Visit to Orthopedic Surgeon 8 June 2011

The visit to the surgeon was interesting, to say the least!

Both hips were examined and pain confirmed on both – and restricted painful movement. It also appeared that the right leg, with the hip replacement was longer than the left leg.

X-rays were taken in the Gold Coast Hospital Outpatients Clinic while I waited – great service – thanks guys!

The x-rays confirmed the arthritis in the left hip and this is going to need replacing.

However, it was the right hip, with the Smith & Nephew Birmingham Spectron total hip replacement which caused the most interest:

• Severe oestolysis around the hip – tissue damage.
• Bone erosion (gone totally) for several centimeters below the collar on the inside leg side.
• Damage to the bone on the outside leg side – mottled and insubstantial-looking.
• Signs of movement of the femoral stem of the hip implant – lines down either side and possible bone damage – the cement contains ceramic and this can then act as a grinding past as the stem moves. This has the potential to release more metal ions.
• These signs of movement may explain the feeling of “popping in and out” that I feel – but without dislocation of the hip prosthesis.
• No cement plug had been used – the surgeon deduced this from the CAT scan I had taken with me.
• The failure of the original surgeon to use a cement plug was confirmed when I got my surgeon’s notes a couple of days later.
• Failure to use cement plug meant that the ceramic-polymer cement had gone about twice as far down the centre of the femur as it should have – must have had dramatic consequences for the marrow that was killed/displaced.
• Also failure to use a cement plug had most likely meant that the glue was not forced back up against the femoral implant stem – hence gluing would not have been tight around the femoral stem.
• My new surgeon was extremely scathing of my hip replacement – “very shoddy job”, but maybe he was just having a bad day! I was sympathetic to his views, however!

One of the most disconcerting things was the observation that the hip replacement components could not have been stainless steel as told to me by my original surgeon. This was confirmed with some detective work when I got hold of my surgeon’s operating notes.

So, I was sent off for more blood tests for the cobalt and chromium ions. These should be back next week. I had blood tests taken by my local doctor two weeks ago but for some reason, the local pathology laboratory takes up to 4 weeks to do these tests, whereas the hospital can do them in about a week.

I was also referred for a ultrasound-guided aspiration of the fluid around the hip – this should happen in the next few weeks. If the fluid is gray this will automatically confirm the metallosis.

Operation Note

OPERATION NOTE

NAME:   Earl Stevens – dob: [removed]

DATE & HOSPITAL:    14 August 2008    [removed] Hospital

OPERATION:  Birmingham/Spectron total hip joint replacement – right

SURGEON:    [removed]

ANAESTHETIST:    [removed]

FINDINGS:

A 50 year old man with inflammatory arthropathy of unknown aetiology with a slightly dysplastic right hip and severe pain.  There was a formal synovium lying over the acetabulum particularly in its inferior aspect and there was marked thickening of the capsule both anteriorly and posteriorly.  Osteophytes at the acetabular rim anteriorly and at anterior aspect of femoral neck.

PROCEDURE:

Spinal plus general plus urinary catheter.  A standard posterior approach was made with release of the insertion of the deep part of gluteus maximus, identifying the sciatic nerve.  The short external rotators plus quadratus femoris were taken down and the capsule of the hip joint excised as completely as possible from the posterior approach.  The hip was then dislocated.  The femoral neck was sectioned using a saw.  The acetabulum was reamed down to cortical bone and 3 or 4 cement holes were inserted.  The cup was cemented in satisfactory position.  The femoral shaft was prepared and the appropriate femoral component was cemented in satisfactory position.

Reduction was achieved and was stable once the osteophytes mentioned above were removed and the thick anterior capsule excised.

A Stryker was inserted and deep tissues closed with heavy Dexon with nylon to skin.  Tulle gras, gauze, Gamgee, elastoplast dressing.

POST OPERATIVE INSTRUCTIONS:

IV fluid, analgesia, anti-emetic, antibiotics as charted.

Remove Stryker on instruction.

Mobilise on Stryker removal.

Discharge 7 – 10 days with removal of sutures as appropriate.

See rooms at 6 weeks.

Warfarin to commence on evening of surgery and ultrasound done day prior to discharge.

COMPONENTS:

Femoral:             No. 2 femoral, distal centraliser, +4 52mm Birmingham head.

