Strange Post-Op News about cup placement

[rboehmer]

Hey, I'm new here, just got my right side BHR 8 days ago. My right leg is still much more swollen than normal, but not too uncomfortable. I'm walking around without assistance, but carrying a cane just in case I need it. I can't wait to get the staples out so I can start showering and pool exercise.

I got some troubling post-op news immediately following my procedure, so I'd just like to see if it is a common occurrence.

Immediately post-op, my surgeon told me that his assisting surgeon had been unable to get the cup completely in place due to the extreme density of my bone (?!). He said he physically could not get it in place. This is in spite of the fact that my procedure went very fast. Obviously, I'm paraphrasing the discussion a bit, as I was still 'out of it'. My girlfriend had to help me reconstruct the conversation in my mind.

He said his hope is that - due to my large size and weight, (6'2", 215 lbs) - I will be able to 'walk it into place' by my 6 week follow-up. Otherwise, he will have to go back in.

This worries me tremendously, because if his assisting surgeon physically couldn't force it in place during my procedure, how can gravity do so? And also, if he couldn't physically force it in the first time, what will be different the second time? Will he bring a bigger, stronger assisting surgeon??

I guess I have 3 questions:

1. Does this happen from time to time, or do I have some kind of freak bone density?

2. What are the chances of actually 'walking it into place'?

3. Assuming I can't 'walk it into place', What are the prospects of going back in at 6 weeks and repositioning the cup? Should I just resign myself to probably waking up to a THR reset?

sigh- trying hard to keep positive, but would love re-assuring info right now.

[Pat Walter]

Hi

Welcome to Hip Talk.

I have been reading email stories about hip resurfacing for over 3 years and this is the first time I have heard of a surgoen hoping that a person could walk a cup into place.

I am not medically trained and definitely don't want to alarm you.  Perhaps this has happened before, but I have not heard of it.

Normally, misplaced cups are surgeon error and either they must be revised and placed again or be revised to a THR.  Again, I am not medically trained and this is what I normally have found and have learned from the really experineced surgeons.

If you have your x-rays, I would encourage you to write to several of the top hip resurfacing surgeons and get several other opinions. 

Do you have copies of your x-rays with your hip device in place?

I could send an email to Dr. De Smet of Belgium who has done over 3000 resurfacings and Dr. Bose of India who has done over 1100 and possibly Dr. Gross who has done over 1600 to try to get you some additional input.

It sounds like a very unusual situation.  Anytime there is a loose cup, it normally will cause a great deal of pain. 

I guess I wonder why the main surgeon did not place the cup? It is a difficult job and must be done properly.  I don't understand why they would sew you up with a misplaced cup - but again, I am not medically trained and don't know everything.

I just wanted to tell you this is not a common occurence and I personally have never heard such a process of hoping a cup will place itself after surgery. 

I don't want to get you to worry too much, but I think it would be best to get input from the best surgeons in the world instead of asking other patients.  We really have no way of judging such a situation since we are not doctors with experience.

Please let me know if you have your x-rays.  You can email me personally if you want to at  pwalter@surfacehippy.info  Since it is Christmas, the responses from the doctors might be a little slow, but I certainly would encourage you to get more input.

Pat

[obxpelican]

That one sounds strange, I've never heard of bone so dense that they could not pound that into place.  I've heard of cups slipping and actually settling into a spot where the patiend did not need a revision.

Are you having any really sharp pain?

I would get 2nd and 3rd opinions on that one.  Although based on the past history where cups got loose, then settled it sounds feasable that it could get bone growth and stick in place if you're lucky.  Your cup would have to settle at an acceptable angle though.

Here's to hoping that the cup does not need to be revised.


Chuck

[B.I.L.L.]

Any update rboehmr ??    How ya doin' ?

[rboehmer]

I'm still looking into second opinions on the cup placement issue.

I suspect that my Dr. will give me the choice of whether to leave the cup out of position or have it repositioned. I doubt very seriously that the cup has 'worked its way into position' but it does appear to be very secure where it is positioned. There is no pain whatsoever; I'll have to wait until further in my rehab to see if there is any hitch in my stride.

Ultimately, it will probably come down to whether or not the joint will perform for me adequately as is, and will last the same as a correctly positioned one. If so, I think I'm good. Otherwise, I'll need a REDO, but I'm not thrilled with that prospect, for sure. I see my Dr. again in 3 more weeks; I'll follow up here when I know more.

Thanks for the inquiry!!

[rboehmer]

Saw my Doc a week ago. (7 weeks PO) The cup is very secure and according to my Doc there is already bone growth around the cup. The X-Ray still shows a gap where the cup should be, but he says that my recovery is progressing well and I'll still be able to return to the tennis courts at 6 months.

I'll wait and see how much of the gap fills in before I make any court reservations, but for now no news is good news! I wonder if I should drink a lot of milk :-)

- Ray

[B.I.L.L.]

Saw my Doc a week ago. (7 weeks PO) The cup is very secure and according to my Doc there is already bone growth around the cup. The X-Ray still shows a gap where the cup should be, but he says that my recovery is progressing well and I'll still be able to return to the tennis courts at 6 months.

I'll wait and see how much of the gap fills in before I make any court reservations, but for now no news is good news! I wonder if I should drink a lot of milk :-)

- Ray

Glad to hear its solid.  I have a friend I race with that broke his arm pretty good and after they plated it the bone had to fill in a pretty large gap (it splintered).  Funny thing happened, after several months of very little bone growth he said screw it and started riding & racing anyway and within 3 months the gap was almost filled in.  The doctor said the jarring may have stimulated the growth.  Good luck to you.

