Quote from: jss on November 24, 2014, 03:29:59 PMeinreb, what reason Rogerson give for not wanting to resurface?  What was Gross's reason for not having that same issue?  And congratulations on the excellent outcome.

Rogerson initially said no.  When I followed up to ask 'why', he then realized how young I was (39 at the time) and said that he would 'try' but that there was a chance he would switch to a THR during surgery.

As i poked him a little more, it became clear that he didn't have experience with Leggs Perthes hips.  I then asked who did and he suggested Dr Bose.  When I asked him about Dr Gross, things got a little weird and he went off a bit about the uncemented part.  Rogerson was(is?) a BHR guy.

You can see my x-rays here (hope this link works)....

http://surfacehippy.info/hiptalk/hip-resurfacing-topics/ramblings-regarding-my-scheduled-216-resurfacing-with-dr-gross/msg15037/#msg15037

If you've seen hip x-rays you should be able to see that my hip was really weird shaped and had a huge cyst.

I spoke with Dr Bose (in India) via email and he had done perthes hips and was confident.  Dr Gross had done 60+ and was also confident.  I was VERY interested in the uncemented route (since shown to work very well) and ended up going with Dr Gross.

btw, here are his latest stats....

http://www.grossortho.com/forms/HRA%20consent-3-12-2014.pdf

98.5% survivorship with the uncemented device with potentially 'high risk patients' at the 7 year mark and a very good trend line.  I'm an engineer and I really  like how he analyzed every failure, made adjustments and made improvements to minimize failures.

Again, your situation is different... but this is an example of how different surgeons approach cases.  I suspect that Dr Rogerson is a very skilled surgeon, but he deals with more of the 'norm'.  When you are 'special', you have to go talk to those that have the experience, interest and success in special cases.

einreb,

I didn't know there was a name for that condition, which I'm reading about right now. That was your left hip?  Here's an xray of my right.  It could almost be a reflection of the same hip!  Thank you so much!

Quote from: jss on November 24, 2014, 08:55:07 PM
einreb,

I didn't know there was a name for that condition, which I'm reading about right now. That was your left hip?  Here's an xray of my right.  It could almost be a reflection of the same hip!  Thank you so much!

Interesting to see that x-ray.

Keep in mind that your hip is what it is and you just need to explore the best options.

Quote from: jss on November 18, 2014, 11:57:27 PM
One says I won't have enough cortical bone on the femoral neck after the cam impingements are removed, and all three say I don't have enough good bone in the femoral head to support the BHR cap.  Two of them will do the BHR if I insist; but that seems ... unwise.

I'm completely shooting off the cuff here, but I think there is a difference that *may* be the reason you're getting pointed away from the resurfacing.

Note in mine that there is a pretty wide neck to the hip under the collapsed ball.  I think it was the collapsed ball on mine that gave Rogerson concern because the normal measurements and templates involve removing the ball with a hole/saw type device to make a 'can shape' that the cap fits on, but the cuts cant notch the neck. 

The neck on yours looks a little more slender and shorter?  i.e. it may not have enough volume to fill up the cap?

Quote from: jss on November 18, 2014, 11:57:27 PMMy problem is this.  In 1973 (I was 10), I was hit by a '61 Plymouth on my bicycle.  I couldn't walk for weeks because of right hip pain.  The doctors said there was nothing wrong with me.  What seems to have happened is that the epiphyseal plate of the right femoral head was damaged such that the head quit growing, and the neck only grew in diameter, not length.

Perthes (what I had) is actually very similar to this but it occurs without an 'accident'.  Usually children, 3-7, growth plate gets messed up ball of hip is starved, collapses, eventually gets resupplied with bloodflow, firms up but is misshapen.

einreb, thank you for the (sobering) input.

I'd made the same observation; that my deformed femoral neck was smaller than your normal neck.  Which leaves me to wonder the same thing; will I have enough neck left to hold the ball?  And I didn't interpret Dr Rogerson's opinion that I was a good candidate to mean that BHR was the way I should go.  Reflecting on the conversation, he didn't say that BHR would be a better route for me than THR; only that I should have a good enough outcome with BHR to return to high impact activities; maybe even another Ironman.

I'd just begun a pre-training regimen as a precursor to another Ironman training cycle when this hip flared up.  As much as I hope to do another race, at this point I am holding onto that hope with an open hand.

While I'm still hoping for resurfacing, THR is more likely in my future, and so I've been researching that route; and have a question...

MoM is persona-non-grata in the THR world.  A number of MoM devices have been removed from the market by the manufacturer or the FDA, and have been replaced with mostly MoP and CoC implants. The reason being the metal debris and ions created as the devices wear.  Reading this site, posters are forever talking about monitoring their own metal ion levels and encouraging others that are in a questionable state to have their metal ion levels checked with all deliberate speed.

The metal ion problem that necessitated the removal of most MoM THRs from the market seems to exist in the resurfacing world with the BHR. Given the experience from the THR world, why has the BHR not been replaced with a MoP or CoC equivalent?

Yea I always wondered the inverse: With advancements in component placement in the HR world that have almost eliminated the wear problem, why hasn't that found it's way back to THRs? I would think that even the metal on plastic would last longer with optimal positioning. Of course that is much more dependent on surgeon skill, but then again some of the well-known HR surgeons are using non-MOM in their THRs so it's an interesting question.

But I'm pretty sure that one of the reasons why you don't see MoP or CoC in resurfacing is because the plastic and ceramic has to be much thicker which would necessitate too small of a ball to cap the femur.

Hi Jss, your question is really loaded and could take volumes to answer. Here is a rough answer.

