15 Months Post-BHR, Discover Device angle is 10% off - Has anyone else had this?

[kathryn]

Hello, All.

I had two hip resurfacings -- one on each side -- within 5 months of each other in 2007.  Surgery was at Columbia in NYC with Dr. Macaulay.  Used Birmingham device in both. 

From the beginning, I had the impression when I walked that the device implanted on my left side (the later surgery) might be "larger" than the one used on the right side .  X-rays looked good so doctor had no concern there.  At 10 months, my left hip started clicking when I shifted my weight (no matter how slight). The clicking felt uncomfortable, but not painful.  My gait worsened, I noticed, and became painful on my left side when I tried to walk with a full stride.  By 12 months, I had pain on and off in the left hip area and stretching across my lower back and down the front of my leg to just below my kneecap.    Over time, it has continued to worsen and now I feel pain stretching down the inside of my hip joint along the groin as well. 

I returned to Dr. Macaulay 15 months after the surgery and had xrays, then ultrasound.  Dr. thinks that I may have a pseudotumor that is pushing the device out of position and allowing fluid into the joint, but tests so far have not proven the existence of a pseudotumor.  Dr. Macaulay did tell me that while the angle of the device on the right side is at a perfect 45 degree angle, the angle of the device on the left side is off by 10%.   

Dr. Macaulay says I will need another surgery to correct the problem with the left hip device and that this second procedure is a bit trickier than the original surgery.  I will be getting a CT scan shortly to obtain more info (to detect the presence of pseudotumor if one exists). 

Further complicating this situation is the fact that I lost my job two months ago and have limited means for medical treatment. 

I have an appt with Dr. Su for a consult (he is very pricey, though) and absent real information concerning these two physicians and my medical options, I fear my choice may be dictated by my dwindling finances.


Questions for the group:

1.  Has anyone had experience with Dr. Macaulay or Dr. Su?  Any information on their track record with original BHRs and redo's would be helpful.

2.  Has anyone had a misplaced device or one that was moved out of place by a pseudotumor or such?

3.  Does anyone have experience navigating the insurance company hurdles (I have a PPO) for a second opinion and a redo surgery?

Thanks for your help!
Kathryn

[Pat Walter]

Hi Kathryn

Welcome to Hip Talk.

To answer a couple questions, I do know of at least one revision of Dr. Su's.  It was early in his series and it was reported by one of his patients.  So I have no way of knowing that it is real, but assume it was.  Dr. Su is now very experienced and has a lot of very happy patients.

I am not sure how many resurfacings Dr. Macaulay has done.  So I can't help with any other info about him.

I attended the 2nd annual hip resurfacing course in LA in 2008 for hip resurfacing surgeons and have not heard about a pseudotumor actually moving an acetabular cup.  Sounds like it would be difficult to move a well set acetabular cup - but I am not a doctor or medically trained.  I do know well placed and properly set acetabular cups don't normally move since they are pounded into place.  I can understand it being placed at an improper angle - that can cause  lot of extra wear which has been one reason for some pseudotumors. 

According to what I have learned, and again I am not a doctor, most patients with high metal ions resulting in pseudotumors usually have revisions of the resurfacings to THRs.  If you keep a device which is not proplerly placed, the tissue around the hip device becomes bad and the device can start to loosen due to bone loss.  That is a layman's description of what I understand.

So I can see you might require a revision.  Since I don't know how experienced Macaulay is, I can't say which surgeon would be best.  You have to decide that yourself based on your experinece with your surgeon and of course your finances. 

I wish I could help more, but can't give you any other info.

I can say the folks on this discussion group are very suportive and we would like you to keep in touch.

Good Luck.

Pat

[obxpelican]

I concur with Pat on that one.....also, how can being 10% off cause all of those problems?  So if nominal is 40 degrees and she is 44 degrees that somehow can cause an issue?  Also, that cup by the time you hit a few months post-op is starting to have bone ingrowth I seriously doubt that a tumor could produce enough pressure on an acetabular cup to push it loose.  Although I am NOT A DOCTOR so take it as just an opinion.

