Revision due to high metal ions without pain

[JMS]

I have recently had a revision of my BHR to a THR because of high ion levels, even though I had no pain, nor any evidence of pseudotumor.  My only symptom was a slipping or clunking sensation deep in the joint. My experience suggests that one can be at risk for metallosis long before symptoms appear, and that patients who have a serious clunking problem that persists would probably be wise to have their metal levels checked.

My resurfacing was done by a highly experienced surgeon 18 months ago. I had a smooth recovery and was delighted to be pain free within a few weeks.  The hip clunked with certain movements, but I was reassured by both the surgeon, and much of the discussion on this website, that this would be a temporary problem that would resolve itself.  It didn’t, however.  In fact, the clunking became more and more frequent – eventually reaching a level of many hundreds of clunks a day. 

At my one year follow-up appointment everything appeared to be fine – x rays looked good,  (acetabular cup at a near perfect 40 degrees), excellent range of motion, pain free, etc. However when I raised the issue of the clunking yet again, this time the surgeon was concerned and arranged for my metal ion levels to be checked.  The numbers came back sky high: 1616.9 for cobalt and 840 for chromium.  When the ion levels were checked again six weeks later, they had risen significantly to 2265.8 and 1219 respectively. 

Given these exceptionally high levels, and the rapid rate of increase,  I was  immediately scheduled for surgery to remove the BHR and replace it with a THR.  The surgery went well. There was a great deal of metallosis but no sign of pseudotumor and no bone damage, confirming the value of the early intervention.  The surgeon was able to remove the acetabular component with minimal bone loss allowing for what we trust will be a successful replacement implant.  So far (8 weeks post surgery) I am very happy with the performance of the new THR, which is pain free and clunk free.  I have been tested for metal ions again recently and am awaiting the results.  Hopefully they will confirm that the levels are dropping.

[Lopsided]

My resurfacing was done by a highly experienced surgeon 18 months ago.

Who was your surgeon?

[Mbstout52]

I have just scheduled my revision from BHR to THR. Surgery date will be April 20th, just about 2 weeks shy of the 2 year anniversary my original BHR. I too had a very experienced surgeon, Dr Pritchett. I've had clunking all along that has increased over time. I'm not in pain but my chromium level is apparently high, 17. I've also recieved differing opinions as to what is going on and why I need a revision. Dr Pritchett believes my cup is loose and recommends a revision to the cup only, a Smith & Nephew R3. The second surgeon I've seen, Dr Clark, reads the film as bad cup placement and that the clunking and ion numbers are due to edge loading. Dr Clark is recommending the THR thinking that the femoral cap has likely been compromised.
What a drag. I'm going for the THR with the hope of just getting something that works. It's good to hear that your clunking disappeared. How do you anticipate your activity level to change from the  BHR to the THR?

[sootie]

I have just scheduled my revision from BHR to THR. Surgery date will be April 20th, just about 2 weeks shy of the 2 year anniversary my original BHR. I too had a very experienced surgeon, Dr Pritchett. I've had clunking all along that has increased over time. I'm not in pain but my chromium level is apparently high, 17. I've also recieved differing opinions as to what is going on and why I need a revision. Dr Pritchett believes my cup is loose and recommends a revision to the cup only, a Smith & Nephew R3. The second surgeon I've seen, Dr Clark, reads the film as bad cup placement and that the clunking and ion numbers are due to edge loading. Dr Clark is recommending the THR thinking that the femoral cap has likely been compromised.
What a drag. I'm going for the THR with the hope of just getting something that works. It's good to hear that your clunking disappeared. How do you anticipate your activity level to change from the  BHR to the THR?

[Dayton96]

You know, at this point, I think I would probably get a couple more opinions. 

Mac

[sootie]

sorry to hear about revision.i have recently found out that first i have one of ths recalled de puy resurface hip replacements,and second my metal ion levels are high.i am having another blood test next month to see if there is any change from the first one.like you i have no pain and from what i could see from the x-ray no evidence of pseudotumours or any problems with bone damage the only problem that i have is an aching felling down both my thighs.dont know if that is an indication of mettallosis.talk to my surgeon about that when i see him,i can understand how ticked-off you were when you found out that you needed a thr,i am not looking foward to having mine done so soon after my resurf (2 yrs) operation and rehab still fresh in my mind what type of thr did you get done was it mom or ceramic.iam not keen to go mom again.
                                                                                     i am glad that everything went well with your thr surgery and you are on the road to recovery and i hope you get many pain free years from this one
                                                                                                                                  regards
                                                                                                                                   sootie

[ReneeP]

Is your thr metal or ceramic?  My BHR was revised to a THR at only 5 weeks due to a fracture.  I have a large metal on metal thr and I do have some clunking.  I am wondering if it's just a metal hip thing because my friend has a ceramic thr and hers doesn't clunk.

