Jared, 23 year old with AVN

MUST read for AVN cases, do not get resurfaced before it is time. AVN is very unique, read this story below.

From: JK
Sent: Friday, October 17, 2008 7:23 AM
To: Dr. Bose
Subject: ** 23 YEAR OLD WITH AVN -- PLEASE HELP **
Dr. Bose,

I truly appreciate your taking the time to read this email. I got your name from Vicky, one of your patients. She is a big advocate of hip resurfacing who is well known for her contributions to surface hippy and other procedures. I have been in touch with her the last few weeks and she put me in contact with you. Both she and I agree that your opinion regarding my case will be the deciding factor for which surgery I choose. Let me give you a brief background of myself.
I am a 23 medical device representative for “Device Manufacturer” living in “X City”. I have been an avid athlete for the last 15 years, playing all different kinds of sports. My main passion, and the focus of most of my efforts, was Ice Hockey. As soon as high school rolled around, I dedicated my life to that sport. I played for a Prep School and College Division II Ice Hockey. Unfortunately with my stature (5'7 155lbs) as an influence, I made the decision to take performance enhancing steroids my senior year of high school as well as throughout the end of my junior year of college. The steroids mostly consisted of deca-durabolin, testosterone, and dianobol. I was on 10 week cycles and then off for 10 to 12 weeks. The only injuries I sustained were a few concussions, a separated shoulder, a broken wrist, broken fingers, a fractured ankle, and bumps and bruises on various parts of my body. Furthermore it was during my senior year of high school that a drunk driver crashed into me, causing me to go through the front windshield of the car. As a result I had to have reconstructive plastic surgery on the entire left side of my face. Since my sinus walls had to be rebuilt I was very susceptible to infections, and therefore was placed on prednisone for one week every month for a few years. As research indicates, that type of steroid may be potential cause of AVN.
Furthermore, this past February I fell down 5 or 6 stairs when I slipped on snow and ice and further injured my hip and leg. I initially went to the E.R. and later to orthopedists. However, their diagnosis was that I most likely had a contusion and I was told not to worry about it. Lastly, I was then involved in a motorcycle accident after another bike crashed into mine. I went flying over the handle bars and skidded about 30-40 feet. There were no apparent injuries due to the fall. CT scans and X-rays were taken from my waste up and nothing came up positive. This trauma combined with the fall down the stairs may have also been an instigator of the AVN.

My pain only increased weeks after the motorcycle accident so I began attending physical therapy. After a few weeks there was no success and I was referred to an Orthopedic Surgeon. He saw the AVN and wanted to take extremely conservative measures to treat my case. I went ahead with his recommendation that I receive a core decompression surgery on June 6th of this year. I did so knowing that if that did not work I would most likely follow up with a vascularized fibular graft, and then resurfacing or THR if necessary. Six weeks after the surgery my leg was still experiencing a tremendous amount of pain in my leg. Thankfully I just took a job in the medical device industry and my bosses were kind enough to help me get appointments with all the best surgeons in X City area.

This is where I really need your advice. Dr. X and his P.A. both feel that my AVN is too far along to not get a resurfacing operation. I have developed a good relationship with them as both a patient and with them as my client, and completely respect and honor their judgment. I am also well aware that Dr. X is considered one the best hip resurfacing surgeons in the country, second to only you. My predicament lies with the following: I have seen seven other highly credentialed hip surgeons and each of them believed my AVN wasn't bad enough to automatically jump to a resurfacing procedure. They suggested that because of my age I should do everything necessary to prevent getting the resurfacing procedure. They feel I should only opt for the resurfacing as a last resort. Naturally they all wanted me to get a vascularized fibular graft first. I agree with their opinion that it is not the best idea to get the resurfacing at my age due since it will only lead to a ticking clock of a THR in 10-15 years. At that rate I will most likely need a THR at 35-40 followed by another one at 55-60 due to my high level of activity.

