Botched resurfacing, let's try cup revision

[Tim Bratten]

    This is my first post, but I've learned a lot from this site. So thanks to Pat Walter and everyone who has contributed to my education.
    Here's my story (I hope it's not too long). After some difficulty trying to choose the right surgeon (I live in Argentina) I had my left hip resurfaced by a local doctor about a year and a half ago. I blamed early difficulties with movability and pain on my own weaknesses, and by 6 months post-op I was rock climbing again, hiking regularly and generally getting as much activity as I could. However I was having problems. For one thing, in spite of increased flexibility lifting my leg behind, I experienced very reduced flexibility lifting my leg in front. To this day I have to cross my leg under my butt to put on a sock. A more serious problem was recurring pain when putting weight on my resurfaced hip. Each time I thought I was over the hump and on the way to full recovery, I would get sore again and revert to limping around for a week or two. During the first 10 months, I tried to convince myself the implant was fine. All I needed was time to work it through. But I certainly had suppressed doubts. At any rate, one insomnolent night, I found an article on line by Dr. Koen De Smet et. al. considering the relation between the cup's abduction angle and metal ion counts in the blood, that showed how to measure the angle by drawing a reference line. So I went to my post-op x-ray and measured. The angle was a good 65 degrees. I suppose everyone around here knows what that means.
    It was clear I needed a blood test for metal ions ASAP. Thanks to this site, I decided to contact Dr. Koen De Smet and Dr.Thomas Gross by e-mail for some initial advice. They were both kind enough to answer. As De Smet put it: "indeed the version and steepness are quite incorrect! It would be good to have your metal ions chequed".  So we did. But the test came back absolutely normal ... for someone who doesn't have a MOM implant. I couldn't believe it, so we did another test at a different lab. Normal again. At this point my own doctor was pretty useless, and my wife and I decided he didn't have a clue. Because of the low metal count, I decided to let things slide and see how it would go.
    For the next 6 months I went through ups and downs. There were times when I thought things were really getting better, but every time I would get hit with another set back and revert to limping around in pain. We found a hip doctor who had a good reputation in Buenos Aires and went to see him. I was curious if he would recognize immediately the poorly placed cup (he did) and what he might say. After looking at one x-ray the guy wanted to do revision surgery. A new twist was the doctor thought the cup was coming loose. By this point I was resigning myself to the need for revision (after a year and a half I was once again back to  limping around in pain) but I still wanted to know what my problem was. Looseness (if that were true) did not explain it. And my metal ion count was still completely normal. Once again it was time to contact the big guns. So I wrote to Dr. Gross and Dr. De Smet again, sending a description of my symptoms, data on implant make and size. etc. and a battery of x-rays. Dr. De Smet was the first to give me a diagnosis. He started his e-mail by writing in caps, just like this: "DEAR TIM, YOU HAVE NORMAL IONS BECAUSE YOU ARE WALKING YOUR OWN BONE INSTEAD OF THE CUP". This made perfect sense to me. We had seen from x-rays that the offset cup was apparently letting the femoral component contact hip bone. My wife had suggested this could be causing my problems. Since my pain and limitations where not unlike the problems of bone on bone from osteoarthritis, hers seemed like the best explanation so far. When De Smet said this was also causing the low ion count, I knew that was right. Holy moly: for a year and a half I'd been walking on hip bone instead of the implant!
    So now I'm off to Belgium to try and get fixed. Dr. De Smet told me cup revision was less certain to work out, but if I wanted to do impact sports it could be worth the risk. So we went for it. If the cup revision can't be done, De Smet will be ready with a large head ceramic on ceramic THR.
    Wish me luck and I'll let you know how this works out when I get back in March.

[OtterDriver]

Hello Tim!

Welcome!  Sorry to hear about your situation.  I hope the New Year holds Good News for you!  In the mean time...enjoy a nice Lomo and some Malbec!

Bruce

[Luanna]

Good Luck to You and Best Wishes for a GREAT recuperation and WONDERFUL New Year. You deserve it. Please keep us informed.

Luanna

[hernanu]

Hi Tim, good luck, if looks like you've got the right surgeon and the right approach!

[Dannywayoflife]

Hi Tim!
         welcome to the forum!
Im terribly sorry for your troubles. I really hope de smet can put you right! Since ive become interested in the subject of hip resurfacing it has really opened my eyes to how badly some surgeons are at there job! I know that in the oxford study they had a cup incination angle of 80 degrees!! I know being a surgeon is a very difficult job but if your not up to the task why carry on doing things your not good enough to do? and harm people in the process?
Anyway please keep us all updated on your progress and we will all suport you as much as we possibly can.
Danny

[Tim Bratten]

Thanks for the kind words ...

Heading to Belgium today. We're gonna spend a few days in Brussels, London and Bruges before the surgery. Should be pretty cool (with record cold in the area you can take that literally). One bar in Brussels is said to serve 1,300 different kinds of beer. We'll go as far as we can with that. Check in day at the hospital is the 13th and surgery is scheduled for the 14th. And away we go ...
 

[Dannywayoflife]

Tim i sincerly hope that de smet can help you out. Please keep us updated on your progress
Danny

[hernanu]

Good luck with the revision, Tim! 

Enjoy the beer - I once belonged to a beer club that did 25 beers in a month, I can't imagine 1300. You've got a great surgeon and whether a cup revision or a large head THR, you'll be much better off.

[Pat Walter]

Good Luck Tim.

Dr. De Smet was my surgeon in 2006.  I think he is one of the best in the world.  If anyone can redo the cup, it will be him.

Stay in touch when you can.  I will keep you in my thoughts and prayers.

Pat

[einreb]

Wow.. that is an amazing story.  Best of luck in getting some resolution to the problem... your decision to go to a top resurfacing surgeon is a good one.

