How much NSAIDS and joint narrowing before surgery is justified?

[RobB]

Hi. I’m looking for some feedback as to how bad my arthritic right hip has to get before a doctor might agree that I’m a candidate for resurfacing. How long can, or should, I stay on the NSAID, meloxicam (Mobic)? Do I have to show bone-on bone in x-rays? 
The OA in my right hip showed up when I was about 50 and has slowly gotten worse for the last decade or so. Basic x-rays (“A/P hip”) taken over the years show gradual joint narrowing occurring. I was interested in resurfacing a few years ago, but I was told the joint wasn’t that bad yet.
Now, I’m having pain from the hip all the way down to my ankle or foot. The knee just throbs. It’s unbearable at times. Recent x-rays show what (to my uneducated eyes) looks like about 50% narrowing. This seems significant…especially considering the pain. I would have had to give up my job if the doctor hadn’t put me on meloxicam to bring the cartilage inflammation under control. He didn’t think a “scope hip” debridement would be of enough benefit to make it worthwhile. He suggested the Mobic for now, and then hip surgery in four years when I’m 65.
The meloxicam really works pretty well if I could just hang out around my home and take it easy. But my work requires me to occasionally walk a hundred yards or two at a time. Even just once in a day, that does me in. The pain returns and takes a day or two to get over. It’s unbearable. 
I’m taking the maximum 15mg dose of Mobic, and I don’t think I can get by without it or something similar. It seems to sit well with me, and I’m in pretty good shape, but the potential side effects of this and all NSAIDs—sudden perforated ulcers, strokes, heart attacks—make me nervous.
(1) Should I worry about this? Is there something reasonably safe and more effective for hip pain?
(2) Do I have to get to bone-on-bone before I qualify for hip resurfacing? Do some good resurfacing doctors do the job when the pain is simply too much, even when x-rays show some cartilage left?
Thanks

[resurface]

Rob

Hello.  I guess this is a personal decision.  In my case, I am 47 and 4 months post-op (May 6th).  I am now bicycling pain free 100+ miles a week and no issues sitting on cross Atlantic flights.  All symptoms are gone.  I was not nearly as uncomfortable as you describe nor was I taking meds beyond Alleve when necessary.  I did have many of the same symptoms: from the hip to the knee and sometimes the area between the shin.

My philosphy on this is get it repaired as soon as it changes your life or interferes in some way that is important to you.  I could have just sat out the next 5 or 10 years but I am an extremely active person.  What is bad enough?  How much of a limp does someone need? 

I bet you hear more of the same but I am 100% pleased with my decision and the results.  I still have rehab ahead of me but man what a difference.  I sat out skiing last year.  Not this year.

Get your life back....

[Lopsided]

It seems to me that when you are bone on bone, it is time. NSAIDs do not really matter, I never took them. And if you take them for too many years they mess up your kidneys.

I though I might have had my operation too early, but afterward the surgeon said he did a bone graft to fill in a cyst.

So don't leave it too long.

[moe]

Rob. Many people here have been through the same scenario. I think you need another opinion from an experienced resurfacing surgeon. My own personal feeling is you are probably at the point of no return. When a walk of a hundred yards is too much then that is a pretty good indication. It will only get worse, so what's the point of waiting? For the wheelchair? You could cause more damage to your knees or back by compensating. If you wait too long you may miss the opportunity by damaging the bone. All those pain killers are not good for your body.

An outside contractor who saw me before and after surgery and watched my recovery recently stopped in and told me he had gotten a THR and was so happy he wished he had done it 5 years sooner. The most important decision is the right doctor and also the right implant. There is no need to suffer anymore. Good luck, moe

[RobB]

Thanks, all, for the feedback.

My impression (apparently wrong) was that most surgeons would say, "You're not bone-on-bone yet, so I won't resurface your hip while I can still see space in the joint."
If that's not the way it works, then I need to stop messing around before I can no longer work. I almost had to bail out and come home early today. That's scary because I'm self-employed and can be replaced.

Now I need to find an experienced doctor to do the job, and maybe one who will "work with" a guy who's going to pay the tab out of pocket.

Thanks, again,
Rob
Ventura, CA

[John C]

Rob,
Here is a short story that may be useful to you. Even though at age 56, I had been having increasing hip pain for almost 15 years, my x-rays did not look horrible; narrowing yes, but not terrible. When I first met with Dr. Gross, he actually spent almost an hour with me trying to figure out if there was some other option that I might pursue rather than a replacement. He finally said that a CTscan would give us a lot more information. Two hours later when we looked at the CT scan, it was immediately obvious to both of us that my hip was shot, in a way that did not show up on the x-rays. When I spoke to him after surgery, he said that the timing was perfect, and it was amazing that I had remained active on that hip. There was a sizable cyst that was indicated on the CT scan, but did not really show up on the x-rays.
So, do not consider x-rays to necessarily be the final word. Your symptoms tell you a lot about your hip, and if you wait too long, a resurfacing may be difficult to do.
If you believe in resurfacing and are a good candidate, my own belief is that the affect on your quality of life should be the prime timing determinant, not the x-ray.

