Hip Talk at Surface Hippy

H i
I   a m   a   5 2   y / o   m a l e ,   f a i r l y   a c t i v e ,   e x e r c i s e   a t   g y m   ( a e r o b i c s ,   l i g h t   w e i g h t s )
5 ' 8 "   1 9 0   l b s
P a i n   w h i l e   s i t t i n g ,   w a l k i n g   c a n   n o   l o n g e r   e x e r c i s e .

D i a g n o s e d   w i t h   F A I   b y   N Y C   o r t h o p o d   h i p   s p e c i a l i s t   w h o   p e r f o r m s                           a r t h r o s c o p y ,   T H R   a n d   m o d e r a t e   #   o f     B H R ) .

M R I   h i g h l i g h t s :
F A I -   C A M
c h r o n i c   n o n   d i s p l a c e d   t e a r   o f   a n t e r i o r   l a b r u m   w i t h   g a n g l i o n   c y s t
A n t e r i o r   l a b r u m   i s   d e g e n e r a t e d   w i t h   n o   t e a r
S u p e r i o r   p o s t e r i o r   l a b r u m   i s   n o t   t o r n
F o c a l   1 . 2 7 c m   ( a n t e r i o r   -   p o s t e r i o r )   f u l l   t h i c k n e s s   c h o n d r a l   l o s s   o v e r   r t h e   s u p e r i o r   a n d   p o s t e r i o r   s u p e r i o r   p a r a f o v e a l   m a r g i n   o f   t h e   f e m o r a l   h e a d
a s s o c i a t e d   w i t h   n o   a c u t e   p r o u d   s u b c h o n d r a l   b o n y   r e m o d e l i n g   1 2 : 0 0   -   2   P M   s a g i t t a l   v i e w
A d j a c e n t   c a r t i l a g e   d e m o n s t r a t e s   m o d e r a t e   t o   h i g h   g r a d e   p a r t i a l   t h i c k n e s s   c h o n d r a l   t h i n n i n g

I   h a v e   r e d u c e d   a c t i v i t y   a n d   d o n e   m i l d   s t r e t c h i n g / P T .
D r   g a v e   a   s t e r o i d   i n j e c t i o n   w h i c h   h e l p e d   a   s m a l l   a m o u n t   f o r   1   w e e k .
N S A I D s   d i d   n o t   r e l i e v e   p a i n

S u r g e o n   a d v i s e d   m e   t h a t   s i n c e   i t   i s   e a r l y   o s t e o a r t h r i t i s   t o   l i v e   w i t h   i t   u n t i l   a r t h r i t i s   p r o g r e s s e s
a n d   t h e n   h a v e   a   T H R .   H e   s a i d   I   a m   n o t   a   c a n d i d a t e   f o r   h i p   r e s u r f a c i n g   o r     a t h r o s c o p y .

I   d o n ' t   e x p e c t   a n y   o f   y o u   t o   g i v e   a   t r u e   s e c o n d   o p i n i o n   b u t   a m   a   b i t                 c o n f u s e d   w h y   I   a m   n o t   a   c u r r e n t   o r   f u t u r e   c a n d i d a t e   f o r   h i p   r e s u r f a c i n g .
M y   S A R I   I n d e x   i s   l e s s   t h a n   6   ( n o   c y s t s ,   g r e a t e r   t h a n   8 0   k g   a n d   m o d e r a t e   a c t i v i t y   l e v e l ) .

I   g u e s s   I     m a y   n e e d   t o   g e t   a   s e c o n d   o p i n i o n

Make an appt with dr su at hss in NYC . He is one of the best and he is in your backyard.  Don't let the 1st opinion be your only opinion.  I was also told to wait, what a joke.  They have no idea about the pain.
Best of luck on your journey

I don't understand all of the details that you have supplied in relation to your condition and given it sounds so much different than my own, I can't really help there.

What I do understand is the feeling that you don't have the the answers that you need from the doctor that you have seen. I am glad that I didn't settle with specialists that I didn't get the information that I wanted to make informed decisions about my health.  I wouldn't advise anyone to go under the knife with a surgeon that didn't completely take away that confusion so that I had complete confidence in the course of action being taken.

I hope that you do find a surgeon that is able to answer the questions that you need answered and hopefully when you do speak to a hip resurfacing specialist, that this is an option for you over total hip.

Your surgeon said that you as a patient are not a candidate for resurfacing, because he as a surgeon is not a candidate for a superior operation.

D.

