Broken hip club - need advice
James P. Smith
consensus on what to do after breaking your hip and deciding what to do with
the hardware a year or so down the road. On Feb 17 of this year I went down
on my bike and ended up with a fractured hip, just below the femoral head
(thank goodness). The ortho reamed out the head and put a threaded insert
in the head along with a plate down the femur, which is attached with more
screws/pins.
I've posed the question to my ortho a few times but he's very wishy washy.
He says I don't need to have it out, it's my choice, blah blah blah. On the
one hand I want it out since I've heard from some of you that it's worse to
have it in if you fall again, but on the other hand I don't relish going
under another time.
I was hoping to race starting this year, but the hip ended that quick. Last
week, however, I went to a local crit to see how the local talent was and
there was a huge wreck with one guy going off in an ambulance with a neck
brace on. During the wreck the first thing that popped into my head was that
titanium hardware crushing the bones if I was in the pileup. Does anyone
have concrete data suggesting the rates of reinjury due to falling with the
hardware still in?
Also, the injury put my running on hold. I'm a bit worried about running as
well. Titanium is stiffer than bone and the pins are fairly small in
diameter. The last thing I'd want is some bearing yield about the pins and
having the pins loosen up. Anyone have experience with that?
Thanks, james
kaiser
wait to have those fuckers taken out of my leg....My doc is saying 15
months between the first surgery and the second.
My doc also states that falling on that exact spot again, while
perhaps unlikely to re-break my hip, it would be _very bad_ if I did
fall that hard again. The bottom part of the plate would be the
logical break point, and with that break, you get to have a nifty
metal rod surgically inserted up the middle of your femur.
So you are about 4-5 months out, and not too far out of your initial
recovery period, and physical therapy. Back then, I found it fairly
hard to distinguish between little annoynaces that were muscle
wekaness-related and those that are definitely the hardware. Now I've
gotten about as far as knee bends and leg lifts will get me, and I can
certainly tell which quirks are related to all the metal attached to
my bone. It's pretty easy to figure out now.
"James P. Smith" <tige...@mindspring.com> wrote in message news:<afr1eo$l01$1...@slb0.atl.mindspring.net>...
jobst....@stanfordalumni.org
> I've looked through the archives of the groups and noticed there's
> no real consensus on what to do after breaking your hip and deciding
> what to do with the hardware a year or so down the road. On Feb 17
> of this year I went down on my bike and ended up with a fractured
> hip, just below the femoral head (thank goodness). The ortho reamed
> out the head and put a threaded insert in the head along with a
> plate down the femur, which is attached with more screws/pins.
Sounds familiar. I have the hardware in a drawer at home where it
belongs after performing its service.
> I've posed the question to my ortho a few times but he's very wishy
> washy. He says I don't need to have it out, it's my choice, blah
> blah blah. On the one hand I want it out since I've heard from some
> of you that it's worse to have it in if you fall again, but on the
> other hand I don't relish going under another time.
By all means get another orthopedist! This guy doesn't sound like the
man for the job. When the hardware is removed, the bores fill with
bone and you don't have a protrusion under the skin to worry about. I
had my hardware removed after 18 months. Make sure the doctor has the
special wrench to remove it and knows what the process entails.
> I was hoping to race starting this year, but the hip ended that
> quick. Last week, however, I went to a local crit to see how the
> local talent was and there was a huge wreck with one guy going off
> in an ambulance with a neck brace on. During the wreck the first
> thing that popped into my head was that titanium hardware crushing
> the bones if I was in the pileup. Does anyone have concrete data
> suggesting the rates of reinjury due to falling with the hardware
> still in?
No I don't but I fell on that hip with hardware in place with no
lasting results. That is, I got back on the bicycle and continued to
ride.
> Also, the injury put my running on hold. I'm a bit worried about
> running as well. Titanium is stiffer than bone and the pins are
> fairly small in diameter. The last thing I'd want is some bearing
> yield about the pins and having the pins loosen up. Anyone have
> experience with that?
