February 2008
29/02/2008
Pain in the leg after total hip replacement
I am 53 years of age.I also got a THR due to AVN more than an year ago. My X-RAY, Bone scan etc are normal. There is no loosening, no infection and X ray looks normal. I still have pain sensation on lower part of the thigh which faces the chair while sitting i.e when it touches the hard surface and the pain while walking starting from thigh to knee and lower part of the legs. The good leg and thigh also pains while walking and sitting but lesser than the operated one. Is there a treatment? No doctor has been able to diagnose the problem. Some doctors call it neuropathetic pain and some suggest revision surgery.
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Answer:
Pain in the leg that was operated on with total hip replacement may have several causes.
In your case the most frequent causes of pain, infection and loosening, were excluded as you say.
The pain in the shaft of the thighbone occurs in some patients operated on with cementless shaft without any obvious reason to be seen on x-rays.
In other patients one can see a wrong position of the total hip component, its femoral (lower) part, even one can see that the end of the component is coming through the thigh bone. This may need a special x-ray projection.
A long scar of subcutaneous soft tissues, hidden under the skin can be another cause of the pain that occurs when the leg comes in contact with the hard edge of the chair.
Short muscle / muscles may also cause pain in the outside of the leg during walking, raising from the chair, etc.
Eventually, there may be a nerve damage causing the trouble, either in the scar, or higher up in the spine.
So what need to be done is a comprehensive examination, inclusive of examination of nerve function by a specialist, new evaluation of x-ray pictures with assessment of the position of the femoral component. An experienced PT should evaluate the state and function of the muscles around your total hip.
Revision operation? What should be operated on anew? When there is no known cause of your pain, revision operation would probably end in a catastrophe.
VS
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28/02/2008
Bad alignment of the leg after total knee surgery
I just discovered your “Total Joints” website and I wanted to say that I am grateful to find it.
For what it is worth, I had a left total knee replacement with a DePuy mobile bearing (rotating joint) as you describe. I have generally been pleased with the results and am now 16 months post-op. my only disappointment is that the surgeon didn’t align my tibia as well as I would have liked and now my foot is very slightly too far to the outside (left). This causes soreness and some loss of feeling in my left foot, but the surgeon doesn't seem concerned.
I was also very interested in your section on materials for total hip replacement prosthesis, as that will likely be my next surgery. My surgeon talked about types that were “metal-to-metal and mentioned cobalt-chromium. He also talked about Alumina-Zircon ceramics, but he said that contrary to what the salesmen say, he had seen them chip.
I have a younger friend who had the surface hip replacement at just over age 50 by Dr. Mott in Baltimore. He has been extremely pleased with it and is back to playing tennis. I do believe his physique helps, as he is short, very slender and has always been physically active.
I don’t know if you can make recommendations for hip replacements, but would appreciate any general or specific comments you might care to make. I am just turned 64, but fairly active, though overweight. I wish to be more active, but have had a lot of pain the last couple of years that has reduced my activity level.
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Answer:
Congratulations to the results of your Total Knee operation. You say that the alignment of your lower leg is not perfect “which causes soreness and some loss of feeling in the foot”. Generally, however, soreness and loss of feeling in the foot, especially on the outside is rather caused by a pressure on the nerve that passes on the outside of the knee (fibularis nerve). If the soreness will increase in the future one should look at the function of this nerve.
As to the total hip materials. The basic rule is to choose an experienced surgeon, an experienced surgeon has his proven total hip model made from materials that worked well in his hands.
Surface replacement is suitable for certain patients. The deciding factor is the quality of the skeleton of the hip joint to be replaced. For patients with good quality skeleton, there is no reason why they should be denied surface replacement surgery. Patients with “moderate” overweight have equally good results as normal weight patients; but their rehabilitation is slower.
VS
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27/02/2008
Numbness after arthroscopy of the knee
I had an arthroscopy on my left knee due to a torn meniscus. During surgery they also had to "clean up the cartilage". I now have a numb area on the left side of my knee and down my shin approximately 8 inches x 4 inches wide. A rather large area. My doctor is dumbfounded. Can you explain this numbness?
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Answer:
Thank you for your question. A numb area after arthroscopic examination of the knee joint occurs with varying frequency.
It is caused by the damage to one of the many thin skin nerves that pass over the knee area. When the surgeon sticks through the skin with the pointed knife to make entry for the arthroscopic instrument, he / she may be unfortunate and cut through one of these thin nerves. This results in that the skin area innervated by the nerve becomes numb.
It then depends on luck if the nerve “grows together” or if a scar tissue prevents healing of the damaged nerve. In the first case the sensibility returns, in the other it will not.
Usually surgeons can find the entry hole in the skin where the skin nerve was damaged and explain to the patient what happened.
In very rare cases, in patients where a bloodless field was used during arthroscopy, the nerve damage may occur through pressure of the inflatable cuff. In these patients the numbness is usually transitory.
