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This is a transcript of a
Live Chat in the Surface Hippy Chat Room with Dr. Schmalzried on
February 4, 2009
[Pat]Welcome to the Surface Hippy Chat Room Dr. Schmalzried. Thank You for taking
time to chat with us.
[Dr. Schmalzried] 8:57 pm: You are most welcome. I
enjoy the interaction.
[Pat] 8:58
pm: I had a policeman recently ask if he could return to work after resurfacing. If he doesn't join us - maybe you can tell us about policemen and
firemen that have returned to duty.
[Dr.
Schmalzried] 8:58 pm: I
have some of each but the most impressive is an active duty Navy Seal with
bilateral MMSR.
[Dr. Schmalzried] 8:59 pm: He has had several
tours of duty since surgery. He sent me pictures with Ollie
North!
[] 8:59 pm: What type of prosthesis do you
use Dr Schmalzried?
[Dr. Schmalzried] 9:00 pm: I have used 4 resurfacing
systems. C+, BHR, Cormet 2000 and ASR.
[] 9:00 pm: Why are so many x-rays needed
in the months & years following surgery? Would another surgery be necessary
if something didn’t look quite right?
[Dr. Schmalzried] 9:01 pm: The x-rays are used to a) document the original
position of the implants and the condition of the bone and subsequent films are
compared to those for change.
[stevel] 9:00 pm: I understand you allow impact sports at 3
months. Is there a concern of fracturing the femoral neck or loosening the
femoral cap?
[Dr. Schmalzried] 9:02 pm: There is always concern for adverse outcomes at all
times! My 10 year experience indicates that impact sports at 3 months do not
pose a risk - I have never had a femoral neck fracture or a loose
component!!!
[pmberman] 9:02 pm:
I have heard ASR saves a lot more bone than BHR. Is that true?
[Dr. Schmalzried] 9:03 pm:
The bone removal with the ASR is less on both the femur and the
socket.
[stevel] 9:03 pm: Has there been a
problem with insurance denying payment for installation of non FDA approved
devices such as ASR and Conserve Plus?
[Dr.
Schmalzried] 9:03 pm: Some insurance companies
require an FDA approved device.
[deserthippy] 9:04 pm: What is you view on lifting weights,
powerlifting, olympic lits, crossfit, etc?
[Dr.
Schmalzried] 9:05
pm: No limitations - the key is the rate of increase. It's like running a
Marathon - you have to train and build up.
[Dr. Schmalzried] 9:06 pm: Pretty much any activity the patient desires is OK as
long as the rate of intensity increase is reasonable.
[] 9:05
pm: I am concerned about the placement of my device. The stem protrudes a little
out of the cortex. With the lateral xray, a couple of other doctors said it may
be common.
[Dr. Schmalzried] 9:06 pm: Hard to comment on a specific case without details. MOst places take an x-ray right after surgery - other than that there may be not
info.
[Britguy] 9:05 pm: Dr., I had a BHR
last August and went two weeks not knowing that it was dislocated until I went
back to have the staples removed. Shouldn't there have been a way that the
staff at the hospital would have suspected all was not well?
[Dr. Schmalzried] 9:08 pm: Hard to know
when it came out. Are you good now?
[Dr.
Schmalzried] 9:07 pm: How are you now?
[Bionic] 9:07 pm: Hi Dr. S: Many patients who post on this site
have reported night sweats and dry skin in the weeks immediately following hip
resurfacing surgery. Do you find that this is common? Does it also happen to
your patients who have had THRs?
[Dr. Schmalzried] 9:08 pm: I don't recall people complaining about
that.
[] 9:07 pm: My
post op xray shows it but they haven't duplicated it in follow-ups
[Gilden] 9:08 pm: I am 14 weeks post hip
resurfacing and still have pain in the groin and buttocks; X-rays show that
surgery was very successful and uncomplicated. Is there anything (e.g, certain
exercises) I can do (other than take muscle relaxants) to help decrease the
muscle spasms and pain?