Hi mate, I had arthroscopy and I had more damage to my cartilage than you and I've been told I'm a candidate for RS. I would seek a second opinion from a very experienced HR surgeon!

Thanks for the responses. The overwhelming consensus is to get a second opinion. I am seeing an HSS physiatrist to help rule out lower back pathology. The hip doc didn't look at my back when I told him that i had symptoms. I also made an appt with Dr. Su in September.

I was a bit perplexed that I was told that there was nothing that I can do until the OA and pain progresses, leading to a THR only.
This original surgeon has performed over 200 hip resurfacings and does many arthroscopies.

So I will see Dr Su and if he states that I am a candidate for BHR, may have it performed in December if he's available.
Thanks for eveyone's input!

Sounds very similar to the surgeon I saw on Monday! Do you have your xrays? If so I would email them to dr Bose,gross& de Smet they will all give you an opinion for free. That's what I've just done! All the best danny

It is always good to get a second and third opinon when a surgeon tells you to suffer in pain until you get old.  Many people have hip resurfacing with FAI.  Dr. Gross does a large amount of FAI patients.  The point of getting a resurfacing or hip replacement is to get out of pain and get on with being active again.  Dr. Su is excellent.  Dr. Gross will give you a free consultation via phone if you email him and a copy of your x-rays in a digital format attached.  That way you get several inputs.  You always need to get an opinon from very experienced hip resurfacing surgeons or you will be told to stay in pain or wait until you are old and gray for a THR.  Large ball MOM  metal on metal THRs are also good solutions if you can't have a resurfacing.  Most people with MOM THRs have no restrictions and are very active.  Don't stay in pain.  Get your additional opinions from several of the top hip resurfacing surgeon.  If you are not a candidate for resurfacing, they are also some of the best THR surgeons in the US.

Pat

I'm not an MD so take anything I say with a pound of salt, but my situation is somewhat similar so I thought I'd share my 2 cents.  I also have FAI and had an MRI done which confirmed it.  It also confirmed some arthritic deterioration  and labral degeneration.  The presence of cartilage degeneration disqualified me for the arthosopic procedure that is done for FAI which involved shaving down the femur and or damaged portion of the acetabular cup and labral repair.  But it does little to address the arthritic process (they often perform a microfracture but that is not thought to give all that much benefit beyond a year or two in the hip).  So I was referred to Dr. Su who told me that I was a candidate for a resurfacing.

Your MRI results sound similar to mine (here's where that salt should be employed) though slighly more advanced.  But they seem to be saying that nothing has happened to your femoral head, only that you've worn through the cartilage in one focused area and have some degeneration in the area around that.  I don't know what in that report would suggest you should not have a resurface.  One of the things that I've learned in obsessively reading this site and all the available literature is that the range of appropriate candidates has expanded considerably in recent years (age, weight, physical complications).  I'd say your conversation with Dr. Su is likely to be very helpful.  I know it takes a while to get in to see the guy, but September? 

Steve

Steve,
I really appreciate that you shared your situation. It sounds quite similar to mine. I am not a hard core athlete but I want to be able to function w/o regular discomfort.
I made an appt with Dr. Su for September and he will have all of my films on file and perhaps may want a more recent x ray since mine will have been taken 3 months prior to the appt.

In the meantime, I will try the physiatry and PT and see if that helps.
Did you decide to have the procedure?

I do intend to have the procedure but not right away.  When I consulted Dr. Su, he seemed to think that I was not all that far along.  He would do the procedure if I wanted, but given the appearance on the films, could imagine I might wait a bit.  I had been in a fair amount of pain at the time but have since backed off a few things that were probably making things worse: certain stretches particularly, but I also stopped running.  I had been a pretty serious weekend warrior a few years back (I'm also 52 now) but now just spend as much time as I can manage in the gym.  Low impact exercises suffice for now and I'm able to maintain basic fitness.  In the meantime, I have two very young kids (4 and 20 months) and my thought is that, given that there's no emergency and I'm not in pain doing what I need to do, I'd like to wait until they're a little older.  I do intend to check in with Dr. Su periodically though, just to make sure that I don't wait too long.

Steve,
How often do you anticipate getting x rays to make sure you fall within the window of being a BHR candidate?
Did Dr Su say how long to wait for another set of x rays?
Just curious since it's difficult to predict the progression of joint damage since there are so many variables. Take care!

Hi 88,

That's a good question, one I did not pose to Dr. Su when I saw him.  I've seen recommendations, also by patients (not MDs) that an annual x-ray might not be a bad idea if you're waiting and considering.  That seems sensible but I think it also matters how far along you are.  I don't feel all that different than I did 9 months ago. I get around fine (except running) and still have relatively good range of motion.  I'd be surprised if an x-ray showed any major change.