Patients are recommended to ask their surgeons for close examination and then discuss possible treatment. (Usually none is necessary)
VS
26/02/2008
Failed femoro-patellar replacement, what to do?
I’m 29 and had a right patello- femoral replacement 3 years ago operations wasn’t successful. I know I need my patella removed and was wondering how long the recovery time is if you can help that would be helpful searched the web and can’t find a thing about this procedure. Any info would help or any website addresses would be great. L
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Answer:
Thank for interesting question. Isolated replacement of kneecap in young patients is not done so often nowadays, so there are only sparse reports on the results of these operations.
It seems that young patients (<40 years of age), patients with previous operations on their knee, patients with pain but no x-ray changes, and patients operated on with certain types of replacement devices ( Lubinus model) run a substantial risk of failure.
Treatment of failed patello-femoral replacement by a new operation is a very responsible dead and should be done after careful evaluation of possible causes of failure. The surgeon who would treat such patient should have good practice in treating these patients.
Depending on the evaluating of the reasons for the failure, one chooses the appropriate treatment. If the cause of failure is further progress of wear of the knee joint cartilage then one often chooses to do a total knee replacement.
Total recovery time after total knee replacement is usually 3 or more months, whereas the hospital stay is usually only some (4 -5) says long.
You are right; it is difficult to find good reports about this issue.
Recently there appeared a report in the renowned The Journal of Bone and Joint Surgery-Am, 2006, 88-A Supplement 4: 122 – 137 about this procedure, written by Doctor Leadbetter and his colleagues. You may ask your librarian to procure a copy of this article for you (there are many pictures there and an e-mail address to doctor Leadbetter). You may perhaps also contact Doctor Leadbetter about his opinion.
VS
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21/02/2008
Infected total hip – should it be removed before antibiotic treatment?
Should a major infection of total hip be treated with antibiotic whereas the device is left in place or should the implant be removed before the antibiotic treatment starts?
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Answer:
Thank you for your very short question. What are you really interested of? Your question is too short, without facts that would help to answer the question.
The treatment of infection around total joint depends on many factors. Very important is the time factor.
If the infection appeared early after surgery the bacteria had not the opportunity to colonize the surface of the total joint. It is then sufficient to remove only the infected blood pool around the total joint and let the total joint stay in place. The antibiotic treatment thus proceeds with total joint in place.
If the infection developed more slowly and bacteria had time to colonize the surface of the total joint, antibiotic treatment only will be ineffective. Bacteria adherent to the surface of the total joint are inaccessible for the effect of antibiotics.
In that case the whole total joint together with surrounding soft tissues that contain adherent bacteria must be removed completely; together with this removal an intensive antibiotic treatment should start. This is called a two stage replacement of infected total joint.
Please read more in the chapter Total hip infection
VS
20/02/2008
PATH operation technique for TH – are there any drawbacks?
I had a total hip replacement on the left side Dec. 6, 2007. It was done in the traditional style. I was not cemented, but was full weight bearing the day after surgery. I returned to work after 8 weeks. I'm very pleased with the results- so far. It was a very hard recovery-painful and slow- and yet I did better than my two friends who also had THR the previous year. I was referred to a Dr. in Cleveland who does the PATH technique. It almost seems too good to be true. I am 58. I need to have my right hip replaced also. What are the drawbacks to the PATH technique versus the traditional method? I am 200 lbs. -but the Wright Medical video I watched says weight doesn't have an impact on the successful placement of the implants. Is that true? Also- since I had my first hip done - ceramic on ceramic- or maybe ceramic on plastic- would there be a problem having metal on metal?
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Answer:
The PATH technique is another of the minimally invasive operation approaches to the hip joint. It was developed by doctor Pennenberg who is collaborating with Wright Company. As you yourself noticed, this technique seems to provide what it promises – quick return of the function in the replaced hip joint.
There are as yet no more comprehensive reports about the results and potential drawbacks of this modification of the minimally invasive approach to the hip joint. From the presentation of doctor Pennenberg it seems that this technique has no obvious drawbacks, except for the learning curve of the surgeon.
If the surgeon is confident with the PATH method, there seems to be no obvious drawbacks.
As to the use of PATH technique in overweight patients: There are no published reports as yet that will give definitive answer on this question. Generally, the overweight patients have equally good results of total hip operation as their leaner colleagues but it seems from some published reports that recovery after operation may be slower in overweight patients and some minor wound complications may occur more often in overweight patients.
The PATH technique is designed to be used with total hip models fabricated by Wright Company specifically. Wright Company has also surgeons who are paid for use of company’s total hip models together with PATH technique.
It thus seems that it would be best to discuss with your surgeon which total hip model he would use in replacement of your second hip joint.