[JMS]

Re Mb Stout52's comment regarding being given different opinions, and having to choose between an attempt to fix the resurf, or to opt for a THR:
I faced this situation too, in fact I went into surgery not knowing which course of action would be taken. The surgeon said it was possible that when he opened up the joint, he would discover a straightforward mechanical issue that could be resolved by replacement of the acetabular component only, leaving the femoral head intact. He stressed that for that to be his choice of action, he would need to be confident that a) I was not reacting to the metal in any way, b) no damage to bone and c) that a realignment of the acetabular cup would indeed resolve the mechanical issue.  He indicated that this solution was not often possible, and that if he had any concerns he would revise to a THR, which in the event was what happened when he encountered so much metallosis.  I was fairly happy with letting him make the choice based on what he found during surgery. If I could have saved the resurf, that would have been good, but I certainly didn’t want to keep it if it was contra-indicated.

[JMS]

sorry to hear about revision.i have recently found out that first i have one of ths recalled de puy resurface hip replacements,and second my metal ion levels are high.i am having another blood test next month to see if there is any change from the first one.like you i have no pain and from what i could see from the x-ray no evidence of pseudotumours or any problems with bone damage the only problem that i have is an aching felling down both my thighs.dont know if that is an indication of mettallosis.talk to my surgeon about that when i see him,i can understand how ticked-off you were when you found out that you needed a thr,i am not looking foward to having mine done so soon after my resurf (2 yrs) operation and rehab still fresh in my mind what type of thr did you get done was it mom or ceramic.iam not keen to go mom again.
                                                                                     i am glad that everything went well with your thr surgery and you are on the road to recovery and i hope you get many pain free years from this one
                                                                                                                                  regards
                                                                                                                                   sootie

Hi Sootie
thanks for the good wishes.  No, I didn't want to go MOM again, either.  Initially my surgeon was talking about ceramic but there are some studies beginning to surface that suggest the ceramic are not as free of problems as they were initially predicted to be either.  Given the problem with the MOM, my surgeon was concerned about giving me anything that wasn't thoroughly tried and tested.  In the end we went with the Smith and Nephew Synergy.

Very best of luck with your revision. I hope all goes smoothly.  jms

[socross31]

JMS,
I am sorry to hear about your issues. But, at the same time relieved to know my husband is not the only one. His levels are also high, but not as high as yours, they are 153/84. Our surgeon is suggesting a THR also. He has only had the Birmingham for 2 1/2 years. so this has been devastating to us as he is 54 and very active. Would love more input from ANYONE!!

[JMS]

Hi Socross,
I'm sorry to hear that your husband has this problem too.  I think once your levels get over 100 you really don't get any choice about having it revised - the toxicity issues are just too serious.
The best encouragement I can give you is that I am doing really well with the THR.  I had thought it would feel very restricted after the resurfacing, but truthfully it feels exactly the same - actually better, because it doesn't clunk any more.  I had the impression that I would have less range of motion and so on with the THR  but in fact it feels and functions just as well as the resurf did. I can bend and stretch and cross my legs and all the stuff I was told would be difficult. 
And my metal levels went down by about 90% within seven weeks of the revision surgery, so your body really can clear the metals well, once the source is removed.
very best wishes to your husband. I Hope his revision goes smoothly.

[Tin Soldier]

Interesting stort JMS - Most of the stories we see on metallosis here, have a high cup anteversion angle, but yours was spot-on.   I have heard that Pritchett has done a number of cup revisions and had good results.  I have a fair amount of clunking, not doing any extra exercise to "tighten" the muscles because of no. 2 being painful.  Certainly makes me wonder.

[JMS]

Hi Tin Soldier
Your comment that my anteversion angle was spot-on is not actually true.  I did have a spot-on abduction angle of 40 degrees but I don’t think my anteversion angle was equally effective – at least not for my particular hip.  From what I can discover, it is less easy to identify a standard target angle for anteversion/retroversion because it is more affected by individual anatomy.  There is also the challenge that a retroverted socket may cause psoas impingement, which of course surgeons try to avoid.  However, go too far in the other direction and it gets anteverted, which can lead to edge loading.  I think it is likely that this is what happened to me.