Acetabular:         58mm Birmingham.

Cement plug:      Nil.

Copious specimens were sent for histology.

When is Stainless Steel NOT Stainless Steel?

Answer: when it is Cobalt Chrome!

As the trip to the hospital had raised a lot of questions, I went searching for answers – the Operation Note above gave me the clues I needed. Like any good nerd I Googled Birmingham Spectron and discovered it was cobalt chrome…

On Surface Hippy (see http://www.hipresurfacingsite.com/)  I found some interesting stuff – see this PDF [Click here] – which is a PDF of what is found here [Click here].

But this is what caught my eye:

The Birmingham Hip Resurfacing (BHR) prosthesis is a metal-on-metal hip resurfacing prosthesis. The device consists of a stemmed femoral head resurfacing component designed for cemented fixation, and a hemispherical acetabular cup designed for cementless, press-fit, fixation. Both components are manufactured from high carbon, as-cast, cobalt chrome (CoCr) alloy (ASTM F75 and ISO 5832-4). The acetabular cups are configured in standard, dysplasia, and bridging designs. All acetabular cups have a single layer of integrally-cast CoCr-alloy (ASTM F75 and ISO 5832-4) beads on the outer surface that are coated with hydroxyapatite (HA) (ASTM F1185). Instrumentation sets are provided as standard; several additional instruments are available as options.

So I went looking for more information – I must say it is extremely hard to find information on Smith & Nephew products on the internet…

But I got lucky and found another site put together by Patricia Walter in 2006 http://www.hipsforyou.com.

Here I found further confirmation of the Cobalt Chrome nature of my replacement hip components.

In particular this page [click here] had the information I needed – and I immediately recognised the shape of the femoral stem prosthesis.

Take a look at the Spectron cemented revision system for total hip replacement by Smith & Nephew or you can download the three pages as a PDF here [click here].

According to this page: The SPECTRON◊ cemented revision system has a proven track record of over fifteen years. The revision femoral stems contain the same features that have made the primary SPECTRON◊ stems clinically successful.

But this is what I was looking for – the stem was also forged Cobalt Chrome:

Forged Cobalt Chrome Material – material of choice for cemented stems to
reduce stem fractures and minimize generation of third particle debris. The system
is comprised of 21 implants in various stem lengths and head/neck offsets.

I must admit I was a little confused when I saw this information:

Excellent Clinical Results

SPECTRON^◊ provides superior performance to Charnley, the industry gold standard, at all time intervals. Results from the Swedish National Registry¹:

¹ Malchau, H.; Herberts, P.; Prognosis of Total Hip Replacement, Results from the Swedish National Registry, A Revision-Risk Study of 134,056 Primary Operations. 1996 AAOS, Atlanta.

BUT: looking more closely – it is not for Metal on Metal – it is for the Spectron system with a poly (plastic) acetabular cup – or that is how I read it.

The thing that is confusing to me is that I have had severe bone and tissue damage around the Smith & Nephew Spectron femoral stem device – so how does this work?

Then… looking closer – another important discovery:

“Estimated PROBABILITY (my emphasis) of Spectron survival 9 YR = 99.2%.

Nothing quite like the old “estimated probability” to give favorable results- but maybe I am just a miserable cynic?

So putting the pieces together

I have the Birmingham System:

Femoral:              No. 2 femoral, distal centraliser, +4 52mm Birmingham head.

Acetabular:         58mm Birmingham.

ALL are cobalt chrome…

So I finally have found the Smith & Nephew site here www.bhrhip.com.

This is predictably positive about the Birmingham Hip Replacement (BHR) system and in the absence of one place to find out about the total hip replacement I have, I have put a few things together, and please correct me if I have joined the wrong dots:

Here is a PDF brochure [click here] from the www.bhrhip.com site – it has some interesting stuff and should be read in full to ensure you understand the information as they intended before I highlight a few things I found interesting:

With metal-on-metal systems, the cap (ball) and the socket components are made from highly polished metal. The BHR System is a metal-on-metal system. Other hip systems can have a metal ball with a plastic-lined socket (metal-on-plastic), or a ceramic ball with a ceramic-lined socket (ceramic-on-ceramic).

