This is a transcript of a Live Chat in the Surface Hippy Chat Room with Dr. Schmalzried on November 19, 2008
[Pat Walter] 9:00 pm: I would like to welcome Dr. Schmalzried to the chat room. Thank You for taking time to be with us.
[burch07] 8:51 pm: Could bursitis be the cause of swelling, pain and immobility on a 3 yr old HRS? Two OS have told me that it is very unlikely. [Dr. Schmalzried] 9:01 pm: I doubt that bursitis could cause all those symptoms. 9:00 pm: Dr., which brand of resurfacing hip do you use most ? [Dr. Schmalzried] 9:01 pm: I use the ASR most, then the Cormet 2000 but have also used the C+ and the BHR. [aroepke2662] 9:00 pm: What is the best maintainance exercises for a bilat 61 yr old with good bone? rt c+ 3/08, lt c+11/11 [Dr. Schmalzried] 9:03 pm: I like bicycling for exercise. Yoga is good too. Swimming never hurts. I don’t have any restrictions – so impact activities are OK if you cna handle it! [sfr] 9:02 pm: I need to have my BHR converted to a THR (my cup was placed too deep and severely limiting my ROM as well as protrusio). 3 surgeons agree on this point. What they disagree on is whether to do bone grafting vs. a reinforcement ring. What’s your opinion and experience with this? [Dr. Schmalzried] 9:04 pm: I don’t think that a reinforcement ring would be necessary. The cementless cups available today can solve most issues without bulk bone graft.
[ajp] 9:02 pm: hi, is sharp upper thigh pain on weight bearing only, two weeks after resurfacing in the face of normal xray cause for concern [[Dr. Schmalzried] 9:05 pm: Two weeks after surgery is really early. Sit tight – you are probably just sore from the operation.burch07] 9:02 pm: Could Bursitis cause swelling, pain, immobility in a 3 yr old HRS? [Dr. Schmalzried] 9:05 pm: Tough to tell without seeing x-rays.  9:06 pm: Dr. Schmalzreid did both of Vern’s hips resurfacing (July & Oct.) We highly recommend him – He did an excellent job & is a very personable Doc! He’s the best! –from Vern & Sherry in Colorado.
[ajp] 9:07 pm: which devices do you like, do you like different ones for certain patients [Dr. Schmalzried] 9:07 pm: I like the ASR but I have a bias as I was one of the developers of that system.
[Bob Singer] 9:07 pm: Dr. S: A question has arisen on Surface Hippy: If the ASR resurf device is not FDA approved, why do you use it? I responded to that with: their clinical trials are done, Depuy must have a reasonable case for approval. [Dr. Schmalzried] 9:11 pm: The FDA approval process moves at a rate that the surgeon has no control of. I was an investigating surgeon in the FDA trial of the ASR and have great results -no failures.[aroepke2662] 9:10 pm: Any problems you know of with conserve plus? [Dr. Schmalzried] 9:11 pm: The C+ has worked very well in my hands. I have >8 year follow-up with this device.  9:10 pm: Would you consider using the Brain Lab Hip Essential the best method for the Birmingham ? [Dr. Schmalzried] 9:12 pm: Navigation can be helpful but there is no data as yet to show that the outcomes are better – in the hands of an experienced surgeon. The best benefit may be for the new surgeon. [Bionic] 9:10 pm: Hi Dr. Schmalzried. It seems to me the different devices are very similar to each other. What are the big differences from the patient’s point of view. Also, I know the early devices had some problems with tolerances–I think the two components had the same radius, which lead to lockup. Do all the current devices use approximately the same clearance? [Dr. Schmalzried] 9:14 pm: There is difference in the clearances – and it makes a difference in lab studies of wear – and some clinical studies – low clearance has less wear and lower ion levels.
