Dr. Mont Chat September 17, 2008

Updated 9/17/08

[Pat Walter Moderator] 7:58 pm: Welcome Dr. Mont. Thank You for giving your time

[Chuck] 7:58 pm: How bad would bone spurs have to be to preclude someone from having a hip resurfacing?
[Dr. Mont] 7:59 pm: For Chuck---Bone spurs on femoral neck are not a contraindication for resurfacing--but obviously each x-ray would have to be looked at individually--almost all arthritis is associated with spurs on neck by the way
[Dr. Mont] 7:59 pm: Almost all arthritis leads to cysts---its just a matter of degree--the longer you wait or tolerate arthritis in general the larger the cysts will become---sometimes patients may wait too long to get a resurfacing because the cysts erode away the bone stock on the femoral head---but these are typically very late stage arthritis
[Dr. Mont] 8:00 pm: Best Chuck is to see x-rays individually of course

[] 8:01 pm: Hi, Dr. Mont, it was a pleasure speaking with you this morning! How does your post-op protocol for bilateral surgery differ from single hip surgery?
[Dr. Mont] 8:02 pm: Hi Wendy--bilateral is a little harder
[Dr. Mont] 8:03 pm: 2 crutches or canes for 5/6 weeks --then unrestricted---that's as opposed to one crutch or cane

[] 8:01 pm: If I have "arthritis" in my hips, diagnosed by mri last summer, is it better to look into hip resurfacing now rather than waiting?
[Dr. Mont] 8:01 pm: I have a lot of squash, racketball, tennis players that are nationally ranked after resurfacing
[Dr. Mont] 8:02 pm: can put you in touch with them if you'd like squasher

[] 8:02 pm: that is very encouraging. Singles squash is a lot of wear and tear. Yes Dr, I would love to talk to all of them! I probably know them-it is a small world!
[Dr. Mont] 8:04 pm: Squasher--call office--for individuals:Number at Office –410-601-8500/8551 -ask for Terri/ Jill/ Colleen
My e-mail is Rhondamont@aol.com but would like to answer individual qs when I see actual x-rays
 

[Pat Walter] 8:04 pm: Do you encourage a lot of walking 2 or 3 weeks post op?
[Dr. Mont] 8:04 pm: Unlimited walking as long as tolerated which is fine in most unless special circumstances which are rare


[Dr. Mont] 8:04 pm: Hi Dr. Mont. I am an airline pilot and am having my hip resurfaced next week. How long do you believe it would take for me to go back to work. My concern is the high level training that I have to do in a flight simulator that requires multiple scenarios requiring full rudder deflection which would be like pushing 25lbs on a leg press and holding it for 5-10 minutes?
[Dr. Mont] 8:06 pm: Flying hippy--can't really answer your questions--that's for your doc since there are variations in approach, style, rehabilitation, etc.

[] 8:06 pm: Dr Mont -thank you for your time in this and the previous chats. I have AVN as a result of a femoral neck fracture. Last October I had a core decompression. I have experienced pain in the hip and down the thigh to and just below the knee since earlier this summer. The femoral head shows clear signs of collapse. My local doctor believes resurfacing would be inadvisable given the possibility for further collapse and subsequent loosening of the resurfacing device. Do you see this as a risk?
[Dr. Mont] 8:07 pm: Brian - I've done over 200 AVN resurfacing hips - our first 42 had 41/42 success and I expect better - at 6 year mean follow-up
[Dr. Mont] 8:08 pm: Obviously Brian --I'd have to see individual x-rays to truly make call but 90% + of AVN can get resurfaced in my opinion
[Dr. Mont] 8:08 pm: in fact they are among the best candidates!!!!