You don't have to race to enjoy bicycling. The hardware used by
competent orthopedists is well designed and works well. I rode over
many passes in the Alps one year after the fracture with no problems.
Jobst Brandt <jobst....@stanfordalumni.org> Palo Alto CA
bi...@ape.net
: Sounds familiar. I have the hardware in a drawer at home where it
: belongs after performing its service.
: No I don't but I fell on that hip with hardware in place with no
: lasting results. That is, I got back on the bicycle and continued to
: ride.
: You don't have to race to enjoy bicycling. The hardware used by
: competent orthopedists is well designed and works well. I rode over
: many passes in the Alps one year after the fracture with no problems.
Oh you're so manly! You mean you really ride that hard. Ohhhhh wow.
Duncan Bourne
An account of a broken hip from a cyclist's perspetive FWIW, and an
interesting read -
http://www.kenkifer.com/bikepages/health/myfall.htm
Duncan Bourne
Brad Anders
"Duncan Bourne" <d.bo...@cqu.edu.au> wrote in message
news:3D223D66...@cqu.edu.au...
> Are there more trolls on this group lately? It sure seems like it.
Pre-Tour warm-up.
Brad Anders
Jim Quinn
ago. After a couple of months I was back on the bike and a few months after
that I was racing again. I couldn't tell that the hardware was even in
there in most occasions. The only time I felt it was when I tried to jog,
it felt really funny when I did that.
After a year I decided to have it taken out and was dreading the aftermath.
I was expecting something on the order of what I went through with the
initial surgery and was not looking forward to it. To my surprise it was
much much easier. I was using crutches the next day and walking normally
very quickly. I was riding a bicycle again in two weeks (not recomended by
the doctor) and racing again in eight weeks. I would have raced sooner but
the doctor said that if I did and something happened to me that I had better
find another Doctor to go to.
"James P. Smith" <tige...@mindspring.com> wrote in message
news:afr1eo$l01$1...@slb0.atl.mindspring.net...
Max Watt
Who pissed in _your_ beer?
James P. Smith
the thing to do is get it taken out next year. Now the only decision will
be when. I missed all the Spring metrics and centuries this year and don't
want to do the same next year. Plus I'd like to do the MS150 (broke the hip
on a MS 150 training ride). But I also don't want to miss out on the Summer
rides. Maybe I can convince the doc to do it this December. A little
early, but it would be a heck of a Christmas present.
BTW, picked up a Computrainer in April to help rehab the leg. Couldn't walk
but I could certainly ride. If anyone out there is unfortunate and breaks
their hips, I strongly recommend getting one to keep your muscles from going
to waste.
James P. Smith <tige...@mindspring.com> wrote in message
news:afr1eo$l01$1...@slb0.atl.mindspring.net...
Mike Murray
"Sounds familiar. I have the hardware in a drawer at home where it belongs
after performing its service."
"By all means get another orthopedist! This guy doesn't sound like the man
for the job. When the hardware is removed, the bores fill with bone and you
don't have a protrusion under the skin to worry about."
"Make sure the doctor has the special wrench to remove it and knows what the
process entails."
as though there was only one design of hip fracture fixation device or that
they all need a "special wrench" and that it would EVER be acceptable for a
surgeon to NOT "know what the process entails".
I think that Jobst has stepped significantly out of his field of expertise
on this. There are advantages and risks associated with both leaving an
internal fixation device in place and with having it removed. In order to
make a decision on this subject you need to weigh many items such as the
type of device, the location, the patient's surgical risks, the demand the
patient is putting on the area and whether the patient is having any
symptoms that may be related to the presence of the device. You also need
to consider the risk of fracture during the healing period after the device
is removed. The cost of the surgery to remove the device is also a
consideration, not only monetary but in terms of time off work, off the
bike, etc.
Most internal fixation devices for hip fractures are not removed but then
most are placed in elderly patients where the costs and risks of removal are
greater and the benefits smaller. In young, healthy, athletic people it is
probably reasonable to remove the device if it is causing symptoms of any
sort, recognizing that there will be a fairly long recuperative period after
the device is removed during which time you will be at increased risk for
fracture.
