Has anyone had Acetabular Cap re-set to fix angle issues?

[kirkp]

Hi:

This is my first post.  I had a resurfacing on March 6, 2009 (with a Stryker device); I went to Dr. Keith Ure at Mt. Shasta Mercy who has considerable experience.  He just reviewed my 12-month follow-up X-rays and concluded that my inclination angle for the Acetabular Cap is too steep -- somewhere in the range of 60 to 65 degrees.  He also, then, went back and reviewed post-op and 3-month-follow-up X-rays and determined that there has been no slippage ... cap has been too steep from the start.

I am doing research to determine whether or not to have the cap re-set immediately.   This board is very helpful --- although posts on this topic are to be found hither and thither, so I am not sure I am finding everything.  From what I have seen, a number of members have had similar issues.  Hope you all don't mind me "calling you out" but from what I can find, such people fall into two camps:
A) Revised to THR - this has typically been done b/c of wear to the femoral cap (kathryn, woodway2, bnickey???)
B) Waiting and seeing - for the reason of not rushing into surgery (Catalina, B.I.L.L.)

Of course, besides doing research here, I will be getting a second (and, who knows, maybe a third) medical opinion before surgery.  But, I am very curious as to whether there is anyone here who has gone down the route that I am most strongly leaning towards --- namely, having the acetabular cap re-set quickly so as to avoid potential problems with undue/premature wear to the femoral cap. 

Has anyone had that experience ... or know someone who has?

Thanks much, Kirk

[Pat Walter]

Hi

To my knowledge, no one has had an acetabular cup redone to change the angle.  I could be wrong since I read hundreds and hundreds of strories.  I do know several had the cup replaced with a special cup with screws and I think they were able to keep their resurfacing.  It is a very tricky situation to go in and try to change a cup.  The cup and cap on the femur must be placed so they work correcly together.  If the cup is wrong, the cap on the femur might not have been placed optimumly. 

The only way to know if this is possible is to ask the top surgeons in the world - they are the most experinced.  The only ones I know of would be Dr. Gross of SC, Dr. Su of NY, Dr. De Smet of Belgium.  Dr. Gross and Dr. De Smet will give you a free evaluation.  Just email them with a copy of your x-rays attached in a digital format as a .jpg     I know quite a few people that required revisions to THR because of cups placed at wrong angles - so that pretty much indicates that it is diffiuclt to just redo the acetabular cup. 

I am not a doctor and would have no way of telling you anything else.  Only the most expeirnced surgeons would consider doing this, the less experienced will just give you a THR revision. 

Pat

[kirkp]

Pat:

Thanks for your comments and recommendations about doctors to talk to.  With my active lifestyle, I am really not willing to revise to THR.  It is not clear to me that replacing the cap should be difficult -- by which I mean difficult compared to the original resurfacing, which involves two major components and much more substantial bone shaping.  I am a doctor ... but not of the medical kind ;-) so I could be mistaken too. 

I'd welcome more comments and will continue to post my learnings here.

Thanks all! Kirk

[B.I.L.L.]

Find any new info Kirk ?  I wonder if there is anyone who keeps track of steep cups that haven't been a problem ?  (Not sure why they would keep track of people with no complaints though) We hear about revisions due to steep cups but I'm curious to know what the percentage of steep cups that need revisions is.  Are there steep cups that have been in 10 years ?   Do some cups past 60 degrees work ok ?   I've been in the wait and see how it goes mode for 18 months now and while I can do almost anything I want now I still have pain and swelling alot of days, but not everyday so I feel like there is still hope it will last.  I would love a definitive answer to my issues but can't seem to get a black and white answer, you know "OK this is the problem and here is the fix" is it bursitus ? am I over doing it ? am I doing the right exercises ? will celebrex help ?    I went to my regular dr last friday with those questions and he couldn't answer one of them, he did schedule me for a colon screening where they run a camera up .....well you know.  I will be traveling to the sacramento area soon to see dr Klug, who is the most experienced hip resurfacing dr in the kaiser system.  Just an answer, good or bad would be welcome at this point.  Being in limbo and not really knowing if your destined for a surgery in 6 months to....a year or 2 ?  or will it be ok and the pain your having is from this or that and your just having a slow recovery ?   My main concern at this point is wondering if the tissue is being damaged from metal ions and am I making matters worse by waiting and seeing ?  I don't want another surgery unless it is Absoluteley needed. I mean I can live with it the way it is, it's waaay better than before surgery and as long as I'm not doing further damage I'll live with it the way it is.  My luck I'll get a thr and they'll screw it up too, seems to me if it's a metal on metal joint you can have the exact same issues with a thr as well.  Oh crap I'm rambling, Sorry, haha !!  Good Luck Kirk and please post any info you find. I hope 10 years from now you've forgotten you even have a fake hip   See ya, Bill   

[John C]

Hi B.I.L.L.
I noticed that you are scheduled for a colonoscopy. Having just researched this issue, be sure to inquire about anti-biotics for the procedure. Dr Gross recommends IV anti-biotics for this, which is the accepted approach. Be sure that your doc is up to speed on this. We are still considered at high risk up to two years, but the recommendations on this are for life.
John

[kirkp]

Hi all:

Wow, what a fabulous community this is!  I am hugely impressed with the compassionate, considered, and absurdly rapid responses I have been getting to all of my queries.  Thanks one and all -- with a shout out to B.I.L.L., Pat, and Nancy in particular.  I wish my friends, family, and work colleagues were as nice and useful as the people on this board.  ;-)

Here is an update.  I sent jpegs of my Xrays to both Dr. Gross and Dr. De Smet.  I was hoping to maybe hear back from one of them at some point -- ideally, without too much added chasing on my part.  In reality, I heard back from BOTH on the SAME DAY I emailed them.  Dr. Gross called me; Dr. De Smet emailed from Europe. 