[Dr. Schmalzried]
9:09 pm: Massage and light exercise - stationary bike. Stretch. NSAID's.
[Dr. Schmalzried] 9:09 pm: Be patient. Healing is a
process.
[Bionic] 9:09 pm: I
know you haven't had any loosenings to date, but in general what happens when
HSR fails due to component loosening? Does it start to hurt? Is it possible to
continue functioning with loose components as long as they don't shift
position?
[Dr. Schmalzried] 9:10 pm: Pain is the usual symptom when
the components are loose. It is often subtle at first - usually with unusual
activity but then occurs with lesser stresses.
[stevel] 9:10 pm: Do you allow downhill skiing at 3 months? What
about a fall? Is the new hip no weaker than the normal hip?
[Dr. Schmalzried] 9:11 pm: Yes on the skiing. If you fall -
worry about your head and neck - not your hip!
[Dr. Schmalzried]
9:12 pm: I suggest the same rule for return to skiing - start with easy runs and
build. Always stop early before you get tired.
[deserthippy] 9:11 pm: What's your view on longevity of the
prosthesis? Does it depend mostly on the bone density of the
femur?
[Dr. Schmalzried]
9:13 pm: There are many factors contributing to the longevity of the arthroplasty. The quality of the bone and soft tissues as well as the position
and fixation of the parts.
[Britguy] 9:12 pm: I had the operation
performed again with none of the complications but still am having a lot of
weakness and not normal feelings in the front inside thigh area. The surgeon
said that he repaired what he could but was vague as to how damage had occurred
with it being dislocated for the two weeks.
[Dr.
Schmalzried] 9:13 pm: Are you dooing PT?
[] 9:14 pm: With no pain no gain in
mind, how far should you push the strengthening process. I tend to overdo. Feel
good one day and exercise too much the next.
[Dr. Schmalzried]
9:14 pm: Try to avoid those mornings when you wake up and you know that you did
too much the day before. You want a slow steady course.
[Gilden] 9:14 pm: follow up question on stretching: what kind of
stretches do you recommend? How long should the stretch be held? (there are so
many different schools of thought on stretching, it's hard to know exactly
what/how to do it post hip resurfacing.
[Dr. Schmalzried] 9:16 pm: Stretching - the
3 T's: temperature, tension and time. Always break a sweat first. Apply low
tension and hold it for at least a 10 count - then reapply a little more
tension...etc.
[Britguy] 9:15 pm: I use a recumbent bike daily as well as the
treadmill when I can.
[JohnC] 9:16 pm: After successful
Resurfacings, some of us may still have unrelated pain in aging knees or other
joints. How do you feel about the use of Celebrex or other related drugs to
manage these other issues, in terms of any affects that it may have on femoral
bone remodeling, bone health around the prosthesis, or any other issues related
to the resurfacing? I am currently seven months out; does your opinion on this
issue change with time?
[Dr. Schmalzried] 9:17 pm: I like NSAID's and suggest you
use them as needed. No good clinical data on adverse outcomes with total
joints.
[] 9:16 pm: How long do you
suggest waiting between having one hip done till you have the
other?
[Dr. Schmalzried] 9:17 pm: I suggest a minimum of 6 weeks
in between bilaterals.
[Dr. Schmalzried] 9:18 pm: deserthippy -
which desert?
[deserthippy] 9:19 pm: Sonoran desert in
Tucson
[Dr. Schmalzried] 9:19 pm: Nice.
[Dr. Schmalzried] 9:19 pm: Golfer?
[deserthippy] 9:19 pm:
Triathlete
[deserthippy] 9:19 pm: basketball
too
[stevel] 9:19
pm: Do you recommend glucosamine after hip resurfacing, when the other joints do
not have arthritis?
[Dr. Schmalzried] 9:20 pm: Glucosamine does not appear
to have much adverse - so sure - why not.
