Procedures: BRAIN CT

07/03/2012
I had the brain CT with iodixanol (contrast agent) today.

The report is as follows:
[MR BRAIN PRE & POST CONTRAST
Technique : Standard brain with diffusion and pre and post contrast and slight imaging of the pituitary gland.
Findings :
Brain anatomy is normal.
No pituitary mass is seen.
Linear T1 hypo / T2 hyperintense focus anterior to the neurohypophysis of uncertain significance. This does not have the appearance of a neoplasm or the shape of a cyst.
Brain parenchymal signal is normal.
There is no intracranial mass, hydrocephalus or midline shift. No abnormal parenchymal or meningeal enhancement is seen.
The craniocervical junction is normal. The intracranial vascular flow voids are normal.
There is a mucosal cyst anterior to the adenoid within the nasopharynx most likely representing a mucous retention cyst.
COMMENT
No pituitary mass or brain abnormality is seen.]

So there we have all. Diagnostic done. I have done EVERYTHING I possibly can.

Procedures: X-RAY

This X-Ray was taken 6 weeks post-resurfacing. The placement is good.

05/03/2012
The surgeon who will doing my revision, said that there may be slight loosening of the femoral component.
Nothing can be confirmed until they open me up!

Research: METAL SENSITIVITY AS CAUSE OF HIP PAIN

Metal Sensitivity as a Cause of Groin Pain in Metal-on-Metal Hip Resurfacing
The Journal of Arthroplasty
Volume 23, Issue 7, October 2008, Pages 1080–1085
We describe 4 patients pooled from our patient populations who presented with groin pain at different periods postoperatively after implantation of a metal-on-metal hip resurfacing. Each patient underwent exploratory surgery after radiographic imaging, hematologic testing, and microbiological assessment of joint aspirations failed to explain their symptoms. Samples of periprosthetic tissues revealed extensive amounts of lymphocytic infiltrates that were suggestive of an immunologic reaction. The patients obtained complete resolution of symptoms subsequent to revision surgery. The incidence of implant failures resulting from metal sensitivity is unknown owing to the difficulty in making a confirmed diagnosis. The possibility that this is the source of groin pain should be considered when other reasons for symptoms of pain and/or joint effusion in hips with metal-on-metal resurfacing arthroplasties have been discounted.

Procedures: REVISION SURGERY

Unfortunately, once resurfacing has been done once, you cannot go back and change the prosthesis and have another resurfacing. The only option is a total hip replacement.
Obviously I am devastated. I went into this being told that resurfacing would last me at least 15 - 20 years. It has  only been 18 months and I need to undergo a total hip replacement.
Usually you would return to the surgeon who did the first surgery, to do the revision, but I cannot as I have issues with the way his practice handled the recall.

Finding the Right Surgeon to do the Revision
05/03/2012
My husband makes numerous phone calls and is determined to find an expert on revision surgery. We strike lucky and find a surgeon in the area who specializes in revision surgery. He fits me in the same day and I feel like there is some hope. His credentials are impressive. He has a special interest in hip revision surgery. He has an MBChB (UCT), an FRCS (Eng) and an FCOrth (SA). He did a knee and an advanced hip fellowship in Bristol, UK in 2004. He has a number of papers published in peer review journals and has presented widely. All boxes ticked.

Here are some points as to why this new surgeon impressed me:
1) He took considerable amount of time studying my X-Ray, MRI and various tests, before he called me in.
2) He was empathetic, yet composed, and sure of himself. I trust him.
3) He did a THOROUGH examination of my hip - different angles, movements, pressure etc.
4) He listened to ALL my concerns and symptoms, and I felt that he genuinely understood.
5) He knew about the developments in MRI protocols and explained what what going on with my MRI. He showed me the images and we talked through all of it.
6) He spent some time on my X-Ray, and confirmed definite loosening of the femoral component. [I was amazed that no-one else had seen this?]
7) He was knowledgeable on metal toxicity and its systemic effects.
8) He had considerable experience with revision surgeries, as well as resurfacing. He said that he stopped doing resurfacing 3 years ago, when he had heard about the high failure rates of the ASR and others. He was a fan of the BHR and I was too.
After considerable discussion, I decide to go ahead with revision surgery. My surgery is booked for Tuesday 13th March 2012.