The bad news is that we are now 3 for 3 on medical opinions.  My cup is far from an ideal angle and should be revised.  I believe Dr. De Smet said it best (and most delightfully):  "Your cup is really malpositioned! He is way too steep!!"

As it has only been about 12 months and I have not been crazy active, there is a reasonably good probability that the femoral component is fine.  If that is true, then it _should_ be possible to only replace the cup.  Note:  I have a Stryker device and one nice feature of this model is that the same femoral component fits into two different cups.  Ideally the identical cup can be used.  If too much bone needs to come out, however, it may still be possible to use the "chunkier" cup and get a good fit.  THR would likely only be needed if the femoral cap is damaged.

I am still getting my head around all of this.  I actually haven't been feeling that much pain, so I was assuming everything was hunky dory with my repair until the latest Xray review.  Hard (and not much fun) to find out that was completely wrong. 

Thanks again to all, and I will keep posting as I proceed with planning/action on this...

Kirk

[revision]

Hi kirk,
Sorry to hear your news. On the positive side the fact that you may only require a cup replacement is pretty good. This means you still end up with a resurfaced hip and probably a pretty good one if you use Dr De Smet or Dr Gross. Think positive. I know it's difficult to get your head around but it will end up ok. Even if you get a ceramic or MOM THR you will be fine. This happens to a small percentage of us but once the revision is carried out by a quality experienced surgeon all ends well. Best of luck with your decision.

Revision

[mccabe66]

Kirkp,
I am in a steep cup situation like you, and really want a cup replacement only.  I have not gotten confirmation that cup-only revisions are being done. 
I did not know that my cup was at 65 degrees until I started to deteriorate about 14 months after a right hip BHR.  I was trying to increase my running mileage and frequency, but was experiencing discomfort at first, then pain. A couple months ago at 17 months post-op, I had so much pain after a 4-mile run (could never get more than 4 miles a couple times a week without my hip telling me to back off) that I went to see my doctor.  He finally admitted my cup angle was not in the target range.  My doctor (Pritchett) was very experienced at resurfacing, having done more than 1000 at the time he did mine,  but admitted he is not sure of the actual cup angle until after the surgery. There is a lesson here - - that even experienced resurfacing surgeons like yours and mine don't get it right all the time.  I would strongly encourage anyone contemplating a resurfacing to discuss with their doctor just how the cup angle will be determined during surgery.  My doctor took a sample of my hip joint fluid, said that it showed no evidence of tissue deterioration (he thought that approach was better than blood metal ion levels) and thought it would be better to leave things as is.  I think he said he had successfully revised 5 of 7 similar steep cup situations, but I was so stunned at the time I did not know the right questions to ask.  I will be getting more info from him.
   I am looking for a second opinion now, still do not know what my blood metal levels are, but was already advised by email from Dr. Boyd that a larger cup would be needed (they need to break the bone growth into the back of the cup, etc.).  I have seen an article about replacement cups for THR (Elke, Berli and Morscher, "Acetabular revision in total hip replacement with a press-fit cup", Journal of Bone & Joint Surgery, Nov 2003) , and the bigger cup looks scary large.  As far as getting the cup angle right, I note Dr Gross has developed a protocol that has or will be published (see this website 3/15/10) for keeping the angle under 50 degrees. I will be asking my revision surgeon to use that or something else that increases the chances of getting a successful outcome. 
  The whole reason I got the resurfacing was so I could continue my running, backpacking, active life style,  so I am not willing to go THR yet unless absolutely necessary.  Please keep this site informed of your progress , and I will do the same.

McCabe 66 

[edfskins]

Wow!  I'm 13 days out with Dr. Pritchett in Seattle and just returned from an uncomfortable 6 hour road trip; Yakima to Seattle and back; yep I drove after testing it out Sunday on a Costco run.  I'm doing well, was able to drive, and am optimistic about my progress.    Dr. Pritchett said he has performed over 2000 resurfacings and as we looked at my x-rays I asked him, "What kind of angle do we got there?"  He grabbed his protractor, affixed it to the x-ray and said 30 degrees. 
For some reason I thought that it should have been closer to 45 degrees, so I asked him if my angle was in the optimal target range.  He said that less is better and that 55 degrees or more is where ion issues come into play.  I would love to hear from any of you hippies that could make me feel at ease with my 30 degree angle  
Kirk~ I hope that you can get your cub re-positioned and have a bit of info for you.  The 60 year old next to me at the hospital, operated on by Pritchett the same day as me, 10-19-10, had a resurfacing done by Pritchett two years earlier.  His acetabular component was off, not sure if it was too steep or shallow, but he had a clunking sound from day one, squeaking, and high metal ions as well.  The guy was a total stud for 60, super active, told me that Pritchett was the man and that I wouldn't be part of the 2% because of Pritchett's expertise; I hope that's true but am still freaking a bit even though all is going great.  Pritchett re-positioned his acetabular cup and it's nice to know that this can be done.  Hopefully he'll have a great result.  Sorry for the long post, but if anyone can shed light on my 30 degree angle I'd appreciate it 

 

[stevel]

Hi Edfskins,

Check out Dr. McMinn's (2 each) three part video interviews with Vicky Marlow and his website for "Lectures", "BOA Sept 2010".
Somewhere in those interviews and presentations, he talks about cup inclination angles and combined cup inclination and anteversion angles (what is too high? and what is too low?).
After viewing the presentations, I got my protractor out and measured a cup inclination angle of 40 degrees from my recent two year post-op x-rays (9/29/10), which is ideal.

[Pat Walter]

Here is Vicky's interview with Mr. McMinn about the negative press and metal ion problems.

http://www.surfacehippy.info/mcminnnegativepr.php

Pat