New to the topic, still exploring options

[livendive]

Howdie hippies,
I'm a 45 year old guy, overweight but reasonably muscled and pretty active.  I've been into skydiving for about 20 years (2600 jumps), like snowboarding in the winter, and my get back in shape activities (down 25 lbs, with 25 more to go) are running and cycling with hopes, perhaps unreasonable now, of completing a triathlon next year.

My hips have been bugging me for about 9 years, mostly in skydiving, where contrary to common belief, hard landings aren't so much an issue as having to arch your pelvis in freefall.  The first time I went to a doctor about them was back when this all started, she did some simple manipulation tests on the exam table and said "Your hips are f*&#ked", but that was all, and I've had good and bad days with each since then.  This spring they were getting worse, with tying my right shoe an exercise in pain and frustration, so I went back to my (new) doctor and told him this was becoming something I couldn't just live with.  He sent me for x-rays which showed osseous bumps on both femoral head-neck areas indicative of cam type FAI, mild degeneration of the left hip, and moderate degeneration of the right hip.  After a couple months of PT which did improve ROM in the right hip and reduce pain signficantly, my left hip took center stage.  I went for an MRI last week and the doctor said the left hip might be repairable with arthroscopic surgery but the right isn't salvageable and should be replaced.  Understanding my concerns related to my age and activity levels, he acknowledged that resurfacing is an option he'd probably look into more if he were in my shoes, but nobody close by does it.  We scheduled ultrasound-assisted cortisone injections in both hips for next Monday and I'm VERY MUCH looking forward to them.  Right now the pain in my left hip wakes me up at night and is, well, really bad every morning.  I've experienced worse pain before, but in most injuries, there are more and less comfortable positions.  This one is unabated by any position and I end up popping painkillers to get me through the worst parts...not a desirable or sustainable solution.

Initial questions:
What's the cortisone injection experience like?  I've had them before in my back with no ill effects and was planning on just going to the doctor in the morning then driving out to work for the rest of the day.  Reasonable expectation? 

Also, it sounds like most people can get by with cortisone injections for awhile, albeit each lasting less time than the previous.  Would it be reasonable to hope that these could carry my right hip though till next August or so, after which I could BHR it and be mostly good to go by the following summer?

I'm new to my insurance company, Group Health, and have never been in a system involving such managed care.  The costs are great, but the process is annoying.  I live in southeastern Washington, just a few hours from Seattle, and Dr. Pritchett seems highly recommended so I was hoping to contact him for a consult.  It turns out I first need to get referred to the Group Health Orthopedic clinic in Seattle and drive over to see their "in house" doctors, then if they agree that resurfacing is medically necessary, they'll weigh options. Presumably they have nobody on staff that actually does the procedure, which means they'd hopefully refer me out of network and treat it as in-network.  My fears are that they might say it's not medically necessary and I should just get a THR, or it is necessary but they've got a new guy trying to build some experience with the procedure so I have to stay in-house.  Unrealistic fears?

The left hip is the one killing me the last few weeks, even though that one seems to have less degeneration (note the MRI was focused on the right hip...the only views of the left are zoomed out for comparative purposes).  My ortho said he'd refer me to an arthoscopic hip specialist in Spokane to confirm his "no way, no how" impression on my right hip, but my hope is to ask him about saving the left hip so I don't have to go through this whole thing again in a couple of years when the OA on that side gets worse.  Anyone who's done this have any thoughts to share on what I assume would be grinding down the hump on the femoral head-neck area and then cutting out any torn up sections of labrum?  The MRI indicated some labral tears and edema on both sides.

Sorry for the long winded questions, it's just all pretty new to me and I'm not sure where and how to focus my plan of attack (understanding of course, that much more information is needed before implementing any plan).

Thanks!

[Dannywayoflife]

Hi Mate and welcome! I cant help you with your insurance issues as ive never been through that.

However it sounds like you have OA in both hips and fro what ive experienced and read arthroscopy is very very rarely effective when OA is present within the joint. I had a scope done and it did nothing good for me in hindsight.

Good luck with your journey and you will find great help and support here!

Danny

[HippyDogwood]

Welcome to the site

I have been on a similar trajectory to you. Danny is totally right in that many here have seen little benefit from arthroscopy where OA is present. However, this could also be because generally the surgeon has done nothing to try to reverse the presence of OA, broadly because there were no credible options, hence it was limited to cleaning up / repair

This is where you have to form a view on stem cell technology. It is getting a lot of press at the moment as being something which may help re-generate cartilage, in which case it could offer a great solution. It is early days with little data. I have decided to proceed with bi-lateral arthroscopy later this year with a combination of micro-fracture and stem cell treatment to seek to provide a solution which could last many years. It may prove to be fruitless, but it feels to me worth a try. I would not be trying it though without adding in the blend of stem cell and micro-fracture, plus placing my trust in the Villar Bajwa practice who are at the sharp end of evolving new techniqiues.