[rboehmer]

Well, I'm now 4.5 months post op. I've been playing tennis (doubles only) for the last month.

I haven't been able to follow up with my Dr. so I don't honestly know how much bone growth has now occurred. But I do know that my hip feels extremely stable.

I plan on returning to full tennis activity (singles and doubles) at the 6 month mark, assuming that I can move well enough to do so.

So far, so good...

[John11]

Hi All,
I wanted to bump this thread because I have not seen this problem anywhere else. I had bone on bone OA. On 12/3/09, I went in for a right BHR. Things did not feel right afterwards. I felt like I had a softball stuck in my hip and that my operated side leg was significantly longer than the non-surgical side. I was told that this feeling was "normal" and that it would pass. It did not.
I was told at my 6 week follow up that due to my extreme bone density, the acetabular cup wasn't able to be set deep enough. There was at least a 5mm discrepancy that resulted in an uncomfortable offset and leg length discrepancy. Like rboehmer, I was told to give it time and it might work its way in. It did not. And like rboehmer, the joint itself became stable, however the pain and discomfort in and around the joint was worse than it was pre-op.
At about 12-14 weeks out, I was advised that I should have the acetabular cup revised and that there was an 80-90% probability of success. Went in on 5/21/10 and once again I drew the short stick. It was explained to my wife while I was recovering, that they were only able to get the cup in another 2-3 mm and this would not be enough to alleviate the problems I was having and that they were at the point of risking nerve damage so they converted to a large head MOM total hip.

So now I'm 4 days post-op and trying to wrap my head around this and how I can be a victim of my own good bone health. And seeing that denial and bargaining aren't on the table, I guess I'll be rotating through anger and depression for quite a while before I reach acceptance. Although I had tried to prepare myself for this potential outcome, it wasn't until after it actually happened that I realized how totally committed I was to resurfacing and how much my future plans were predicated on a successful outcome.

JW
RBHR 12/3/09
Revision to MOM THR 5/21/10

[Pat Walter]

Hi JW

I am very sorry to hear that you required a revision of your hip resurfacing.  I understand your frustration and anger.

I have heard of several cases where a person's bones were so hard that it was almost impossible for the doctor to do a hip resurfacing.  The one that comes to mind was from Dr. De Smet of Belgium.  He said the case was the worst he ever did and it took him much longer to do the resurfacing.  In that case, he was very experinced and was able, with a lot of extra effort, to do the resurfacing correctly.  He has done over 3000 resurfacings.  That is the continued advice I always give - use the most experinced hip resurfacing surgeons since they have the experince to deal with the diffiuclt problems.

There are always a few people that have problems and NONE OF US want to be those few.  Unfortunatley, you were.  Again, I am sorry that you went thru 2 surgeries.  A MOM THR is still a good solution to hip problems.  You should be out of pain and be able to be just as active as with a hip resurfacing.  

I wish you the best and hope you will keep in touch.

Pat

[DonC]

I don't understand. If the acetabular cup was difficult/impossible to fit correctly during a resurface why would the conversion to a THR be any easier? Acetabular cup placement is the same for either procedure. If the bone had been too hard for the first procedure why did the conversion to THR help make the situation any easier?

Who was the Doctor?

Don

[John11]

DonC,
My understanding is that because the femoral component was already in place from my first operation and needed to be preserved, this made access to the acetabulum more difficult than a regular resurfacing. The choice of replacement acetabular components was also limited due to having to match the size of the existing femoral component. When the decision is made to go to THR and the femoral head is amputated, I just have to assume that it opens up a great deal of space (relatively) to work in and provides a wider choice in sizing of components.

The point of my post was not to disparage anyone but to blow off a little steam because of my unusual situation. There are many posts on this board where people had bones too brittle for a successful resurfacing, sometimes not discovered until the actual surgery. We don't often consider that there could be problems at the other extreme end of the bell curve. Outside of rboehmer's case and mine, I had heard of no others. Pat certainly has access to way more statistical info than I. And as she also stated (but far more eloquently) sometimes s*it just happens.

My surgical team is highly experienced, highly successful and highly recommended on this board, I would not hesitate to use them again.

JW

[revision]

Hi JW,

I am also one of the few cases that needed a MOM THR a few months (5) after resurfacing. I fully appreciate your comments about acceptance of the fact that you now have a THR.

If I can offer any words of encouragement it would be that the MOM THR works really well. I have been up and down ladders all day today. lifting things and being pretty normal as usual. I'm off to train my soccer team this evening as I do every week.

JW, it can be really tought when this happens but with your excellent bone density your new MOM THR should take and fit really well. I am sure in the long term every thing will be good.

Very best wishes,

Revision

[DonC]

I don't blame you one bit for expressing your disappointment. I do appreciate your sharing your story. We need to hear the good and the bad.

I'm not a doctor but I can't help but wonder... if they had done a THR right from the start they would have encountered the same difficult acetabular placement due to bone density
since there is no difference in the acetabular component.

It appears the acetabular was never seated correctly right from the start and this could have occured with either a resurface or a THR. It would seem that the cap on the femur head doesn't take up that much more space (if any) than the natural femur head but I guess they were restricted in some way. Interesting.

The good news is you are on the road to recovery and soon you will be 'walking in the sunshine' once again.

My thoughts are with you!



Don