If you are having no symptoms related to the device then there is little
reason to remove it. Yes, you would be at increased risk for fracture at
the end of the plate but that would take a fall with force as significant as
the one that broke your hip in the first place. These are fairly uncommon.
I, personally, would take that risk rather than having the surgery to remove
the device if I was without symptoms.
The same advice does not apply to all implanted fixation. Some should be
removed essentially every time and some should be left in place nearly every
time. My son has a fixation plate in his forearm that we have no plan to
remove. The only deleterious effect he has noted is that he occasionally
sets off airport metal detectors.
Talk it over with your orthopedist. If you are not comfortable with the
information and discussion you have with him then you should seek opinions
from other orthopedists. Ultimately the you get to decide.
--
Mike Murray MD
jobst....@stanfordalumni.org
>> "Sounds familiar. I have the hardware in a drawer at home where it
>> belongs after performing its service."
>> "By all means get another orthopedist! This guy doesn't sound like
>> the man for the job. When the hardware is removed, the bores fill
>> with bone and you don't have a protrusion under the skin to worry
>> about." He further continues: "Make sure the doctor has the
>> special wrench to remove it and knows what the process entails."
> as though there was only one design of hip fracture fixation device
> or that they all need a "special wrench" and that it would EVER be
> acceptable for a surgeon to NOT "know what the process entails".
I guess you missed the description of the hardware but it is the
common modern type used for this operation. My removal surgeon had no
idea what he was going to find when he got in there and proceeded to
hammer and screw on the thing as I listened to his bewilderment and
that of the and assistants. He did not know how it worked and nearly
advanced the screw into the hip socket, which would have cause serious
damage.
> I think that Jobst has stepped significantly out of his field of
> expertise on this. There are advantages and risks associated with
> both leaving an internal fixation device in place and with having it
> removed. In order to make a decision on this subject you need to
> weigh many items such as the type of device, the location, the
> patient's surgical risks, the demand the patient is putting on the
> area and whether the patient is having any symptoms that may be
> related to the presence of the device.
It was on the advice of the surgeon who installed the device that I
had it removed. He explained why and what the effects would be,
making obvious sense. I don't understand what you find inappropriate
about removal. Maybe you can expand on that and for what reasons.
> You also need to consider the risk of fracture during the healing
> period after the device is removed. The cost of the surgery to
> remove the device is also a consideration, not only monetary but in
> terms of time off work, off the bike, etc.
There is no "healing period" except for the incision, the holes left
in the bone being in the neutral axis (by design) and their absence
only strengthens the bone as it fills in. The purpose of the hardware
is to pull the ball of the hip joint back into position on the
fracture. It does not supply support any more than any tension strut
(which it is) within a tubular member. The main1q bone screw is under
spring load when tightened to the proper torque. The small screws
perpendicular to the femur arrest device rotation like safety clips
and have no structural role.
jobst....@stanfordalumni.org
>> "Sounds familiar. I have the hardware in a drawer at home where it
>> belongs after performing its service."
>> "By all means get another orthopedist! This guy doesn't sound like
>> the man for the job. When the hardware is removed, the bores fill
>> with bone and you don't have a protrusion under the skin to worry
>> about." He further continues: "Make sure the doctor has the
>> special wrench to remove it and knows what the process entails."
> as though there was only one design of hip fracture fixation device
> or that they all need a "special wrench" and that it would EVER be
> acceptable for a surgeon to NOT "know what the process entails".
I guess you missed the description of the hardware but it is the
common modern type used for this operation. My removal surgeon had no
idea what he was going to find when he got in there and proceeded to
hammer and screw on the thing as I listened to his bewilderment and
that of his assistants. He did not know how it worked and nearly
advanced the screw into the hip socket, which would have cause serious
damage.
This occurred even though I made sure he got the pin-wrench with which
it was installed. I even made a mechanical drawing of the piece from
x-ray pictures so there would be no mistake. The device was installed
in France while the removal took place in Stanford by a macho football
injury orthopedist. I have the evidence of his hammering the device
in the wrong direction from the dents in the stainless steel. When I
heard the hammering, I was highly worried. What a klutz!