[] 9:19 pm: I hear JohnC, all of my joints
hurt in my legs, but you cant replace everything.
[Dr. Schmalzried ]9:20 pm: We would all love to be 22 again - some experts are
working on that - but I can't help there!
[obxpelican] 9:20 pm: which devices do you commonly use for
HR?
[Dr. Schmalzried] 9:21
pm: I use the C+, the BHR, the Cormet 2000 and the ASR.
[Dr. Schmalzried] 9:23 pm: No
differences in the clinical outcomes of the 4 systems in my hands at this
time.
[wayne-0] 9:20 pm: How much time til the
muscles are fully healed and holding the implant in place
[deserthippy] 9:21 pm: so you don't advocate epo or
hgh?
[obxpelican] 9:21 pm: do you see any
difference in results one over another?
[Dr.
Schmalzried] 9:21
pm: The soft tissues continue to mature for 18 months or more! They are "good"
enough by about 3 months.
[Dr. Schmalzried] 9:22 pm: Epo is
indicated for some patients pre-op. I can't comment on other uses of
those!
[Bionic] 9:22 pm: What are the symptoms of
component loosening? Can a person live with a loose component for a while, or
does it require immediate action?
[Dr. Schmalzried] 9:24 pm: Pain is the most common
presentation of a loose component. Depending on the level of stress - some
people manage well of months to years.
[obxpelican] 9:24 pm: do you have a favorite to
install?
[Dr. Schmalzried] 9:24 pm: I greatly prefer the ASR -
but I have a bias as one of the developers of that system.
[deserthippy] 9:24 pm: If you were a betting man how would you
place your bet regarding average longevity of HR's?
[Dr. Schmalzried] 9:25 pm: No need to bet.
The data is already out. For people under 65 - not small stature - the 6 year
survival of HR is better than THR!!!!!
[Dr.
Schmalzried] 9:28 pm: In the "at risk"
patients - young, active, etc. - the data favors HR.
[] 9:25 pm: What metals are the ASR made of and are there new
surfaces being tested?
[Dr. Schmalzried] 9:26 pm: The
ASR is a CoCrMoNi alloy - similar to the others. Ceramics and polymers are being
evaluated.
[chrisb9341]
9:27 pm: I am 2 yrs post op and running @15 miles per week along with alot of
gym exercise. I would like to push the mileage up to @30 per week but am afraid
of maybe damaging the hip somehow. What are your thoughts on
running/jogging.
[Dr. Schmalzried] 9:28 pm: I have a patient - 7 years out - has completed 3
ultra-marathons and his hips look great.
[Bionic] 9:29 pm: Do you think it's possible
that running and other impact sports actually help the implants to stay
attached?
[Dr. Schmalzried] 9:29 pm: These things are hard to do
this way - there are many factors - but I want you to know what's
possible.
[Dr. Schmalzried] 9:30 pm: I believe that there is an
"activity window" for each patient - they need to have a certain level of joint
stress to maintain the bone and the fixation.
[Dr.
Schmalzried]
9:31 pm: I don't know where the upper limit is.
[Bionic] 9:31 pm: So, stress in moderation may be a good thing.
But all out sprinting for a 200 pound man is probably pushing
it.
[] 9:32 pm: what about lifting weights - good
or bad?
[Dr. Schmalzried] 9:32 pm: I agree with
the moderation concept. I don't know about the top. I have one patient who is an
NBA official and he runs hard several nights a week. Stay tuned!
[JohnC] 9:32 pm: Because of my summer
activities around coral reefs that involve many minor cuts and minor infections,
do you have any thoughts on minor skin infection management and treatment as it
relates to HR prosthesis.
[Dr. Schmalzried] 9:33 pm: Keep the cuts clean. Take antibiotics if they get
"angry". Stay in good general health.
[wayne-0]
9:33 pm: At what point after surgery is the femoral head back to it's maximum
strength?