-Bernie

[Tim Bratten]

Here's how it went:

Looking over x-rays with Dr. De Smet the day before the surgery I could tell he was skeptical about the possibility of successful cup revision. Not only did the cup look loose, but it seemed also the femoral component was loosening as well. Cup revision might entail yet another surgery in a year or two, with more possible bone loss. I told De Smet I didn't want any more surgeries and I trusted him to make the best decision once he was inside and could see things more clearly. Why would everything be loosening? I asked. He speculated that maybe I was having a reaction to metal ions (in which case the blood tests in Argentina were wrong) or perhaps I was one of those extremely rare cases that has metal allergy. We took another metal ion blood test, just to compare.

The morning after surgery, I was already feeling pretty darn good (by about two hours after surgery I didn't need any more pain drugs) when Dr. De Smet came to talk with me. He had informed my wife the night before that he had opted for THR, so I knew about this. He told me he didn't want to worry me, but I should know the truth. Apparently things were pretty much a mess inside. Lots of debris (bone and tissue) that needed to be cleaned up, the bone above the acetabular component had been poorly prepared and they found some shrinking of the femur. One little tap and the acetabular component had popped right out. The placement of the femoral component was also less than optimal. The kicker was they found staph infection, another gift from the previous surgery. In Dr. De Smet's opinion, this probably accounted for the weakening of the bones (the infection, plus the fact I had been walking on the bone probably caused the debris and the loosening). I was immediately put on a massive dose of antibiotics which needs to continue for two months (actually about 6 and a half weeks more).

To conserve bone and get an optimal cup placement Dr De Smet decided to use a screw. This entailed a 40 mm ceramic ball (without the screw he might have used something larger). He carefully explained to me why he placed things like he did (e.g. the angle of antiversion, etc.) while I just nodded in trust and apologized that I had given him such a mess to clean up. And now I think: if only I would have gone to De Smet in the first place I would have saved my self 5,000 Euros and a second operation! Better not to think about it.

The rehabilitation was actually pretty fun (for me and my wife). De Smet had done (I think) six surgeries on Tuesday and six more on Wednesday. I was the last of the group on Tuesday (he saves the most difficult for last, everyone told me). Seven of the patients were medical tourists who stayed at the Holiday Inn, and we got along just fine, watching each other improve rapidly and going out on the town to enjoy the city of Gent. Now after two and a half weeks I'm back home and I feel really good. If anything, I have to be careful to not do too much, because they tell me I've just been through a difficult revision surgery (which seems like a cakewalk compared to my last surgery).

There is one remaining wild card. The blood ion test came normal (like in Argentina) supporting De Smet's diagnosis, but there remains one question. Was the weakening of the bones (e.g. the shrinkage of the femur) due to the staph infection (as De Smet suspects) or possibly due to a metal allergy? At some point I will need to do the right hip, so do I go for HR or THR? I guess we'll wait and see. At any rate, I plan on returning to Dr. De Smet, even though this means paying out of my own pocket.

As Warren Zevon said: Enjoy every sandwich!

[Pat Walter]

Hi Tim

Glad to hear the revision went well and you are out of pain and active.  Sorry about the infection, but hopefully that antibiotics will take care of it.

I appreciate you taking time to tell your story.  It certainly has a message that you need to use the most experienced hip resurfacing surgeon possible.

I am a Dr. De Smet patient and I feel he is one of the best hip resurfacing and hip surgeon in the world. Glad to hear you don't need a lot of pain meds.  His surgical techniques are fantastic.

Please keep us posted on your recovery when possible.  I will also post your story on the main part of the website.

Good Luck.  Thanks again for sharing.

Pat

[Dannywayoflife]

Glad your on the mend Tim. Did de smet tell you which THR device he used? And did he place any activity restrictions on you?
I believe the likes of my surgeon and Mcminn often blame excessive trauma for neck narrowing.

[Tim Bratten]

Glad your on the mend Tim. Did de smet tell you which THR device he used? And did he place any activity restrictions on you?
I believe the likes of my surgeon and Mcminn often blame excessive trauma for neck narrowing.

I have the stickers to the devices stashed away in an envelope. The stem was made by Wright while the ceramic ball and ceramic lined cup were made by a company I'd never heard of. As far as restrictions I have the usual six week stuff.

Cheers
Tim

[hernanu]

Good stuff, Tim - happy to hear you're on a good track.

[mslendzion]

Wishing you the best. What brand went bad and was replaced.  Did you feel any effects prior to the surgery from the staff infection?

[Tim Bratten]

Wishing you the best. What brand went bad and was replaced.  Did you feel any effects prior to the surgery from the staff infection?

The old implant was the Cormet 2000, but Dr. De Smet said (even though he doesn't use this brand) he didn't think it had anything to do with my problems.

The weird thing about the infection was that it didn't have any outward effects (e.g. in blood tests, fever, swelling etc.) although it was apparently slowly pulverizing my bones. I feel very fortunate that De Smet was heads-up enough to take some samples during the surgery and check for this. Nothing about this possibilty was mentioned before the operation

[Dannywayoflife]

Glad your on the mend now tim! I hope your new THR lasts you the rest of your life!
Keep us informed Danny

[sootie]

tim
  sorry to hear about your troubles. i hope your revision goes well.i can empathise with you regards a revision i am 10 days post op after an asr revision i am in for a long rehab after the damage that was done,so my only advice to you is please do not push yourself too hard .take every day as it comes by all means do your exercise and walking but just remember its not a sprint its a marathon
                          regards sootie

[Tin Soldier]

Thanks for the story.  That's really too bad the HR didn't originally work out, although you sound like you've got a pretty positive perspective on it all and you sound like you're recovering well.  Good job!