ALVAL, PSEUDOTUMOUR, HYPERSENSITIVITY … WHATEVER
YOU CALL IT, IT’S A REVISION TO THR

Having visited this site numerous times over the last few years, I
thought it was time that I shared my experience with other past and
future hip patients. I have recently undergone revision of my ASR to
a THR because of a reaction to the metal on metal bearing. I know
this issue is in the spotlight of the orthopedic hip community
internationally just now as more patients emerge at the 3-5 year
post-op mark with unique reactions.

I am a female and was diagnosed with osteoarthritis in my left hip
when I was 33 years old (I am now 42). At the time I was an amateur
triathlete competing at local events but struggling to meet training
goals because of pain. Once I had the diagnosis at least I knew the
cause, and also knew that heavy use of anti-inflammatory eased the
symptoms. Ultimately however, whether I was resting or training the
pain continued. In addition to the OA, I had some bone spurs and
when I was 35 I agreed to have the spurs removed (“femoro-acetabular
debridement”) in the hope of alleviating impingement and delaying
serious OA. My first major surgery.

After 12 months it was apparent that the debridement was
unsuccessful and in fact the OA had worsened to the point where I
was ready for a resurfacing. My second major surgery.

The resurfacing was wonderful in that it got me back to pain-free
life; walking, sitting, sleeping, cycling. In fact I became a strong
cyclist, riding over 100 km every Friday morning at a strong pace in
our local peloton, and going on a number of international
cycle-touring holidays. I kept trying to run – that was my ultimate
dream. Once or twice over the years I managed to belt out 5 or 6 km,
but usually I would start experiencing enough discomfort to make me
walk after just a few hundred meters. I was still taking
anti-inflammatory off and on for general aching in my left leg.
Range of motion was definitely improved, although not to the point
where I could, for example, sit with my legs crossed. I saw my
orthopedic specialist quite regularly – both professionally at his
clinic for follow-ups, and also socially as he is also a keen
cyclist and we spent many hours chatting whilst spinning along at
30+ kph. My x-rays looked perfect.

At about the 3.5 year mark, I started to notice weakening in my hip
flexor. I was dropping off the back of the peloton and couldn’t do
anything to get stronger. I saw my physiotherapist and concentrated
on strengthening the surrounding muscles for six weeks before
confessing to my doctor that I was really facing problems. The only
anomaly that was apparent on x-ray was re-growth of bony spurs,
which we discussed removing.

Before another major surgery however, we decided to run a battery of
tests … bone scan, bloods, MRI, CT, ultrasound. All these tests were
inconclusive, except for the ultrasound which showed some fluid in
the groin. It also showed that the tip of one of the screws
remaining from my resurfacing procedure (“trochanteric flip”) was
protruding into my groin so we agreed to first try a less drastic
approach of removing the screws. My third surgery.

I was only on a crutch for a few days, but the swelling and limping
continued for months. My range of motion improved almost
miraculously – it felt like a brick had been removed from my groin
and I was sure this was a success! By three months though I still
had a strange half-golf-ball sized lump over the trochanteric wound
site and I still had pain. Back to the doctor, where alarm bells
started ringing again. He excised the lump that same day … expecting
to drain fluid but in fact finding dead tissue. My thigh was finally
flat again but not for long … by the next day the lump was back.

Infection, cancer and loosening were all ruled out. A metal-ion test
was requested of the pathologist, but seemingly there was nothing
apparent. Things were not looking good but a definitive diagnosis
was difficult.

Around this time there were a couple of European conferences which
my doctor was attending, dealing specifically with hip resurfacing.
He was able to talk to the presenting pathologist as well as a
colleague of his who represented the European Advisory Committee for
adverse reaction to MoM implants. Now the diagnosis was conclusive …
classic symptoms and the only option was revision to a ceramic THR.
Surgery number four.

(It turns out that the fluid – actually necrotic tissue – had
drained from my hip joint and down through the holes left by removal
of the screws to present on my outer thigh. An incredibly unusual
scenario! I think if this hadn’t happened our next step would have
been needle aspiration of the hip joint to get a sample of the
fluid/tissue. I have a whole new appreciation for ultrasound.)

I am now at six week’s post-op. Again the surgery went perfectly
(6.5 hours) and the x-rays look great. Definitely it has been the
most difficult of all the procedures I have had, with a slower
recovery. I am walking on one crutch, but thankfully can get in the
pool and swim with the squad using a pull-buoy instead of kicking.
I’m still taking pain meds and imagine I will need them and the
crutch for another couple of weeks. For a semi-revision surgery
though I think I am doing okay; I am at work and am planning on
joining a gym this weekend to start getting some strength back in my
legs. In a couple of months I will get back on the bike (maybe not
in the peloton) and there is a surf-ski endurance race at the end of
the year that I would like to train for.

Whilst I breezed through the previous surgeries I found this one
very traumatic emotionally as well as physically. Over the months I
have spent loads of time surfing the web for stories and information
and experiences. I thought it was time to share mine. If anyone has
been through this I would love to hear how your recovery is; and if
anyone is facing this I would be absolutely happy to talk about it
more.

Paula