SuperPath total hip replacement- continued pain

Hi Richard,

Thank you for the reply.  I am in the States.  My surgeon was specifically trained to perform the Super Path and I have full confidence in him.  He has performed all 4 arthroscopes on both hips prior to the THR on the right hip.  Honestly, at this point it's the technique itself that I question, as I believe several of us here on this page do.  He has even suggested at this late date that I may want to seek a second opinion.  He said that he would even be interested in knowing what another surgeon's opinion is. He is one of those surgeons that you don't find often. He truly cares, and is concerned as to why I cannot completely be without pain and why i have restricted, Painful movement within the joint 18 mos. post-op.  He is baffled.  He said that he has only seen one other patient with similarities, and he did not do her replacement.  Between July-December 2017, I saw a Pain Management Dr. for nerve blocks, because I was diagnosed with RSD - (Reflex Sympathetic Dystrophy).  Basically, this is nerve damage from trauma. The trauma can be anything from a bruise, to a major surgery.  It is irreversible.  The affected nerve(s) is constantly "turned on" as if consistently trying to fight inflammation.  It's as if surgery just occurred, and your nerves are inflamed, but in this case - the nerves never "turn off".  If that makes any sense.  The nerve blocks only help for a couple of weeks and have never gotten rid of ALL the pain.  I don't have them any longer, because the large amounts of steroids in the body for extended periods of time is not good!  

So this is how my situation with the THR is that I had done.  I never know from one day to the next what the day will be like, pain-wise.  Going from an avid exerciser, to not being able to walk a long distance without a cane is very life-changing.  Still however, I am VERY blessed and thank God everyday for all of my blessings!  Just am continuing to pray that something will be found that can help.  Praying as well, that the left hip (which has anchors in it for now), holds up for a few more years.  The last surgery on that hip was 3 years ago.  Needless to say, I am NOT ready for a THR in that one too.  I have enough on my plate right now as it already is.  

Dear Deana

Thank you for such a full account of your situation which I'm sure many following this thread will find very interesting as I did.

It is so sad that what should have been a relatively routine surgery has not had the outcome that you had every right to expect.

As some here will be aware I have a high degree of scepticism for new medical procedures where it is promoted in a commercial setting, I'm reminded of something that used to be often said in years gone past but still worth remembering. "The adverts speak well of it."

Whenever I read descriptions of new advanced cutting edge procedures where the promotional emphasis seems to be geared to unnerve, or unsettle people or to gloss over aspects of the surgery or create unrealistic expectations I think. RUN! Where a very experienced surgeon or surgeon decides to stop using a particular"new" method and goes back to a well tried and tested method for what to me sound like very logical reasons that are actually less cost advantageos to the hospital I take notice.

Cheers Richard

Richard,

As one of the most experienced members on the forum with a long history in joint replacement your opinion hold a certain extra weight and I agree skepticism is a healthy perspective of evaluation however I would take exception in some degree to your specific objection to the Super Path surgical approach for the following reasons: Firstly, I have noticed repeatedly many if not most of the forum contributors are hazy at best regarding which specific surgical approach they have undergone.   Several discussions on the subject indicate a confusion or misunderstanding of what and how their surgery was done, often with mixed up nomenclature and terms.  Even certain people who have had the Super Path approach in Arizona, USA where there is  a clinic that pioneered and specializes in this technique and have an exceptional record of success misunderstand the procedure, insisting that no muscles or tendons are cut.  While that is generally true and one of the perceived benefits of the procedure it is not universally true or correct.  From personal consultation with a surgeon who has over 200 operations with the technique I learned that in some cases, mine unfortunately, the periformis muscle would need to be be released because it is so tight it would restrict prosthesis placement and would be reattached in closing.  This reduced the attraction for the procedure, for me.  If someone is going to take a scalpel to open my body in an elective surgery, I'm going to know quire a bit about what parts of my anatomy are undergoing dissection and as much about the approach as I can learn, from the horses mouth as it were.  I've found that is not a universally shared attitude and many people are satisfied with hearsay and unsubstantiated internet assertions.  I consider it their loss just as it it their obligation to be informed in the "therapeutic alliance" between doctor and patient.

