MRIs show synovitis in 68%

[John C]

I came across this new article that came out today. It talks about a study done at the Hospital for Special Surgery in New York (one of the best surgical hospitals overall, as well as for resurfacings). The study which reviewed MRI results shows an unexpectedly high incidence of synovitis in asymptomatic resurfacings (68%), almost as high as in problematic hips. The study claims that these MRI tests would be a better predictor for long term MOM results than serum ion test or the presence of symptoms. An interesting read.

http://www.sciencecodex.com/tissue_damage_from_metalonmetal_hip_implants_appears_before_pain_symptoms_appear-112260

[Pat Walter]

Here is the original HSS public news release on the Surface Hippy Website.  It loads faster than the link above

http://www.surfacehippy.info/mom-tissue-damage-appear-mri-before-pain.php

Interesting information.

Pat

[todd4e]

Jeez, this is surprising, especially since it was done at HSS. Which means I can't pooh-pooh the results.

Anyone else thinking about getting an MRI? And would insurance pay for it?

[bluedevilsadvocate]

That's a bit disconcerting.  But I'm not sure what the "take away" is.  Why were the 69 subjects "referred" to HSS for MRIs?  Surely they were referred for a reason and not just idle curriosity.  Did their x-rays show that their HR cups were at questionable angles, or was there some other reason to think there might be a problem?  The report says that synovitis was identified in 68% of the asymptomatic hips, but how many asymptomatic hips were there among the 74 hips studied?  I.e., what was the size of the asymptomatic sample, and was it large enough to support a valid conclusion?

Your thoughts, John??

[Baby Barista]

You nailed it BlueDevil... this report tells us nothing unless we know the distribution of those 74 hips. For all we know, only one of them could have been asymptomatic.

[bluedevilsadvocate]

Another possible reason that the subjects were "referred" to HSS: they had ASRs and were concerned after all of the adverse publicity and the withdrawal of the ASR device.

[hippy hippy shake]

13/19 would give you 68%.   Seems to work with the other numbers fairly well.

I asked Dr. Su about the previous MRI study, and basically it is early research.  They have to figure out the implications of it yet. 

[hernanu]

It's always good to get more information; it can't help but keep us knowledgeable about our implants.

I'm curious what the impact of these findings is. It seems that in osteoarthritis, one of the side 'benefits' is inflammation of the synovial membrane. This can cause increase in volume of the synovial fluid within the hip.

Synovial fluid, though seems to be this amazing compound that is built to deal with not just lubrication in the traditional sense (surfaces sliding across each other), but also to provide buffering as pressure is applied. So it works on motion and on weight being applied.

The measure of how effective it is seems to be based on its main 'sliding' component, hyaluronic acid. This is what grabs on to surfaces of healthy cartilage and healthy bone and lubricates all movement. In our case, it probably grabs on to the metal surfaces and lubricates away.

What can compromise hyularonic acid is anything that digests it. Although if its not digested, but just broken into chunks, it still is able to perform correctly.

Synovial fluid as a whole has been identified as comparable to blood plasma, so coagulation can take part in it. So anything that introduces the components of coagulation, like inflammation, may increase clotting within the synovial fluid and so volume.

In Degenerative Joint Disease (osteoarthritis, which we had), as the linked article notes,

"The synovial fluid from joints with degenerative joint disease is usually clear, although haziness or flocculence due to cells and cartilaginous debris may be found. The fluid is usually pale yellow to straw-colored.

Unless significant joint effusion is present, viscosity is normal, and the mucin clot is usually rated fair to good. Protein and glucose values usually remain unchanged, although a slight reduction in glucose can occur in fluids with increased cellularity due to glycolytic activity of the cells.(20) Low glucose values must be interpreted in light of any delays in synovial fluid analysis.

"

Which points to less impact from blood clotting within the synovial fluid from osteoarthritis. If this also means no interference with the hyaluronic acid, then the synovial fluid itself is still active as normal.

I think this research is a valuable new way to look at our HRs. The more we know, the better off we are. The questions I have are:

• Does this impact my ability to move, etc. If I'm asymptomatic? It seems based on the above that the synovial fluid, unless enzymes are introduced that will digest hyaluronic acid, will continue to be my friend, and I can move to my rhythm.
• If the synovial membrane is irritated in a low level, is that a steady state issue (will it stay at that level) or does it inexorably progress to a worse state? It seems like many more hippys would be complaining of pain if that were the case, but I would like to see more studies of that possibility
• Synovial fluid can be extracted without surgery, if the levels of metals are an issue, can that or other treatments be used to lower the inflammation.
• How does the membrane's inflammation complicate a revision? Ideally we won't need one, but if I need one, am I really complicating things by having an asymptomatic, low level inflammation?

I'm not a medical person, although at one time did do medical research. Anything that adds to our knowledge is a good thing to me. These are some of my questions, I'm sure there are a lot more things others can think of.

