Bicycle Crash Possible Femoral head damage

[n2fun]

I had a right BHR in January 2009.Recovery was great I was back to cycling and in the gym quickly with few problems. In September 2010 I had a nasty wreck on my road bicycle landing on my right hip. I went back to my Dr and was told the xrays didn't show any problems. I stayed in the gym (doing a boot camp class) and on the bike, after five weeks I didn't seem to be recovering I was still riding and in the gym. The pain got worse even though I started to back off my activity I went back to the Dr. and he suspected a fracture which the new xray didn't show. I am now 13 weeks out from the crash and on crutches. My Dr. says my femoral neck has shrunk and he suspects the femoral ball is loose. Is it possible to have a fracture or loose ball and not be able to see it on xray? Is there any other test that will show the damage under the metal? My Dr. says CT and MRI won't show in these areas. Any imput is welcome. I have another appointment Wednesday I fear the dreaded revision word will be discussed.

[obxpelican]

As far as femoral cap loosening the only way your doctor could tell is if the device was sitting at a different angle when the x-ray was taken versus the position when it was last taken.  Your device is metal so the x-ray cannot see the bone area.

Femoral neck shrinking could be the result of bad "loading" or the femoral device actually impinging, but probably more like a loading issue.  The more the bone is used with "loading" the better the bone will be.

I've heard of loose heads actually reforming bone through growth as long as the femoral device stays at a good inclination.  I do not know if the cement that was used will help or hinder bone growth, the argument that has raged on different forums always mentions non cemented devices being able to re-grow.

Don't give up yet, ask about possibly staying off of your hip or say 10% weight bearing for a while, you never know.

Good luck.

Chuck

[n2fun]

I do recall my Dr mentioning loading being a possible cause of the femoral neck shrinkage. I am very active and do a lot of cycling (4000 miles/year) and weight training 2-3 days a week. What would cause a loading issue ? Until the crash I was pain free.

[resurface]

A subtle neck fracture can be missed with a standard xray.  I have seen literature reports of up to 7% of the time.  Only a CT / MRI will provide a definitive diagnosis.  Neck fractures are hard to heal and it depends on the neck location.  The femoral head does not get a great deal of blood supply naturally to aid healing.  You may want to talk to your surgeon more as well as see a specialist who treats neck fractures.  Usually trauma surgeons treat these.  Yes, your regular ortho guy sees these cases but not as often as a trauma surgeon.  You have the added "complication" of the implant.  Good luck. 

[obxpelican]

Bones become stronger with use, loading is where the weight is distibuted properly on the bone, one of the negatives to THRs is the lack of loading, instead of the bone being pushed down evenly the weight is distributed from the stem which is now inside your femoral cavity. This is one of the good things about resurfacing, the loading is more natural.

You may be losing bone because the cap is loose and is not loading properly on the femoral head. 

I've read where sometimes if the person goes non/minimal weight bearing that the bone reforms.  Again, a lot of supposition on my part as I only know what I've read and been through myself.


Chuck

I do recall my Dr mentioning loading being a possible cause of the femoral neck shrinkage. I am very active and do a lot of cycling (4000 miles/year) and weight training 2-3 days a week. What would cause a loading issue ? Until the crash I was pain free.

[Pat Walter]

You did not mention what doctor you are working with.  Dr. De Smet of Belgium and Dr. Gross of SC will look at your x-rays and are very, very expeirnced in seeing problems.  Many times the less expeirnced surgeons that have not done thousands do not see what the top surgeons see.  You can send them an email with a copy of your x-rays in a digital format as a .jpg and see what they think.  It is always good to have a second opinon.

Pat

[n2fun]

I am working with dr castle in charleston WV. Based on what I hear tomorrow I plan on contacting dr gross. He is only 6 hours away. Thanks for the information. I will post results From my appointment tomorrow, I appreciate any information anyone has to help with the difficult choices I have.

[n2fun]

Does anyone know how long it takes to get femoral neck shrinkage due to a loading issue, My accident was 13 weeks ago is that long enough to see shrinkage on an xray?

[obxpelican]

I really don't think anyone here is at that pay grade that would know that answer.


Chuck

[n2fun]

I saw the Dr today, the xrays clearly show the femoral cap has moved, he suspects the bone has withdrawn under the cap either due to a glue issue or blood flow to the area. He states this happens in about 4% of the cases, lucky me. The socket look to be good and is set at a good angle within the limits of 35-45 degrees. He suggest replacing the femoral unit with a Smith and Nephew Anthology device which should correct the problem. He also said there is a remote chance If I do no load bearing for an unspecified amount of time It may repair itself but he gave it a less than 10 % chance. With the femoral cap obviously moved is there any real need for another opinion? The pain is getting worse by the day and there is a risk of fracture. Any imput or information is appreciated. also Smith and Nephew wants to look at the device to determine the root cause.