Orthopedic Surgeon #3

Prosthesis Options

05/03/2012

My surgeon discussed my options with me, and has selected the design of the hip replacement and size of femoral ball to give me the range of motion and stability that I need to function. I have 2 choices of hip prosthesis to consider, each using varying materials and having different pros and cons:

1. Ceramic Ball and Ceramic Liner

I will be taking the Smith & Nephew Ceramic prosthesis. In Pink .

Ceramic is the 21st century answer to hip replacement as it is both hard and durable, it wears minimally and the material is widely deemed to have no toxic or side effects in the human body. Because I am a very active and still young, my surgeon has recommended an all-ceramic hip joint. Ceramic-on-Ceramic is a good combination with longevity and reliability.

There has been a history of two issues with ceramic hips: catastrophic shattering and squeaking. Shattering was more of an issue in the 1980′s and 1990′s but the product has been substantially improved since then, essentially eradicating the shattering problem. Squeaking, however, remains a bit of a problem for a few patients. Often the noises abate over time but sometimes they don’t. If the squeaking is intolerable, a revision may be necessary.

Ceramic is the hardest implant material used in the body, and has the lowest wear rate of all, to almost immeasurable amounts. Consequently, there is usually no inflammation or bone loss, nor systemic distribution of wear products in the body. New ceramics offer improved strength and more versatile sizing options.This is first prize. If this won't work, my second option is metal ball and polyethylene liner.

2. Oxidized Zirconium

Because of its durability and performance, Metal-on-Polyethylene has been the leading artificial hip component material chosen by surgeons since hip replacement surgeries were first been performed. It is also the least expensive bearing.
OXINIUM material has no detectable nickel content. Compared to the traditional metal used in hip implants, the zirconium and niobium contained in OXINIUM material are more biocompatible. This makes OXINIUM heads an appropriate choice for patients with metal sensitivities. Whether it’s metal sensitivity or metal ions you are concerned about, OXINIUM heads on XLPE liners address both of these issues. OXINIUM, oxidized zirconium is a metallic alloy with a ceramic surface that provides wear resistance without brittleness. OXINIUM material combines the best of both metal and ceramics.
The combination of OXINIUM heads on XLPE liners offers:
• No risk of fracture, chipping or squeaking
• Hypoallergenic Biocompatible solution for metal sensitive patients
• Proven low wear rates
In addition, OXINIUM heads and XLPE liners are available in a wide variety of head sizes and neck offsets, which allow you the intraoperative flexibility to help restore a full range of motion.

09/03/2012
I am making notes of what I need to discuss with my surgeon pre-surgery on Monday:
1) Will he be willing to film the extraction of the DePuy ASR and also comment on any visible damage as a result of the DePuy ASR.
2) Will he be willing to photograph any damage caused by the DePuy ASR
3) I must have my periprosthetic tissues sent for testing, to see if they will reveal amounts of lymphocytic infiltrates, that can be suggestive of an immunologic reaction.

4) I want to retain possession of the prosthesis so that it can be sent in for testing.

5) I would like copies of his surgery/theater notes as soon as possible so that I understand what was found.

Procedures: My Hip Resurfacing Surgery

My resurfacing surgery was done on the 5th July 2010 by one of SA's most brilliant orthopedic surgeons. 

Risks: CANCER

Hip replacement patients could face increased risk of cancer (very important article) By Laura Donnelly, Health Correspondent , Tuesday, Feb 7, 2012 THE TELEGRAPH: ENGLAND

Fresh fears have been raised over the safety of hip replacements received by tens of thousands of British people. Early findings from a study on the effects of "metal-on-metal" devices suggest the implants could increase the risk of cancer and genetic damage.

One patient who took part in the research, and was found to have abnormal cell changes to the bladder, said he was now desperate to have his implant removed because he feared for his long-term health.
The British study is understood to have detected changes to cells in the bladders of more than one in five patients who were monitored after being given "metal-on-metal" hip replacements.

The disclosure of the study comes after last week's investigation by The Sunday Telegraph, which revealed that regulators have such grave concerns about the safety of 30,000 of the devices that they are preparing to issue new guidance on them.