John

[Big Bill]

Big Bill here ...I agree with all of the above comments...my doc always told me that with or without meds, I would know when I was ready  . I went in about every 6 months to have x-rays to monitor the deterioration of my hip(osteoarthritis). I tried Celebrex,but Mobic was the best for me. When you use NSAIDS  for long periods of time, periodic testing should occur to assure that there is no damage to your kidneys or other organs. When I started getting to the point where I was limping more, mowing the grass was a killer the day after,couldn't drive, sit or sleep well (normal activities),got really grumpy(being in pain does that to ya  ), I went back for another x-ray in about 3 months and I had 3-4 cysts visible. That was in May of 2008...Dr. Kreuzer told me and I agreed, that  it was time.That x-ray was gnarly  ! He told me that if I were to wait too much longer, I may not be a candidate for resurfacing   .   I had researched resurfacing for nearly 2 years and consulted with several surgeons outside Texas. I was not going to risk losing my opportunity to get back my active lifestyle  ! The Cormet device was now FDA approved and Dr. Kreuzer here in Houston recommended it. I scheduled my resurfacing that day.  Do not wait too long !!! I am glad that I am on the other side  . I only wish I could have done it sooner....especially knowing the result !  July of this year was my 2 year mark and I still check out ths forum regularly and will continue ! Thanks to all !    


Big Bill  

[ReneeP]

Hi Rob,

I have to agree with everyone else here.  My hip doesn't look terrible on x-ray, but I've had pain for 22 years (since college)...I had torn cartilage, and was told at age 39 that I have dysplasia and OA and would need a THR someday when I could no longer stand the pain.  Some angel on another website told me about resurfacing.  I found a different surgeon who has been telling me for 3 years that I am a candidate for resurfacing, but to wait if I can until I'm a little older (I'm 42).  However, I saw him in July and had another x-ray.  He walked into the room and I asked him how it looked and how much longer he would make me wait for the resurfacing.  He looked at me like I had 3 heads and said, "You have very good reason to have the resurfacing now, if you want it."  I told him I thought I had to wait because the x-rays weren't showing much change...although my pain level has certainly changed.  He said that my x-rays don't show where most of my damage is, so we can't completely go by the x-rays.  I have been living on mobic and tylenol arthtritis which only takes the edge off the pain.  I take tramadol on the really bad days which are becoming more frequent.  I have pain when walking, sitting, lying down, and I wake up from the pain at night.  I also have wicked knee pain and the pain sometimes goes down to my ankle and foot.  I only limp when I've been sitting for a while, or it's a really bad pain day. It was a relatively easy decision to book my resurfacing.  It's scheduled for November 2nd, and now that I have a date, it can't get here fast enough.  My advice is to take everything into consideration...not just the x-rays.  They don't always tell the whole story.

Renee

[RobB]

Thanks again, all. I'm going to put a presentation together for Dr. Bose (Chennai, India) this afternoon. I contacted him three years ago, but my x-rays didn't look too bad, I wasn't on a prescribed course of NSAID, and he wasn't quite convinced. I think he may be this time. Yesterday I went back to my doctor's office and snapped digital pics of the latest x-rays in their light box. The (young) x-ray tech didn't think it would work, but they turned out perfect. (Just remember to turn the flash off and let the camera auto-focus.)
Does anyone know Dr. Bose's current package price for resurfacing? (I will ask this again as a separate post.)

Here's hoping....

Rob

[SteveT]

I'm deliberating about the same thing.  My x-rays show some narrowing but not much, some evidence of cysts (an MRI confirms the cysts - says they are extensive) but I've been limiting my activities more and more the last two years.  I had consulted with Dr. Su and he seemed willing to do the procedure but kind of implied to me that it was a early; most of his patients were worse off. So, for instance, I have no difficulty getting shoes on, clipping toenails, going up and down stairs etc., many of the things that posters here say they were limited in doing when they opted for a resurfacing.

Then I was prescribed celebrex for something else and I felt like I was 10 years younger.  It's not that it eliminated all the pain in my hip, but a lot of it.  I could walk as long as I wanted (had been limited to a mile or less before) and even stretch a little. If I felt like this all the time, I wouldn't be considering the surgery.  So, I suppose the question is how do people employ NSAIDs when they work?  How often and for how long?  I know there are reasons to be careful about them, but can anyone shed any light on the issue.  If it's no big deal to take them daily for however long they work, then I could easily imagine postponing my surgery for a fairly long time. 

Thanks,

Steve

[RobB]

Hi, Steve,

    I had almost forgotten about this thread I started in September. I did indeed visit Dr. Bose in India and had hip resurfacing surgery on October 28. The basic A/P view X-ray of the hip joint taken there looked just like those taken here in California...some joint narrowing at the top but no apparent bone-on-bone. It was my symptoms--the sometimes-agonizing referred pain all down my leg--that convinced the doctor to proceed. After the surgery he said that he was a bit surprised to discover that much of the cartilage on the inner (or back?) side of the femur head was just GONE. That's why it hurt so much. My timing was perfect because I got the resurfacing before cysts formed. This situation left uncorrected probably would have resulted in the development of such cysts which, at the very least, create pockets that reduce the amount of contact area between the bone and the inside of the steel hip resurfacing head component. I have 100% contact. This is always preferable. And, at age 61, I believe I was at greater risk of "necroses" of the neck portion of my femur than a younger man would have been.
    So I'm glad I went ahead. If, without Celebrex, you have pain that refers to your knee or shin, or ankle as I did, I don't think I'd wait too long. Or maybe at least see if you can get an "oblique" (I think it's called) x-ray or some other imaging to see if there's more going on behind the easily visible part of the joint. Good luck.

Rob