Metal on Metal hip > pseudotumor & pain = revision?

[bb2008]

Hi, 

I am a fifty three year old male, relatively healthy, active and fit.
I had a hip replacement done on my right hip in June, 2008, by a top orthopedic surgeon at the NYU Hospital for Joint Disease.
It was a combination of total and resurfacing, using a Smith & Nephew total implant in the femur and a resurfacing cup in the hip. This allowed for a larger diameter metal on metal implant.

Everything was fine until Aug 28, 2010. I bent over to tie my shoe and within a couple of hours severe pain and a lump in my right rear hip appeared.
X-rays and a blood test show no infection, dislocation or implant problems.
Later that week a MRI and a blood test for cobalt & chromium. Blood test OK, but MRI showed a "pseudotumor".
The lump went away after several days but the pain has continued. The pain is mostly around the scar from the initial surgery, Sometimes it radiates down the thigh, occasionally down from the groin.
My surgeon was perplexed, he knew metal on metal allergies can appear if the implant is set at an improper angle that cause uneven wear, or if certain types of devices are used (such as the recently recalled Johnson & Johnson Depuy device.) I then had an aspiration of the hip joint, which pulled dark red fluid, but no metal particles.
An arthrogram of the hip joint showed no immediate migration of the dye, but the next day the lump was back. Lump again stayed for a few days.
Next step was to inject anesthesia into joint. It was difficult to tell if there was any relief because of pain from injection and keeping foot pointing inward for length of procedure, but it did seem to relieve the pain.
A neurosurgeon performed a cursory exam and did not find any reason to suspect nerve damage. My back is pain free.
Another MRI was scheduled. On route to the hospital that day, another lump (pseudotumor) started to grow, which also increased the pain, making it difficult to walk. This time the lump was where the surgery scar is. The earlier lumps were a bit further behind, upper right buttock.

After this latest MRI and pseudotumor, my surgeon feels there is no choice but to revise the hip implant, to one that is not metal on metal. But he is still not completely convinced changing the type and materials of the implants will end the pain.

Another note of interest:
When I now ride a bicycle, my right foot points outward, about 10 to 15 degrees. My heel now hits the chain stay of the frame?

He says he has not seen this condition in the thirty years he has been replacing hips. Does anyone have a comment or suggestion?

Thanks

[obxpelican]

None of that sounds right to be honest with you.

Have you had your x-rays examined by anyone else?   There are many surgeons who will give you their opinions at no cost whatsoever.

My advice, request your most recent x-rays, get them to Dr. Gross, Dr. DeSmet or Dr. Bose.  Sometimes a fresh eye can do wonders, sometimes the surgeon just wants to revise to shut you up, sometimes they make an error that they don't want you to know about, probably none of the above but many times a 2nd opinion helps a lot.

Normally a pseudotumor is caused from metal debris, that is normally caused from a device that was not implanted properly.

Chuck

[bb2008]

I agree, it doesn't sound right.
My x-rays have been seen by someone else, a colleague of my surgeon. He felt the device was set correctly.

"My advice, request your most recent x-rays, get them to Dr. Gross, Dr. DeSmet or Dr. Bose."
How do I go about doing that?

"Normally a pseudotumor is caused from metal debris, that is normally caused from a device that was not implanted properly."
I understand this. Has anyone seen it caused by a device that is implanted properly?

thanks for the help!
Bill

[obxpelican]

Bill,

You're welcome, BTW, when I go for 2nd opinions, I ALWAYS go out of the practice, not within.

You are doing the right thing, you are being your own patient advocate.



Chuck

[obxpelican]

Ooops. digitize them, I sent you an email Bill.

Have to learn to read more closely.

Chuck

[Pat Walter]

Hi Bill

I agree with Chuck and definitely would get several other opinons about your problem.  Did you get a blood test to find out your metal ion level?

I would try Dr. De Smet of Belgium and Dr. Gross of SC.  Both will give you a free consultation if you send them an email with a copy of your x-rays in a digital format as a .jpg    http://www.surfacehippy.info/listofdoctors.php   Here's a page about converting your x-rays  http://www.surfacehippy.info/xrayconversion.php

It will be good to get some more input from several of the top surgeons about your problem.  They can often see things that less expeirnced surgeons can't see.

Please keep in touch and let us know if you need more help.

Pat

[bb2008]

terrific!
I'll see about getting the x-rays tomorrow.

I did have a blood test for cobalt & chromium, I believe it was around 3?
My surgeon said it was slightly elevated, but not alarmingly high.

thanks, Bill

[DirkV]

Hi Bill,
This is only a minor piece of info, related to your cycling issue (toe out, heel inward). The issue may be symptomatic of reduced ROM. If you have ROM limitations that hinder you from "stepping over the top" of your pedal stroke in your normal fashion, you would accommodate as you describe. I had similar problem before resurfacing. I also had the affected knee move out of line to attempt to allow my foot to clear the top of my pedal. Obviously, you want to take care of your problems asap, but I was able to address my cycling issue by getting shorter cranks (until I had resurfacing).
Good luck,
-Dirk

[bb2008]

Hi,

Thanks for all of the advice.

Dirk, what is "ROM"?

I got the exact #s of my blood test for cobalt & chromium.
Cobalt: 3.4
Chromium: 3.0

Dr. De Smet & Dr. Bose both responded after I sent them x-rays and a letter.
They both agree I need revision surgery ASAP.
Dr. Gross requires some additional info I need to acquire before he can give his opinion.

I am scheduled for hip revision surgery January 11, to replace the metal on metal to alternative materials, I believe ceramic & titanium?, I will confirm that with my next meeting with my surgeon.

It is none too soon.
The pain continues to get worse, it is like fire in my hip.

Bill