VS
14/02/2008
Osteoarthritis of the hips and changes in the spine
I've had osteoarthritis in my hips for nearly forty years (old Perthes disease) and now find after x-ray of my dorsal spine that I have widespread moderate disc and joint degenerative features. I asked the GP if anything could be done to ensure that it doesn't get worse and he said not to bend or twist too much. Should I be referred to a consultant? There would be no point unless something could be done to help me. I have always tried to watch my posture and as far as I know I haven't lost any height yet. Can you suggest anything that I can do to help myself.
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Answer:
Thank you for an interesting question. I assume that you do not have any special pain from your dorsal spine and that the quality of bone tissue (as shown on x-ray pictures) is good, no signs of osteoporosis (lacking of bone tissue).
In that case one should consider the widespread disc and joint degeneration in your dorsal spine as “accentuated” signs of aging. There is hardly any known method how one could slow down this process.
A PT can instruct you about the right exercises and life style to preserve the resting motion in your spine as long as possible.
An orthopaedic specialist may assess how osteoarthritis in your hips influences changes in your spine. He / she should also assess if any physical therapy would be useful to mitigate the stiffness in your hips which is usually present in patients with hip osteoarthritis.
VS
January 2008
21/01/07
Overstretched nerve after total hip operation?
Sorry to have not given you enough information. The leg that is longer is the right leg which has had the 2 revisions on. The shorter leg is in my opinion a lot shorter as I have to have the all my shoes built up not a lift. The x-rays do show the right leg 3/4 inch longer. My surgeon says the position of the new cup is great. What kind of test would show the function of nerves? Is it common to pull on the nerves to make them stretch over a new hip part? Will the nerves adjust on their own?
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Answer:
To ally your fears, I must say that it is exceedingly uncommon to overstretch the nerves that pass over hip joint during a total hip replacement operation.
If it happens, it is only under special circumstances, such as when there was a previous operation on that hip joint that produced much scar tissue. Such scar tissue may fix the nerve so that it then cannot move away during surgery.
Such overstretched nerve is a serious complication. It causes severe pain and produces grave signs of disturbed nerve function that are not difficult to discover even for a surgeon. I think such complication could not your surgeon miss and you would not stand the pain for so long time.
Less damage of the nerve that may cause pain can be, however, difficult to discover by “untrained” people and would need assessment of a trained specialist in neurology,
Most pain in the total hip area, where the x-ray pictures “look normal” is caused, however, by overstretched muscles. Although it is impossible to make any diagnostic conclusion on Internet, one can say that lasting pain in the total hip of a patient who has too long leg is often caused by overstretched soft muscles and tendons.
So my previous recommendation is, I think, still valid: Seek examination by an neurologist to exclude the nerve damage and discuss with your surgeon and your PT the possible overstretching of your muscles and tendons and how to treat such condition.
VS
13/01/ 2008
My X-ray pictures look fine, says the doctor- but I have still pain
Once again thank you for all your help, and again I have another question for you. When I had my last revision done, the surgeon had to make my leg longer so that I had no more impingement. This was done in July. I went through months of Physical Therapy. But, I am still having pain. I do wear a shoe with a lift of 3/4 of an inch at all times. The sciatic nerve is very sore. In your opinion, how long does it take for the muscles and nerves to stretch to finally absorb the trauma of stretching of surgery? I do Physical Therapy and swim everyday. What else can I do to make this better? The doctor is at his wits end as the x-rays look fine. He believes that it has to do with the stretching of the nerve. Any Advice?
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Answer:
I read this phrase “My x-ray pictures look fine, says the doctor” so often from patients with continuing pain in their total hips. Something must be wrong there.
Because there are always two possibilities:
One, that in reality the x-ray pictures do not look so fine, notwithstanding what the doctor says.
The other one: that the pain is caused by damage to soft tissues around the total hip. These damages are not visible on x-ray pictures and thus do not exist for some surgeons.
(I do not reflect here about the third possibility that the pain has its origin somewhere else then in the total hip area). Se also the chapter: Pain in the total hip.
You write that your surgeon made your leg longer at last revision, but you also say that you still wear shoe lift (1,5 centimeters high); this makes little sense. You do not say which leg is shorter, the operated one or the opposite? This is important to know closer examination of the leg leg difference may decide why you have still pain.
What did show x-ray pictures of both of your hips: has one of your legs been really shorter after the second surgery and which one?
Is the position of the new total hip, of both components, really right?
With wrong placement of total hip components you leg may be in faulty rotation, shorter, and the stretching of soft tissues may produce severe pain.
After deciding these questions one should do careful muscle examination to decide which muscles are shorter (contracted). These muscles would need special PT treatment.
One should also carefully examine the function of the sciatic nerve to see if the nerve shows signs of overstretching or signs of other damage. If there are signs of nerve damage, one should find where is this damage located and what treatment it needs.
With all these carefully done examinations (and it will certainly need an experienced neurologist and radiologist too) one can then make straightforward treatment plan.
