[Pat]
7:57 pm: Welcome to our Chat with Dr. Mont
[Pat] 7:57
pm: Dr. Mont is from Baltimore MD and has done over 1600 hip
resurfacings.
[Dr. Mont] 7:57 pm: Hi Pat and everyone.
Thanks again Pat for hosting this educational session.
[Pat] 7:58 pm: Thank You for giving your time to help answer
questions.

[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