Dr. Mont Chat September 3, 2008

Updated 9/3/08

Chat with Dr. Mont on Sept. 3, 2008 in the Surface Hippy Chat  Room

[Wendy] When do you recommend water therapy and what do you recommend?
[Dr. Mont] 7:58 pm: To Wendy: various surgeons differ but I allow pool exercises after sutures are out (10-12 days)
[Dr. Mont] 7:59 pm: Remember the water reduces gravity by 50 to 90%
[Dr. Mont] 7:59 pm: However, one can also overdo it and vigorous swimming not recommended early
[Pat] 7:59 pm: Do you encourage your patients to do water walking or do you add more exercises and stretches
[Dr. Mont] 8:00 pm: I love water exercises. You can only do so much exercises and then it can get detrimental - but I say unlimited water walking
[Pat] 8:00 pm: Do you have to be careful with the type of kick you do? I assume a frog kick would not be very good.
[Dr. Mont] 8:01 pm: certain kicks are verboten

[Jon] 8:00 pm: Dr. Mont, thanks for taking our questions. I was curious about ceramics possibly being used for resurfacing. Do you think this will ever happen, and if so, when?
[Dr. Mont] 8:01 pm: ceramic resurfacing will be a reality in next generation but not for at least a few years

[nengland] 8:01 pm: You mentioned in a previous chat that you are investigating the possibility of using the direct anterior surgical approach. Does this approach give adequate direct visual exposure for precise preparation and positioning of both the femoral and acetabular components? Does it depend on x-rays or other electronic guidance systems for femoral/acetabular preparation and component positioning? Thanks, Nelson England
[Dr. Mont] 8:02 pm: for many patients (not extremely obese) the same visualization. Don't need special x-rays more than usual[Dr. Mont] 8:02 pm: I like to use 1 xray in Or to check that acetabular component is well-seated

[] 8:02 pm: What percentage of your patients are post-menopausal women, aged 50-60?
[Dr. Mont] 8:04 pm: About 15% are PMP women - we just published a report on patients over 60 with resurfacing - many women - did just as well as under 60 at mean 5 year follow-up

[] 8:05 pm: Is the anterior approach you're investigating similar to the one used by Dr. Matta et al for total hips?
[Dr. Mont] 8:06 pm: very similar--though I'm doing it without special table---fortunately I have a lot of help in operating room

[] 8:06 pm: Many people are complaining of very bad pain right in the middle of the cheek of their butt some weeks after surgery. What would normally cause that?
[Dr. Mont] 8:07 pm: cheek is where sciatic nerve runs--maybe they are sitting too long--should get out of chair every 45 min--we all should do this!!!

[Jon] 8:07 pm: I'm pre-resurfacing, and am concerned about metal ions. How much more of a track record do you think the C+ device (with A-Class metal) will have to establish, before it can be considered as "tried and true" as the Birmingham device?
[Dr. Mont] 8:09 pm: Hard to say about track records--I think the results are quite similar--differences noted are more dependent on surgical technique

[] 8:09 pm: Are metal ions an issue in metal on poly devices? If not, why only on metal on metal?
[Dr. Mont] 8:09 pm: metal on poly not typically an issue unless device fails
[Dr. Mont] 8:10 pm: levels of metal ions are higher in blood with MOM versus metal on poly

[Pat] 8:10 pm: Have you used a lot of Wright C+ devices for your patients?
[Dr. Mont] 8:11 pm: Used over 1600 C+
[Dr. Mont] 8:11 pm: also use many BHR and Corin

[] 8:11 pm: Is it known why?