[Amy] 9:11 pm: I’m 54 yr old active female, xrays show cyst, should I consider resurfacing? [Dr. Schmalzried] 9:13 pm: The cyst, by itself, is usually not a problem. If your bone density is good – and the shape of your head and neck are good – resurfacing is probably a good option.[Gilden] 9:12 pm: Dr. S: are there typically any problems with leg length discrepancies post op HR, and if so, can it be fixed during surgery? I’m assuming the surgeon would typically assess for this potential problem during surgery? (I forgot to ask him about it prior to my surgery) [Dr. Schmalzried] 9:17 pm: Limb length can be an issue with resurfacing – but probably less than with THR. Our data indicates that on average we gain 4mm of length. [daniel] 9:12 pm: I am here in Germany, and had the Birmingham used, is it common practice for a rep of the device to attend the surgery? This doctor attends all surgeries this device is used in, within Germany, so although my surgeon had not many procedures behind his belt, I was 21…this other Dr has had thousands [Dr. Schmalzried] 9:17 pm: It is common to have the rep in the room at surgery. [daniel] 9:14 pm: My surgery was yesterday:) [Pat Walter] 9:14 pm: Hi Daniel – you are doing great! Congratulations! [daniel] 9:14 pm: Thanks Pat…. [nslocum] 9:15 pm: Hi Dr. Schmalzried, What is your response to the recent research and 11/8 NY Times article showing “red flags” for doing the hip resurfacing procedure on women? [Dr. Schmalzried] 9:16 pm: The Aussie registry, and the experience in several single-surgeon series show higher failure in women. More recent data indicate that it is more related to SMALL SIZE. Probably the fundamental variable is cross sectional bone mass – the short term failures are usually neck fracture. [Dr. Schmalzried] 9:20 pm: Resurfacing can be done on women with great success. It is not a gender issue per se. It is a bone mass issue. Anyone with decreased bone mass has a higher risk of FNF. [Dr. Schmalzried] 9:20 pm: Femoral neck fracture – FNF.  9:18 pm: Recently I discovered Smith and Nephew had a recall on Birmingham due to product packaging misslabelling. Who usually notifies the patient, the Dr., the hospital, or Smith and Nephew of a possible problem ? [Dr. Schmalzried] 9:21 pm: No data on the S&N recall. [tammy] 9:20 pm: can you talk about leg length issues? [Dr. Schmalzried] 9:21 pm: Our data indicates that we gain and average of 4mm with resurfacing. [james] 9:21 pm: what do you think of bone density drugs like fosamax? [Dr. Schmalzried] 9:22 pm: I like a combination of nutrition, exercise and – in appropriate patients, chemical treatment of osteoporosis. [Gilden] 9:22 pm: in terms of post HR surgery activities, do you allow your patients to engage in downhill snow skiing? (provided that moguls and high speeds are avoided?) [Dr. Schmalzried] 9:23 pm: I do not discourage any activities. There is no data on “appropriate” post-op. activity – and I have researched and published more on this topic than anyone. [nslocum] 9:22 pm: Back to the size issue. I am a small/petite woman, at 5’4″. How can I determine if a hip resurfacing is a good option for me? How do I know if my bone mass is sufficient? [Dr. Schmalzried] 9:24 pm: For the petite woman – I can usually tell by looking at your hip x-rays. [ajp] 9:23 pm: How early and how late do most of the femoral neck fractures occur. The 4mm is that over and above patients normal anatomy or return to their normal before loss of cartilage [Dr. Schmalzried] 9:24 pm: Most FNF occur within the first 6 months. [Dr. Schmalzried] 9:24 pm: The 4mm is more than they were just before surgery. [Amy] 9:23 pm: How many female FNF have you experienced? [Dr. Schmalzried] 9:25 pm: I have not had any patient have a FNF – yet! [Bionic] 9:24 pm: I am still confused by the plethora of different implants on the market. As far as clearances are concerned, which implants do you think are best? Is implant selection something patients should be concerned about, or do you feel it’s more about the physician’s preference? [Dr. Schmalzried] 9:25 pm: The ASR has the smallest clearance. I think that the surgeon should choose. [daniel] 9:25 pm: Is there any data on rehab? I am in the hospital for 6-10 days, start rehab today (CET), and then I am trying to get into an in-patient rehab hospital for more intense rehab. [Dr. Schmalzried] 9:26 pm: Little data on rehab. The patient is the biggest source of variability. [burch07] 9:25 pm: Thanks for the response regarding bursitis. OS can not find source of problem of pain, swelling, immobility 3 year after HRS. X-ray, CT, bone scan, aspiration show components have not moved or loose and no infection. Any ideas, I am at wits end. Thanks. [Dr. Schmalzried] 9:27 pm: Have you had an ultrasound? If there is a large fluid collection, it could be a sign of metal sensitivity. [sfr] 9:26 pm: What is metallosis and who is at risk? Symptoms? [Dr. Schmalzried] 9:28 pm: Metallosis is high wear if the bearing with the generation of lots of metal wear particles. It is usually a result of sub-optimal component positioning. [nslocum] 9:26 pm: If a hip resurfacing fails (neck of femor fracture), does it complicate a subsequent revision to a THR? My thinking was that I should go ahead with the resurfacing and, if I am not in the fortunate 94% of women for whom the procedure works, I would