> I think that Jobst has stepped significantly out of his field of
> expertise on this. There are advantages and risks associated with
> both leaving an internal fixation device in place and with having it
> removed. In order to make a decision on this subject you need to
> weigh many items such as the type of device, the location, the
> patient's surgical risks, the demand the patient is putting on the
> area and whether the patient is having any symptoms that may be
> related to the presence of the device.
It was on the advice of the surgeon who installed the device that I
had it removed. He explained why and what the effects would be,
making obvious sense. I don't understand what you find inappropriate
about removal. Maybe you can expand on that and for what reasons.
> You also need to consider the risk of fracture during the healing
> period after the device is removed. The cost of the surgery to
> remove the device is also a consideration, not only monetary but in
> terms of time off work, off the bike, etc.
There is no "healing period" except for the incision, the holes left
in the bone being in the neutral axis (by design) and their absence
only strengthens the bone as it fills in. The purpose of the hardware
is to pull the ball of the hip joint back into position on the
fracture. It does not supply support any more than any tension strut
(which it is) within a tubular member. The main1q bone screw is under
spring load when tightened to the proper torque. The small screws
perpendicular to the femur arrest device rotation like safety clips
and have no structural role.
Jobst Brandt <jobst....@stanfordalumni.org> Palo Alto CA
Mike Murray
" I guess you missed the description of the hardware but it is the common
modern type used for this operation."
I don't believe that ever described the hardware, or the fracture for that
matter, in your original note. The hip can fracture in several different
ways and there are different devices used for each type of fracture. In
addtion there are several manufacturers producing several different models
of hip fixation devices. As you unfortunately found out, the method of
fixation and devices used vary from country to country, or even in different
locations in the same country, often having much to do with where the
surgeon trained. Your statement that the device was placed in France and
that the Stanford surgeon that removed it was unfamiliar with the removal
process suggests that the description of the device as "the common modern
type" may be a bit inadequate.
Jobst Brandt further wrote:
"My removal surgeon had no idea what he was going to find when he got in
there and proceeded to hammer and screw on the thing as I listened to his
bewilderment and that of the and assistants. He did not know how it worked
and nearly advanced the screw into the hip socket, which would have cause
serious damage."
This is, clearly, unacceptable.
Brandt again:
" There is no "healing period" except for the incision, the holes left in
the bone being in the neutral axis (by design) and their absence only
strengthens the bone as it fills in. The purpose of the hardware is to pull
the ball of the hip joint back into position on the fracture. It does not
supply support any more than any tension strut (which it is) within a
tubular member."
This description is accurate of some fixation devices, but not all. Holes
left by screws which are placed perpendicular to the bone are places through
which the bone can fracture. While the device is in place the bone can
fracture at the ends of fixation plates. Some devices have more problems
with this than others do. The description of the device as something that
holds the bone together on appropriate position rather than providing
mechanical strength is a fair description of all fixation devices.
"Brandt again:
It was on the advice of the surgeon who installed the device that I had it
removed. He explained why and what the effects would be, making obvious
sense. I don't understand what you find inappropriate about removal. Maybe
you can expand on that and for what reasons."
I don't find any thing inappropriate about the removal of that fixation
device from your hip fracture. That doesn't mean that it can be
extrapolated from your experience that all fixation devices should be
removed, or that even all hip fracture fixation devices should be removed.
Since most hip fractures occur in elderly, inactive and often chronically
ill patients with high surgical risks it is reasonable to say that most
fixation device should not be removed. It is a completely different story
for younger, active healthy patients. I discussed the considerations in my
first posting.
--
Mike Murray MD
Carl Sundquist
"Mike Murray" <mike....@obra.org> wrote in message
news:AGkV8.246492$nZ3.111876@rwcrnsc53...
warren
<car...@cox-internet.com> wrote:
> Could it be that Jobst is using -- horrors! -- ANECDOTAL EVIDENCE?