Problems occur with the implants when friction between the metal ball and cup causes minuscule metal filings to break off, which can seep into the blood and cause inflammation, destroying muscle and bone.
There are also concerns that metal traces in the blood could put major organs at risk of being slowly poisoned, and increase the chance of cancer - in particular in the kidneys and bladder.

The new in-depth research on 72 patients found genetic damage to the bladders of 17 people - including three patients who developed full-blown cancer.

The proportion of patients who had suffered DNA damage may be significant, because such changes can cause mutations which in turn lead to cancer. Orthopaedic consultants in Bristol who undertook the study said they hope to present the results to other surgeons next month. Their study was launched after the Medicines and Healthcare products Regulatory Agency (MHRA) warned that all 40,000 Britons with "metal-on-metal" devices should undergo annual checks, with scans and blood tests if doctors find symptoms that suggest metal leakage.

A type of device made by one company, DePuy - a subsidiary of global health giant Johnson & Johnson - which was received by almost 10,000 patients was taken off the market in 2010 because of concerns about its high failure rate.  One of the participants in the trial, David Jose, 51, from Clifton, near Bristol, had a hip "resurfacing" operation in 2007, a year before retiring as a police officer. The father of two had been suffering hip pain from playing football and rugby. In May last year he was told that the tests had found atypical cells which were not at this stage cancerous.

He saw Angus Maclean, an orthopaedic surgeon at Southmead Hospital involved in the study, who said that the trial had established three cases in which patients had developed bladder cancer, and 14 more including Mr Jose who had changes to their chromosomes.

The doctor told him researchers "could not believe" what had been found, describing the findings as "shocking". He said he was expecting the research to "make front page news", when it was published in a couple of months' time. Nine months on, the findings have not been published. Mr Jose, who now suffers from a host of unexplained health problems has now undergone further procedures which have established that so far he does not have bladder cancer. However, he remains in fear about the consequences of the cell changes, and is desperate to have the device removed.

He said: "I do not know what this thing is doing to me; that is what is frightening, the fact that this is all unknown."

Mr Maclean said he could not talk about the study, except to say that he hoped the findings would be presented next month, at the annual British Hip Society conference. A spokesman for the University of Bristol, which is running the study, said analysis of the results from the trial was still ongoing, and that the research would be peer reviewed and published. The MHRA said there was no evidence of an increased incidence of cancer among people with metal-on-metal replacement hips.

A spokesman for DePuy said that since the recall decision, the company had worked to provide patients and surgeons with the information and support they needed.

Metal-on-metal implants were introduced in the UK in the 1990s when they were promoted as offering better mobility than replacements which use a metal ball and plastic socket.
They were seen as a better option for younger patients, who were likely to be more active and put more pressure on the joint.
The problems have been found to affect people of all ages but studies have found young and petite women are particularly at risk.

Many thanks to Connie from My DePuy Recall for this article on her blog.


Surgeons urge ban on new metal-on-metal hip joints

The British Hip Society, which represents surgeons carrying out replacements, is so concerned about the failure rate of the metal joints that it has said no more should be used.
There are currently 49,000 people in Britain with the large metal-on-metal hip joints.
The new statement from the British Hip Society comes days after the health devices regulator said all patients with the large diameter joints should have annual blood tests and possibly MRI scans for the lifespan of the joint.
The tighter regulations have been brought in after research showed the large joints rub together causing miniscule particles of metal to leach out into the surrounding tissue and bloodstream.
Experts in Bristol have found abnormal cells in the blood of patients with the hips that could trigger cancers, it has emerged.

