Hard Cases: What does 'first do no harm' mean when it comes to an asymptomatic patient?

 This article is part of LinkedIn's Hard Cases series, where healthcare professionals share the toughest challenges they've faced in their careers. You can read more about it here and follow along using hashtag #HardCases.

I’m often asked by patients what made me decide to choose a career in Orthopedics. As a hip and knee replacement specialist, the answer is simple: see arthritis, fix arthritis. Joint replacement is one of the more black-and-white areas in a medical profession that deals primarily in grays. This is not to say that arthroplasty is free of controversies, complexities, debates, or challenges. However, patients are often noncompliant with hypertension or diabetes treatment because having a lower blood pressure or blood sugar doesn’t make a patient feel any better. Why take a diuretic that might lead to frequent urination or painfully stick your finger several times a day to check your glucose level if doing so doesn’t have an immediate, demonstrable improvement in your quality of life?

Arthritis treatment is more concrete. X-rays reveal the problem in an undeniable roentgenographic form that is easy for patients to understand. Painful joints cannot be ignored like asymptomatic hypertension or hyperglycemia. Hip and knee replacements eliminate pain; patients feel better, postoperative x-rays confirm the cure, and everyone is (usually) happy. See arthritis, fix arthritis. The ability to take a patient limited by debilitating joint disease and treat their problem with a definitive solution is what drew me to joint replacement. But what would happen if the opposite were true? What if you did an operation on a patient who was without symptoms and made him worse? And what if it was without question the right thing to do? How could such a scenario be possible? Meet my hard case patient, TR.

Surgeons hate surprises. I first met TR in October of 2016 when he came to see me for right hip pain. TR had a history of slipped capital femoral epiphysis (commonly known as SCFE, pronounced “skiff-ee”), a disease of pre-adolescents that causes damage to the hip growth plate. As a boy, he had surgery to insert and later remove pins from his hips to prevent disease progression. Such patients often develop arthritis later in life, and TR’s left hip had been replaced seven years prior by another surgeon. Though his right hip had been bothersome for some time, prior unemployment had cost TR insurance coverage and access to health care. A new job had restored his health insurance and led to that day’s office visit.

Other than his prior hip difficulty, TR’s medical history was unremarkable. SCFE is often associated with childhood obesity, but TR (48 years old when I first met him) was of average weight and otherwise in good health. His history of present illness and right hip exam were typical of a patient with early stage arthritis (groin pain and stiffness). As part of the standard workup for hip pain, we obtained right hip and pelvis x-rays that day in the office. A pelvis x-ray has the benefit of showing both hips on the same film which aids in comparison of one hip against the other, particularly when it comes to anatomy and leg length determination. While the x-rays did show right hip arthritis, they also revealed a surprise: TR’s previously replaced and currently failing left hip.

“Catastrophic failure” is a term used to describe joint replacements that aren’t just wearing out, they are doing so in extreme fashion. While TR had not presented with complaints about his left hip, the pelvis x-ray showed that the plastic liner of his hip replacement had almost completely worn through. His femur bone and acetabulum (hip socket) were being dissolved by a process known as osteolysis that occurs when the body has a severe inflammatory reaction to microscopic plastic particles. Osteolysis can weaken bone and cause fractures or loosening of the prosthetic parts. TR’s parts did not appear loose, but the bone had been significantly eroded and was at risk of spontaneous fracture. If the plastic liner were to wear completely through, the ceramic ball would be grinding against the titanium socket leading to catastrophic failure of his hip replacement. 

After reviewing the x-rays, I immediately changed the focus of the visit from the right hip to the left. Incredibly, TR denied any pain or abnormal sensation in the left hip. He was dumbfounded when I told him about the x-ray findings and could not understand the urgency of the problem. After all, his right hip was the symptomatic one. I strongly recommended he have the left hip addressed as soon as possible before catastrophic failure occurred. However, he was reluctant to agree to surgery due to his lack of symptoms and inability to take time off from his newly started job. I simply could not convince him to agree to revision of his left hip. TR ultimately acquiesced to close follow up and a repeat x-ray in three months. He was to contact me immediately with any change in the status of his left hip. 