BHR Metal on Metal Acetabular Cup and Resurfacing Head - from http://www.rediscoveryourgo.com/Product.aspx?Product=BirminghamHip

However, specific potential benefits of the BHR System include:
• The BHR’s metal cup will not chip or crack as ceramic components can.
• The BHR does not cause thighbone (femoral shaft) fractures as total hip replacement systems can.

One-piece acetabular component versus two-piece acetabular component designs:

o The BHR acetabular component is provided in a one- and two-piece design.
o The potential benefits of the two-piece design for the patient include an option for additional fixation using bone screws, and an easier revision to a total hip replacement system if such replacement becomes necessary in the future. With the two-piece design, if the metal outer  shell is well fixed, the surgeon has the option at a future revision surgery of leaving the metal outer shell in place without further disturbing the hip socket bone and replacing the metal liner with a plastic liner that can mate with a new total hip replacement system head and femoral
stem.
o The potential benefit of a one-piece design is that there is no risk of unintentional component disassembly.

From the same PDF brochure I found this to be interesting – the risks with any hip replacement:

5.0 What Are Some of the Potential Risks of the BHR Device?

The potential risks of any hip joint replacement include:

• Damage to blood vessels, or temporary or permanent nerve damage during surgery,
• Sudden drop in blood pressure during surgery due to the use of bone cement
• Blood circulation problems because of surgery or during recovery including blood clots in the legs or lungs or heart attack.
• Allergic reactions to the device material or to medications you are given,
• Surgical wounds that take a long time to heal due to many reasons such as poor skin condition, infection, poor blood circulation, bad hygiene, etc.
• Infection related to surgery and wound healing. Infections may occur months to years after surgery and these infections are difficult to treat and may require reoperation with removal surgery and later replacement at another time,
• Dislocation of the hip, device loosening/shifting, or device wear/breakage due to muscle and fibrous tissue lack of firmness (laxity). Device placement in the wrong position in the bone, poor attachment of the device to the bone, too much weight or activity put on the device, or accidents affecting the hip joint like falls (trauma),
• Damage to the bones and tissue (tissue necrosis) near the hip joint, including loss of the surrounding bone (osteolysis) or staining of the hip joint fluid (metallosis) due to wearing away of the metal parts over time.
• Change in the length of the leg in which the device is placed,
• Device breakage due to weakening of the metal over time (fatigue fracture),
• Bone breakage due to osteoporosis or accidents (trauma),
• Bone loss or too much bone formation near the implants in response to the surgery or to the presence of the device in the bone.
• Increased hip pain and/or reduced function.
• Temporary or permanent device related noise such as clicking or squeaking.
• Inflammatory tissue response to high levels of wear debris resulting in peri-prosthetic aseptic lymphocyte dominated vasculitis associated lesions (ALVAL), fluid collections, or soft tissue masses (Pseudotumors).

These potential adverse effects may require medical attention or additional surgery. Rarely docomplications lead to death.

Overall, reading the brochure you are left with the feeling that the BHR resurfacing system is one of the better ones on the market – the Australian Orthopaedic Association collect studies for all hip replacements in Australia and it seems that the BHR system is one of the best – here is the summary of the data off the Smith & Nephew site [click here].

Where is my total hip replacement system?

Despite quite a few days looking I cannot find one place where the combination of my hip replacement components is fully detailed. Very frustrating!

Ah ha – found it here – http://www.smithnephew.com/au/Standard.asp?NodeId=2692

And here is the PDF in case it moves! [click here]

The SPECTRON cemented revision system has a proven track record of over 15 years.

The revision femoral stems contain the same features that have made the primary SPECTRON stems clinically successful.

Circulotrapezoidal Neck — provides increased range of motion compared to a circular neck of the same strength.

Anterior/Posterior Grooves — increases rotational stability without increasing cement stresses.

Smith & Nephew Spectron

Trapezoidal Stem Cross Section — ideal stem geometry to minimize tensile stresses and aid in compressing the cement under load.

Longitudinal Stem Taper — allows the stresses to be distributed throughout the length of the implant and enhances compressive loading of the cement.

Forged Cobalt Chrome Material — material of choice for cemented stems to reduce stem fractures and minimize generation of third particle debris. The   system is comprised of 21 implants in various stem lengths and head/neck offsets.

Long Straight Implant — designed for revision of femoral distal defects such as holes, windows, or fractures around the end of the previously implanted stem.