Timeline: Metal On Metal Hips

1975: Study describeslocal tissue reactions caused by cobalt and chromium ions from metal-on-metal hips
1988: Study shows human synoviocytes killed by cobalt in vitro (Rae T.Clin Orthop 1988;232:244–54)
1989: Metal-on-metal hip resurfacing designs start in Birmingham
1990: WHO International Agency for the Research on Cancer lists trivalent chromium as a potential carcinogen and cobalt ions as a probable carcinogen
1991: First metal-on-metal hip resurfacing device is implanted in Birmingham
1994: Study shows dissemination of cobalt and chromium ions into lymph, liver, and spleen5
1996: Patients with metal-on-metal hips found to be at increased risk of cancer compared with those with metal-on-plastic hips: relative risk of haematopoietic cancer 1.59 (95% confidence interval 0.8 to 2.8) and leukaemia 3.77 (0.9 to 17.6) (Visuri T, et al. Clin Orthop 1996;329 (suppl):S280–9)
1997: Birmingham Hip Resurfacing (BHR) implant comes onto the European market
1998: Particles of cobalt and chromium shown to be toxic to monocytes in culture (Haynes DR, et al. Clin Orthop 1998;352:223-30)
2000: NICE guidance on selection of prostheses for primary hip replacement and resurfacing sets a benchmark revision rate for conventional hip replacement of ≤10% at 10 years
2003: Derek McMinn and Ronan Treacy publish paper showing positive results with BHR. This kickstarts the trend for larger heads in total hip replacement
2004 McMinn, designer of the BHR, says, “Caution still needs to be exercised until longer term results are available”
2004 One of DePuy’s modified stems with a shortened trunnion is cleared by the FDA, which says the modified design “does not raise any new issues of safety or effectiveness”
2005: Internal DePuy memo reflects early concerns about health risks of wear debris from metal on metal hips. “In addition to inducing potential changes in immune function, there has been concern for some time that wear debris may be carcinogenic”
2006: MHRA Committee on Safety of Devices says there’s growing concern over the biological risks of metal wear debris
2006: The Department of Health’s Committee on Mutagenicity concludes that “some metal on metal (those using cobalt-chromium) hip replacements may be associated with increased DNA-changes, and increased genotoxicity in patients.” It says this “may present a potential risk of carcinogenicity in humans”
2007: Implantation of large diameter metal-on-metal hips starts to increase rapidly in the UK, and resurfacing peaks. Metal-on-metal hips account for 20% of market this year
2007: UK expert advisory group chooses not to contraindicate metal-on-metal hips in women of child bearing age—even though metal ions had been detected in the umbilical cord and placental blood
2007: The MHRA’s Committee on Safety of Devices recommends that all patients sign a consent form setting out the risks associated with metal wear debris. But this recommendation is not widely communicated
2008: Study shows 20% of patients with DePuy’s Pinnacle hip system have metal ion levels over the upper limit accepted by occupational health experts
2009: Japanese surgeons raise concerns with the design of DePuy’s large diameter metal-on-metal system. They report seeing “generated metal debris between stem taper and head, and final necrosed tissue” and blame it on the poor connection between the two
2009: All joint replacement implants are re-classified as class III devices after the implementation of Directive 2005/50/EC
2010: In an internal email obtained by the BMJ, a senior figure in DePuy writes: “I feel the problem [with large diameter metal on metal] is emerging as more serious than first thought.”
2010: DePuy recalls its ASR hip prostheses. Some studies show a failure of the total hip replacement secondary to adverse reactions to metal debris of 50% at 6 years
2010: DePuy promotes Pinnacle—including metal-on-metal—as “an alternative for the majority of patients”
2011: Tony Nargol and his team warn the MHRA of failures with the Pinnacle implants
2011: British Orthopaedic Association writes to surgeons to say that large diameter metal-on-metal total hip replacements should be “carefully considered and possibly avoided”
2011: A two year follow-up study in 144 patients shows an incremental increase in metal levels over the study period in a range of large head metal-on-metal implants made by companies including Zimmer, DePuy, and Smith and Nephew
2011: FDA writes to about 20 manufacturers to say that it is requiring post-marketing studies in cases where an implant’s failure could have serious consequences. Companies would be expected to take blood samples from patients to measure metal ions.
2011: National Joint Register describes large diameter metal-on-metal and resurfacing prostheses in some people as a “cause for concern”
2011 Trial comparing large diameter Birmingham hip replacement with conventional hip is terminated after 2 years. Metal ion levels were raised above the MHRA advised safety level (7 µg/L) in 20% of the metal-on-metal group and in one patient in metal-on-polyethylene group (who had a metal-on-metal implant on the contralateral side)27
2012: At the annual American Academy of Orthopedic Surgeons conference manufacturers promote metal-on-metal products to the 40 000 attendees






With much thanks to Connie. Read her blog, My DePuy Hip Recall

Research: METAL TOXICOLOGY

Metal Toxicologist Part 1: Background & Expertise of toxicology expert Dr. Michael McCabe

Metal Toxicology Expert Part 2: DePuy ASR Hip Replacement Recall

Metal Toxicology Expert Part 3: Effects of elevated cobalt & chromium levels

Metal Toxicology Expert Part 4: Testing blood for cobalt and chromium - "Trace ...