There really is no right and wrong answer, its just a case of seeking lots of good quality advice and then backing your instinct

Good luck

[Dan L]

The injections, for me, were expensive and did not help at all in the worse hip.  In the other hip they bought me a few months, which, with the risk of infection, was probably not worth it.  The pain mgmt doc would do them to try to help, but my HR surgeon said to avoid them due to risks.

If you need HR, and are willing to go through the process and follow the restrictions and rehab, that's going to be a better investment of time and effort, IMHO.  I was and am so much better for having them done, they are my "magic" hips now almost 3 years from the first BHR.  I can do anything without the grinding bone pain I had before.

Good luck as you consider, it is not a small thing and a significant decision, and only you will know when you are ready.

[oldsoccerplayer]

I had a better experience with cortisone injections than Dan L. The first one was partly for diagnostic purposes - "if this eases the pain then we know it's your hip that's the culprit".
I had one every 3 - 4 months for about 2  years until they stopped being effective. I knew I'd be heading for surgery eventually but wanted to delay it as much as possible. It turns out that Dr. Gross is not a fan of those injections - not sure why - but I think it's because it only treats the symptoms but actually accelerates the degradation of the joint. With hindsight I might have been better off having the surgery sooner, just to get it out of the way so I could get on with my life.
I don't think there's a right or wrong answer here. I'd say that it's worth a shot (no pun intended, maybe) and see if it helps. If so you can decide if you want to buy some more time to research the options or just postpone the surgery, or whether you want to get it over with as early as possible.
Good luck with whatever path you choose!

[livendive]

Thanks for the responses folks.  I have to admit, the reports on arthoscopy are discouraging, but if I'm being honest, I remember reading that in a few places previously and must have just selectively forgot them in hopes of an easy fix on one side.

I really am hoping the cortisone injections help and will keep banging my head against the insurance wall.  Also, I don't think I've heard of microfracture/stem cell options.  I'll see what Google has to say about it. 

[Dan L]

Oldsoccer reminded me that my surgeon indeed said the cortisone would have a negative impact as far as further degeneration of the joint.

Thanks

[dfox]

Hi livendive, 
Welcome to the site. Sorry to hear about the pain you are in. I am an active person like yourself and used this site as my main source for research.  I couldn't see the benefit of getting a shot for temporary relief of the pain when the hip could be repaired with resurfacing. I scheduled mine for as soon as possible in order to get healed up and on with my life. I'm now 4 months post op and thrilled with the results. The biggest benefit to me is being pain free. I'm starting to ramp up my activity level and have no pain. Rode my mountain bike 18 miles on trails this last weekend. I'm sleeping much better also. This was just my approach and doesn't make it right for everyone.

Good luck with your research.

Dave   

[lgbran]

I had 1 injection before my surgery in the hope of buying me sometime. It didn't tickle nor in my case did it do much. The pain relief was short lived . Bedt thing I did was have the surgery and I only wish I had done it years earlier.Goog luck in your endeavours
Cheers Len

[livendive]

Update: The cortisone injections produced mixed results.  First, while shooting the right hip, the PA hit a "big" nerve that caused me to jerk pretty good.  That's not his fault at all, just bad luck, but it did have an unexpected outcome.  After months of poor sleep has compromised my immune system, apparently trauma to that nerve was enough to rouse the chicken pox that had been lying dorman in it since I was four years old.  Yep...the weekend after the shot, I was diagnosed with shingles.  Fortunately it was a small bout, limited to a patch the size of a 50 cent piece on the side/back of my right hip.

Other than that, the cortisone did seem to relieve my pain in the left hip signficantly and I'm sleeping much better.  The right hip saw little if any improvement.  I met with Dr. Pritchett last week and enjoyed the experience, however wish I'd gotten an email address from him for a couple of follow-up questions I didn't think of while there.  Basically he didn't think arthroscopy was likely to benefit either hip, both of which show signs of deteriorating bone.  He did tell me he would want to separate the two hips by at least 6 weeks, saying he used to be willing to do both at the same time when he was younger, but has stopped because the patients always seemed so miserable.  I'm meeting tomorrow with the arthroscopic doctor in Spokane I was referred to.  I fully expect him to agree there's nothing he can do for the right hip.  The cynic in me says he'll offer fantastic outcomes in my left hip, but that's based purely on economics (sales), I've never met him or heard anything bad about him.  It's also possible he'll agree with Dr. Pritechett that neither hip is salvageable, or that he'll want more imaging before suggesting a path forward.  It would have to be a pretty compelling argument to convince me to try scoping the left hip.  Right now I'm looking at a year of not doing stuff I enjoy while I rehab and strengthen my right hip.  I don't want to give up another 12 months of fun in a few years for the left hip when I could just do them both now and be done with it.