simply revise to a THR at that point. I was willing to accept the risk/possibility of some pain (it must hurt when the neck of the femor breaks) and inconvenience (no one likes to have to go through surgery and the concomitant recovery process. [Dr. Schmalzried] 9:29 pm: There are now 2 studies – Amstutz series and Mont series – indicating that the conversion of a SR to a THR gives a good result. [tammy] 9:27 pm: Do you ever go into the surgery with the intention of doing resurfacing, but once inside, decide that a hip replacement is what is needed? [Dr. Schmalzried] 9:30 pm: I make the decision before surgery – I am pretty selective on resurfacing. We published selection criteria in 2005 and I stick pretty close to them – so I don’t have to make decisions in surgery. [james] 9:28 pm: what generally would contribute to femoral neck fracture within 1st six months? too much impact too soon? what were folks doing when it happened? [Dr. Schmalzried] 9:31 pm: FNF is basically a mis-match between the strength of the neck after surgery and the loads imposed on it by the patient activities. The factors include the density and size of the femoral neck, the quality of the surgery and the activity of the patient. [Amy] 9:29 pm: How can you determine “good bone density” prior to surgery? [Dr. Schmalzried] 9:32 pm: Bone density can be assessed on the x-rays and by a DEXA scan. [sfr] 9:29 pm: If components are positioned incorrectly, how long before metallosis can occur? [Dr. Schmalzried] 9:33 pm: If the components are well-made and well-positioned – metallosis will not happen. [Bionic] 9:30 pm: Dr. S: Do you recommend that patients be tested for metal sensitivity before receiving MOM implants? [Dr. Schmalzried] 9:33 pm: There are no good tests for metal sensitivity to deep implants.  9:31 pm: How can you find out if you have elevated metal ion levels and or metalosis which is what the Smith and Nephew Urgent Medical Device Recall may happen if you received a mislabeled Birmingham. [Dr. Schmalzried] 9:34 pm: Ion levels can be determined by a blood test. The issue is what level is too high? [email@example.com] 9:33 pm: Hello Dr I am looking forward to getting my hip done by you in 2.5 weeks and was wondering if you use Biomet ? [Dr. Schmalzried] 9:35 pm: I have not used Biomet. There is not good data on gender and sensitivity yet. Women may be more sensitive – but it is not clear. [nslocum] 9:33 pm: I was told by a reputed surgeon in Boston that women have a higher rate of allergic reaction to the metal ions released over time from the metal on metal prothesis? What do you know about this? [tammy] 9:33 pm: Has there been any problem having insurance cover the non FDA approved devise that you use? [Dr. Schmalzried] 9:36 pm: Some insurance companies do balk – but I also use FDA approved devices. [firstname.lastname@example.org] 9:36 pm: What device do you use ? [Dr. Schmalzried] 9:37 pm: I mostly use the ASR and sometimes the Cormet 2000 – I have also used the C+ and the BHR. [Gilden] 9:36 pm: I’m five weeks post op HR by a highly experienced HR surgeon, and my MD has released me from crutches and hip precautions. Are there any particular physical therapy exercises that you like at my stage of recovery? [Dr. Schmalzried] 9:37 pm: I would stretch for abduction, external rotation and flexion. I like the stat. bike and swimming at this stage. [sfr] 9:37 pm: What type of pain meds do you prescribe most for ongoing, chronic pain? [Dr. Schmalzried] 9:38 pm: I don’t recommend pain meds. I try to find the cause and recommend treatment. [nslocum] 9:38 pm: Why don’t the protheses come in smaller sizes? My surgeon thinks the smallest Birmingham will not fit me but thinks one of the smaller Styker protheses will? Does the rod change size proportionately with the size of the prosthetic head of the femor (ball)? [Dr. Schmalzried] 9:39 pm: Some systems have smaller sizes and some have proprotionate pins. For example, the ASR and C+ have small sizes and proportionate pins. [tammy] 9:39 pm: Do you do a spinal? Do you use cement? [Dr. Schmalzried] 9:40 pm: Spinal – yes. Cement on the femur. [Bionic] 9:40 pm: Dr. S: What is your take on uncemented femoral implants with porous bone ingrowth surfaces? [Dr. Schmalzried] 9:41 pm: Uncemented femurs were used at UCLA in the 1980’s and they can work. There is little data on cementless femurs with the current generation implants.  9:40 pm: If an x ray reveals an oversized Birmingham hip that does not fit the femoral neck that is placed in 120 degree of angulation and is having substantial varus with clear lucent lines around the prosthesis does this sound like more of a surgen error, or the mislabeled Birmingham error or possibly both ? [Dr. Schmalzried] 9:43 pm: Not proper for me to comment on a specific case. Would need to review in detail. [daniel] 9:40 pm: screw the spinal…I slept like a baby yesterday during my procedure, no reason to smell and hear the stuff going on, LOL [Dr. Schmalzried] 9:42 pm: With a spinal – we still put the patient out. [Dr. Schmalzried] 9:42 pm: The spinal can keep the legs numb for 24 hours. [nslocum] 9:43 pm: Do you usually have patients do a CT scan pre-op? [Dr. Schmalzried] 9:43 pm: NO pre-op. CT. [tammy] 9:43 pm: Do you think a hospital rental bed for the home following surgery is necessary? [Dr. Schmalzried] 9:43 pm: NO rental bed.
