

Bill,

Check out Jane's BHR Revision to a THR.  Click on "Hip resurfacing problems post-op" on the home page of this website.  What a disaster.  I met Jane at the HSS.  She successfully had a ceramic THR replaced by Dr. Su. 

[JohnS]

Hi BILL,
A couple days ago I promised an xray of my RBHR after my 2 week follow-up.  Unfortunately (I guess) they did not take an xray at this point.  In fact I haven't seen any xray of my new hardware yet.
I'm sure glad to see you've had some progress of late.  However, I sure feel for you.  You have had a rough recovery and may even need to do much of it all over again.  I'll try to send good vibes your way.
JohnS