[Jon] 8:12 pm: As a patient trying to decide betweeen BHR and C+, what parameters would you suggest I look at in making my decision (assuming the surgeon has no preference and will do either)?
[Dr. Mont] 8:13 pm: I try to be impartial to devices and try to make procedures the same regardless of device whether BHR, Corin, or C+---I'm more interested in resurfacing doing well for all companies involved
[Dr. Mont] 8:14 pm: I'm not sure it is a big issue as I feel that all will do well if implanted correctly

[Jon] 8:15 pm: Thanks - Is the claim for reduced metal ion exposure with A-Class metals legitimate, though, in your view?[Dr. Mont] 8:16 pm: these are laboratory claims--It's probably legitimate but only time will tell after analysis in patients at yearly intervals--so far data is great

[Pat] 8:16 pm: Many people complain that their operated leg feels much longer. Is this a normal feeling and what causes this?
[Dr. Mont] 8:17 pm: initially, patients may feel longer because they have an apparent leg lengthening but - this is not a true leg lengthening
[Dr. Mont] 8:18 pm: the hip abductor (outside) muscles are tight after surgery and pull the pelvis down or tilt it to operated side[Dr. Mont] 8:18 pm: this creates an apparent lengthening which can be treated by stretching in physical therapy

[] 8:18 pm: Is it possible to sleep on one's stomach immediately after surgery? I've seen lots of precautions about sleeping on the side, but not on stomach. Sleeping on the back seems problematic for a lot of people - me too.
[Dr. Mont] 8:19 pm: I don't like stomach sleeping because the anterior capsule has been cut
[Dr. Mont] 8:19 pm: sleeping on side with simple pillow between legs shouldn't be a problem
[Dr. Mont] 8:20 pm: we've recently started lowering restrictions because of low amount od instability/dislocation problems with resurfacing

[edgenowlin] 8:18 pm: In the August 08 issue of Popular Science was an article on advances in sports medicine with resurfacing being referenced for hips. Added to the description was a teaser, though, about a new procedure involving microsurgery on the joint smoothing the rough places and then in some way repairing the damaged areas with ceramic plating. Is this a new procedure or new direction being developed?
[Dr. Mont] 8:21 pm: ceramic plating I believe could refer to various synthetic partial replacements - not sure what that is referring to
[Dr. Mont] 8:22 pm: many new devices, cartilage substitutes being worked on and being developed
[Dr. Mont] 8:22 pm: these will initially be used for early stage Osteoarthritis or focal lesions
[Dr. Mont] 8:26 pm: We are currently working on a project on knees where we inject cells that produce purportedly new and normal cartilage---a great genetic engineering project

[Pat] 8:22 pm: Would a firefighter or policeman normally be able to return to active duty after hip resurfacing? Do you have any patients that have returned to active duty?
[Dr. Mont] 8:23 pm: We have scores of patrolmen/women who have returned to active duty - full duty - 1-2 firemen as well
[Dr. Mont] 8:24 pm: many patients who desire resurfacing are young and active - to me the best candidates
[Pat] 8:24 pm: There have been a lot of firefighters asking that question lately. Could they return with a MOM THR?
[Dr. Mont] 8:28 pm: firefighter could also return with any THR---I like resurfacing for them
[Pat] 8:29 pm: A firefighter with an old fashioned small ball plastic/metal THR would not have problems?
[Dr. Mont] 8:32 pm: Most people are using 32 mm heads or larger  -  36-40 for firefighters and can return without problems
[Dr. Mont] 8:33 pm: Please note that for all of these procedures the Rehabilitation is key

[Jon] 8:24 pm: A surgeon who is opposed to resurfacing, has posted some data which he claims shows that resurfacing has a higher risk than total hip replacement for dislocation in a mildly dysplastic hip. Since I have a mildly dysplastic hip, should I be concerned, or is this just coming from the current state of medical politics?
[Dr. Mont] 8:27 pm: Resurfacing has lower dislocation rates for all conditions from my data and in almost all data bases of surgeons that do many--including dysplasia
[Dr. Mont] 8:27 pm: By the way - dysplasia is my most common indication

[Pat] 8:27 pm: I get many personal emails about this subject - especially the women. No one wants to discuss it much publically. Your opinion - How soon can people begin to have normal sexual relations after hip resurfacing?
[Dr. Mont] 8:29 pm: how soon can you have sexual relations after a woman gives birth? ----- A gentleman usually waits...
[Dr. Mont] 8:30 pm: we have sheets on sexual relations and positions--contact me and I'll send them - usually full relations without restrictions between 6 and 10 weeks