[] 8:08 pm: I'm intrigued that it's possible for the x-rays for 2 people with OA to look similar, but for 1 person to have significant pain and the other person have none. Any idea why this happens?
[Dr. Mont] 8:09 pm: Pain is based on combo of many genetic, physical, emotional and hormonal factors

[] 8:10 pm: I know my left hip is worse than my right but I think both my hips are in pretty rough shape. Is there an advantage to doing them both at the same time or within a few days of each other. Do you have to have xrays to evaluate my situation or is an mri of the hips more useful for you to evaluate?
[Dr. Mont] 8:10 pm: the most obvious way to look at pain responses are biomechanically--some people run 10 miles every day others sit around the house all day--who do you think is going to have more pain from their arthritic hip?

[Dr. Mont] 8:11 pm: MRIs not necessary since you already have diagnosis
[Dr. Mont] 8:11 pm: good x-rays are necessary and then decisions are based on a number of factors - would love to chat with you after see x-rays squasher

[] 8:11 pm: Dr. Mont how long before you allow your patients to golf post surgery?

[Dr. Mont] 8:13 pm: They can get on golf course for light swinging by 6-8 weeks but really unleashed at 10-12--one patient of mine shot a 76 at week 10--I think that's probably unwise--but about 12 weeks full blast if you are motivated--Chuck

[] 8:11 pm: But you do want current x-rays, right?
[Dr. Mont] 8:13 pm: x-rays need to be reasonably current--within about two months

[] 8:11 pm: Thank you Dr Mont. So core decompression and collapse do not preclude resufarcing - great news. I am collecting my x-rays and MRIs (if you want) to email to you (see contacts above - thanks). On Dr Pispati/Dr Bose's discussion of AVN, they believe it is important to wait as long as possible on AVN cases, however from the last chat, you indicated sooner is better?
[Dr. Mont] 8:14 pm: I'm not sure why Dr. Bose would wait - it could be too late if you wait too long - and he's done a lot of AVN supposedly

[Pat Walter] 8:15 pm: I had several surfers write to me. Do you allow surfers to return to their sport?
[Dr. Mont] 8:16 pm: They allow themselves to return - I'm not a fan but you can't keep them down

[] 8:17 pm: I will send them. What have you experienced in terms of return to squash after a bilateral resurfacing? A range of time would be fine in terms of your experience. How long til I might expect to begin serious training, sprints, competition assuming I do everything you and the PT says (ballpark idea?) I will be sending my x-rays down as you suggested after I have them done in the next week or two.
[Dr. Mont] 8:18 pm: Range is 18-26 weeks for full return--remember that I have a wide range of age patients - including champions at 40-50 year ranges and also > 65 years so variability there
[Dr. Mont] 8:19 pm: you can speak to them since there are many that are so appreciative of returning to their level of sporting activity

[] 8:20 pm: Dr Mont - I suppose if one can return to squash after Resurfacing, one could return to Paddle as well? Do you think that would be the case with THR too?
[Dr. Mont] 8:21 pm: Yes--there are people that return with standard THR as well
[Dr. Mont] 8:22 pm: Maybe its worth reviewing my view of advantages and disadvantages of resurf vs. THR - Advantages of a resurfacing in my hands are (1) more range-of-motion, (2) less risk of dislocation, (3) more normal "feeling", (4) leaves options open for later conversion to standard THR, (5) Easy revision if necessary, (6) useful for certain deformities, (7) preservation of femoral bone stock
Disadvantages are (1) harder to do, (2) less follow-up--up to 10 years max, (3) risk of femoral neck fracture, (4) pos

[stevel] 8:20 pm: I watched Dr. Gross's videos of the actual surgery. For one side hip resurfacing surgery, is blood transfusion unnecessary?