Mike displays class and restraint while Jobst tries to tell Mike about
his profession.
I do like my killfile.
-WG
jobst....@stanfordalumni.org
>> I guess you missed the description of the hardware but it is the
>> common modern type used for this operation.
> I don't believe that ever described the hardware, or the fracture
> for that matter, in your original note.
I think you ought to review that. It was there and the fracture was
described.
> The hip can fracture in several different ways and there are
> different devices used for each type of fracture. In addtion there
> are several manufacturers producing several different models of hip
> fixation devices. As you unfortunately found out, the method of
> fixation and devices used vary from country to country, or even in
> different locations in the same country, often having much to do
> with where the surgeon trained.
I don't know why you feel compelled to defend the incompetence of my
removal surgeon. I gave him the name of the device, the manufacturer
and asked him to be sure he had the tool to remove it. He had his
staff get the stuff but apparently never read it or inspected the
pictures describing insertion and removal. I have the device and tool
and it is so simple that it takes a lack of skill in the process to
not understand it... without text or pictures.
> Your statement that the device was placed in France and that the
> Stanford surgeon that removed it was unfamiliar with the removal
> process suggests that the description of the device as "the common
> modern type" may be a bit inadequate.
You say "may be a bit inadequate" from which I take it you are not an
orthopedic surgeon. From the description given:
* I've looked through the archives of the groups and noticed there's
* no real consensus on what to do after breaking your hip and deciding
* what to do with the hardware a year or so down the road. On Feb 17
* of this year I went down on my bike and ended up with a fractured
* hip, just below the femoral head (thank goodness). The ortho reamed
* out the head and put a threaded insert in the head along with a
* plate down the femur, which is attached with more screws/pins.
>> "My removal surgeon had no idea what he was going to find when he
>> got in there and proceeded to hammer and screw on the thing as I
>> listened to his bewilderment and that of the assistants. He did
>> not know how it worked and nearly advanced the screw into the hip
>> socket, which would have cause serious damage."
> This is, clearly, unacceptable.
>> There is no "healing period" except for the incision, the holes
>> left in the bone being in the neutral axis (by design) and their
>> absence only strengthens the bone as it fills in. The purpose of
>> the hardware is to pull the ball of the hip joint back into
>> position on the fracture. It does not supply support any more than
>> any tension strut (which it is) within a tubular member."
> This description is accurate of some fixation devices, but not all.
> Holes left by screws which are placed perpendicular to the bone are
> places through which the bone can fracture.
Not so. These arresting screws are transverse and leave only small
holes. In any case, they cannot lend support even when in place.
They serve only to prevent the plate from rotating, the means by which
the unit is installed and removed, the shaft being hexagonal and keyed
to the plate. You might look at one of these when you get a chance.
> While the device is in place the bone can fracture at the ends of
> fixation plates. Some devices have more problems with this than
> others do. The description of the device as something that holds
> the bone together on appropriate position rather than providing
> mechanical strength is a fair description of all fixation devices.
So? That sounds like another good reason to remove it but I doubt
that this is a serious hazard. I took a dive on the fixture and it
caused no harm and have done so several times since removal, also
without further ado.
>> It was on the advice of the surgeon who installed the device that I
>> had it removed. He explained why and what the effects would be,
>> making obvious sense. I don't understand what you find
>> inappropriate about removal. Maybe you can expand on that and for
>> what reasons."
> I don't find any thing inappropriate about the removal of that
> fixation device from your hip fracture. That doesn't mean that it
> can be extrapolated from your experience that all fixation devices
> should be removed, or that even all hip fracture fixation devices
> should be removed.
Not all devices need removal, but the ones that fit this description
do. Without knowing what is under discussion as you state above, you
draw unfounded conclusions and offer criticism of my understanding of
the matter almost as if I were criticizing a medical decision you
made. Is this the case or does your response just sound aggressively
defensive?
> Since most hip fractures occur in elderly, inactive and often chronically
> ill patients with high surgical risks it is reasonable to say that most
> fixation device should not be removed. It is a completely different story
> for younger, active healthy patients. I discussed the considerations in my
> first posting.