[Pat] 8:28 pm: Do you do a lot of AVN cases?
[] 8:31 pm: I've done over 200 AVN cases
[Dr. Mont] 8:31 pm: We published results at 5 years of AVN with 41 of 42 successful

[Jon] 8:32 pm: As regards new cartilage substitutes, I'm one of those patients with a focal lesion (Grade IV lesion in the acetabulum). Do you have any advice for how to decide when it's time for resurfacing?, (versus whether it may be worth holding out for a year or two with the hope of a new technology coming online.)
[Dr. Mont] 8:34 pm: Jon--Grade 4 small lesion might be worth holding off on and being evaluated with scope
[Dr. Mont] 8:34 pm: Jon--have you had a hip arthroscopy?
[Jon] 8:35 pm: Yes, Dr. McCarthy last year. But still having a fair amount of groin pain.
[Dr. Mont] 8:36 pm: would like to see x-ray--more data...
My phone number at the office is (410) 601-8500. Ask for Terri, Colleen, Jean, or Jill. I will be happy to call you if you send x-rays and a brief history.
[Dr. Mont] 8:36 pm: Dr. McCarthy is an excellent doctor by the way
[Jon] 8:37 pm: Thanks very much. And yes, I think McCarthy was great.

[Pat] 8:33 pm: Have you had to do resurfacing for any teenagers? I know of several that have had resurfacings.
[Dr. Mont] 8:35 pm: We have done about 20 teenagers - am currently writing a report on resurfacing in under 25 group - have done well
[Dr. Mont] 8:37 pm: It's a lot of responsibility dealing with teenagers - but I prefer THR or resurfacing than hip fusions
[Pat] 8:38 pm: I know some doctors are pushing hip fusions and that worries parents
[Dr. Mont] 8:40 pm: however now that modern devices are doing better - I think the pendulum is swinging way away from fusions
[Dr. Mont] 8:40 pm: I just did a Hip Fusion takedown today
[Pat] 8:41 pm: Does that mean you fused the hip or took the fusion apart?
[Dr. Mont] 8:41 pm: much prefer THR or resurfacing in young patients - they can be close to normal activity
[Dr. Mont] 8:41 pm: Converted the hip from a fusion to a THR

[] 8:34 pm: In your last chat, you mentioned that spinal anesthesia is used for shorter procedures, that longer ones require general or epidural. What is the difference between spinal anesthesia and epidural? I've also heard of a nerve block being used. Is this another type of anesthesia?
[Dr. Mont] 8:42 pm: spinal and epidural are similar
[Dr. Mont] 8:42 pm: spinal is shorter acting
[Dr. Mont] 8:43 pm: epidural can be left in place post-op for pain control after op
[Dr. Mont] 8:43 pm: various nerve blocks used more for knee surgery

[Jon] 8:43 pm: Could you say more about what constitutes proper rehab. E.g., would it be something a typical PT could handle or are there special resources you'd recommend?
[Dr. Mont] 8:44 pm: Typical rehab was designed for patients years ago who had average age of 76 years
[Dr. Mont] 8:44 pm: also--they had all worries about dislocations with small heads/posterior approaches
[Dr. Mont] 8:45 pm: With resurfacing - less worry about dislocation risk and younger patient age

[] 8:45 pm: I've read great things about Sinai's rehab dept. Is there any way to keep them involved with the rehab process for out-of-towners?
[Dr. Mont] 8:45 pm: we want more than simply walking so need to do more aggressive physical therapy
[Dr. Mont] 8:46 pm: I typically have my Rehab head see the patient at least once and then he can communicate with the therapists from around the country
[Dr. Mont] 8:47 pm: For some patients with multiple joint problems, I encourage a pre-op eval and sometimes a gait study to see where we are starting from