Neck Replacement Implant — In addition to the indications for the Long Straight implant, the Neck Replacement implant can be used in both primary and revision arthroplasty where bone stock is deficient to the neck area due to femoral neck fracture or failure of a primary stem leading to resorption or destruction of the calcar area.

The instrumentation is designed for a broach-only technique with a minimum number of procedural steps. This makes for a simple, straightforward surgical technique that is highly reproducible.

And guess what?

The femoral head options do NOT include stainless steel – so I do have a cobalt chrome femoral head…

Cobalt Chrome Femoral Head

Good luck – found a BHR Surgical Technique guide which seems to confirm that it is also cobalt chrome – download it here:

More good luck – found a Medical Release from Smith & Nephew [download here]

On page 3 it states:

The acetabular cups are configured in standard, dysplasia, and bridging designs. All acetabular cups have a single layer of integrally-cast CoCr-alloy (ASTM F75
and ISO 5832-4) beads on the outer surface that are coated with hydroxyapatite (HA) (ASTM F1185). Instrumentation sets are provided as standard; several additional instruments are available as options.

Some more useful stuff

Also – found  this useful summary on this website [click here]:

Birmingham Hip Resurfacing (BHR) / Surface Arthroplasty of Hip
Surface Arthroplasty of Hip (Birmingham Hip / ASR)
Total Hip Replacement has been a revolutionary surgery in orthopedics. Millions of people, attained pain free mobilization following this surgery. However, with the conventional hip replacement there are reservations about this procedure in relatively younger people because of the amount of bones to be scarified and need for reversion surgery later on.

Hip Resurfacing Surgery (BHR Surgery) has come as a boon for younger patients, resulting in very little bone loss and almost normal unrestricted movements and functions following this procedure.

This can also be done in relatively older patients (up to 65 years) if bone stock is good and there are no other contraindications to Surface Arthroplasty of Hip.

Certain criteria must be met for suitability of Surface Arthroplasty such as BHR / ASR.

Combination of two or more of following would make Surface Arthroplasty unsuitable:

•     Femoral head cyst > 1cm
•     Decreased bone mineral density.
•     Lateral head-neck remodeling; (Loss of contour of lateral head-neck).
•     Poor shape / biomechanics.
•     Short femoral neck < 2 cm.
•     Shallow or small acetabulum
•     Poor head to neck ratio.

Well, that explains why I didn’t have the resurfacing – the cyst I had on the femoral head was about 2.5 cm…

This table from the same place also helped my understanding too:

Who needs Hip Resurfacing?

Conventional Hip Replacement Birmingham Hip Resurfacing Suitable for Elderly Patients Suitable for Younger Patients Head of femur (thigh bone) removed Bone not removed Articulation is metal with plastic Articulation is metal with metal Wears our rapidly in young and active patients ‘Everlasting’ – based on 35 year history in Birmingham of metal on metal articulation Activity restriction required after surgery for fear of dislocation Activity restriction not required after surgery as there is hardly any risk of dislocation (can sit on floor ,squat, use Indian toilet ,etc) Sport not advised as the usage is inversely proportional the life of the hip replacement Sport and High demand activities encouraged as usage is not related to life of resurfacing implant Revision surgery invariably necessary in younger patients Revision surgery not Required for younger patients

The outstanding problem in conventional Hip Replacement is the young active patient with an arthritic hip. The problem is worse if the patient is male (higher loosening rates with THR), has an active job and wishes to play sport or engage in physical activity to keep himself healthy.

The BIRMINGHAM HIP Resurfacing System (BHR) is the global market leading hip resurfacing system with over 60,000 implantations worldwide. Introduced in 1997, the BIRMINGHAM HIP Resurfacing System was designed using knowledge gained from first generation metal-on-metal total hips and a thorough understanding of hip resurfacing principles. Indraprastha Apollo Hospitals, Delhi has pioneered in many Orthopaedic procedures like Hip and Knee Replacements and specialise in BIRMINGHAM HIP Resurfacing & Disc Replacements.

So, in my case…

It seems that the total hip replacement was my only option – and Metal on Metal was probably selected due to my age and expected life time between replacements – and I am over 100 kg too.

This table is useful in thinking about total hip replacements:

The scientific article from which the table has been taken is really well written and informative – download the PDF here [click here].

