What can be done to fix a failed hip revision?

Bones, joints and muscles
1

I'm 58 year old female with a history of hip replacement surgery on my right side. I've had 4 surgeries to replace, revise, and repair hip fractures and femur fractures due to severe osteoporosis. I had a hip revision on November 19 of 2013 with no real healing or signs of fusion. Xray showed lucency around the posthesis and small crack in pelvis as result of surgeon over-tightening the screws to get a tight fit. After putting me off for months, he finally ordered an MRI. It shows that the hip revision is not fusing, hardware very loose and soft tissue damage including: (sorry for the length of this report):Soft tissue reaction:

Pseudocapsule fluid: Small amount of fluid. Posterior capsule disrupted

with decompression of fluid into the greater trochanteric bursa. There is

mild wall thickening of the greater trochanteric bursa up to 4 mm. There

is a 1.1 cm body in the greater trochanteric bursa with susceptibility

artifact, possibly a smaller fragment.

Soft tissue mass: Absent.

- Nerve involvement: The ruptured posterior capsule contacts the right

sciatic nerve, which is otherwise normal in morphology.

- Vascular involvement: No.

Osseous:

- Fracture: Healed fracture of the proximal femur.

- Osseous Integration: No geographic osteolysis. Possible rim of bone

resorption around the acetabulum but assessment is limited by motion. The

femur appears well integrated.

- Heterotopic Ossification: Absent.

Visualized muscles/tendons/entheses:

Flexors: Fatty atrophy and replacement of the right iliopsoas with mild

edema.

Extensors and abductors: Moderate to severe fatty atrophy and replacement

of the gluteus minimus with partial tear and scarring of the tendon.

Moderate atrophy and fatty replacement of the gluteus medius, with

partial tear of the lateral footprint and scarring. The posterosuperior

footprint of the gluteus medius is intact. Moderate edema of the gluteus

insertions. Postsurgical changes at the greater trochanteric insertions.

Adductors: Mild fatty atrophy and replacement.

Rotators: The short external rotator tendon is dehiscent and scarred to

the posterior capsule. There is moderate fatty atrophy and infiltration

of the obturator internus, piriformis, gemelli, and quadratus lumborum.

Hamstrings: Mild tendinosis without tear.

My question: Can any of this be fixed surgically (the soft tissue damage and tears) or will he recommend steroid injections? Has anyone ever experienced these complications after a surgery? Thanks so much for any response!

2

Wow! I hope somebody on this forum has some suggestions...I'm at a loss to even understand what it means...also feel so humbled by your situation...will make an effort to stop complaining about my own little niggles....

hope something can be done for you to relieve all this..

Chris

3

Thanks for responding Chris. I realize that most of my post is technical in nature and I wouldn't expect anybody to be able to understand it clinically. I'm interested more in hearing if anybody has experienced these kind of problems after a surgery. Keeping in mind that most of the soft tissue damage wasn't caused by any action on my part...I'm not an athlete....had no trauma between the initial surgery and today, I'm at a loss to figure out how this happened. I've been in a wheelchair for many years having undergone 14 total spine and hip surgeries at Johns Hopkins Hospital here in the States, so it isn't as if I went out and ran a marathon or something!! Hopeful that somebody on the forum will have knowledge about how they fix all these tears in the tendons and "capsules". All the best!

4

I'm not a clinician but I can decode quite a bit of the jargon and simply summarised; it is bad news. The bone isn't happy and neither are the muscles. You are running out of good options and into what the medics term as 'salvage'. They will be trying to leave you with as little pain and as much function as possible.

Basically, your muscles are reacting to all the upset in your bone, you haven't been able to use them and there are all sorts of biochemical messages coming from the failed implant which are making the situation worse. The plus is that they haven't reported any infection which would make things even worse. Johns Hopkins has a good reputation and my advice would be to talk to a couple of surgeons with a good reputation and assess the options open to you. Given that you have been using a wheelchair for some years my feeling is that I would tend to favour pain relief over function.

I'm hoping that I never have to face the sort of decisions you may have to make, especially given all the treatment you have needed. already. I wish you well, keep us posted and I know that we hope the medics can come up with something special for you.