This is on you and on your surgeon. If your surgeon cannot continue with your treatment you should find an experienced surgeon who can.
VS
10/01 /2008
Cementless total hips – are they full of holes like Swiss cheese?
Are there any total hip instruments that bone grows into , thus being non-cemented? Am 49 Yr. Old looking at reversal of total hip fusion (10 degree mobility only for 49 years) which will be UNDONE and revised with a total hip replacement. I’m told 20-30 year life of prosthetic, but which is better? metal on ceramic? ceramic on ceramic? metal on metal? I Am told that bone can grow into shaft as if shaft resembled Swiss-cheese holes. This would solidify bond and prolong life. Is there such a thing? Surgery in two months.
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Answer:
Yes, the modern total hip devices in young patients are fixed to the skeleton without the use of bone cement. The surgeon makes a precise bed in the skeleton and the device is then pushed into it. The surgeon call it “Fit and fill” fixation.
The surface of the device is covered with a spongy layer of metal. Thus, not a Swiss cheese but rather a microscopic sponge. The openings and holes in this layer are only 20 to 50 thousands of a millimeter large, that is the size that the bone tissue needs to grow into it. This ingrowth of bone tissue would create a lasting and stable fixation of the device that surpasses the fixation with bone cement. See also the chapter “Cemented and cementless total hips”.
When it comes to the question which combination of bearing surfaces is best, metal on polyethylene, ceramic, metal on metal my answer is: Let the surgeon decide together with you.
An experienced surgeon uses proven total hip models that produced good results for him/ her – otherwise he/ she would not stay in the trade. When the surgeon finds a total hip model with which he / she is comfortable with and which gives excellent results he/ she uses this model only. It is economical too.
It can be that the surgeon uses models with different bearing surfaces for different categories of patients (old vs young, for example).
If the patient finds the surgeon’s arguments good then there is no reason why not to accept the total hip model recommended by the surgeon.
VS
06/01/2007
Stiff and painful total knee 9 months after surgery – what to do?
. IM 49 YEARS OLD. HAD A FULL KNEE REPLACED IN 5 MARCH 2007. AFTER OPERATION VERY BAD PAIN. AND SWELLING. RANGE OF MOVEMENT WAS 95 BUT WENT RAPPID DOWN TO 67 PERCENT BEND. BACK INTO HOSPITAL ON 9 AUGUST 2007. HAD SCAR TISSUE REMOVED. BEND WAS 90 PERCENT. IN NOVEMBER THE 12. 2007 HAD MORE SCARE TISSUE REMOVED. WICH MADE THINGS WORSE. BACK DOWN TO 90 PERCENT BEND. THE WHOLE TIME I HAVE HAD BAD PAIN. AND SWELLING FROM DAY ONE. MY SURGEON HAS NOT TAKEN EX-RAY OR A MRI SCAN. I AM STILL ON 400MG OF TRAMADOLL. AND DIXCOLFLEX. BUT STILL IN PAIN. MY SURGEON DOESN’T KNOW WHAT TO DO NEXT. DO YOU KNOW. IM MORE DISABLED NOW THAN BEFORE.
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Answer:
I understand that your have severely limited flexion (bending) and pain in your total knee, not improved since surgery. There is no information what treatment, especially rehabilitation you had, except that there was an unsuccessful arthroscopy and manipulation in narcosis.
Actually, there is a well known pathway how the surgeon should examine a stiff, swollen, painful total knee and how to treat it.
First the surgeon should assess the size and the placement of the total knee prosthesis on good conventional x-ray pictures. Wrong placement and / or too big size of the total knee prosthesis are often the cause (or one of the many causes) of total knee stiffness.
If this cause of stiffness may be excluded, the surgeon should evaluate whether there are signs of ongoing infection. Blood tests and bacteriological testing of joint fluid should be done to exclude this possibility.
When / if this possibility was excluded, the surgeon should evaluate what soft tissues may cause the stiffness, especially what caused the lack of the flexion (bending) of the knee.
Most often the cause is too short / contracted quadriceps muscle. The treatment of this condition is by comprehensive and intensive rehabilitation. One uses often special elastic braces and electric muscle stimulation.
When a course of such intensive rehabilitation is not successful, one may conduct arthroscopic examination that must be followed by a new course of intensive rehabilitation.
Pain may be also caused by compression (impingement) of the nerve on the outside of the knee (peroneal nerve). There are specific signs how to discover this complication. If there is such nerve compression the operative decompression (making the nerve free) is usually successful.
Stiffness may be also caused by too much joint fluid. It such increased quantity of joint fluid is present it should be tapped out by joint puncture.
Now I think this is a clear pathway how a stiff painful knee should be examined and treated.
You may discuss this treatment plan with your surgeon or find a surgeon who is experienced to treat such total knee problems for a second opinion.