[JimS] 8:47 pm: Well, I have only recently begun researching resurfacing as an alternative to the THR I was told I required. This is due to my age (49) and activity level (high). My concern is dislocation, revision frequency, bone loss, etc. etc.
[Dr. Mont] 8:49 pm: Dislocation close to nonexistent, your age group revision frequency same as THR from Australian registry--should be quite low at mean 5 year follow-up, ???bone loss

[Jon] 8:50 pm: re: Rehab. Great! (That's the approach I've been looking for.) For patients with both lumbar and hip issues, is it often the case that you see the lumbar issues resolve/do better post resurfacing?
[Dr. Mont] 8:50 pm: Yes - lumbar issues can resolve

[JimS] 8:50 pm: My reading has led me to believe that some of the acetabulum inserts are responsible for pelvic bone loss. This is also the situation that one of my colleagues at work is dealing with and required a bone graft prior to her first revision.
[Dr. Mont] 8:50 pm: we need to know where we are starting from to help plan post-op rehab individually
[Dr. Mont] 8:51 pm: I don't like to leave it up to random chance--you'll just get better with general rehab
[Dr. Mont] 8:52 pm: Many earlier generation poly insets led to micrparticles that set off inflammatory response and led to bone loss
[Dr. Mont] 8:52 pm: This is much less of a problem at least in mid-term - at approx 10 years with modern inserts

[JimS] 8:53 pm: That is the type of product my surgeon uses exclusively for the past 20 years, and thus my concern.
[Dr. Mont] 8:54 pm: many of inserts have improved in quality over last 20 years--more cross-linking, etc.

[Jon] 8:55 pm: Patients with general OA often report having a very quick "meltdown" (i.e., hip degenerates very quickly). Would you also expect this scenario in those of us with specific lesions?
[Dr. Mont] 8:56 pm: quick meltdown is not typical of OA but more common in RA-Rheumatoid arthritis or AVN
[Dr. Mont] 8:57 pm: There is a condition called Rapidly Progressive OA--but probably in AVN patients
[Dr. Mont] 8:57 pm: Jon--your probably talking about symptoms
[Dr. Mont] 8:57 pm: pain---not X-ray appearance

[Pat] 8:57 pm: I had a question about a 65 year old man recently. They are recommending a THR and I said if he was active - he should check out hip resurfacing. With good bone stock, would you do a 65 year old man?
[Dr. Mont] 8:58 pm: I've done plenty of 60 and 70 year olds - if they have good bone stock and are active--they can do well
[Dr. Mont] 8:58 pm: age is relative also

[Jon] 8:58 pm: Thanks. Yes, it was probably pain that people were talking about (and I suppose that could be related to synovitis and other issues)

[lbh425] 8:59 pm: This chat maybe a little out of my league, all I know is I have AVN in both hips and have been putting off resurfacing because of insurance referrals. I was first turned down for stem cell therapy a year ago. My quality of life is slipping fast. I am on a pain meds, How long do most patients last before they require replacements?
[Dr. Mont] 9:00 pm: lbh---should see your x-rays
[Dr. Mont] 9:00 pm: I'm happy to talk individually with any one of you--though would like to see x-rays first
[Dr. Mont] 9:01 pm: you don't want to wait to long if you want resurfacing--because you might lose your remaining bone stock of head if you have AVN
[Dr. Mont] 9:01 pm: lbh  just need x-ray if its been that long

[JimS] 9:01 pm: I would be very interested in further discussions. I can obtain my 2001 and 2008 xrays and provide them.
[Dr. Mont] 9:02 pm: 2008 fine--Jim-----call Terri at 410-601-8551/8500--to send

[edgenowlin] 9:02 pm: Good to hear age is relative; I'm 65 & am focusing on bilateral resurfacing; when you have a bilateral case, do you perform both at the same time & do you have the patient have blood stored "in case"?
[Dr. Mont] 9:03 pm: I do bilateral 1 week apart--I think that is safest option

[Pat] 9:02 pm: I would like to Thank Dr. Mont for taking time to talk with us. I think we learn a lot each time we have a chat.
[Dr. Mont] 9:03 pm: Pat --I want to thank you once again for making this possible
[Dr. Mont] 9:04 pm: your welcome