Question
I apologize in advance for the length of this inquiry, but I feel a full background is in order for you to fully understand my situation.

I was diagnosed with ulcerative colitis in the mid 1990s.  It continued to worsen over the following years in spite of large, continuing doses of prednisone and multiple hospitalizations in which I received daily injections of salu-cortef  In 1991 the UC was declared non-responsive and in October of that year I received a colonectomy.  Over the next 8 months I had a proctectomy and ileostomy closure.  I was told that with an immune system so non-responsive to steroid therapy, along with the fact that I suffer from eczema, that I needed to be on the watch for Ryder's Syndrome and was referred to a rheumatologist to monitor my joints.

In September 2002 I began experiencing severe bi-lateral hip pain and was diagnosed with avascular necrosis resulting from the extended steroid therapy.  I saw an orthopedist that performed bilateral core decompression but these were failures and bi-lateral hip replacement became my only option.

Due to the fear that my immune system would reject most prosthetics I was recommended porous ceramic prosthetics.  There was one orthopedic surgeon in my area who had performed this kind of replacement.  He specialized in sports injuries and had done less than 5 of this particular procedure.  He assured me that the ones he had performed had a "100% success rate".

I had my left hip replaced.  In the fourth week of physical therapy I began experiencing agonizing pain in the hip - as bad as the AN.  A CT scan showed that the prosthetic had been improperly placed and needed to be re-done.  In spite of this he proceeded with the right hip first, which seemed to work out fine.  He then repeated the procedure on the left, which seemed to work out fine as well.

A year out from the final surgery I was still experiencing chronic pain in both hips - nothing like before, but enough to be distracting and, as it worsened throughout the day, exhausting.  The surgeon said that I was "imagining things" and referred to the symptom as "phantom pain".  He did order an x-ray which he said showed no problems at all.

The rheumatologist was more sympathetic and, while he could do nothing directly, supplied me with pain medication in order that I might lead a semi normal life.

Finally tiring of years of this, I sought out another orthopedic surgeon - a hip specialist considered to be at the top of his field who had, fortuitously, recently set up practice in my home town.  He took the problem very seriously and ordered a CT scan.  This revealed that the right socket prosthetic was improperly aligned raising concerns over impaction and striping.  He did an arthroscopy which discovered considerable scar tissue accumulated around the ball and socket area of the prosthetic which he removed.  He also took muscle tissue samples to test for infection.

Before I proceed, I feel it necessary to mention that in the midst of all this I was diagnosed with PTSD and severe chronic depression.

The surgeon, after expressing continued concern, although not urgent, on the impaction issue brought out the big guns.  One of the tissue samples from very near the prosthetic had tested positive for staph in one out of four cultures.  He said it was very possibly a contaminated sample, but due to the area from which the sample was taken it needed to be monitored very closely.  If the pain has not fully resolved by April 24th (the arthroscopy was Feb. 18th) then he wanted to do a much more intrusive surgery in which he aligns the prosthetic correctly and does  extensive testing for staph.  If positive for staph, the procedure he quickly outlined is as follows -

Removal of the prosthetic and replacement with a temporary plastic prosthetic for six weeks while they treat the infection, followed by another replacement with a permanent prosthetic.

The very thought of this, after all I have endured, makes me nauseous.  It has thrown my psychological state into such disarray that the quality of my work is considerably suffering and my wife and friends will barely speak to me.  Were the pain resolving I wouldn't be falling apart, but the fact of the matter is that the spot from which the pain has continually radiated, while somewhat reduced, is still there and shows no indication of going anywhere.  I am performing PT exercises daily to no noticeable effect.

Finally, to my question.  Or questions.  Beyond the outline of the staph treatment procedure the surgeon laid out, what does this treatment involve?  Is the incision left open during the six weeks spent with the temporary prosthetic?  What is done to prevent muscle atrophy during this period?  Are the risks of blood clots significantly increased with a procedure of this scope?  Will my immune system attempt to reject the plastic temporary?  What is a realistic recovery time when all is said and done?

I apologize again for the length and detail of this email.  I am, I feel reasonably, very concerned and feel that knowing as much as possible about what may likely occur will help me mentally prepare for the ordeal.