VS
02/01/2008
Night snoring – is it an obstacle to total hip and knee replacement?
Needing both knees and both hips. I have a-fib and have just been told I have severe low oxygen levels due to sleep apnea. I am on oxygen at night and when needed tell I get c-pap machine. When can I have my surgery or surgeries I am in so much groin pain.
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Answer:
A very interesting question. However, it can be answered only by an anesthesiologist -the doctor that would give you anesthesia during operation.This doctor will also tell you the risks associated with your condition when undergoing total hip and / or total knee operations. I recommend that you ask him/her directly.
VS
December 2007
29/12
Scan showed small activity areas around my total hip – what is this?
Because I was having pain in my new hip I was sent for a scan in the nuclear medicine dept. When I saw my consultant for the result, he said there was no loosening of the joint and does not want to see me for four years. He said the same in the letter to GP. I phoned up to ask for a copy of the scan report and it says that there are two areas in acetabulum with very minor degree of uptake (of nuclear injection presumably) and medial aspect of greater trochanter. It concludes that the appearance is inconclusive for loosening. Does it sound OK to you?
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Answer
Thank you for your question. It does say that you have had a scan, but not what kind of scan. I presume that it was the commonly used Strontium scan to asses the bone turnover activity around your total hip.
The finding of “two small uptake areas” of injected radioactive material in the skeleton around your total hip is assuring. It means that no great destruction of skeleton with great bone turnover is ongoing around your total hip. (But this examination is not regularly done for a painful hip joint).
But of course this examination says nothing about the cause of the pain in your total hip joint.
Please return when something is unclear.
28/12
The perpetual question: which total hip model is best?
I will be having hip replacement soon. I have two doctors that I am comfortable with. One uses a Zimmer hip and the other uses a Biomet hip. The Biomet magnum hip looks to be a good choice for someone my age. (I am 48 and in good health) Do you have an opinion on either of these? Do either of these have a history of success or failure?
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Answer:
As to the question which total hip model is best: The ground rule is: Choose an experienced surgeon and then accept the total hip model that your surgeon is acquainted with and has been using for his patients.
An experienced surgeon would never use a bad total hip model. In that case the failures would force him / her out of the trade.
23/12
The perpetual question: which bearing surface? Is ceramic the best?
I am on the eve of hip replacement surgery and I am struggling with my choice of surfaces. I am a very athletic 48 year old male cyclist, approx. 68 kilograms. Six years ago I had a complete replacement on my right side..
I am leaning towards the ceramic on ceramic surface because the wear rate is so minimal as compared to metal on metal, and metal on poly. I understand the ceramic on ceramic surface has been used in Europe for over 30 years but only recently adopted in Canada. My big question is: "is the risk of failure very small as compared to the benefit of no particulate and subsequent revisions?
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Answer:
As to the question which total hip model is best: The ground rule is: Choose an experienced surgeon and then accept the total hip model that your surgeon is acquainted with and has been using for his patients.
An experienced surgeon would never use a bad total hip model. In that case the failures would force him / her out of the trade.
For young patients it is said that ceramic bearing surfaces are best because they produce the smallest quantity of wear particles. The reasoning then goes that the lover the quantity of wear particles the lower the risk of late failure of the total hip joint.
So long is all well. However, the experience with the ceramic total hip is still short, the modern ceramic total hips have still the follow up observation time maximally around 10 years (You may look at the chapter Ceramic total hips).
So it all boils down to recommendation to discuss the option of the total hip with the surgeon whom you confide enough to carry out the surgery on your hip joint
VS
19/12
Stiff total knee – a sorry story
I had total knee replacement on Feb. 6, 2007. It has not gone well. I had a manipulation done May 18. The surgeon finally told me on June 18 that my leg was misaligned and I needed a redo. He sent me for a second opinion to a surgeon who agreed that it needed to be done over. After, they conferred, they said it was mainly a scar tissue issue but the only way it could be done was to be cut open again. If they noticed it needed to be redone, they would do it at that time. I went to doctors of my own choosing for a second opinion, they said the knee was misaligned, rotated wrong and that the surgeon had hyper-extended my leg. One suggested I might now need a hip replacement before the knee would be redone due to the misalignment issues. Two doctors said it was not a scar tissue issue but a botched surgery issue. Another suggested trying arthroscopic knee surgery to remove scar tissue first before going through a redo. I really am confused to know how to proceed. Should I try arthroscopic scar tissue surgery to remove scar tissue as one surgeon has said or would this be a waste of time if the device is in wrong? Is there research that shows that arthroscopic knee surgery works to remove scar tissue?
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Answer:
I really can understand that you may be confused by so many different answers from so many surgeons.
What is this “misaligned total knee joint” ? Every healthy knee joint has a mechanical axis (see picture of it in the chapter Total knee operation). This axis is changed by the knee joint disease. The surgeon must restore the mechanical axis at the total knee replacement operation. (It is not easy and small deviations from perfect restoration do not matter).