One of the primary benefits of the Super Path surgical approach is that it has overcome the need to manually dislocate the femur from the hip either with or without a Hanna table.  One of the not uncommon effects of THR surgery in general is that leg dislocation results in additional trauma during this part of the procedure; the leg muscles, tendons, ligaments and especially the major nerves are stretched and twisted in unnatural positions and extremes.  This often causes major trauma that often results in post operative complications, many of which are documented here and result in long term difficulties for the patients.  The Super Path technique overcomes this in a clever, albeit technologically challenging manner.  The head of the femur is left in the hip cup when it it dissected from the femur.  A screw is then inserted into the head of the femur and used to leverage the head of the femur from the hip separately without stretching the entire leg thereby bypassing the trauma caused by the extreme stretching of the related tissues.  There is an excellent animated video of the procedure that is easily located on You Tube that explains the surgery.  There is also substantial information to be found regarding the Headly Institute in Arizona a primary pioneer of the procedure.  It's worth a looksee if only for the edification.

Access to the hip, or restricted view/approach to the hip joint is much less a concern in the Super Path surgery than in the Anterior.  The Super Path incision is much more in line with the Direct Superior approach which closely follows the traditional posterior approach but tends to be smaller and separates muscle to access the hip capsule rather than cutting through them.

One of the gentlemen who reported on complications from the Super Path he underwent mentioned his surgeon had performed this surgery "several times".  That would be a red flag for me.  "Several" surgeries, as I think we'd both agree is simply an insufficient number for me to bet on.  Possibly, if the surgeon could demonstrate absolute success rates, with no post surgical complications and complete post surgical return to function with such small numbers I would consider it, but I'd want to see those number unequivocally demonstrated.  Perhaps the lesson to be learned, or relearned, is above all else it is the skill of the surgeon that matters, and if undertaking an approach that is new to them, the training and skill development must be scrutinized more than expected.  That scrutiny is a part of the patients obligation in the therapeutic alliance: being an informed and actively participating patient, ready to do their full share including all the pre operational preparations and post surgical self care.

I can not agree with you more that "marketing" is in general a scourge on society.  Even more so when applied to medicine and surgery where peoples fears are preyed on.  There is a surgeon in Tennessee who's website's advertising implies a danger of considering surgical techniques that are more invasive than the Super Path technique he "sells".  The lack of syntax and the spelling mistakes alone would alert me to seriously question their competence.  Just out of curiosity I attended a seminar on Tues. for a network of medical providers promoting stem cell research and therapy as an alternative to joint replacement surgery.  Needless to say the gentleman leading the presentation, who identified himself as a doctor but truthfully had more the appearance of a glib and very well dressed entertainer employed all the subtle, coded, suggestive and subliminally undermining terminology of a well versed "Ad Man" straight from Madison Avenue.  

What it boils down to for me is that this is supposed to be science.  Science is meant to be quantitative and forward moving but especially demonstrable and affirmative.  I think it's just best not to throw the baby out with the bath water.  One needs to be open minded and clear eyed which means taking off any rosy colored glasses and if necessary refusing to accompany anyone down any primrose paths.

As always,

Jim

Hi Jim, did you read my post? Just wondering why I would have swelling PO on both thigh/hip areas. Is it possible that the muscles/nerves are damaged?

Dear Jim.

As always a very interesting read from you, and I'm in agreement with much that you have written. However I was commenting in general rather than specific terms and at no time referred to a particular technique.

Cheers, Richard

Rosemary,

I have no medical training or standing to make any recommendation of diagnosis nor would I ask that of any unknown personage posting on an internet forum.  You should be discussing this with your doctor.

Best,

Jim

I understand Jim. I will be seeing my surgeon in a week. I'm new to this site.

Rosemary

The cutting of the piriformis muscle (1 of 4 muscles that allow for external rotation of the hip) is often required for both Superpath and anterior approach, it is cut to allow implantation of the new femoral implant. It cannot be reattached. In the case of posterior approach the piriformis and superior gemeli muscles (2 of 4 external rotators of the hip) are detached and later reattached to bone and will heal over 4–6 weeks.

ptolemy,

I'm not sure where you received this information regarding the cutting and non-reattachment of the piriformis muscle during the Super Path surgery.  I specifically discussed this issue with the surgeon I consulted who performs this surgery and he told me while the pirifomis is generally not released during the SP surgery and instead is spread with special retractors, in my case because of its shortened condition it would need to be released [cut], however it would be reattached after prosthesis placement and would in fact be done so in a manner that would allow more length and mobility.  Please let me know the source of your assertion regarding non reattachment.  Best.

