Surgeon Disagreement

[Saddlepal3]

Greetings,


I had my right hip resurfaced with a MOM Conserve Plus prosthesis in 2006 by one of the most experienced resurfacing surgeons in the US. I won’t mention names for reasons that will become obvious as you read my post.


Background: I am female, 5’3”, 120lbs, 67 years old. The resurfacing has been a complete SUCCESS for me despite everything I have read about metallosis problems for female patients.


In February 2018, I had a total hip replacement on my left hip. I knew I was not a candidate for resurfacing. That has gone well. In conversations with my current surgeon, I decided to have my blood ions tested. They came in somewhat high (7s & 8s). As a precaution, the current surgeon ordered a MARS MRI.


I sent all this info to the surgeon who did my resurfacing. He wasn’t concerned about the blood levels, but when he saw the MRI image, he recommended a revision. He saw some fluid around the joint. I was stunned because I have no symptoms: no pain, no swelling, no anything. In a phone call with him, he said that it would not get better, only worse, and he thought it was wise to do the revision early.


So I emailed the most experienced resurfacing doctors in the USA for second opinions (all are highly visible on the Surface Hippy site). One of the most experienced asked for a packet of info as well as all the images. After review, he called me and adamantly advised AGAINST revision. He stated that the blood ions were not a problem, and the fluid was no more than 10cc. He stated that nearly all prosthetic joints have a minor fluid build up and he is convinced that I do not have metallosis. He also was complimentary about the placement of the resurfacing joint, calling it “perfect placement.” He said he thought there was a good chance that I would never need a revision and it was not good to do one unless medically necessary (which I already knew). He recommended having my blood tested again in 2 years. He offered to email his thoughts to the first doctor and I encouraged him to do so. Finally, he said that he was suprised that he had a differeing view from the first surgeon (because, I assume, they are both top docs).


I emailed my first doctor and told him briefly what the second doctor said. They do know each other and, I believe, have mutual respect. The first doctor thanked me for the new information and told me it was up to me. (Not so helpful). I asked him to please get back to me with his thoughts after he has heard from the other surgeon.


I’m not sure how to proceed. Both surgeons are highly knowledgeable and experienced. I am not eager to do a revision, but I don’t want to ignore a problem that could be brewing.
Any thoughts?

[moe]

If I were in your position I would not get a revision unless multiple surgeons agreed that a revision was needed. I am surprised that your original surgeon recommended one without you having symptoms. Good luck.

[Saddlepal3]

Thanks Moe. In fairness, one other surgeon agreed with my first doc but I had the feeling that he was deferring to the first doc rather than providing a carefully thought through opinion.

[karlos.bell]

  Yep
Ask De Smet he uses conserve plus.He may have ideas for you.
My MOM is down to about under  0.5-ppm for 2 hips
0.191 cobalt 0.141 Chrom.

[MattJersey]

Saddle I would check with another top surgeon but do not brief them. Ask them for their opinion on placement as you had been worried after reading something. Basically get them to take a full review but give them none of your current information so they don't have that bias. (If they say go see your original surgeon say that you didn't want to embarrass due to being a layperson questioning the expert over the quality of his work. You have no pain but had been worried following reading about getting your THR since you were no longer a candidate etc.)

[Saf57]

You have no symptoms, and all seem to agree that the ion levels are ok. Why would you get a revision, it makes no sense. If you ever become symptomatic, then the issue can be revisited.

[catfriend]

Doctors do disagree on things. That's why we seek out medical "opinions". If you aren't symptomatic in any way, and your blood ions are within reasonable limits, I wouldn't rush into surgery. First, surgery always has risks. You should never have surgery unless you really need it. If you're not comfortable waiting two years for blood tests, wait a year instead. If there are no significant changes, then why have surgery? Second, you state you don't have any problems or symptoms. No pain, no swelling, nothing. So why fix something that doesn't need fixing? Since you've been made aware that you could have problems eventually necessitating a revision you know to watch for this. If it were me, I would skip surgery for now and be aware for the future.

[Saddlepal3]

Thanks everyone for your excellent advice. I have continued to seek opinions from the top national and international surgeons on this site. After seeing the MRI images, three of them have advised revision surgery. One said it was unnecessary.
If the three are correct, I don’t want to ignore the problem and the sooner I do it, the less damage there will be. The hope is that I can revise one component of the resurfacing. Am leaning towards going ahead with the revision.

[John C]

If I may ask, what brand of components do you have, which half would be revised under the plan, and what would be used to replace that revised portion. It would be great if you could share the options that you have been offered for partial revisions.

[Saddlepal3]

Hi John,
My current prosthesis is a Conserve Plus. 44mm head. The hope is to replace the femoral component only, with a longer stem. There have been problems associated with revising a resurfacing to a Total Hip Replacement, so we hope to avoid that. As we all know, the surgeon will have to see what he finds when he gets in there.

[Saf57]

If you are able, can you please let us know the reason(s) for the revision recommendation. Given the perfect placement, and no symptoms, it would be useful for us to know the thinking here. Thank you.

[John C]

Sorry to bother again but it would also be interesting to know the articular surface of the new ball. I am assuming ceramic, since you seldom see poly on the ball?

[Saddlepal3]

Saf57,
My understanding is that the MRI shows that the joint is starting to fail. There is fluid building up within the hip capsule and the doctors who advise revision are unanimous that it’s best to address this before the fluid area enlarges (and starts to damage surrounding tissue).  The fact that I have is a small size femoral head (44mm) accompanied by somewhat elevated blood levels suggests that things will worsen. One doctor speculates that cup may be loosening and fretting against the bone. Another doctor believes that my body is no longer able to metabolize the metal ions after 12 years and this is leading to metallosis.


If I wanted to, I could choose to monitor this and wait until I have noticeable symptoms, but after a lot of thought, i am choosing to address this at the early stages with hope that I’ll have a better outcome. It’s obviously a controversial and personal decision. Am hoping for the best.


John C: discussion has been about a “coated titanium head”. If course if the cup is compromised, something different may occur.

[karlos.bell]

  Sounds all  pretty logical.
Like everything sometimes it is different when they operate so good on you for finding out and paying attention to the detail.
This was very much so when De Smet operated on me.
Previous operations took away much needed bone he could have used (FAI Surgery) and he had to make do. This was not foreseen before operation. His comments were "you were very difficult"

I am glad you have had specialists to bounce ideas off.

Not everything if life goes to plan and I wish you all the best in your operation and recovery.

Kind Regards K