Now, x-ray pictures of the whole leg standing should demonstrate how much the mechanical axis of your total knee deviates from normality.
This should your surgeon show you and you should discuss with him how much is the mechanical axis misaligned (he should to show you on x-rays) and discus what to do about it.
Is stiffness of the knee joint your main problem? Is the misalignment really the cause of your knee joint stiffness?
You do not tell what your total knee problems really are and what treatment you have had. For example; What was the mobility of your total knee before the manipulation that your surgeon did on May 18 and how much it improved after this manipulation?
Did you have a comprehensive rehabilitation program for your total knee, really directed at “soft tissue problems”?
With the scarcity of information on your your total knee problems I am sorry that I cannot come longer.
15/12
Cancer related to metal / metal total hips – need to worry??
I have corresponded with a few times in the past but it has been awhile, I was just was wondering have you heard from any colleagues about cancer that is related to m/m hips or any other metal ion issues. I have had my m/m hip for 5 years and it is doing fine.
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Answer
Total hip and cancer is a well rehearsed question. Presently, there is no clear evidence that metallic ions released from total hips increase the risk of cancer. The modern metal / metal total hip have too short observation period to come to clear conclusion, the “old” m/m total hips (yes, the first total hips used only metallic parts) on the other side have no good observation data.
One (Finish) surgeon, doctor Visouri, published in the 1980’s a statistics that demonstrated that the “old” total hips were associated with greater risk of blood cancer. Later on, he, however, retracted his previously published report on a conference on the modern surface replacements.
You may also look at the data in the chapter Total hip and cancer.
I think that patients with m/m total hips should not be concerned unnecessarily by the possible risk of cancer, because if this risk exists at all, it is very small, several times lower than for example the cancer risk associated with smoking.
10/12
Impinged and short muscles around a total hip – find people who can treat these problems
I am a 50 year old male entering my 3rd post-op year posterior MIS LTHR. Pre-op I had 40 years of severe bone deformity subsequent to fractured hip and tibia at age 8. A few months after my surgery I experienced, and continue to experience more pain post-op then I ever did pre-op. My operative leg is slightly anatomically longer post-op then it was pre-op, but only by 1.4mm (as revealed on CT Scanogram). There are reports indicating a leg length discrepancy also due to pelvic obliquity representing a functional leg length discrepancy. My muscles are extremely tight with predominant pain in Psoas, Iliacus (Iliopsoas), Rectus Femoris, Piriformis, Gluteus muscles, IT Band - Tensor Fascia Lata, and suspected Trochanteric and Iliopsoas Bursitis. The pain is in my groin area and down the front and side of my thigh. I have received long term PT over the past three years – (land, manual and aqua therapy, ultra sound, etc.), multiple trigger point injections through Pain Management Center at Cedars Sinai, prescribed anti-inflammatory medications i,e, Mobic, as well as a variety of medicated Ketoprofen creams – all with no improvement. I have consulted with a few surgeons and underwent extensive work-ups over the last three years with every test/study known to mankind but all came back negativeGetting in and out of the car is painful. Any false movement (on average 1-2 times a day – I’m not clumsy) triggers the Iliopsoas pain. It is painful to sit, walk, or stand for lengthy periods of time. Sleeping on affected side is also painful around trochanter area. When I attempt to chase after my kids (mission impossible) to prevent them from crossing the street I am absolutely helpless due to weakness and pain. Walking up flights of stairs is difficult and painful. I am unable to strengthen operative leg due to increased pain. Trochanter is sensitive to the touch. It appears that all conservative measures have been exhausted. I suspect that 40+ years of severe bone deformity resulted in extremely shortened muscles, and that, compounded with functional discrepancy maybe the possible culprit. Post-op I have learned that MIS is not recommended for patients with severe bone deformity and that lengthening of overly shortened muscles is sometimes recommended at time of THR, however this was not performed.
I have reviewed some of the published articles that discuss surgical procedures involving removal of Bursas as well as articles pertaining to surgically lengthening and/or releasing the Iliopsoas,
One surgeon is contemplating surgical removal of suspected iliopsoas and trochanteric bursitis, and if that doesn’t work to perhaps release I believe the illiopsoas, however, a radiologist at Cedars advised today that there is no evidence of bursa “fluid build-up” per 64 Slice CT. The surgeon has prescribed a CT or ultrasound guided injection of the Psoas and Trochanter (is this same as a “Sonography”?) to confirm diagnoses of bursitis and I assume Iliopsoas Impingement. However, the radiology department at Cedars believes that ”…..this test would be doing something for the sake of doing something, and that it is not deemed medically necessary”. Another surgeon advised that he “…only treats bones and joints and has nothing to offer” and is against doing any type of injection due to risk of infection with THR implant. He believes that CT guided injection “would only serve my curiosity”. However, I did consult another surgeon 18 months ago in Las Vegas – Dr. Tod Swanson – who recommended “12 weeks of rigorous physical therapy to include stretching of adductors, abductors, IT Band, and rectus femoris” and if this was not successful he believed that “it was possible to surgically release several of these structures in order to provide some relief”.