Jim

From my orthopaedic surgeon who has now reverted back to the posterior approach. He does around 154 hips a year and has been doing it for around 15 years. He is also none too sure about ceramic hips as he thinks there is a suspicion that debris may be caused.

Hmm, I think quite a few of us have ceramic hips...

Hmm, I think quite a few of us have ceramic hips...

Hmm, I think quite a few of us have ceramic hips...

Sorry didn’t mean to post that 3 times!

Hi Judith, 

He may be wrong of course! 

I am not actually sure what difference debris makes, he just mentioned that about ceramic hips. I have just looked on the internet and it does seem it is a possibility. I assume they are improving them now though, as I believe early ceramic hips also did very occasionally fracture and I am sure that has been improved.

Hi Judith,

He may be wrong of course! 

Wear debris from artificial joints if more than your body can deal with can cause osteolysis. This is the reason for the failure of many joint replacements and is the reason that I had to have my five year old total ankle replacement revised a few weeks ago in an operation lasting six hours.

This was carried out by a very experienced ankle revision surgeon here in the UK. The recovery will be very long and it will be another couple of months before I have any idea how successful the surgery has been.

Cheers Richard

Hi Richard, I do hope it all works out for you. It is interesting that you had problems with debris, I know that this was a problem with the metal on metal hips as a friend had one a while back and they are looking at redoing it.

Dear Ptolemy

Thanks for your good wishes. The main wearing component is the poly cup or in the case with ankle joints the poly spacer. This component is the main cause of debris but any wear debris is potentially bad news.

What seems to happen is that this microscopically small debris triggers the development of bone cysts which slowly degrade the bone like Aero chocolate if you are young enough to remember. Eventually there is a failure of the prosthesis as the bone supporting it has collapsed.

We should all be aware of this and specifically ask our surgeon's to check when annual or whatever X rays are made because the cysts can be cleaned out and filled.

Cheers Richard

ptolemy,

Tried to reply before but it isn't showing.  Quite confused by this assertion.  The periformis muscle is an essential core/external rotator muscle needed for ambulation and function.  Not reattaching it and returning it to functional would leave a patient more or less unable to walk.  This doesn't make sense.  Best.

Jim

Hi jimbone, the only person I know who had the piriformis muscle cut was someone needing to relieve sciatica. He was able to walk afterwards.

ptolemy,

There is a condition known as Periformis Syndrome.  The sciatic nerve usually follows a line along the periformis muscle, in some cases it will pass through the muscle and when the muscle spasms the nerve is pinched with ensuing pain.  There is a surgical procedure to address that, possibly it is what your friend had done.  In THR when they speak of cutting or releasing the muscles they are generally [in the case of the periformis muscle] talking about cutting the muscle attachment to the bone via tendons.  The repair is to reattach the muscle at the cut tendon so it can heal and return to function.  The difference being a muscle can be either cut into or cut off at its attachment sort of like the difference between a laceration and an amputation.  A laceration can be stitched up but an amputation needs to be reattached.

I know about Periformis Syndrome and it was not that. It was for sciatica. I have several friends who are orthopaedic surgeons so I will ask them.

ptolemy,

I would be very interested in learning what you find out.  If possible please convey what they tell you about this.  Thanks,

Jim

Absolutely Jim.

I would love for you and Jim to read my issue as you both seem so informative!

Would love for you to look at my post as it looks like you are very informative. Thanks.

Changed to Rosemary1950 from rtb. Hope you can find my post.

I am always interested in different methods. I think things are slowly improving over time, but I think some surgeons may be a bit macho. 

Hi Jim,

Thank you so much for your reply/insight.  I just replied to Richard as well, and most of what I wanted to reply is in that post too.   I DO agree, that the system in place is for the MEDICAL INDUSTRY!    The prosthetic companies are making a killing!   Sadly, at our expense.   I'm not afraid to hold anyone accountable - as I am the one who has to live daily with this for sure!   My surgeon is a good surgeon who truly does care.  He WANTS to make it better for me and he can't right now.  :-(     And that bothers him.   I went to another surgeon in the beginning and they didn't "see" anything different, or that could be wrong either, much to my dismay.   Now my surgeon himself says that he WANTS me to get another opinion - just in case someone else may see something that he may have possibly missed, because he really wants me to be able to live a full and healthy, active life.  I mean after all, that's why we did the THR in the first place!

Thanks again for your reply.

Deana