[Jon] 8:22 pm: Is it true that you've started to use the "Direct anterior" surgicall technique? If so, what are the issues versus posterior approaches?
[Dr. Mont] 8:23 pm: Jon  - I can do all of the approaches - my previous answers to question
[Dr. Mont] 8:23 pm: The choice of approach to use for resurfacing has received much attention and I believe extra "hype." In multiple studies now published, there are no reported clinical differences in the short term and up to ten years of follow-up between anterior and posterior approaches. I believe that any approach can be used and the surgeon should use what they feel most comfortable
Short-term differences that patients may report with either approach have to do with other factors in my opinion.
[Dr. Mont] 8:24 pm: . I use the antero-lateral approach because it affords me easy exposure, lower dislocation risk, less chance to disrupt the blood supply of the femoral head---among other reasons. However, I have no problem with posterior approaches and am currently working on and performing an even more minimally invasive anterior approach in selected patients. Again, I would repeat that a recent prospective randomized study showed no differences in all three approaches.
[Dr. Mont] 8:24 pm: I've been lately using the anterior approach in selected cases
[Dr. Mont] 8:25 pm: Also sometimes I do posterior because of patient request - can do all three
[Dr. Mont] 8:25 pm: Your surgeon should do what they feel most comfortable with

[stevel] 8:23 pm: I bought a pair of folding crutches Wal-mart for $37. Are these usually furnished by the hospital for a patient to travel home with?
[Dr. Mont] 8:26 pm: Steve - crutches are usually supplied by hospital - make sure you have correct length!!!
[Dr. Mont] 8:26 pm: otherwise you can hurt your shoulder - like Wendy? lol
[wendyk320] 8:27 pm: Yikes, now everyone knows my secrets!

[Pat Walter] 8:25 pm: What kind of stitches do you use? Staples?? glue???
[Dr. Mont] 8:28 pm: I usually use staples - lead to great looking wounds - though some patients want me to use sutures so these are done per request - we try to be accommodating - especially when it really doesn't make a difference medically

[] 8:26 pm:  I keep hoping someone will develop something that can be injected into the hip to regrow cartilage? Wishful thinking?
[Dr. Mont] 8:28 pm: Squasher - my lifetime goal - though not probably ready for some years

[Jon] 8:26 pm: Could you say more on activity restrictions post-surgery: e.g., would you prefer patients to play tennis on clay versus hard courts?, what about alpine with minimal jumping? How about backcountry skiing where some jumps always come up?
[Dr. Mont] 8:29 pm: Clay is obviously better than hard - less pounding
[Dr. Mont] 8:29 pm: though lot of hard court players--and that's where you play squash/racketball
[Dr. Mont] 8:30 pm: Would get best shock-absorbing sneakers for any sports - even if expensive

[] 8:28 pm: Dr Mont - given my AVN, even though I can participate in most activities (golf, biking, tennis) with moderate discomfort, would you advise reducing my activity level to try to avoid further deterioration? How about riding stationary bike, elliptical, etc (in addition to the general resistant band and ankle weight exercises I do to just keep the hip strong as possible)?
[stevel] 8:29 pm: Yes the crutches are adjustable and fold in two for travel. They are the arm pit type.
[Dr. Mont] 8:31 pm: Brian - you may want to reduce your activity if you want a resurfacing or just don't worry about it and you might end up with THR
[Dr. Mont] 8:32 pm: or you can do swimming/stationary bike/elliptical in that order and avoid the treadmill and hard pounding

[Jon] 8:30 pm: Thanks. What exactly is the problem with shock - risk of femoral neck fracture or premature wear of the implant?
[Dr. Mont] 8:32 pm: Jon - shock is not really fracture at all but increasing wear which can make any device wear out

[Pat Walter] 8:30 pm: Do you make your patients wear TEDS? What do you do to prevent blood clots post op?
[]Dr. Mont 8:33 pm: Pat--I like Teds and aspirin in most or arixtra for ten days if slightly higher risk
[]Dr. Mont 8:34 pm: By the way --no study on this but resurfacing may have a lower embolic rate than THR since you don't invade canal

[stevel] 8:31 pm: What about blood transfusions for a one side hip operation? I have a rare blood type B Neg and I'd like to bring my own blood if necessary.
[Dr. Mont] 8:35 pm: Steve--pre-donate 1 unit of blood and we use a cell saver during case so should be no risk of getting other persons blood

[] 8:31 pm: Is there always a squeaking with these resurfacings? Do most people get the sensation that one leg is longer than the other with just one resurfacing or is that unusual?