Kathyrn, I would get 2nd and 3rd opinions, even email some digital x-rays out to some doctors from out of the NY area.

In regard to insurance questions you can usually call your doctors office and ask if they take your insurance carrier.




Chuck

[kathryn]

Pat and Chuck - Thanks so much for your support and for your responses.  Dr. Macaulay had not said anything about revision to a THR in our last appointment.  Only that he thought a second surgery would correct the problem with my left hip and that I could reasonably expect an outcome as good as I have had with my right hip.   

I will seek a second opinion from Dr. Su and nail down the specifics before doing anything.  I'd like to add that reading member's accounts on this website have been very helpful.  My heart goes out to those who are struggling after surgeries that went wrong. 

I will be back after my appt with Dr. Su.  Thanks again.

Kathryn

[kathryn]

Hi everyone.

I had my appointment with Dr. Su, followed by an MRI and blood work to detect metal ion levels.  Dr. Su confirmed that the position of the acetabular cup is off by 10% (should be 45 degrees; mine is angled at 55 degrees).  The blood work showed that my chromium level is 7 or 8 times what it should be as a result of the malpositioned cup scraping against the femoral head component.  MRI showed swelling in the joint.  As the problem is mechanical, another surgery will be required.  This will be my third surgery as I had bilateral resurfacings prior. 

Dr. Su will try to save the resurfacing but that will depend on the condition of the femoral head; if it is too damaged, then he will do a revision to a THR using a ceramic device.  I'm not a happy camper about this but I am looking forward to the prospect of walking, bending, sitting and living without pain.  FYI, I'm 52 years old.

Surgery is scheduled for tomorrow.  Keeping fingers crossed that all goes well.  Will keep the group informed. 

Kathryn

[stevel]

Good luck with surgery tomorrow.  I met Jane, who also had a misplaced hip resurfacing socket replaced with a ceramic THR by Dr. Su.  Her story is on this website and is explained in more detail on Vicky Marlow's website.  You mean the socket placement is off by 10 degrees not per cent.  Somehow the font is showing % rather than degrees.

     

[Pat Walter]

Kathryn

I want to wish you good luck tomorrow with your surgery.  I am sure Dr. Su will do the best he can to save your resurfacing.  He is an excellent surgeon and I know he will do a great job for you.  If for some reason, he does have to revise to a THR, at least you will be out of pain and get on with your life.

I will keep you in my thoughts and prayers.

Pat

[kathryn]

Thanks, Steve and Pat.  I learned this afternoon that it will not be possible to preserve the resurfacing.  Dr. Su will be revising to a ceramic THR.  Although disappointed, I have faith in Dr. Su and believe all should go well.  Will be back in touch with you after the surgery.  Thanks again for all your support.

Kathryn

[lindalynn]

I am new to this site and this is my first post.  My heart went out to Kathryn who was heading into a redo with Dr. Su.  I was wondering how she is doing and if anyone has heard from her.  When you have to have a redo to a THR, how do they get the acetabular cap out of there when it is grown into the bone?  If the angle is off.. wouldn't they have to replace it to do a THR.

Lynn

[Pat Walter]

Hi Lynn

Welcome to Hip Talk.

I am not a doctor and can't give medical advice, but I know many people have revisions of their resurfacings and even THRs.  They have a way of removing the acetabular cups if required.  Not sure how.  Good question for me to ask of the surgeons.  A THR is not as critical in placement as a resurfacing and I would guess there is a possiblity that the cup might not have to be removed.  I don't know for sure. Some people that have revisons of their resurfacings do get to keep their acetabular cups if they still have good bone ingrowth.

Thanks for your post. 

Pat

[Catalina]

I would sure like to know what happened to this person who was about to have a THR.  I hope she will post an update.  I have a very similar situation:  My cup is now off by 11 degrees (it is at 56) and I have elevated metal ion levels.  I am being advised to have a THR because my surgeon, Harold Boyd in Salem, Oregon (who says he has done over 4,000 of these ) is concerned about metal sensitivity and he doesn't want to regret just redoing the cup with another metal cup. 