I like to face things head on, so had to think about this a bit. I see a bit of good initial research that needs to be expanded on. I'm thankful that they are looking at things in a different way; it may point to ways of treating this early so we lower the revision rate.

The quote I used was from a paper that is very interesting and extensive; it is a veterinary paper, but applies to humans and treats with synovial fluid well from my limited perspective

http://cal.vet.upenn.edu/projects/saortho/chapter_86/86mast.htm

[podgornymd]

I agree with Hernanu, that it is always better to acquire as much knowledge as possible to help figure out solutions.

i also agree this is concerning especially since i am only 4 weeks out of surgery.

The study itself is a very small sample size and there are alot of questions which still have to be answered before we get worried aobut this. How long did they have the resurfacing, How many women vs men, how did they choose the asymptomatic group, another one that i think may be important is what type of activity are they doing. Are they all runners and participating in high impact sports or some type of overuse type activity.Also what type of resurfacing did they have?What angle is the hip sitting at? These all need to be looked at to see if there is any commonalities to why they have synovitis.

I work in an emergency room and order lots of MRI's and CT scan and i can tell you there are so many incidental findings that we dont know what to do with.

An example is if i get an MRI on a preganant female to see if they have appendicitis ,occasionally the radiologist will see a bulging or ruptured disc in the lumbar spine but when i ask the patient she has no back pain. This happens quite often with all type of patients. The point i am making is they need to follow the asymtomatic patients further along and see if they will need revisions.What if 2 months later they get an MRI and the synovitis has resolved?

What gives me hope is reading about alot of the people on this website that have had theirs for years and have had no problem.

Would be nice to hear from someof the orthopedists like Dr.Su or Gross.

 

[hernanu]

It is a bit scary, but there are a large amount of asymptomatic people in the Australian registry who seem to have not graduated to symptomatic and revised.

Ten years of data that supports good results. That doesn't mean that this is not significant and may not lead to much better treatment, but it is a very raw and early study. From the description, synovitis is painful, so it would be good to see some followup studies to this.

I'm three years (almost) along, and am pain free (knock on noggin) so far, so it seems to run counter to my own personal experience. I'm always open to new information, so hopefully this becomes a way to make our use of our hips better and safer.

[Dan L]

In addition to all the great points raised above, also wonder about distribution of device mfr, surgeons experience level, etc, etc.  Presuming there is a distribution of different devices, that further slices the sample sizes by device down, and could impact the interpretation.

Those volumes involved "of synovitis was 5.0 cm3 in the asymptomatic group, 10.2 cm3 in the mechanical causes group, and 31.0 cm3 in the unexplained pain group" seem really huge, it is difficult to visualize that much inflammation in the hip joint.  Scary to imagine.

Thanks to all for this thread.

[bluedevilsadvocate]

Pat -

Dr. Su is listed as one of the doctors involved in the study.  Do you think you could get him to give us his thoughts and comments?  Perhaps when the actual study is published in the Journal of Bone & Joint Surgery it wil provide more detailed information, but insight from Dr. Su in the meantime could be helpful.

[todd4e]

Is there any way to find out who the surgeons were who operated on the patients in the study?
It would be interesting to see how experienced they were.

[Dannywayoflife]

Personally I'm not worried by this.

[Kiwi]

I'd appreciate someone explaining what all this means in Layman's terms. It's likely to create more questions & doubt in people's minds than anything else. I for one think I need to get an MRI now, as I've been getting some pain around the hip every-time I do excess exercise. I was told it was my soft tissue & due to the rigours of the surgery would never be the same. I.e. Play hard, feel pain, rest, go at it again. This concerns me a bit..

[Pat Walter]

Personally, I would not stay up at nights worrying about the study.  It is a small one along with many on the website about various hip resurfacing subjects.  As with the high metal ion blood test, not many labs do it and there is no standardized test.  I think it is the same with the MRI.  You need a surgeon that would want the test and then be able to analyze it.  There are so many small medical studies that look positive or seem interesting - but that is what they are, small medical studies from only a surgeon or two and with only a small number of patients.

The overall retention rate of the BHR at 11 years post op from the national registries is great, so I am not worried.  I tend to go with the big medical studies and national registries and top surgeon series for information.  I read all the small medical studies with interest. I read them a lot but sometimes don't even bother to post them.

Sleep well if you have a hip resurfacing and out of pain being active.  The odds are with you that you will have a great outcome from the national registries. I am an optimist and don't have time to worry about the small stuff.  I enjoy my artificial tissue aortic valve which will last maybe 10 or 15 years along with my BHR which I hope will last my lifetime.  If either fail, I will need a revision - meantime I am enjoying life with my artificial parts   8)

Pat

Pat

[Kiwi]

Thanks for putting the study into context, Pat.

[tonyp]

Not sure if folks are still looking at this post but as I read it, it seems worth more discussion.  I agree with the idea of hearing a response from one of the docs being really great.  Would be very cool from Dr. Su at HSS.
Anyone look more closely at this lately?

cheers,
tony