[] 8:33 pm: I never liked running - so that's OK!! But you advise stationary bike over elliptical - presumably due to lower weight bearing?
[Hip Resurfacing]: david has entered at 8:33 pm
[Dr. Mont] 8:36 pm: Brian --more people have probs with elliptical than bike but that may be personal--may have to just lower the resistance

[Pat Walter] 8:34 pm: Our guest a few weeks ago with one kidney did get her bilateral surgery last week. She is recovering nicely. The doctor is going to do some follow up blood work to watch things.
[Dr. Mont] 8:36 pm: Good luck to your one kidney guest

[wendyk320] 8:35 pm: How much of an issue is post-surgical waddle due to disturbance of the abductor muscles? In what percentage of patients does it occur and is it completely resolved by PT?
[Dr. Mont] 8:38 pm: Wendy - may depend on approach, pre-op status, patient motivation---should be eliminated completely or nearly with appropriate rehab and maintienance

[] 8:35 pm: Wow Dr. Mont. I thought continuing with eliptical and weights would be a good thing to keep me in some modicum of fitness before the surgery. I have also been doing a little tennis, but I have brutal pain at night when I try to sleep -burning pain in the back of the buttock. Is that a common symptom of hip arthritis? I thought the common symptom was pain in the front top of the thighs? Do your patients complain of pain in the "rear" from arthritis of the hips?
[Dr. Mont] 8:39 pm: pain at night is typical of arthritis after daily stimulation gone

[] 8:37 pm: squasher - I have AVN with deformity of my femoral head but still with very good spacing between pelvis and femur - I experience pain at various times (i.e. not all at the same time) in all of the above - and lower thigh, outer thigh (bursa), top of knee, below knee - there seems to be a lot of radiating pain with the hip joint.
[Pat Walter] 8:38 pm: Many people complain of pain right in the middle of their but after surgery. It is one of the biggest complaints I hear about
[Dr. Mont] 8:39 pm: Pain in the rear is atypical but can occur either directly or indirectly by hip arthritis causing leaning and extra pressure on back
[Dr. Mont] 8:41 pm: Do your best to maintain your flexibility - but not at expense of severe pain
 

[] 8:39 pm: Is it ok to do Yoga (beginning classes) or will the cross-legged positions make things worse? I am trying to regain flexibility which is very limited in the hips. Is this a bad idea?

[stevel] 8:40 pm: So I should draw one unit of blood, locally and transport it with me for my travel for out-of-state surgery?
[Dr. Mont] 8:41 pm: Steve - that's done for you via Red cross - you don't do any of it except donate it

[] 8:41 pm: Thanks Brian-maybe that is why I am having shooting pains from butt down to knee and sometimes to ankle. Doesn't bother me much during day while I am sitting. I am having chiropractic because I was thinking my back is involved due to the radiation, but maybe it is just the hip as you are saying Brian. I think I'll up the ante with a Cosmo, injected directly into the hip.
[Dr. Mont] 8:43 pm: Squasher/Brian sometimes that's how you differentiate back from hip pain - inject the hip and see what that does to pain - if the local anesthetic takes away the pain then its from the hip
[Dr. Mont] 8:44 pm: you can also use injections to differentiate pain coming from the hip and or knee

[Pat Walter] 8:43 pm: It seems most patients with bad hips also have back problems - do you find that true Dr. Mont?
[Dr. Mont] 8:45 pm: Pat---think about it--if your wobbling from your hip(s) its going to eventually through off your backs
[Dr. Mont] 8:45 pm: back--everything in the lower extremity is biomechanically connected
[Pat Walter] 8:46 pm: Yes and everything gets out of balanced. The opposite hip takes a beating too. People ask me if their unoprated hip will get better after getting the worst one done.
[Dr. Mont] 8:47 pm: Often the unoperated hip will get better
[Dr. Mont] 8:47 pm: before the resurfacing the unoperated hip is taking the majority of the force---then this gets releved by the successsful resurfacing and feels better