The full citation is:

R. Stephen J. Burnett, MD, FRCSC, Dipl ABOS. Total hip arthroplasty: Techniques and results. BCMJ, Vol. 52, No. 9, November, 2010, page(s) 455-464 — Articles.

The Quest Continues…

I just located this authoritative review entitled – click on the title to download the PDF:

Technology Assessment: Horizon Scan on Hip Replacement Surgery

December 22, 2006

Prepared by
ECRI Evidence-based Practice Center
David Snyder, Ph.D.
Richard Chapell, Ph.D.
Wendy Bruening, Ph.D.
Karen Schoelles, M.D., S.M.
Janice Kaczmarek, M.S.
Evelyn Kuserk, M.L.S, M.A.
Eileen Erinoff, B.A.
Vivian Coates, M.B.A.

Agency for Healthcare
Research and Quality
540 Gaither Road
Rockville, Maryland 20850

and finally found out information about the Smith & Nephew Spectron Hip implant system. You will notice in this table that Smith & Nephew did not respond – I am left wondering if the paucity of information on the hip implant I have is by design?

This doesn’t totally make sense as I know I have a cobalt chrome acetablular cup cemented in.

Can’t help but wonder if I got given “old technology”. Maybe NZ is a great place to get rid of excess stock?

Useful Snippets

I have located this website which is peppered with useful snippets of information: http://www.totaljoints.info/total_joint_home_page.htm.

Here is snippet which is worth a read http://www.totaljoints.info/what_new1.htm#22/04/2011

22/04/2011

METAL ON METAL HIPS – THE EVIDENCE SO FAR

New information on mteal on metal surface and total hips is an avalanche with new and controversial data being published almost every day. What was true yesterday is not valid today.

Ten renowned British orthopaedic surgeons, among them three Professors published recently a report of our present knowledge, but also ignorance of influence of high blood levels of metal ions on patients with metal on metal (MoM) hip joints implanted.

Some interesting conclusions:

The so called pseudotumors are only one form of reaction of the organism against the presence of metal particles and ions in the body. Some surgeons believe that the pseudotumors develop also in metal on polyethylene total hips…

The reaction may be either local allergy reaction on the presence of even small amounts of wear particles or a direct toxic effect of a high concentration of wear particles around the MoM artificial joint.

The incidence of cancer is not higher in metal on metal joint patients, but the follow up even in the latest series is actually only eleven years on average, too short for cancers where the latent perion is 20 years at least. So further surveillance should be continued.

Both implant size, implant position, and implant’s design are important.

The authors recommend continuous controls of blood levels of cobalt and chromium serum (!) levels in patients with symptomatic (painful) MoM joint. “The identification of high serum levels of metal ions is an indication that the hip is functioning poorly” say the authors. What are the “high serum levels”, however, is defined by different authors differently. So, not much help here. United Kingdom Health authorities put this level (“cut off level) at 7 µg/L for both cobalt and chromium, other authors recommend 4 µg/L as cut off level. Not to say that the levels depend on the measurement method and the measured issue (whole blood, serum, erythrocytes).

The patients with MoM should be followed annually for the first five postoperative years, thereafter the annual follow up should be reserved for “symptomatic patients”  only.

The authors conclude that “favorable outcomes can still be expected” in young, strong, otherwise healthy male patients with relatively normale anatomy of the hip joint.

Seems to me you must be really healthy to have a chance to by operated on with MoM hip. But if you are healthy why to have a MoM hip joint implanted?
___________________________
References:
Haddad F.S. et al: Metal-on-metal bearings  J Bone Joint Surg –Br 2011; 93-B:572 -9

19/03/2011

 RESULTS OF SURFACE REPLACEMENT ARTHROPLASTY

Although the modern surface hip replacement is in use since 1990’s, we are still lacking reliable reports of efficacy of this arthroplasty spanning over ten years and longer. The British National Institute for Clinical Excellence postulated a “benchmark” for good results of hip arthroplasty. The hip arthroplasty operations should have less than 10% failures during the ten postoperative years to achieve this benchmark.

The Dutch surgeons started a search after published reliable statistics over results of Surface Hip Replacement (SHR) surgery (van der Weegen 2011). They found 540 published articles that were relevant but after closer study only 29 articles contained usable information about the results of SHR operations and surface hip models available on the market just now (2010).