Thank you for your time.

Answer
Brit,
My AVN was also a result of extended prednisone usage and the first thing I would like you to do is to see if your rheumatologist suggests that you go on a medication like Fosamax which will build bone mass.  My concern though is that your stomach problems may prevent you from taking this medication or similar medications.  Prednisone, even if you are off of it, can continue to do damage to your bones   the other thing you should ask for is a blood test to determine your Vitamin D levels.  See if they are low, you may need to go on a supplement that is not over the counter, but prescribed.  

Secondly, my heart truly breaks for you due to all you have been through.  It is must have been a painfully slow road for you and you have done wonderfully to come this far.  The first surgeries are in the past so regardless of whether or not the doctor was competent or not, is a moot point now, but frankly, if this surgeon had not done THR攕 on patients with additional problems such as yours, in my opinion, he should have referred you out to someone who had done more than five THR抯, but that again, at this point is moot.

Whenever a surgeon says that a patient is 搃magining things?is a red flag in my head.  No surgeon should ever say that to a patient who has had multiple hip replacements.  The reason being that each time you revise a hip, there is less bone to use and the recovery is harder and more involved.  I have had four revisions on each side so I know that your pain is probably very real and that you have a right to someone taking your pain issues seriously.  X-rays do not always show problems and the doctor should have gone further and done an arthroscopy.  (Now I am not a diagnostician, but that test would have shown more of a detailed result than an x ray).

I am glad that your rheumatologist supplied you with pain relief.  But that really only masked what was going on.  I do think you need to investigate this further.

Your PSTD and chronic depression, I believe has been a result of all you are going through, your pain issues, your loss of independence and the fact that your first doctor did not diagnose you properly and you were in pain with no relief until your second surgeon did the CAT scan and arthroscopy.  

I am not surprised at all that you suffered from PSTD and depression.  Many, many THR patients including myself suffer from emotional problems from the effects of pain and multiple surgeries.  I will address that at the end of my answer to you.

I cannot answer what the outcome will be with muscle atrophy, no one really can promise you anything at this point.  Your surgeon can only give you his best guess.  Here is my advice:

1.   Get yourself to a good mental health therapist immediately.  When I have surgery, I ALWAYS go and get on an anti depressant.  I experience panic attacks, depression and PSTD when I need my revisions.  I get on an anti depressant as a matter of course, until my independence is restored and then I wean off the anti depressant.  This is NOT, and I repeat, this is NOT a sign of weakness.  You must take care of your mind as well as your body and you must find someone who you can talk to.  You cannot keep all you are feeling to yourself.  I continue to go for therapy even now, years after the fact.  
2.   You need to clear up whatever is going on with your hip.  If you have an infection, you must deal with it.  I have never had an infection, so I cannot really address the recovery, but I did know someone who did have an infection and they did put in 搕emporary?prostheses until the infection cleared and he was fine.  But you must take care of that infection.
3.   I would suggest looking into these following places for other opinions before you put yourself into the care of another doctor.  I am NOT saying that your current orthopod is unqualified.  Just the opposite, it sounds to me as if he knows exactly what he is doing.  But you should look into another opinion.  Check out the Hospital of Special Surgery in NYC or the Hospital of Bone and Joint Diseases.  The doctor you are looking for in NYC is Dr. Douglas Padgett.  I am not sure which hospital he is involved with, but it抯 one or the other of those NYC hospitals.
4.   Check out INOVA clinic in Arlington Virginia at Mount Vernon hospital and Dr. Charlie Engh.  I was sent there and they are the best in the country.  Their group is abele to construct THR prostheses on an individual basis.
5.   Or check out Dr. Thomas Einhorn who works out of a hospital in Boston Hospital.
6.   The last person you might want to look at is Dr. James Dowd, he is my doctor who started out in Arlington Virginia and has moved to Norfolk VA.  He is with the Jordan Young Institute and he is phenomenal.
I hope this answers your question and if not, or you have additional comments, please contact me again.
From the bottom of my heart, I wish you the best.
Sharon..