Dr. Surin perhaps you can attempt to answer the following question; Since the radiology department advised no evidence of ”fluid build-up” is it possible to have “Iliopsoas Impingment” without Iliopsoas bursitis? If so, then I am still left with question of touch sensitive trochanter.
I am becoming increasingly frustrated. In the interim do you have any relations with surgeons in my area (as that is my preference) that have experience treating these specific symptoms? I look forward to your comments and suggestions.
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Answer:
Thank you for your e-mail that reveals your insight in the orthopaedic surgeons’ ways of thinking. Really, many of surgeons see only the bones and artificial joints; because the soft tissues are not depicted on plain x-ray and other (CT) pictures, these structures do not exist for the majority of orthopaedic surgeons.
It is impossible to arrive at a diagnosis from an Internet letter, but it is possible that your total hip problems really are caused by short / impinged muscles around your total hip.
Now, there are really 19 such muscles, not only the iliopsoas, but also rectus femoris that may cause pain anteriorly, there is a muscle called tensor fasciae latae that may cause pain on the side that is indistinguishable from the trochanteric bursitis, and there are also other muscles that may be short, irritated and cause problems.
Personally, I think that doctor Tod Swanson’s advice and assessment of your total hip problems are very valuable. Perhaps he has also a good PT that can guide you through the course of rehabilitation and assess which muscles are short and possibly would need lengthening.
You asked after someone who treats these soft tissue problems that occur in patients with total hip joints. Living in Sweden my knowledge of these people in the USA is rather limited.
You may in every case read an article from Anil Bhave and colleagues: “Functional problems and treatment solutions after total hip and total knee joint arthroplasty”, which was published in The Journal of Bone and Joint Surgery 2005; 87-A Supplement 2: 9 – 21.
His address is:
Anil Bhave, PT, (collaborates with doktor Mikael Mont) and works at: Rubin Institute of Advanced Orthopedics, Sinai Hospital, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address: abhave@lifebridgehealth.org or anilbhave@yahoo.com .
10/12
Stiff and painfull total knee – cannot find people who will take care of it
Had total Knee replacement on right knee,3 years ago and it still is so tight and when walking the pain. I been to at least 4 doctors. They said the x-rays look fine, one did a bone scan couldn't see anything wrong. And a year and half ago a doctor did arthroscopey and could'nt find anything. I don't know where to turn, I know its tight and hurt, in a degree 8. I don,t know what to do, I know its not in my head. Thank you. if you can advise me in any way. thank you again
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Answer:
There are a lot of causes that make the total knee joint stiff. Some of them are not possible to see on an x-ray, because they reside in the soft tissues around the total knee joint.
You may read about then in the chapter Stiff total knee.
It is difficult for me to find a specific surgeon for you. Perhaps you may start with a good PT that may evaluate and find which soft tissues (muscles, ligaments) around your total knee joint are shortened, then find a good radiologist to evaluate your previous x-ray pictures to find whether your total knee device is not too big (so called “overstuffed”) or whether the patella (kneecap) is not placed too low,
After all this assessment is done it would be time to find an experienced surgeon to discuss how to treat your problems.
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06/12
Suspect total knee infection – or ”lot of reactive tissue”?
I am currently 61 and have had tkr in both knees. the right one done in 2002, left done in 2004. surgeries went well with no complications. the last year or so i started having complications with the right knee. have had 4 episodes in the last 18 months of fever (lst time was 104, subsequent times was 102), knee swelling with pain enough to put me back on a walker . . feeling very sick each time. fever disappears after a couple days and in about a week to 10 days i'm back at work doing my office job. on episodes 3 & 4, my orthopedic surgeon did an aspiration. got very little fluid out that showed nothing. he commented that blood tests done at the time showed lots of elevations. (not sure what that means). he finally scoped the knee in november. found no infection but did find lots of "reactive" tissue with alot of fluid that shoudln't be there. said he cleaned it out. i am recovering good but still have some discomfort when bending the knee. got any hints on what might be causing this problem? i do have psoriasis but have never been diagnosed with psoriatic arthritis.
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Answer:
Patient with a swollen, painful total knee joint and fever should be evaluated to exclude the infection. The blood tests should include ESR (Erythrocyte Sedimentation Reaction) and CRP (C Reactive Protein). The samples from joint fluid should be tested (cultivated) for the presence of bacteria. Notice that these tests may by influenced by ongoing antibiotic treatment so that they show almost normal values even in presence of ongoing total knee infection.
X-ray pictures should be investigated for signs of bone destruction caused by infection.