[Dr. Schmalzried] 9:34 pm: No real data. Bone can get
stronger in proprtion to stress. Maybe a better question is when is it similar
to pre-op.? I think that is in the 6-12 week window.
[Gilden] 9:34 pm: how long does the pain
last post-op? At 14 weeks out after an uncomplicated surgery, I still have
significant pain and take a muscle relaxant and pain med; both help a lot, but
I'm concerned about dependency. I know that people heal at different rates, but
I've been told to expect pain for as long as six months. Is this
typical?
[Dr. Schmalzried] 9:35 pm: Pain for 6 months is unusual. Get a second
opinion.
[deserthippy] 9:35 pm: So do you think
generally that it takes at least 12-18 months before one is able to push it
100%? Like a 300 lb squat or a 5 min mile?
[Dr.
Schmalzried] 9:36
pm: More like 6-12 months.
[Bionic] 9:37 pm: Very cool. I thought my
days of squatting were over.
[Dr. Schmalzried] 9:37 pm: You see -
it takes stress to get the bone and soft tissues stronger. The key is the rate
of stress increase.
[deserthippy] 9:37 pm:
gotcha
[Dr. Schmalzried] 9:38 pm: I have taken care of a couple
of strength coaches who like to squat. The key is the rate of stress
increase.
[deserthippy] 9:38 pm: depth of squat
seems to be the initial obstacle for me
[Bionic]
9:38 pm: I figure I'll start with body weight (which is substantial :)
)
[Dr. Schmalzried] 9:39 pm: Good.
[] 9:39 pm: I had one person asked if they could
return to surfing? Have you done any serious surfers?
[Dr. Schmalzried] 9:39 pm: Yes -
many "serious" surfers - big waves. I have lots of photos!
[] 9:39 pm: Are there complications if a person doesn't get much
exercise following HR?
[Dr. Schmalzried] 9:40 pm: Not that I know of. The issue is compared to what? How
much better that person would be with exercise?
[stevel] 9:40 pm:
Will the hip resurfacing device wear more when backpacking a heavy weight (say
80 pounds) over a long distance over mountainous terrain?
[Dr. Schmalzried] 9:41 pm: Not necessarily. Once it is worn in - and the
components are well positioned - the synovial lubrication can keep the wear rate
down regardless of load.
[Bionic] 9:41 pm: So it sounds like exercise is really good
medicine after resurfacing. It keeps the implants happy and well
protected.
[Dr. Schmalzried] 9:42 pm: Again - the
issue is the rate of return to "vigorous" activities. The more energy - the more
risk of injury to all body parts!
[Bionic] 9:43
pm: Have any of your patients had problems with metal ions? Do you think these
problems are in the realm of rare complications?
[Dr. Schmalzried] 9:44 pm: I have one patient that had an adverse local tissue
reaction - so in my series it is rare.
[] 9:45 pm: Do you think high metal
ions are most likely due to misplaced acetabular cups causing a high wear
rate?
[Dr. Schmalzried] 9:47 pm: Component position plays a role in ion
levels for sure. However, some people are sensitive regardless.
[Britguy] 9:46 pm: Dr., Have you had or
heard of anyone having a dislocation between the recovery room and their room?
My biggest problem was not being able to bend my leg in any position and had to
keep it straight out when sitting. After the second operation I could bend the
leg with little discomfort.
[Dr. Schmalzried] 9:47 pm: Let's stay on the ions - but dislocation can occur
early after surgery.
[Pat] 9:47 pm: I
have heard of a few cases of revisions due to high metal ions and metal
allergies from the Discussion Groups and private mail
[Dr. Schmalzried] 9:48 pm: High ion levels
per se may not be enough to justify a revision. If the patient is not feeling
good - that is the key for me.
[Bionic] 9:49 pm:
I think people see ions as the only potential drawback to resurfacing, but many
of us are not convinced that it's a real issue, at least for most
people.