My dilemma is this: I have one of the best doctors in our country telling me that resurfacing is the only option, and I have a number of other doctors, also incredible and esteemed surgeons, saying my condition isn't that bad yet and I should do a graft first. Some of these doctors who recommended this procedure to me are very close family friends, so their opinions do mean a lot to me. As you can see I am very conflicted about this issue. I am exceptionally thankful to have gotten in touch with Vicky, as she led me to you. As for any piece of literature or doctor would say, you are the world's expert in hip resurfacing and would never do a case where the patient's body does not call for it. Can you please take a look at the following X-ray and MRI pictures I have attached to this email and give me your opinion on what you think I should do. I feel that your decision will give me the closure I need before I can decide which surgery to undergo.

Thank you for your time, I cannot begin to tell you how appreciative I am of your advice!

Thank You,
JK

From: Dr. Bose
Date: Sat, 18 Oct 2008 08:14:15 +0530
To: JK
Subject: Re: ** 23 YEAR OLD WITH AVN -- PLEASE HELP **

Dear Mr. K,

Thanks for the mail. I have read your history and reviewed the images. I think the decision making in your case is not all that complex.
Your x-rays do not show jnt space narrowing and sec. osteoarthrits. Doing a resurfacing at this stg would have a high rate of failure. I certainly will not recommend it. This is the commonest reason for me seeing failures in hip resurfacing done in other centres and referred to me for revision.

You may be suitable for resurfacing in future when sec. changes set in. Even in that stg if someone is doing a BHR - a very critical assessment of the residual bone must be made and he must have the BMHR (Birmingham Mid -head resection) as a back up. I do not agree with the view that a BHR / BMHR will last only 15 yrs. My guess is that it will last many times that. (based on the metal on metal historical devices from Birmingham. I have done BHR for 350 cases of AVN now and I am confident that it must not be done in your stg at this point in time.

So the decision basically boils down to whether a vascuarised fibula will be indicated. You have to make this choice based on the present level of symptoms. I personally think the chance of it being successful after a failed core decompression is less than 50 %. It is still worthwhile to take it as there is no other intervention for you in the present point in time. For patients who do not opt for a graft, I put them on alendronate, vit D calcium combined with a daily routine of swimming and pool exercises with ankle weights. You can choose either option based on your personal outlook and circumstances.

I hope that this has been useful. If you have any queries, please do not hesitate to write to me. I wish you the very best in the successful management of this hip problem. Please say hi to Vicky when you contact her the next time.

With best regards,
Vijay Bose
Chennai

From: JK
Sent: Monday, October 20, 2008 12:14 AM
To: Dr. Bose
Subject: Re: ** 23 YEAR OLD WITH AVN -- PLEASE HELP **

Dr. Bose,

Thank you so much for your quick response. It seems that my choices now have been limited down to a graft or rehab. Have you noticed a decreased amount of pain and increased activity from your patients that have chosen to take a non surgical route and wait till their avn stage is ready for a resurfacing. If I went forward with skipping the graft surgery and went ahead with physical therapy, do you believe I can return back to minimal impact activities such as bike riding, swimming, or roller blading, non or light weight bearing weight lifting now or would have to weight months still I strengthen the bones and muscles around my hip area to prevent a neck collapse?

Thank you,
JK

From: Dr. Bose
Date: Mon, 20 Oct 2008 07:55:52 +0530
To: JK
Subject: Re: ** 23 YEAR OLD WITH AVN -- PLEASE HELP **

Dear Mr. K,

Thanks. It is impossible to predict the course of AVN in a particular patient. This is the most important aspect of AVN and this makes success rates of any grafting procedure difficult to guage. About 30% will do very well without any surgical intervention whatsoever due to a favourable natural history. Therefore if some sort of grafting procedure is done, one may mistake the good outcome of the natural history as the success of the grafting procedure. The purpose of the grafting procedure is to increase the chance of good outcome from the 30 % to about 50 to 60%.

The problem is that there is no way to find that you lie in this 30% though the size of the lesion has a loose correlation.

The collapse that occurs in AVN is part of the disease process. The only thing to avoid is impact activities like jogging, badminton etc. Other activities does not have influence on the disease process.

You have to make a personal choice regarding the grafting procedure. Either decision would be justified. No one else would be able to make this for you with conviction.

With best regards,
Vijay Bose
Chennai