But if I already had evidence that I was bone on bone and had major symptomatic limitations, I'd be inclined to be really on top of it so as to not miss the window of opportunity.

Steve

That is a good question.  I was told by Boyd in Salem, OR that you should probably be getting an x-ray every 6  to 12 months so you can see if any serious damage is happening that might limit you from a future HR.  I think the degeneration rate really depends on the individual. 

Also, the term FAI seemed to get me in some trouble.  I fussed about with studying FAI and looking for a solution with arthroscopy and it took a visit with an arthroscopic surgeon specializing in FAI to tell me I was too far gone for arthroscopic cleanup of the hip.  Shaving away the acetabular rim would de-stabilize the joint, due to the loss of spacing between femoral head and ace.  Then the large cam-osteophyte would simply grow back if it were shaved off the femoral neck.  He did however suggest HR.  It seems that arthro techniques may gain you a few years before needing a HR or THR, as long as the hip is not too degenerated.  As Danny points out, and I've heard this elsewhere, that you may still be on the road for HR or THR, it's just delayed, which isn't necessarilly a bad thing.  FAI and arthroscopic surgery of the hip is a bit a newer area and it tends to be weighted in the athletic world, and so I would like to think that arthroscopic surgeons will be better suited to suggest HR, unlike the average THR surgeon. 

Also, FAI is simply early-stage osteoarthritis and once I realized I had full-on osteoarthritis I spent my energy researching HR.

BTW - I'd send images to more that just one doc.  I agree with all the names folks have suggested here.  It's always good to gain confidence from more than one set of eyes.   

Just a further comment on FAI - my research on this comes up slightly different than Tin Soldier's in that I found that there are cases of FAI that are not considered early arthritis.  FAI simply refers to the poor geometry of the joint such that the cup bangs into some portion of the femoral head often tearing the labrum.  Surgeons performing FAI procedures prefer to catch patients before there has been arthritic degeneration. (The question of whether that degeneration is inevitable remains controversial. IIRC there seemed to be some sense that early repair might prevent degeneration of the joint.  But given that the diagnosis and the procedure is quite new there is yet no longitudinal data to address that issue.)

I was offered the option of a microfracture procedure with the FAI surgery.  This, I was told, would give me a year or two of relief but not much more.  The convalescent period after microfracture sounds like a giant pain and the cartilage that results lacks the resiliency of the original thing. Microfracture, I have since learned, is well established for knees, but not so much for hips and I came to distrust the surgeon who suggested this.

The guy to speak to about FAI at HSS is Dr. Bryan Kelly.  But he declined to perform the procedure on me because of the clear presence of arthritic degeneration (though somewhat early) on MRI.  As that sounds like the case with you as well, I suspect you would hear the same thing.

Thanks Steve, that's an interesting perspective.  I have not been looking at FAI in over a year.  That's a positive note about not necessarilly being stuck on the OA road.  I think some folks would be pretty interested in that.

BTW - I'm not a surgeon and I get pretty ramped up on some of these issues, so take what I say with a grain of salt.

Hi tin & Steve,
                     I too agree with Steve I have been told that I have FAI in my right hip but there's no sign of OA in the joint and there's plenty of healthy joint space there. This will probably be another fight to get put right for me!

I had my MRI report and x ray e mailed to two of the recommended US surgeons and the consensus was that I am a bit early in the arthritic process but will definitely be a BHR candidate in the near future unless the symptoms worsened. My x rays were from 4 weeks ago. Both would consider doing the procedure now but seemed to prefer to wait until there are more degenerative changes vissible on the x ray. The MRI report shows more chondral damage and the labral tears.
I do have an appt with Dr.Su but wonder if the x ray will show much OA change in 3 months time. I have been contemplating delaying the appt for at least 3 additional months. Dr Su was one of the docs who commented on my x ray, MRI report and history.
I guess my current game plan is to have the next set of x rays at Dr. Su's office which will be 6 months after the initial x ray. I am trying some manual PT and see an HSS physiatrist in the mean time.

I haven't tried to exercise at all and may just slowly use the elliptical and see how things go. I dont have time or access to a pool on a regular basis.