Metal Toxicology Expert Part 5: What studies have been conducted regarding cobalt exposure?

Metal Toxicology Expert Part 6: What are the effects of elevated blood cobalt levels ...

Metal Toxicology Expert Part 7: Symptoms of Cobaltism

Metal Toxicology Expert Part 8: Effects of high levels of chromium

Metal Toxicology Expert Part 9: Effects of metal wear debris from metal hip implants

Metal Toxicologist Part 10: Cobalt blood levels after hip replacement revision surgery

Metal Toxicologist Part 11: Should all metal-on-metal hip implants be ...

Metal Toxicology Expert Part 12: Do high cobalt and chromium blood levels cause cancer ...

Research: EFFECTS OF COBALT

Symptoms of cobaltism include irritability, fatigue, tinnitus, hearing loss, headaches, loss of coordination, cognitive decline, and depression.

Arthroprosthetic Cobaltism : Neurological & Cardiac Manifestations - The Journal of Bone & Joint Surgery
Oct 29,2010

International Agency for Research on Cancer
The IARC has determined that cobalt is possibly carcinogenic to humans.

The Journal of Bone & Joint Surgery, Volume 92, Issue 17
Many patients with metal-on-metal hip implants may develop renal impairment with time. Neurological and cardiac assessments should be considered for patients with a serum cobalt level of =7 µg/L. Revision arthroplasty should be considered for patients with periprosthetic metallosis and those with neurological or cardiac impairments temporally linked to elevated serum cobalt levels. Surgeons need to be aware that the high serum cobalt levels found in some patients with metal-on-metal hips may cause neurological or cardiac damage that is in part reversible with timely revision surgery.

US National Library of Medicine, National Institutes of Health
MoM hip bearings are being scrutinized due to high early failure rates and concerns that the results of the revision surgeries will be poor. However, orthopedic surgeons and the general medical community are unaware that patients with MoM bearings are also at risk for cobaltism. Medical providers need to know that hip arthroplasty implantees that present with symptom complexes that include tinnitus, deafness, vertigo, visual changes, rashes, hypothyroidism, tremor, dyspnea on exertion, mood disorders, dementia, heart failure, and peripheral neuropathy may be presenting arthroprosthetic cobaltism. These patients need to be asked if they have had a hip replacement and if so what type. For those patients implanted with a MoM bearing or those with a history of hip revision for a failed ceramic bearing obtaining a [Co] is indicated. MoM implantees with renal failure are a particularly high risk for cobaltism. Patients with a cobalt levels of greater than 7 mcg/l bear observation of neurologic and cardiac function. Those patients with levels greater than 20 should be advised to have revision of their hip arthroplasty to a bearing that eliminates cobalt. Most patients implanted with MoM bearing have cobalt levels greater than those allowed in industry and cobalt exposed workers may have an increased incidence of subclinical cognitive and cardiac impairments.

Department of Orthopaedics, Rheumatology and Musculoskeletal Surgery, University of Oxford

Theoretical, desirable features of second-generation metal-on-metal (MoM) hip prostheses have led to their widespread use. However, the bearing surfaces, consisting of complex cobalt-chromium alloys, are subject to wear and the release of cobalt and chromium (CoCr) nanoparticles. These nanoparticles can reduce cellular viability, induce DNA damage, lead to chromosomal aberrations, and possibly stimulate increased metal hypersensitivity. Clinically, the effects can be both local (soft-tissue reactions) and systemic (arthroprosthetic cobaltism). This review assesses the literature concerning the in vitro and in vivo cytotoxic, genotoxic, and immunotoxic effects of CoCr wear particles, which is increasingly important in view of the large number of MoM arthroplasties performed.