I didn't see any reference to "elderly, inactive and often chronically
ill" bicycle riders in this case.
newsgroupie
Read the thread "Worst part about cycling..."
He's simply giving the exact same responce Jobst gave to the
OP in that thread.
Mike Murray
" I don't believe that you ever described the hardware, or the fracture for
that matter, in your original note."
Jobst Bradt replied:
" I think you ought to review that. It was there and the fracture was
described."
In reviewing Brandt's orginal post the only thing that I can see that comes
close to a desciption of the fracture and hardware is the statement "Sounds
familiar. I have the hardware in a drawer at home" following James P.
Smith's description of his fracture and fixation device. Perhaps this is
what Brandt was referring to or maybe there is another note that did make it
on my news server.
Brandt wrote:
" I don't know why you feel compelled to defend the incompetence of my
removal surgeon."
I don't. My response to his desciption of the removal process was:
"This is, clearly, unacceptable" as was quoted by Brandt.
With regards to the holes left by screws for fixation plates Brandt wrote:
"These arresting screws are transverse and leave only small holes."
The holes are small but they do represent a point at which fractures are
seen. This is something that can happen even with the device in place,
since, as Bradt points out, the screws only provide fixation for the plate
and not structural stength.
I wrote:
"While the device is in place the bone can fracture at the ends of fixation
plates."
and Brandt responded:
"So? That sounds like another good reason to remove it but I doubt that
this is a serious hazard. I took a dive on the fixture and it caused no
harm and have done so several times since removal, also without further
ado."
We then agree that the risk of fracture at the ends of the plates is one of
the reasons to consider removal. We also agree that this risk is fairly
small. I should point out that just because Brandt never broke his hip
again doesn't mean no one else has.
Brandt writes:
"Not all devices need removal, but the ones that fit this description do.
Without knowing what is under discussion as you state above, you draw
unfounded conclusions and offer criticism of my understanding of the matter
almost as if I were criticizing a medical decision you made. Is this the
case or does your response just sound aggressively defensive?"
I guess it will be up to others to decide whose response is overly
aggressive. In my original note I stated "In young, healthy, athletic people
it is probably reasonable to remove the device if it is causing symptoms of
any sort." This seems to describe Brandt's case and it seems like the
removal of his device was appropriate, even if the process of it's removal
was very inappropriate as described. It is also reasonable to leave in
place a device which is causing no symptoms. Brandt has stated otherwise,
which I think is incorrect. As I stated in my original posting, the risks
and benefits need to be balanced as for any other medical procedure. For
most hip fixations, since they occur most frequently in the elderly, the
balance will fall toward leaving the device in place. My criticism of Brandt
was related to his advice to Smith:
"By all means get another orthopedist! This guy doesn't sound like the man
for the job. ... Make sure the doctor has the special wrench to remove it
and knows what the process entails."
The specific criticisms are:
1) It is not necessary to remove a device which is not causing symptoms.
The advice from Smith's orthopedist in this regard was correct. I don't
believe that based on Smith's note you could appropriately describe his
orthopedist as not "the man for the job".
2) There is not a "special wrench" required to remover all fixation devices
that match Smith's description.
3) It is never acceptable for a surgeon to NOT "know what the process
entails" so this advice is trivial. Always make sure that the doctor can
fully explain and understands the suggested procedure. Evidently Brandt had
bad experience in this regard.
Brandt wrote:
"I didn't see any reference to "elderly, inactive and often chronically
ill" bicycle riders in this case."
That would be because there was no such reference. Elderly, inactive and
often chronically ill would, however, describe most hip fractures.
To try to make this redundantly clear:
It is appropriate to leave in place a fixation device placed for fracture of
the proximal femur if it is not causing symptoms. It is appropriate to
remove it if there are any symptoms which are thought to be caused by the
device in an otherwise healthy person, which would describe most people that
break their hip cycling. Most hip fractures occur in the elderly where the
risks of removal are higher. Due to this, most hip fracture fixation
devices are left in place.
--
Mike Murray MD