Hi Gib,

Your situation sounds structurally, remarkably like mine though it also sounds like you're having more pain in activity than I currently am.  So it's worth noting that Dr. Su told me that, though I could certainly wait, if I was feeling too limited he would do the surgery.  Certainly high performance athletes have tended to pull the trigger sooner than others as even early degenerative changes have profound effects on their lives.  If, as you seem to be implying, using the elliptical - one of the less punishing machines - is difficult, then perhaps you're already at a point where your hip is saying "okay, now" regardless of what's appearing on x-ray.  Btw, (and again, pass the grains of salt please) I've heard that x-rays can sometimes be misleading and that the doc sometimes finds more damage in the joint than was revealed on film.    It does sound like a HR is in your future, just when is the question being debated.  The issue, I suppose, ultimately comes down to quality of life and the anticipated demands of have the surgery and recovering. Which brings us back to Dr. Su again. I hope he can shed light on your situation. 

Steve

I wanted to reinforce Steve's comment on X-rays not always telling the whole story. When I first went to see Dr. Gross, I had been limping badly for years and was in constant pain. He said that my x-rays did not look great, but not that bad either. He was kind enough to spend half an hour with me discussing whether he might be able to send me to some other surgeons for arthroscopy. He finally said that he really wanted to see a CT scan to be sure. I drove to the imaging center, brought him the CT scan two hours later, and we looked at it together. It was clear to both of us that this hip was really shot in ways that the x-rays did not clearly show. When he did the resurfacing, the damage was much worse than the x-rays showed, including a cyst.
I had a similar experience 25 years ago when no one could diagnose my back pain from x-rays. When I finally had an MRI, even I could clearly see where the disc had herniated and the nerve was being crushed.
X-rays are simple and inexpensive, but they do not always tell some of the important parts of the story.

Hi
Since this is a relatively new condition for me, I plan to go through some PT and physiatry treatment for several months.
I am trying manual therapy which seems to help a fair amount but to be honest, have not been active much lately
I will see how things progress (or not).  I plan to keep the appt with Dr Su for September unless I decide that I can live with the symptoms for awhile.
I have decided to attempt the elliptical with minimal effort and see if there is pain
An x ray in 6 months may demonstrate more changes than the one taken last month. I will not wait more than 6-9 months to have a repeat x ray.
That may be the motivation to plan for the surgery for late 2012.

Oh well.
Enjoy your weekend!

I'll third the xray thing! When I looked at mine with my arthroscopy surgeon he said it's not that bad and he was very confident that he would be able to fix me but said after the op that my joint was very warn. So they only tell part of the story!

With my X-rays, the spacing was so far gone that it was obvious to arthroscopic surgeons and HR surgeons that HR was probably the best treatment.  I guess I was lucky that the x-rays, pretty much, told the whole story.  I had severe pain in the left hip  (operated in Feb) yet the spacing was more and degeneration was more apparent on the x-ray of the right hip.  Each of the docs that looked at me were rather astonished that the pain was worse in the apparently less degenerated hip.  I think they were missing the fact that I likley had a torn labrum in the left hip.  Never had an MRI so we really never confirmed what that pain was from, but from what I've read, it was likely torn labrum.  My HR surgeon didn't say antyhing about it.

BTW - I never really finished my search for a surgeon that would do arthroscopic cleanup.  MY PT, who actually worked with Marc Phillipon in CO, said that, like most surgeons, they'll be choosy about who they work on.  He thought maybe someone would be willing to do arthroscopic surgery on me, but based on the fact that the surgeon in Portland (Wagner) gave me a pretty convincing argument that the hip would not be stable after arthro work, I figured I'd better stick with HR.

There didn't seem to be any question from my x-rays that the gap was pretty narrow.  There was amazement that I could function as well as I could and wasn't in more pain.

@Tin -  did I know that you saw Wagner in Portland also?  That is the ortho that told me to wait and come see him for a THR.

That's funny about Wagner.  I really liked the guy and I thought for sure he was the one that recommded HR.  Maybe it was my PT that recommended it, geez, maybe I just stumbled on this website without anyone telling me about HR.   How the hell did I get here?  I guess it's been a pretty long run for me on OA and I lose track of some of this stuff.

I had two additional surgeons respond after reviewing my case, mri report and x rays via e mail. These two surgeons (McGinn and Marwin) suggested that I explore arthroscopy and consult with a highly experienced hip surgeon. I spoke to Dr Bryan Kelly's office and they suggested that he review my case to see if I should consult with him. Within 1 day I received a call stating that I am not a candidate for arthroscopy and referred me to a hip surgeon at HSS, Dr. Padgett. I understand that Dr Padgett is not an advocate of resurfacing. I am going to PT and being treated by an HSS physiatrist and all the resurfacing surgeons feel that I should try and hold off a bit before surgery.
Is there any purpose in seeing Dr Padgett? He will probably tell me that the next step is a short stem THR.
Thanks!