Some curious results appear from this report. For example: Although the SHR patients worry about their high blood levels of metal ions there is no published report about the relation between high metal blood levels and results of the SHR. The reason: to measure the blood levels of metal ions is expensive and all such studies are done on a small number of patients. It follows that the reports either contain information on SHR results of many patients or the blood levels of the few patients but never both data simultaneously.

On the market there are today (2010) eleven different models of SHR devices but results (of different quality) of their efficacy were as yet published only on five of them. Most reports were published on the Birmingham Surface hip Device  (Smith & Nephew) -13 reports. Other devices with reported results are the ASR device (DePuy, now retracted), Conserve Plus (Wright), Cormet (Corin), and Durom (Zimmer).

The survival of SHR reported in these published articles was better than the benchmark for all studied devices but for the ASR device. This device was meanwhile withdrawn from the market.

For comparison here follow two diagrams depicting the published results of two SRH devices, the Birmingham Hip Replacement and the ASR replacement device.

In these diagrams every point shows the reported survivorship published in one article. The red line is a trend line. It summarizes the development of survival during the successive follow up years after surgery,

Diagram shows survival of BHR devices as reported in thirteen articles. Note that no report followed the patients up ten or more years. Of the 13 reports, only one showed survival worse than the benchmark (one point under the benchmark line at 6.5 years).

Diagram shows survival of ASR device as reported in four articles. All reported survival figures lie under the benchmark line. This is an example of an “improved device” that failed. Remember that behind these figures there are many patients with severe pain and other sufferings after failed SHR surgery with wrong device.

What is the responsibility of surgeons who “invent” such a products and that of the manufacturers (DePuy in this case) who manufacture and sell such products?

This reports shows on the positive side that the majority of published results on the efficacy of the SHR show good results in the first eight postoperative years.

On the negative side the report shows that the majority (6 out of 10) devices on the market have no published report about their efficiency. Be careful what type of  SHR device you will be offered.

This report does not contain any information about the selection of patients suitable for SHR surgery.

___________________________
References;
Van der Wegen et al: Survival of metal-on-metal….. J Bone Joint Surg-Br 2011; 93-B: 298 -306

18th July 2011

11 am rolled around quickly…

This was the first time I had met the private orthopaedic surgeon and I was very pleasantly surprised at his openness, approachability and professionalism.

We reviewed my X-rays and confirmed the osteolysis and bone loss. The health of the bone at the top of the femur is a concern and I am going to have a nuclear medicine bone scan tomorrow morning to see what is going on with the blood flow to and around the bone.

I had a biopsy taken later in the day at the hospital and there was not much in the way of fluid – more a greyish fibrous capsular type of tissue – now with the pathologist.

The movement of the prosthesis, or lines suggesting movement within the femur where obvious (it seems?).

Regardless, the hip pops and clicks in and around audibly a few dozen times a day as I move, standing and sitting.

So – bottom line, for whatever reasons, this hip is not performing and so the surgeon is intending to remove it in a few weeks and put a lovely Smith & Nephew Ceramic on Ceramic hip in its place.

This is from the Smith & Nephew website:

It is the 99% ceramic in ceramic that is going to do the job…

They go on to say:

Ceramic on ceramic

Another option for extending the life of your hip replacement is ceramic on ceramic. These implants reduce wear by 99%³ in laboratory testing when compared to traditional metal on plastic. With ceramic on ceramic hip replacements, both the ball and socket are replaced with ceramic. These implants have an excellent reputation for reducing wear, but have limited flexibility in design options due to manufacturing limitations of the ceramic material. Therefore these implants are not suited for all patients. Talk with your surgeon about this technology and if it is right for you.

Not a Small Job…

It is going to the a biggish operation as the press-fit acetabular cup will have to come out and a bone graft will be required to fit the new cup plus a few trusty screws...

And then he will need to dig out the femoral implant but the way it looks that should come out very easily – but he will then have to dig out the old cement and the cement that spewed down the femur when the last surgeon did not use a glue cup.

A longer femoral stem will be required and he may get away with a press fit – time will tell.

Bone Scan

So tomorrow – bone scan and then back to see the surgeon Thursday 28th July….

Will keep you posted.