[Dr. Schmalzried] 9:49 pm: The diagnostic criteria for metal allergy are not well
defined and we need to be careful on what we call things.
[] 9:49 pm: It seems some of the patients don't have a lot of pain
- but some surgeons suggest revisions when they find out they have high level of
metal ions.
[Dr. Schmalzried] 9:50 pm: I would
never argue with a conservative position - but revision surgery is risky and we
need to be sure that the benefit of revision out-weights the
risks!
[Pat] 9:51 pm: I always tell patients to get
second opinions from the really experienced surgeons. Always good to have as much
input as possible.
[Bionic] 9:51 pm: A couple of patients
posted on WebMD saying they felt sick after hip resurfacing and were later
tested and found to have extremely high ion levels. Personally, I suspect those
people may have kidney problems, but at least according to their reports, the
problems were brought on by the operation.
[Dr.
Schmalzried] 9:52
pm: When things are not as good as usual, it is helpful to have a fresh set of
eyes look things over.
[Gilden] 9:49 pm: another question from me
at 14 weeks post-op from uncomplicated HR: most of my pain (groin, buttock) is
when I'm sitting, not when I'm walking nor when on the recumbent bike or
elliptical. Driving a car is the most painful period. Is this to be expected
post-op? Or could it be some other joint issue acting up?
[Dr. Schmalzried] 9:49 pm: Pain with sitting can be
from a spine problem.
[] 9:52 pm: If a revison is
needed, what is usually recommended - THR?
[Pat] 9:53 pm: Please remind folks that the
serious problems for resurfacing are few and far between. Sometimes we get
focused on the negative instead of all the positive.
[Dr. Schmalzried] 9:53 pm: When there are issues with a resurfacing - the usual
move is a conversion to a total hip.
[Dr.
Schmalzried] 9:54
pm: I agree with Pat - most HR patients are highly satisfied and highly
active.
[stevel] 9:54 pm: Is it possible to revise
an improperly placed socket (too steep an angle) and keep the femoral head
cap?
[Dr. Schmalzried] 9:55 pm: Yes - the socket can be
revised to a better position.
[DirkV] 9:56 pm: hi. i recently posted a
question based on some rounded numbers from bicycle riding: 10 hr per week. avg
cadence of 85 = 51,000 pedal strokes *per week*. any concern? one person said he
thought it would all be synovial fluid, not metal on metal.
[DirkV] 9:56 pm: re the cycling, it's all in a relatively small
rom
[]Dr. Schmalzried 9:56 pm: Should be OK. How do you
feel?
[DirkV] 9:56 pm: great
![Dr. Schmalzried] 9:57 pm: If it feels good, and it's not
illegal or immoral - go for it!
[] 9:56 pm: After my 2 surgeries (done by you Doc), &
comparing with others, I TOTALLY agree that HR is the way to go if at all
possible.
[] 9:58
pm: vk1105 - thank you. pmberman - socket position is key. I think that patients
should ask the prospective surgeon how he verifies the position. See how he
answers.
[pmberman] 9:57 pm: sorry to be late to
the discussion, but you mentioned socket position. Are issues with ions and
sensitivity mostly the result of bad placement of the socket. And how can
patients be sure they are going to a surgeon who will get it
right?
[Dr. Schmalzried] 9:59 pm: If the surgeon plays down the
socket position issue - see someone else!
[Dr.
Schmalzried] 10:00
pm: In the past 5 years, we have moved from femoral issues to socket issues.
Getting the socket right is the focus today.
[Pat]
10:00 pm: Dr. Schmalzried - Thank You very much for taking time to answer all
our questions.
[Pat] 10:00 pm: I know people really
appreciate your help and input.
[Dr. Schmalzried] 10:01 pm: I enjoyed it!
[Dr.
Schmalzried] 10:01 pm: You are all welcome. I
appreciate your interest. Visit our JRI website too!
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