Are you seeing Dr. Moley?  He is good and is in the same office as Dr. Su.
David

No I am not.
My physiatrist is going to give me some PT and an injection under flouroscopy since my lower back also hurts. I do not have the classic anterior groin pain since my pain appears deep within the hip, the piriformis and sacroiliac region. This injection is to rule out lower back involvement.
Might as well get a definitive diagnosis and do some PT until I see Dr Su in 2 months.

Most of us have received similar terrible advice. These are the issues as I see them:

The reason for asking you to wait for resurfacing is that the blood supply in the severely arthritic joint becomes intra-osseous. This consideration does not apply to THR, but why would you want one of those?


"I am sceptical to do resurfacing in a joint which does not show these changes because the blood supply is outside bone which could be damaged during the resurfacing and the increased blood supply situation has not yet occurred. There could also be a phase in early arthritis where the blood supply could be less to trigger these changes which eventually becomes favourable for resurfacing.
The other reason is that of course when the joint space is still maintained one has to think whether other the pain is originating from somewhere else and not the hip per se." - Vijay Bose.

They ask you to wait before having a THR because they don't last very long.

If you have lost mobility and your quality of life is diminished you have a problem that demands a solution. Cortisone injections may provide relief but will accelerate degeneration to some extent, they are not without side effects, similarly NSAIDS (strong ones that work) reduce bone density and attack the digestive system. These options will compromise your health long-term, as will inactivity.

If you are really at an early stage of OA, arthroscopy to relieve the cam impingement and repair the labrum may give you a few more useful years; you could then get resurfaced. It didn’t work for me because I had no cartilage left; I was resurfaced the following year.

In short, you need more information; I would suggest sending your x rays in jpeg format to Bose or De Smet.

Gary,
Thanks for the solid advice.
My x rays have been evaluated by Dr Su, Rogerson, McGinn and Marwin.
All thought that I would eventually be a BHR candidate. The latter two advised me to  explore the possibility of arthroscopy. Dr Bryan Kelly told me that I am not an arthroscopy candidate..
It appears that the options are running out and I will do my therapy and see Dr Su or Marwin in the fall. If the symptoms worsen, then I assume the x rays will show more advanced OA

I should mention that not all practitioners believe in arthroscopy, in fact not all believe in F.A.I. It's a new treatment for a new diagnosis. The fact is, once your O.A. is categorised as 'moderate', you wear the joint out pretty quickly if you are active, and that takes the guesswork out of it. The main thing is to find a resurfacing surgeon with plenty of experience and one who is an enthusiastic advocate for the procedure. They really do want you to succeed!

Good luck G.

Gary - great stuff, I think I took the guesswork out by playing soccer and having no clue that I had FAI or early signs of it.  You'd think the fact that I had trouble clipping my toenails at least 5 years ago would sort of suggest something to me.  I think the increased pain and stiffnees I would get from playing soccer twice a week could possibly be drectly proportional to the amount of damage I was doing to my hips.  Pain for 1 week = 1 more mm of spacing.  I'm being extreme here, but I think there is some truth to it.

For me, FAI was an interesting topic that provided me a little hope that maybe I wouldn't need a full-on prosthesis.  It was fun while it lasted and then I came here.  The ironic thing is that the cranky old surgeon that told me I have bi-lateral OA at the very beginning, was right.  He justed neglected to give me more info on FAI, OA progression, HR, or even THR. 

Yes, great info.
Does anyone know how to contact Dr. Smet? Perhaps he can review at my x rays and MRI report and give me an opinion.
He sounds like one of the most experienced surgeons in the world and has more flexibility of devices than most of the US surgeons due to FDA approval process. Thanks!

If you google dr de Smet it will bring up his clinic, also why don't you google dr Bose in India I contacted them both and they were very helpful especially dr Bose.

Thanks for the info. All the surgeons advised me to wait for HR due to early arthritis. I guess Gary's info regarding the vascular supply helps explain why it's premature to have an HR until there are greater arthritic changes.
Several of the top surgeons on this site advised exploring arthroscopy for the CAM FAI but Dr Bryan Kelley at HSS says I am not a candidate. Other than PT and physiatry visits, do I have any options or do I need to live with the discomfort and adjust my lifestyle until the arthritis progresses to the point where I am an HR candidate? The various NSAID pain meds don't help at all. Thanks again!