The surgeon should then take decision about further treatment considering the state of the patient’s total knee joint, results of blood tests and changes on x-ray pictures.
So the answer to your question “what might be causing this problem” can be answered by a person who examines your replaced knee joint personally and has knowledge of the results of blood tests and x-ray examinations.
If infection of your total knee may be excluded one should look further and exclude such possible causes as loosening of the total knee joint or excessive wear of the polyethylene component of the total knee device.
Please ask more if something is unclear.
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04/ 12
Pain in the hip, maybe a muscle impingement –where to find people who woult treat it?
After my previous discussion with you I visited my surgeon. He, however, gave up and referred me to a hip replacement professor in an ortho department at the local University. They did more x-rays, a bone scan (low to moderate hot spots in the pelvic area only), blood work, aspirated the joint (60 cc of fluid, cloudy but not infected), and injected lidocaine to see if it solved any problems. The lidocaine worked for pain in my thigh, for about 3 hours. Significant improvement during that period.
After all that, I met with two surgeons independently (they are partners). One said nothing should be done, and my expectations for the hip may be too high. Wait it out. The other said sometimes metal on metal causes ion related pain, and a slight lengthening of the leg is causing muscle pains. If I chose surgery, he would pull the socket, dig it deeper, and replace it with a smaller ball, and a plastic cup. I currently have a Biomet M2a Magnum Large Articulation metal on metal.
Beyond radical surgery, I was told to "wait it out".
- These guys "don't believe" in cortisone in the joint. They think it increases infection rates to much (thus not an option)
- They "don't do" tendon division. They looked at me like I was nuts when I asked about it.
- They have done nothing to diagnose impingement, although they have not ruled it out.
This was a top U.S. medical university. I live with the pain every day, and feel something is not right.
Who specializes in this? I have private insurance, and plenty of frequent flier miles. Is there anyone who can look at all my recent records/test results and form an opinion short of a radical TH replacement? I prefer the eastern half of the U.S.
Thank you for your web-site. I find more information on your site than anywhere else.
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Answer:
Thank you for your e-mails in every case. It shows that your problems are continuing and that you are nor willing to give up. Excellent!
Now, there are really 19 such muscles, not only the iliopsoas, there is a muscle called tensor fasciae latae that may cause pain on the side and cause the that that the operated on leg feels longer.
So you are right that one needs to find people who can deal with these rather complicated “soft tissue” problems
Living in Sweden my knowledge of people in the USA who deals with these problems is rather limited.
You may in every case read an article from Anil Bhave and colleagues: “Functional problems and treatment solutions after total hip and total knee joint arthroplasty”, which was published in The Journal of Bone and Joint Surgery 2005; 87-A Supplement 2: 9 – 21.
If you are tired of reading you may contact him directly:
His address is:
Anil Bhave, PT, (collaborates with doctor Mikael Mont) and works at: Rubin Institute of Advanced Orthopedics, Sinai Hospital, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address: abhave@lifebridgehealth.org or anilbhave@yahoo.com .
03/12
Is it possible that a total knee device can freeze inside my body in cold weather?
…is it possible in extremely cold weather, your tkr feels like frost bite has set in, and when going inside you experience a thawing out with burning feeling throughout your replacement. my ortho. thinks i'm nuts.
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Answer
All people with joint problems have increased joint problems in cold weather. Patients with total joints are no exception.
Now, the regulation of the temperature inside your body is excellent also in your extremities. So your artificial total knee device cannot become cold to the point that it freezes in a frosty weather and thaws in a warmth of inside rooms.
But it is highly probable that the replacement operation may change the circulation in the patient’s knee joint area and changes their temperature perception in the knee area. Some patients may even feel that their total knee device is freezing.
VS
02/12
Draining fistula after revision total knee operation – a dangerous complication
After my mom had revised knee replacement, the doctor explained to me he installed the new knee as loose as possible for a better range of montion. Does he mean that the joint is not installed firmly together?
Secondly, her scare continues to discharge clear/yellow fluid 3 week after her original surgery. Does this mean infection has sent within her knee? What type of damage can this cause?
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Answer
Every total joint device must be anchored firmly to the skeleton for pain free good function. On the other hand, the knee joint ligaments and tendons should not be stretched too much by too big total knee device. The surgeons use the term: the total knee should not be “overstuffed”.
Such overstretched ligaments and tendon would make the knee joint stiff and painful. This is probably what the surgeon meant when he spoke about installing the new total joint “as loose as possibly”.
Of course, if the ligaments and tendons are too lose the new knee joint may be less stable, but if that happens a brace will render it stable.
The second problem, the fistula discharging clear fluid for more than 3 weeks after revision surgery from the total knee is a rather serious problem. It is possible/ probable that the fistula has connection with the knee joint. Bacteria from outside can travel up streams and infect the new total knee joint.
This problem should be solved by the surgeon without delay.
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