5

Thanks ros007! Your post has given me information that I did not have previously. Just wondering though....can any of this be fixed by surgery or would the doctors insist on cortisone injections to heal the tears? I think he's going to have to go back in with an open procedure to replace the hardware with something that fits better and has a better chance to fuse. Is surgery probably in my future? BrittleBones

6

My instinct, and I'm not a medic, would be surgery. What they would do I'm not sure, part of it depends on how much half decent bone is left. They may do some work on the muscle while they are in there as well. I'm a bit of a novice on muscle physiology, I can decode the terms but I don't get all the implications. Sorry. My experience is that if the implant is moving around it won't settle. There are a couple of anecdotal reports where implants have stabilised when the movement was almost eliminated.

One of them, don't know whether it was published or not, was a case in Exeter UK where a woman who was a poor anaesthetic risk was put into plaster (full hip spica to be precise) to see if that would reduce the pain for her. Some stability was achieved over 2-3 months - the surgeon concerned was Robin ling, now retired.

Another one, they took out one component of a total hip and the other component fixed itself. I can't remember the details, I have a vague recollection it was at Wrightington hospital in England, if it was it would probably be connected with Mike Wroblewski but I heard about the cases over 20 years ago and I haven't thought about the problem for years.

Don't know whether this is relevant to your case, the techniques for dealing with the joint are 'heroic' and may cause further loss of muscle mass.

Sorry can't help more

Ros

7

Hi Ros - thanks! I was hoping to hear from my surgeon by now (he's supposed to phone me tonight and it's now 6:12 pm on the east coast, US time). All I can do is wait to hear his plan for how he might fix this mess! What really has me stumped (forgive me if I'm repeating myself) is HOW this tearing and fluid and damage happened! Somebody else mentioned that these are the kind of injuries you see from trauma or athletic use of limbs over time. I've done nothing but some physical therapy starting 8 weeks after surgery. I took PT for 3 weeks, twice a week. It was at the end of the third week that I couldn't get out of bed. Was unable to put any weight on hip. It's a puzzlement! Thanks again Ros!

8

Hmm, I had my THR 16 months ago and have been consistently complaining of lower thigh pain and swelling above the knee which has been increasing in pain over time.

Last week at blasted last the consultant listened to me instead of a fob off after I told him GP thought a tear of the muscle was a possibility and was requesting an MRI. He looked worried and came back and sent me for an immediate xray to return 15 mins. The xray obviously showed something and he said he would see me in 3 months as he was concerned about micro movement in the uncemented spike and wanted to see bone density over a 3 month period. He said I must lose weight otherwise the pain would remain (?) I am 15 and half stone. Not a slim thing @5ft 4ins but I am surprised he thought that weight loss was the whole answer. I am on a diet and have been unable to walk far without pain. Exercise helps weight loss so I asked if I could utilise crutches to illeviate the risks of exercise when walking distance or shopping and he said it was a very good idea.

My question is is it purely a weight / mass issue or actually that the bone is not strong enough - would time heal or weight loss alone?

9

If you have an uncemented stem then a surface is created which the bone should grow onto and lock - rehab is often slower but they hope that a successful interface will last longer than a cemented one. It tends to be used more often in younger patients.

My experience - well out of date - is that loose prostheses do not lock tight unless the movement is reduced. Weight loss is good - standing on one leg produces a load through the hip joint of about 3 times body weight because of muscle forces. So losing 1 stone produces a reduction of load of more than 3 stones when walking. Obviously the more load across the interface the harder it is for the bone to grow into it because it is more likely to slide.

My advice would be to lose weight, try swimming crawl which is non-weight bearing and doesn't involve rotation, consider cycling - foot cycles maybe and upper body exercise to burn some calories and tone up your metabolism.

Crutches are good - they reduce joint loading.

If it doesn't settle and you are losing bone then my instinct would be to consider early revision and discuss the advisability of using a cemented stem. Don't be afraid to ask for a second opinion if you are unsure about your first surgeon and choose one who is experienced in revision surgery. I am not medically qualified but I used to work on the engineering side and read a lot of the, now obsolete, medical literature.

Good luck

10

Hi, I had a total hip replacement and now have atropyhy tissue and muscle, because of this I have a big indentation  where my scar is and pain. Last week I had a MARS MRI so I am waiting for the results. I hope I won't need revision surgery. ,ugh.

11

I had a hip repkacement on my right hip March 2012 July that year had the left one done. July 2013 had it done again. Still in pain lots of it. Now been told it's tissue not attached to bone and not much can be done. Anyone else heard of this. Very frustrating