I'm still a bit concerned about metal sensitivity.  Dr. Pritchett suggested that it is very unlikely I'll react to the implants, but the recourse if that does occur is what...ceramic THR?  It doesn't sound like there's a good correllation between skin sensitivity to cheap jewelry and an internal reaction to MOM prostheses, and it sounds like many doctors dismiss blood tests as inaccurate/unreliable.  I know I have no problems with quality stainless steel, gold, titanium, or palladium, but the pins that connect a watch band to the watch always get to me within a couple days, as do some metal pant buttons, and a couple cheap jewelry pieces I've worn, presumably due to nickel content.  Dr Pritchett said ceramic and polyethylene coatings were certainly options, but for the lifestyle I want back, he would recommend MOM.  I need to research blood tests more, but am tentatively targeting early January for my right hip and mid February for my left.  I'm looking forward to moving past this!

[hernanu]

I had both done with three months in between. It was good for me to have them done that way, since I felt I could recoup a bit before the second.

Some folks here have had great results having both done at the same time, so it's different for each person.

As for metal sensitivity, the incidence is low, it ranks much lower as a cause for revisions, but that doesn't minimize it for those of us that got it.  You need to be comfortable with the possibilities, no matter how low the percentages, since nothing is guaranteed.

I've had great results from my two MoMs, so I personally (not a medical person) can only recommend it.

[Pat Walter]

Hi
Dr. Pritchett's email address is listed with his info:

bonerecon@aol.com

I would make sure to get your questions answered.  If he doesn't answer them thru the email, call his office and ask for the answers.  All the top surgeons want all of their patient questions answered

Good Luck.

Pat

[livendive]

Thanks for the email address.  Apparently I hadn't found that part of this site...I just saw people saying lots of good stuff about him in the forums. :-)

[Pat Walter]

Here is the link to the doctors list

http://www.surfacehippy.info/listofdoctors.php

Here is the list of all articles on the main website

http://www.surfacehippy.info/sitemap.php

Here is  a new visitor's guide
http://www.surfacehippy.info/visitorguide.php

Personal Hip Stories
http://surfacehippy.info/hipresurfacing/index.php

Pritchett stories

http://surfacehippy.info/hipresurfacing/stories/dr-pritchett

Doctor video interviews
http://www.surfacehippy.info/shvideos/doctor-interviews-Patricia-Walter.php

I hope that helps you find some useful information.

Pat

[livendive]

Well, I met with the third doctor I was referred to, and he agreed that neither of my hips would benefit from arthroscopic repair.  He did not seem terribly impressed with resurfacing and suggested that I just go with THR, indicating I would be able to run and skydive to my hearts content for 40 years on a zirconium ceramic ball and XLPE lined socket.  After emailing Dr. Pritchett and getting a prompt response, I've decided to move forward with resurfacing.  Now the question I'm trying to answer is Birmingham (MoM) or Synovo Preserve (Ceramicized Ti on XLPE)and I'm trying to weigh the advantages and drawbacks of each.  As best I can tell, the basic design is very similar, with the exception of materials used.  The benefits and drawbacks seem to boil down to the following at first glance:

Metal on Metal (CrCo) advantages: lowest wear other than ceramic-on-ceramic, least likely to fracture, most popular by large margin facilitates greater options for care, zero chance of PE induced osteolysis
Metal on Metal (CrCo) drawbacks: greater chance of metallosis or allergic reaction, greater chance of squeaking

Ceramicized Ti on XLPE advantages: nearly zero chance of allergic reaction or metallosis, lower likelihood of squeaking joint, possible shock dampening by XLPE
Ceramicized Ti on XLPE drawbacks: Possible PE-induced osteolysis (may be mitigated by XLPE and daily Simvastatin which I'm already taking for cholesterol), somewhat greater wear but likely insignificant in my lifespan.  Less common use reduces options for treatment if Dr. Pritchett retires or becomes otherwise inaccessible (e.g. hit by bus). 

Do these look about right to the rest of you?

[John C]

One correction to your very good analysis. Metal on metal does not have a high likelihood of squeaking, and in fact it is quite rare (unlike some clunking during the first few months which is fairly common). Squeaking is most common in ceramic on ceramic.
The wear rate with ceramic on poly resurfacings does not have a long track record, so for me it must be looked at as an unknown medium to long term. As you probably know, Dr Pritchett was a pioneer in resurfacing back in the 1970s when they did mostly metal on poly with disastrous results because of the unexpected high wear rate from using large metal heads on poly. Since he was around to see how badly that experiment went, I would expect that he must be pretty comfortable with the new ceramic on XLPE poly to be using this new approach. It does have some appeal, so I will be keeping my eye on it down the road when I have my second hip resurfaced some day.
My complements on your thorough research.