The Journal of Bone and Joint Surgery (American) 0:JBJS.J.00125-jbjs.J00125 (2010)
A serum cobalt level of >7 µg/L indicates possible periprosthetic metallosis. A normal serum cobalt level is 0.19 µg/L, and 95% of those who are unexposed to cobalt have a value of <0.41 µg/L.
A serum cobalt level of >1 µg/L indicates excessive cobalt exposure, and levels of >5 µg/L are considered toxic. Patients may become high risk for cobaltism if renal function declines and those in which ASR implants are used. [Mine is 16.9 ug/L]

The Poison Review

A recent letter to the BMJ (Arthroprosthetic cobaltism associated with metal on metal implants. BMJ 2012;344:e430) describes several patients who received the metal-on-metal hip implants who developed progressive hip pain, elevated cobalt levels, cognitive impairment, neuropathy, and cardiomyopathy. Associated symptoms included new onset depression, anxiety, tinnitus, and thyroid abnormalities.

Effects of Cobalt Nanoparticles on Human T Cells

Department of Orthopedics, The First Affiliated Hospital of Soochow University, People's Republic of China released this study marking the potential gentoxic/cytotoxic effects that cobalt might have on the patients T cells. In genetics, genotoxicity describes a deleterious action on a cell's genetic material affecting its integrity.
Cytotoxicity is the quality of being toxic to cells. T cells or T lymphocytes belong to a group of white blood cells known as lymphocytes, and play a central role in cell-mediated immunity. Lymphocytes identify invaders in the body and destroy them. In this case, we would be targeting cobalt as an invader in the body which the system would want to wipe out. If the T lymphocytes are not working properly and are inhibited, problems could arise of various sorts. The function of T cells and B cells is to recognize specific “non-self” antigens, during a process known as antigen presentation. Once they have identified an invader, the cells generate specific responses that are tailored to maximally eliminate specific pathogens or pathogen infected cells. B cells respond to pathogens by producing large quantities of antibodieswhich then neutralize foreign objects like bacteria and viruses. These tests were conduced in vitro. that is, they are lab experiments NOT conducted on humans or organisms.
Limited information is available on the potential risk of degradation products of metal-on-metal bearings in joint arthroplasty. The aim of this study was to investigate the cytotoxicity and genotoxicity of orthopedic-related cobalt nanoparticles on human T cells in vitro. T cells were collected using magnetic CD3 microbeads and exposed to different concentrations of cobalt nanoparticles and cobalt chloride. Cytotoxicity was evaluated by methyl thiazolyl tetrazolium and lactate dehydrogenase release assay. Cobalt nanoparticles dissolution in culture medium was determined by inductively coupled plasma-mass spectrometry. To study the probable mechanism of cobalt nanoparticles effects on T cells, superoxide dismutase, catalase, and glutathione peroxidase level was measured. Cobalt nanoparticles and cobalt ions could inhibit cell viability and enhance lactate dehydrogenase release in a concentration- and time-dependent manner (P < 0.05). The levels of cobalt ion released from cobalt nanoparticles in the culture medium were less than 40% and increased with cobalt nanoparticles concentration. Cobalt nanoparticles could induce primary DNA damage in a concentration-dependent manner, and the DNA damage caused by cobalt nanoparticles was heavier than that caused by cobalt ions. Cobalt nanoparticles exposure could significantly decrease superoxide dismutase, catalase, and glutathione peroxidase activities at subtoxic concentrations (6 μM, <CC(50)). These findings suggested that cobalt nanoparticles could generate potential risks to the T cells of patients suffer from metal-on-metal total hip arthroplasty, and the inhibition of antioxidant capacity may play important role in cobalt nanoparticles effects on T cells.




Imperial College London, Department of Musculoskeletal Surgery, London
Blood metal ions have been widely used to investigate metal-on-metal hip replacements, but their ability to discriminate between well-functioning and failed hips is not known. The Medicines and Healthcare products Regulatory Agency (MHRA) has suggested a cut-off level of 7 parts per billion (ppb). We performed a pair-matched, case-control study to investigate the sensitivity and specificity of blood metal ion levels for diagnosing failure in 176 patients with a unilateral metal-on-metal hip replacement. We recruited 88 cases with a pre-revision, unexplained failed hip and an equal number of matching controls with a well-functioning hip. We investigated the 7 ppb cut-off level for the maximum of cobalt or chromium and determined optimal mathematical cut-off levels from receiver-operating characteristic curves. The 7 ppb cut-off level for the maximum of cobalt or chromium had a specificity of 89% and sensitivity 52% for detecting a pre-operative unexplained failed metal on metal hip replacement. The optimal cut-off level for the maximum of cobalt or chromium was 4.97 ppb and had sensitivity 63% and specificity 86%. Blood metal ions had good discriminant ability to separate failed from well-functioning hip replacements. The MHRA cut-off level of 7 ppb provides a specific test but has poor sensitivity.