[Jon] 8:48 pm: During a resurfacing, do you have any ability to change the femoral neck angle? I'm wondering if by decreasing the (obtuse) angle, you could improve the function of the glut. med.'s (for those of us told that we're "coxa valgus" (sp?)
[Dr. Mont] 8:49 pm: There is some leeway with changing valgus/varus angles but this would have to be reviewed individually

[stevel] 8:49 pm: I had a pelvic x-ray in 2002 which showed degeneration of the left hip and the right hip is OK. Do you routinely check out the opposite right hip (good hip)? Recent x-rays have only been taken for the distressed left hip.
[Dr. Mont] 8:49 pm: in extreme cases we do gait evaluations to assess walking and joint reaction forces and angles of muscle pulls or moments
[Dr. Mont] 8:50 pm: Steve - most of time your Pelvis view captures both hips and yes we routinely check that

[mzee] 8:51 pm: mzee how is leg length diagnosed and/or adjusted with resurfacing?
[Dr. Mont] 8:52 pm: leg length is assessed by physical exam pre-op and evaluations of pellvic radiographs - it usually doesn't change much with resurfacing
[Dr. Mont] 8:52 pm: its easier to correct shorter limbs with standard THR

[Pat Walter] 8:51 pm: How often do you x-ray a resurfaced hip and have a follow up
[Dr. Mont] 8:53 pm: Resurfacings x-rayed typically at 6 weeks/ 10-12 weeks/ 3rd: 9-12 months/ 4th: 2 years/ 5th : 5years

[Sue] 8:53 pm: I've just been "listening in" so far...squasher is my neighbor and she recommended this chat! My husband has a congenital hip deformity (oval shaped femoral head) and has been told he will need an early hip replacement/surgery. He hasn't had updated X-rays in 10 years, but he's on Celebrex daily for past 2 years and really feels it if he forgets his meds. He's 42 now and we're just trying to gather info. Should he wait until the Celebrex is no longer working before considering surgery?
[Dr. Mont] 8:55 pm: Sue he may want info - probably should review x-ray but in general hold off on considering surgery as long as possible if non-operative treatment modalities working

[mzee] 8:53 pm: what is the bad hip has the longer leg length?
[Dr. Mont] 8:56 pm: If bad hip has longer length that needs review for reasons why and resurfacing may be best option for not further increasing length--would need to see x-rays
[Dr. Mont] 8:57 pm: Steve - send x-rays and phone number - and will call:Number at Office  - 410-601-8500/8551 - ask for Terri/ Jill/ Colleen
My e-mail is Rhondamont@aol.com but would like to answer individual questions when I see actual x-rays

[stevel] 8:54 pm: For out of state patients, do you require a post-op visit or are x-rays OK
[Dr. Mont] 9:00 pm: Steve - I usually have patients send in 5 week x-rays but I want to see them once - usually at 10-12 weeks to make sure they are on right course and then further visits can be done by mail/phone

[Sue] 8:57 pm: Thanks...that's what we've heard so far. Very interesting discussion...I'm a PT but haven't seen too many resurfacing patients (currently working with geriatrics in home care may be part of the reason!)
[Dr. Mont] 8:58 pm: Sue - maybe you want to go to 2nd annual hip resurfacing course in S in LA--October 24-26? open to allied health professionals

[stevel] 8:59 pm: After hip resurfacing, do you require a post-op visit for out of state patients?
[Dr. Mont] 9:00 pm: LDM-----10-14 days

[Dr. Mont] 9:01 pm: Pat---thank you for another great situation and for all excellent questions
[Pat Walter] 9:01 pm: I would like to Thank Dr. Mont for his time and Thank everyone for joining the Chat. We are trying to have the every other week and will have more doctors joining the chats in the future. Dr. Mont does a great job and I appreciate his effort to help people learn about hip resurfacing.