I’m not sure how frequent your clunking might be, but if you or others reach the point where you are triggering a clunk with everyday minor movements (e.g. leaning forward to brush your teeth or press an elevator button) then you might want to consider getting your ion levels checked.  There are some serious potential side effects. Just yesterday, I was informed that I have developed left atrial enlargement, and as you know, of course, cardiomyopathy is one of the side effects of cobalt toxicity.
Hopefully I won't discover any other legacies from my elevated metal levels.
Best
JMS

[cwg]

Hey- Just clicked on all your messages- My levels are high, but not as high as yours. I feel unwell, comes and goes but can come on big, seemingly out of nowhere.. And I clunk. Have gotten used to hearing that was "normal", so I live with it
After reading your stuff, am not so sure about anything.
And I don't want to keep posting here, publicly, except now and then
Any chance we can e-mail?
Thanks

[Tin Soldier]

CWG - send JMS a PM.

The clunking is a weird deal.  I have it in both, but I'm still pretty early on.  It went away when I got more active, which is what you read about.  The idea being that the muscles around the hip get tighter with exercise.  The "rubber bands" tighten up and hold the ball in the cup better.  I also have heard some stories with metallosis where the person complained of the clunk being more prevalent and getting more pronounced.  JMS has a lot of info on this topic.

Good Luck.       

[cwg]

Thanks Tin and everyone here, really- am going to sit back and just read you  guys, until I know more about my stuff-

Am on a waiting list for the top hippie guys in Vancouver- As I've written before, my BHR was done in 2007, in Hong Kong, where I was living- My  Australian Doctor in Hong Kong's name is Dan Hooley. As far as I know, he and his ex partner Dr Brockwell? have performed a large number of BHR's - I do not know anyone else's outcome.

I had some seizures the first 3 nights until I insisted being taken off Pethidine (sp?) after having my husband check my meds on the Internet. My operated leg dragged on crutches and I could barely hold my head up. Obviously I'd had other dormant issues going on.
Like I've said earlier, I am certain now that I was not a good  BHR candidate.
I was 52.

I  walk Stanley Park,do reformer pilates, sometimes chiropractor ,and  have a personal trainer once a week. All work hard with me (gentle hard) and none really understand, nor do, I the extreme weakness on the side of my operated leg. Sometimes I feel like I am hanging by a thread. With my 'flat as a pancake" right glut muscle. And groin inner thigh feel "empty"
I "have no core" still.. And work the core ALL the time
This being said, today I had a great work out with my trainer- my attitude is less "fear" and just "fk it" We even did a little bit of boxing.
Tonight I go to my on camera class- I am an actor and director.

So, now people know my gender, my age  my work my doctor's name..and I am normal weight for my age.

My levels are not in the hundreds yet, just barely three quarters there.
One step at a time

[John C]

Hi cwg,
With your higher metal ion levels, and the "flat as a pancake" glute; you might consider asking for some tests specific to soft tissue, such as MRI, CT scan, or even ultra sound. The standard X rays may not provide enough information to clarify what is going on.

[JMS]

Hi cwg
Yes of course we can email. If you go to the member's list, and find my name, you can click on the envelope icon next to it and send me a private message. Then I can reply directly to your email address.
best
J.

[ScubaDuck]

cwg-

Sorry to hear about your issues.  Keep asking for answers because there have to be solutions.

I am up in Vancouver area about three weekends a month because my girlfriend lives in Surrey.  If you want to get together and chat, let me know.  My gf and I love Stanley Park and we are aquarium members.

Also my gf has some shoulder issues.  I met her surgeon and he has done some BHR implants.  He seems very no nonsense and very competent.  I don't know if he has done any revisions or not.  Let me know and I can give you his contact information.

Best wishes
Dan

[cwg]

Chuckle- I was not going to write here, just read.. But this site is great, and I am grateful for it.

To DG, yes that would be great. I will PM you with my cell number. Am interested in your GF's surgeons name.

Today I met with a "physiatrist" , a specialist in physical rehabilitation in surgeries gone wrong. Had this appointment booked 6 months ago, long before my ion metals were tested a couple of weeks ago.
He is concerned, and booking me with some "top guys" at VGH- This doc is at St Pauls.

My "family doc" ( at Khatsilano Clinic) also, is trying to get me in with the same guys.
The system here works differently than it does in HK and referrals take a while. Am kinda new to Canada.

This guy today, said the only way out of the heavy metal results, is surgery. Yet I also hear and read that it needs to hit 100 before one does anything..Mine is not quite 70.

I don't really know what to think right now.

And frankly, I don't trust what every doctor says. I've made this mistake before. AND you get many different opinions. Ultimately, you choose the opinion you want to hear. I believe.

Thank you for your generous offer of meeting up or at the very least, a conversation.

Cheers