[obxpelican]

IF (big if) the femoral component were at correct angle right now I might try to see if it would reseat, if it's at an incorrect angle right now, I would revise.  The unknown right now is, with cement will bone reseat itself into the component?  The other unknown, with cement being present how well would it bond?  Cement is usually not the cause of these situations.  Your neck could be dying off.  Possible.

A femoral neck fracture is EXTREMELY PAINFUL, much worse than you are experiencing now, IMHO if your doctor is thinking this is a possibility, I would take his advice and revise ASAP, again, my opinion.

The good news is, THRs have improved immensely and you will be getting a large ball MOM which I believe is what your doc is recommending to you.  Recovery is like a hip resurfacing and the final results are usually very good.

Just all my opinion.

Chuck

I saw the Dr today, the xrays clearly show the femoral cap has moved, he suspects the bone has withdrawn under the cap either due to a glue issue or blood flow to the area. He states this happens in about 4% of the cases, lucky me. The socket look to be good and is set at a good angle within the limits of 35-45 degrees. He suggest replacing the femoral unit with a Smith and Nephew Anthology device which should correct the problem. He also said there is a remote chance If I do no load bearing for an unspecified amount of time It may repair itself but he gave it a less than 10 % chance. With the femoral cap obviously moved is there any real need for another opinion? The pain is getting worse by the day and there is a risk of fracture. Any imput or information is appreciated. also Smith and Nephew wants to look at the device to determine the root cause.

[n2fun]

The femoral component has moved there is an obvious void below the stem in the xray and the angle has changed. The Dr did refer to loss of blood flow to the area and the neck dying off I have lost about 20% of the femoral neck size to date. He did not seem to think it would take care of itself. Right now the pain is slowly getting worse so I will most likely schedule the surgery soon. Thanks for your input obxpelican it has been helpful.

[Pat Walter]

I am sorry to hear about your problem.  Is the neck had deteriorated so much, it seems like there is little chance of it getting better.  It is good that your acetabular cup is well placed and tight. That would make a revision to a THR easier since only the femoral component has to be replaced.  A MOM THR is not a bad solution to a painful hip and normally does not have any restrictions as an old fashioned small ball THR.  I am sorry to hear you will probably require a second surgery, but you want to be out of pain and active again.  A revision is proably the fastest way to do that.  Waiting a long time in hopes the femur neck will heal is a big gamble.  You can ask Dr. Gross and/or Dr. De Smet what they think.  Both will give you a free consultation.

Meanwhile, please keep us up to date.  I hope you can find a solution soon.

Pat

[n2fun]

Thanks Pat, I sent an email to Dr. Gross today this site has been such a good source of information to me.

[n2fun]

Well it appears that the femoral component has failed. Dr. Gross reviewed my xrays and agrees with my Dr. to reuse the acetabular component. The femoral neck and bone around the femoral component has shrunk and is very noticable in the xrays. But the exact cause is not known yet. My Dr will send the component off and we will then likely know what caused the failure. I am scheduled for revision surgery 12/20 Merry Christmas. The thing that suprises my the most is the rapid transition from very athletic to crutches. Don't get me wrong I am not bitter it is what it is and I will make a quick recovery I'm sure, just wish I had a definate reason, based on xrays I will one day be a bi lateral.

[newdog]

n2fun,
So sorry to hear about your situation. However it sounds like you did things the right way to get the help you need. I will be thinking and praying for you with your upcoming surgery. The new MOM THR's are miles ahead of the old ones. You will be O.K. and will be active again.

Steve (newdog)

[n2fun]

Had my revision surgery 12/20/2010 Dr Castle used the acetabular component and placed a large MOM femoral component from smith and nephew. The surgery went well and I was up on crutches with total body weight today and discharged from the hospital. Very little pain and I don't notice a lot of difference yet. I realize it is still very early but since there were no muscles taken off the bone I expect a quick recovery. It appeared there was some blood vessel damage in the feroral head area and bone loss we think the bicycle wreck was a catalyst and not the root cause. I will post my recovery and cause ( if ever fully determined) in the "My Replacement requires a THR revision"Thanks to everyone for your input.

[hawaiieric]

N2fun,

I want to wish you a safe smooth recovery.  Thank you for keeping us updated on your situation.  There are many of us who do excessive extreme sports and this makes you think twice about some of the daring things we think we can do without the thoughts of what could go wrong.  This makes me think of my choice of sports and its risks. Best wishes for your recovery during this holiday season.

Eric
rBHR nov8,08