Pat posted something about leaving a misplaced cup because it's placement is not so critical in a THR.  I wonder about this as an option.

I am going to the local hip person where I live regarding a THR but I don't know who to ask regarding hip replacement options.  I live in Oregon and as I said Dr. Boyd is in Salem.  Who else is there who is as experienced as him nearby and how do I contact him?

[kathryn]

Hi All. 

I am now 3.5 months post-op following a revision to a THR and am still recovering.   My femur fractured during the surgery and recovery has been a more complicated process than originally expected.  Dr. Su, the surgeon who did the revision surgery, had told me before the surgery that healing process following revision surgery takes a bit longer -- it would be approx 8 weeks or so before I would be back on my feet, so to speak.  I certainly had not expected such a lengthy and difficult process.  Because of the fracture, I enjoyed 9 days in an orthopedic rehab facility following my four-day hospital stay.  I would be partial weight-bearing for the first 6 weeks or more following the surgery and had precautions up the ying yang because of the fracture.  (Partial weight bearing means toes only; heal is raised).  My stay in rehab was absolutely necessary in order to learn how (given all my precautions) to move around my apartment safely, to take a shower, to get in and out of bed or on and off the sofa, etc.  Following the surgery, I used a walker, then graduated to crutches.  Fortunately, I had the help of a wonderful neighbor and family who regularly came by because I was unable to do much of anything during this period.  I continued with crutches into my 7th and 8th weeks.  Now, I am walking with a cane (often still with sharp pain), have a pronounced limp and significant muscle weakness.  My energy is still quite low and I continue to have trouble sleeping at night because of pain in my hip, buttocks and lower back.  I'm working with Dr. Su and a talented physical therapist to become stronger and regain function.   

Cathy, I am so sorry that you too are having a difficult time.  As each person's circumstances are different, all I can suggest is that you continue to research doctors and seek out a second opinion from a very experienced resurfacing surgeon, not just a doctor who does THRs.  This way, you will learn the full range of your options given your particular circumstances.  You may be fortunate enough to keep your resurfacing.  Personally, I chose Dr. Su for a second opinion and for the revision surgery because of his reputation and considerable experience as a resurfacing surgeon.  Just talk to the best doctor you can find, then follow your gut.  Perhaps Pat Walter can help you locate good choices near you. 

Thanks again to everyone for your support and kindness. 
Kathryn

[Pat Walter]

Hi

The anteversion angle is different from the angle talked about for the normal cup placement.  That is really an angle measured from the horizontal while the anteversion is measured vertically.  There was discussion at the 3rd annual hip resurfacing course I attended about problems with anteversion angle too - but there is no good way right now of measuring it since it doesn't show up on x-rays.

The more the doctors learned about the placement of the cup, the more they suggest using only the most experinced surgeons available.  They doctors have also changed from placing the femur cap center on the femur ball to centering it on the femur neck.  So things continue to change as the doctors learn more and more.

I am not sure if I have any exact information on the anteversion angle.  Much of the correct placement depends on the surgeons experinced and what seems right for the patient. They will adjust the angles somewhat by the way a person's hips are developed and the activities they do.  Someone doing a lot of ballet will get a different placement than the person that just walks and rides a bike - according the the discussion I have heard.

Not sure if I helped, but hope that gives you a little more insight.

Pat

[Josephine]

I have had ongoing problems since my resurfacing one year ago. I have recently found out that I need a revision too. The inclination angle of my acetabular component is 55 degrees and it is likely that this is causing the problem. I am awaiting bloods for metal ion levels but surgery is booked for next week.

[Pat Walter]

Hi Josephine

I am sorry to hear you are still having problems.

Who was your doctor?  What hip resurfacing device do you have?

I would certainly want to know if you had high metal ion levels before revision surgery.  Have you talked with any of the really experinced surgeons to get second opinons?  I am sorry if I already asked that.  I talk with hundreds of people and sometimes forget things now and then.

This is very serious to have a revision. Are you having your original surgeon do the revision? Are you getting a ceramic on ceramic THR or somthing different?

Pat