SWIMMING

1993 - 1995
I receive provincial colours and compete at SA Championships, schools level. Without any training my swimming is brilliant, and I realise I was born to swim. I never competed after school, until friends of mine encouraged me to start swimming again for the Masters league in 2009.
September 2009
I officially join Amakhosi Masters Swimming Club in East London, and start training for South African Masters Championships.
March 2010
I have to back out of the National Championships due to hip pain and my impending hip replacement.
July 2010
This is hip resurfacing surgery month and I cannot wait to get back into the water.
November 2010
I register for SA Masters Championships, taking place in 4 months, and start a moderate training routine. The swimming makes me feel great, and I start feeling competitive again.
March 2011
I swim breaststroke, backstroke and freestyle. I bring home 6 medals (2 gold; 3 silver). I felt elated and empowered again. Breaststroke was difficult, as it's my strongest stroke and I was not ready to train for it, so the 50m I had swam left me with terrible pain later in the day and the days following. My times were better than my goal times, and this experience has pushed me to go for World Championships and Masters Olympics. Etana promotes my achievements - and sponsored me. Read the article here.

November 2011
I register for 2012 SA Masters Championships and I'm determined to qualify for the 2012 FINA World Masters in Italy in July. I joined Virgin Active to have access to the pool and my training starts.

December 2011
Tinnitus and headaches are preventing me from focusing on anything, and I stop training and stay out of the water.
January 2012
I have my first swim in a month, and later that night I suffer from the most painful headache and my ears feel blocked. I tell the team that I have health problems and that my training is suffering.
February 2012
I find out about the DePuy recall and completely withdraw from Masters Championships this year, blowing my chance of qualifying for the World Masters Championships. I'm devastated because I know I will need to undergo revision surgery, and that I will be out of the 2013 championships as well. I also know that I will miss the 2013 Pan-American Masters in Florida. Not only will my swimming career be set back by 2 years, but I am missing out on all the sponsored travel to Europe and USA during 2012 and 2013. I also wonder if my FINA-approved racing suits will fit me again - after spending R5,000 on them.
I am honestly heart -broken. This is a bitter pill to swallow.

PROCEDURES: MRI

29/02/2012
MRI was done today.

I asked what protocol was used, because MRI's  done on patients with metal components are difficult since the metal content of the implant creates large distortions (warping) in the generated images. An optimized MR imaging technique has been developed in New York and Los Angeles, called the MAVRIK and the MARS protocol. It's a newer imaging technique to further reduce metal artifact in generated images, allowing for even better visualization of the bone and soft tissues surrounding metal-on-metal hips.
The radiologist had no idea what I was talking about:(

Left: MRI of right hip resurfacing using optimized metal artifact reduction imaging techniques. There is significant artifact around the metallic components, which limits the ability to visualize the surrounding bone and soft tissue.

Right: MRI of right hip resurfacing using MAVRIC. Greater clarity of the surrounding soft tissues (red arrows) and surrounding bone (yellow arrow) is shown.

Read the published study on MAVRIK protocol MRI by the Department of Radiology and Imaging, Hospital for Special Surgery, New York (September 2011)
The study confirms:
- Visualization of the synovium was significantly better on MAVRIC image
- Synovitis was detected only on the MAVRIC images
- Osteolysis was detected only on the MAVRIC images

02/03/2012
Consultation with my surgeon today. He has not heard of this specific protocol, but the most important thing he said was that there is no problem with the prosthesis and that everything looked normal. The radiologist comments that if there was a small lesion, it would not be seen due to the artifact. So ultimately, the MRI is useless.
03/03/2012
I've had sleepless nights worrying about this problem ,so I have a plan:
1. I need to get a second opinion.
2. I need to question the radiologist about developing the MAVRIK protocol and what it will entail. If this option is not available to me in South Africa, I intend on approaching the Sports Science Institute to look into it. (Why do I get the feeling that South Africa is always the last to know about advancements in this field??)