There was a long period before the use of poly and ceramic for total hip replacement when all hip replacements were crude metal on metal devices. Even resurfacing. But it worked reasonably well. Then polyethylene came along and it worked even better. But it was only successful in improving the small ball total hip replacement. When tried in resurfacing the poly broke and wore out too quickly because the material needed to be very thin to fit in the tight space. Ceramic also was far too brittle when produced as a cup and shell for resurfacing.

So poly and ceramic were good for THR but not resurfacing. As good as it had become, THR was still not durable enough to last in young patients or active patients. So around 1980 some surgeons began to try metal on metal again because the technological advances in metallurgy made it possible to manufacture advanced low wear metal on metal joint bearings that could not have been produced before. That was the beginning of the BHR.

The BHR has been performing about equally as good as the most modern THR devices since it began being implanted. Unfortunately, the stigma of metal ions from the old THR and resurfacing devices came back when a couple of poorly performing resurfacing devices made it to the market. They have since been withdrawn.

Why check ion levels? Any device (poly, MOM, or ceramic) has certain levels of wear particles that are shed from them. When any of them are implanted at less-than-optimal alignment, the wear rate and particle shedding goes up. With ceramic and polyethylene, you get bits of those materials foreign to the body accumulating around the hip joint that just stay there. The interesting thing about resurfacing is the materials in the device are chromium cobalt and nickel. These are naturally present elements so the body will eliminate them as they are shed unless the device was put in poorly and the rate of shedding is to high for the body to process. So if someone is experiencing problems, an early way to see if it might be the device is to look at the concentration of chromium and cobalt in the blood to see if they are higher than someone who doesn't have a resurfacing device.

Chuckm

Jhippy and chuck, thanks for the info, it does make sense.

I just hung up the phone with Dr Gross and got his 2 cents on it; which is just a more technical version of what y'all just said. He belabored that metal ions are not a problem unless the patient has an innate problem with them, or unless the implant was improperly positioned.

His opinion is that, even with the deformity from the accident, that I have the same probability of a positive outcome as someone without that deformity.  I have plenty of bone that is strong enough to support the implant.

I'll talk it over with my wife tonight and sacrifice a few more brain cells on it; but given the confidence of both Drs Gross and Rogerson, I'm heavily leaning that direction.  As Dr Gross has a published successful record with my deformity, he would of course be my first choice.

Any information and wisdom anyone would like to share would be appreciated.

Thanks, jss

Quote from: jss on December 01, 2014, 05:26:26 PM
His opinion is that, even with the deformity from the accident, that I have the same probability of a positive outcome as someone without that deformity.  I have plenty of bone that is strong enough to support the implant.

Gross said he could do a resurfacing?

Quote from: einreb
Gross said he could do a resurfacing?

Yes.  He gave me the same probability of a positive outcome and of femoral neck fracture as anyone else.  Last night we thought up a few more questions.  When/if I get to ask those, I do intend to revisit the "I have enough bone in the femoral neck" question with bilateral measurement comparisons I've taken from my xray.

Quote from: jss on December 02, 2014, 09:56:49 AM

Yes.  He gave me the same probability of a positive outcome and of femoral neck fracture as anyone else.  Last night we thought up a few more questions.  When/if I get to ask those, I do intend to revisit the "I have enough bone in the femoral neck" question with bilateral measurement comparisons I've taken from my xray.

Ah, cool.  Then you have options.   As for your follow-up question to him, I suspect there is enough bone for him if he is saying its doable. :)

I'm scheduled for BHR with Dr Gross on Jan 7.  He says there's a good chance that my marathon/ironman career is not over.

Guys, I'm trying hard to be stoked that Rogerson and Gross say that I'm a good candidate for BHR. But looking at my xray I am concerned that I will never have the confidence to do the things I want to do.  Below is my pelvic xray with some measurements I've made. The intertrochanteric line along the neck is 25% wider on the good hip. The epiphysial line between the neck and head on the good hip is over 50% wider. I'm trying to share Rogerson and Gross's confidence that this is plenty of bone for me to pound out 430 miles of running during a marathon training period with a BHR, but ... I can't.  Any thoughts?

If the femoral neck you have now has been through high impact activities before, then it will be fine. The BHR femoral component is fitted onto the head and maintains the same load transfer to the neck. Except for the stem that is inserted into the femoral neck, the neck remains the same and can become stronger after the surgery (after a six month healing period - the neck can be weaker for a few months before it regains its strength). Dr. VJ Bose even argues that the BHR "splinting" effect eventually makes the neck stronger. What doctor's watch for are cases where the femoral component will only fit if some of the neck has to be cut (notched) to fit the cap. That is not the case for you.

Good luck
Chuckm

Quote from: jss on December 08, 2014, 12:08:19 AMI'm trying to share Rogerson and Gross's confidence that this is plenty of bone for me to pound out 430 miles of running during a marathon training period with a BHR, but ... I can't.  Any thoughts?

To a certain extent, you will need to put your complete trust in the surgeon making the decision.  They don't want their patients to fail, so if there was significant risk... then they wouldn't do the surgery.

Also, your hip is what it is.  If you don't do the resurface and get a THR, where does that land you with marathons and iron-man length races?  I may be missing something, but there is not a lot I've seen on folks doing that sort of distance work with a THR.

-B

Thanks chuck, that is encouraging. I've been looking for information of the integration of the bone into the metal surface. I would like to find some data on the measured strength of that (if it exists).

Ben, you're right of course. I know that someone with Dr Gross' eminence on the subject can be trusted implicitly. And yes, most doctors strongly contraindicate running after a THR; so most recipients stop. I've been researching that issue and have yet to find a single instance of a horrific complication of anyone that's resumed running after a THR.

Does anyone know of a bad outcome of a THR because of running?

Thanks for the thoughts guys.