When TR presented again in March of 2017 (later than the agreed upon date), he continued to deny left hip symptoms. Repeat x-rays showed that the plastic liner was now almost certainly worn through. The concerning areas of bony erosion had grown larger. Surgery could no longer safely be delayed. And yet, TR could not understand why his painless left hip was the cause of so much concern. After much discussion, he grudgingly agreed to undergo surgery -- but not until three months later. In the interval, a comprehensive workup was undertaken to rule out infection (negative), blood metal poisoning (negative), and metal allergic reaction (negative). Surgery would have to wait.

Finally, in June of 2017, I brought TR to the operating room to address his still asymptomatic left hip. Throughout the process, he remained skeptical of my left hip diagnosis. However, he put his faith in me that proceeding with revision surgery was the right decision. My hope was to simply place a new plastic liner in his existing titanium socket, bone graft the areas of bony erosion, and keep his existing metal stem and shell. Such a procedure would be relatively quick and only moderately invasive with about a six-week recovery. The prudent hip revision surgeon always expects the worst, and I was prepared to perform a complete revision, removing all existing parts and placing new ones if necessary, a much more extensive and invasive surgery with a longer recovery.

TR’s surgery would prove to be one of the most challenging of my career. His hip, scarred from multiple prior surgeries, was incredibly stiff and exposure was difficult. Shortly after dissecting through the superficial tissues, I encountered graphite gray staining of the muscle, a dreaded sign of metal debris and catastrophic failure. During exposure, despite my best efforts to reduce stress on the bone, a part of TR’s femur known as the greater trochanter (an important attachment point for the hip abductor muscles) fractured through one of the areas weakened by osteolysis. The metal stem was damaged more than I had hoped, and as feared, the plastic liner of the hip socket had worn completely through and was broken. The ceramic ball had eroded into the titanium shell producing metal particles and damaging the shell beyond the point of salvage. Fixing this problem would now require complete removal of his existing parts (which were well fixed to the bone) and placing new replacement parts in addition to repairing the now fractured femur bone.

Removing well-fixed hip replacement parts can be an exercise in frustration and has tested the patience of many a joint replacement surgeon. Removing TR’s stem and socket took two and a half hours of blood (his), sweat (mostly mine), and tears (also mine) as well as several well placed swear words. Once the parts were removed, reconstructing the damaged hip and closing the incision took another two and a half hours. Five hours of surgery for a hip that had never once caused him pain or limitation. When the surgery was complete, postoperative x-rays in the recovery room demonstrated a reasonable reconstruction of a catastrophically damaged hip replacement. Despite the length and difficulty of the case, I was satisfied with the immediate outcome. Repairing his fractured greater trochanter had proven to be challenging as the bone had been reduced to the thickness and fragility of an eggshell. Failure of the bone to heal could lead to a significant lifelong limp and would be nearly impossible to remedy. 

Throughout the process and recovery, TR remained optimistic and positive. He was facing three months of restricted activity, a difficult healing process, and weeks away from his new job. Despite his skepticism about the diagnosis and need for surgery, TR continually deferred to my judgement and placed his unwavering trust in me. Recovery went as smoothly as could have been hoped. In fact, I was concerned that he was healing too quickly and placing excessive stress on his freshly reconstructed left hip. At six weeks after surgery, TR requested to return to work. I hesitantly agreed with the caveat that he remain on crutches and stop working if his pain increased. He never missed a day.

This month will mark two years since I operated on TR’s asymptomatic left hip. Last winter, I finally replaced his arthritic right hip, the original reason he had come to see me in October of 2016. His recovery from that surgery was (not surprisingly) quicker and easier. The left hip has healed as well as could be expected. The eggshell bone has remained in position, but TR still has a mild left-sided limp that wasn’t present before surgery. While the left hip doesn’t cause him pain, it does not function as well as it had prior to my surgery. Though he has never fully understood the extent of his left hip problem, TR is appreciative of my expertise and has never complained about his surgery or recovery. His case represents one of the rare instances where the concept of “primum non nocere” (first, do no harm) appears to have been violated for good purpose. In retrospect, allowing his left hip to progress further into catastrophic failure may have damaged the bone and tissue beyond the point of salvage. Waiting almost surely would have led to an even more difficult problem and worse outcome. The decision to operate was the correct one but will forever remain one of my hardest cases.