Cheers

Earl

Bone Scan results

Bone Scan went well – no major necrosis issues highlighted.

Three days until R-Day! 29 August 2011

• Well time flies when you are having fun! Or so my late Dad always used to say – I figured it passed whether it was fun or not!

I went and had my final meeting with my surgeon today and we had a good review of all the things that were most likely to happen on the day – 1 Sept 2011.

He has put the afternoon aside – no golf that day! will take about 3 – 4 hours.

So – the procedure will be something like this:

• Open up the hip – have a nice handy road map (read scar) from the last operation.
• Split the femur – effectively take the top off – like a convertible roof on a sports car!
• Dig out the femoral prosthesis and all the excess glue from the last surgery as the original surgeon did not use a glue restriction cup.

• Wire the femur back together again.
• Then most likely press-fit the revision femoral stem which will be a little longer than the stem used first time round. And it will be flanged – a Zimmer implant.

Finished job with the wires should look a little like this:

Then the next step will be to dig out the acetabular cup – which is press fitted in – despite the original surgeon’s notes saying it was cemented!!!

Most likely there will be a need for a bone graft or some form of packing & screws for the new cup.

Then in goes the ceramic insert and femoral head – presto; a new man!Will probably be staples not sutures as it will be harder to hold together with the normal dissolving sutures – unless he uses non-dissolving sutures – but they hurt on removal as I recall from last time! LOL.

Will have 1 – 2 drains – the more the better from what I have read.

• May need to have a transfusion – getting cross-match done on Wednesday.
• Will have some of my own blood recycled too.
• Cather up the old fella – won’t have to worry about passing urine for a few days!

Pain relief will be intrathecal morphine – and a pain pump once I am back in the ward.

Had a long discussion about opioid induced constipation and agreed that I would get lots of stuff to help along the bowel motions – and some medication to offset this effect. However, there won’t be much action for about 3 – 4 days I am certain!

Will be given Clexane (low molecular weight heparin) for about a month via injection – much better idea than Warfarin  I had last time – all those blood tests and calculating what dose to take!

The normal stay in hospital for a revision is around 7 – 10 days but I will be keen to make it shorter – but the extent of the operation and the need to get some stability back in the hip may slow things down a little.

A few weeks on crutches is likely.

So I will keep you all informed with my trusty camera and laptop!

Had some new X-rays done today – two months since the last ones – seems to me that there is more osteolysis and bone loss – possibly some fragments but I am not a medical doc and I haven’t discussed these with the surgeon yet. Will do on the day of the surgery.

What is interesting is 3 radio-opaque spots showing up in the pelvic area – not sure what those are.

Quality of the photo’s below – OK for an iPhone 4 shot of the X-Rays held up by my son against a white background!

Will be taking iPhone and laptop to hospital to send you all the holiday snaps!

And these X-rays are much more modest that the last ones!

Related articles

• Femoral Osteotomy Treatment & Management (earlsview.com)
• Hip revision surgery (earlsview.com)
• Hip Implants – from American Academy of Orthopaedic Surgeons (earlsview.com)
• Femoral Osteotomy – commonly used for adults in the treatment of hip fracture nonunions and malunions (earlsview.com)
• Visit to the Surgeon Monday 18th July 2011 (earlsview.com)
• Birmingham Hip Resurfacing or Surface Replacement Arthroplasty (BHR) With Stem (earlsview.com)
• Total Hip Replacement (earlsview.com)
• Mr. Michael Solomon, Sydney Australia Surgeon Gives Advice on Hip Replacement (earlsview.com)
• UK – Advice for GP’s – Hip Joint Replacements (earlsview.com)
• Revision Hip Replacement (earlsview.com)
• Hip Dysplasia – all you didn’t want to know! (earlsview.com)
• My Revision is Planned for 1 September – Yahoo!!! (earlsview.com)
• Revision Hip Replacement (RHR) (earlsview.com)
• Hip replacement and hip revision (earlsview.com)
• Hip Implant Removal – Total Hip Revision (earlsview.com)
• Revealed: Britain’s top surgeons for hip replacement (earlsview.com)

 

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• DePuy Orthopedics Gets FDA Approval For Ceramic-on-Metal Hip Implant Pinnacle CoMplete System – Is This A Potential Replacement for the Other Ones Out There? (ducknetweb.blogspot.com)

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