[Daytona Dave]

Hi Livendive,

Its great to know you have chosen a BHR over other options.
I cannot add anything to the very knowledgeable people who regularly post on here. Other than my perspective from the skydiving angle.
I had my first  MoM BHR 5 years ago and have  skydived ever since with pretty much no problems. My only word of caution would be unlike me, leave it at least 6 months or even a year before a return to it.
I am having a lay off at the moment due to my second MoM BHR ( on the other hip!). I am just short of 6 weeks post op and looking forward to the spring/summer and bunging myself out of a perfectly good aircraft.

Good luck!
Dave

[Dannywayoflife]

Personally I would say that the synovo device is an unknown. If it were me I would allow others to test that out when there is the bhr with 17+ years of published data for.

[livendive]

Hi Livendive,

Its great to know you have chosen a BHR over other options.
I cannot add anything to the very knowledgeable people who regularly post on here. Other than my perspective from the skydiving angle.
I had my first  MoM BHR 5 years ago and have  skydived ever since with pretty much no problems. My only word of caution would be unlike me, leave it at least 6 months or even a year before a return to it.
I am having a lay off at the moment due to my second MoM BHR ( on the other hip!). I am just short of 6 weeks post op and looking forward to the spring/summer and bunging myself out of a perfectly good aircraft.

Good luck!
Dave

Thanks man!  19 years in sport and 15 years of tandems have taken their toll. :-D  I had taken a year and a half off for grad school, but just went and re-upped all my ratings in August, then did an AFF recurrency jump with my wife who was ending a 3 year hiatus.  Her jump went great and was fun for both of us, but arching through the top on exit had both of my hips screaming and sleep was hard to come by for a couple weeks afterward...reinforcement that it's time for me to get these fixed.  Pritchett has advised that I take a full year off due to some bone loss and degraded bone quality in my right femoral neck.  A lot of doctors don't understand the nature of risks in this sport, but I'm inclined to trust his judgement on this one and have enough jumps that a year off isn't going to kill me...so I boat more for one summer.  The ortho I saw Tuesday was insisting that fractured heels are the most common injury from skydiving, so I shouldn't worry about dislocations with a THR.  I started to tell him there's a reason tib-fib and femur are verbs, with shoulder dislocations and ACL injuries also common, but didn't get anywhere, so left him to his misunderstanding.  Hell, I've seen more fatalities than I have shattered heels...we aren't jumping rounds anymore. 

Blues,
Dave

[livendive]

Personally I would say that the synovo device is an unknown. If it were me I would allow others to test that out when there is the bhr with 17+ years of published data for.

I would be inclined to agree with you, as I normally refuse to beta test anything that serves a critical function.  Easily reversible stuff like software, car parts, etc...sure, I like the latest & greatest even if it comes with an increased likelihood of hiccups, but surgical options or critical safety equipment, I want tried & true and will happily leave the beta testing to others.  That said, I'm pretty concerned about having a reaction to metal-on-metal.  My skin sensitivity is enough that I don't even need to be in direct contact with a source, just close enough.  My surgical stainless watch triggers a reaction where the little pins connect the band to the body, even though those don't touch me.  I only wear plastic framed glasses, but sometimes the hinges are close enough to my skin to trigger a reaction.  The nickel (my presumed nemesis) content in a Birmingham prosthesis is estimated at .5% or less which would hopefully not be enough to cause a problem, and I understand that there is not a direct correlation between skin sensitivity and reaction to a prosthetic.  However when 25% of well functioning prosthesis have positive skin reaction, compared to 60% of those with poorly functioning or loose implants, and pre- and post-implantation sensitization tests show increases for all three significant metals (Co, Cr, and Ni), well, I'm a bit leery.  As somewhat of a nerd, I'm tempted to make a Venn diagram, but I'm not sure I can without data on what percentage of implants go into sensitized patients (presumably some doctors refuse to MoM known sensitized patients, and my current insurance lists it as a contraindication for resurfacing).  Also, I don't think the Synovo is terribly new.  Watching Pritchett's youtube videos on it (he seems to be its biggest champion, is it possibly his design?), it appears they have 12 years of use on the system and he's yet to remove one for reasons of wear.  However it's clear that the option hasn't really taken off, with Birmingham winning the popularity contest by a very large margin.  I suppose that's whey I'm struggling with the decision.  I see value in following the crowd for something like this, but don't want to be revising a year or two later if easily avoidable.  It's not clear to me whether it would be possible to revise from BHR to Synovo or if I would be stuck going to THR in that event.

Blues,
Dave