[email@example.com] 9:43 pm: How long is the hospital stay typically for resurfacing surgery [Dr. Schmalzried] 9:45 pm: Our usual hospital stay is 2 days.[james] 9:44 pm: any way currently to gauge bone density in femoral neck after resurfacing? [Dr. Schmalzried] 9:45 pm: Bone density can be measured by a DEXA scan and there are at least 3 published studies on this. [burch07] 9:45 pm: If I have metal sensitivity, what is recourse? [Dr. Schmalzried] 9:46 pm: If your really have metal sensitivity – you may need a conversion to a non-metal-metal bearing THR. [tammy] 9:45 pm: Some people seem to go into a rehab place following surgery. What is your take on that? [Dr. Schmalzried] 9:46 pm: I don’t favor rehab. units for my patients. [Amy] 9:46 pm: I have hip dysplasia, am I a candidate for HR or THR? [Dr. Schmalzried] 9:47 pm: With dysplasia – it depends on the amount of socket bone and the anterversion of your femur. A look at x-rays can tell. [uncontrarymary] 9:46 pm: I had a displaced fracture of the neck of the left femur one year ago and have three pins. Due to pain and limping I had an MRI and the radiologist said I have effusion but no AVN. Then I had a nuclear bone scan and that radiologist said highly suggestive of AVN. If it turns out that I do have AVN could I be a candidate for resurfacing? [Dr. Schmalzried] 9:48 pm: You may be a candiate for resurfacing. Many hips with AVN have been successfully resurfaced. [ajp] 9:47 pm: do you think that one can wreck the proceedure by being to active very early like full weight bearing. Or is that just a pain issue [Dr. Schmalzried] 9:49 pm: There is the possibility to over-stress the resurfacing before adequate healing. [nslocum] 9:49 pm: ok, one last question from the petite woman. It seems like you are saying that a hip resurfacing may be just fine for someone like me but the key factor really is bone density, correct? [Dr. Schmalzried] 9:49 pm: Little lady – you are right on! [tammy] 9:49 pm: what is adequate healing time? [Dr. Schmalzried] 9:50 pm: Adequate healing time is dependent on patient and surgical factors – it is not a definite line.  9:49 pm: What is AVN? [Dr. Schmalzried] 9:51 pm: AVN = avascular necrosis.
[tammy] 9:51 pm: where do you put your incision? [Dr.Schmalzried] 9:52 pm: I put my incision exactly where it should be – and that is posterior! 9:52 pm: Should I be concerned about getting my hip redone due the recall and the pain or live with it, and what about my opposite hip it is now severly in pain also should I still consider another Birmingham or some other model for a resurfacing. [Dr.Schmalzried] 9:53 pm: I don’t have enough information about your case to comment. [burch07] 9:52 pm: Is surgery the only way to determine metal sensitivty? [Dr.Schmalzried] 9:54 pm: Metal sensitivity can be determined by an examination of tissue from around the hip – so a biopsy can give that information.  9:53 pm: What is avascular nedrosis? [Dr.Schmalzried] 9:54 pm: AVN – death of the bone due to inadequate circulation. [Bionic] 9:53 pm: I exercise on a recumbent stationary bike. About how long after surgery should I wait before restarting. [Dr.Schmalzried] 9:54 pm: Recumbent bike – wait one week. [tammy] 9:53 pm: posterior – meaning the tush? [Dr.Schmalzried] 9:55 pm: Posterior = the tush!
[Bionic] 9:55 pm: I guess Claratin wouldn’t cut it for dealing with metal senstivity. But are there any other drugs that can?  9:55 [Dr.Schmalzried] 9:56 pm: No drugs I know of for metal sensitivity.
pm: aren’t a large number of patients resurfaced due to AVN? [Dr.Schmalzried] 9:55 pm: I think that it is only about 10%. 9:56 pm: Do you see a lot of cam FAI in young men? [Dr.Schmalzried] 9:57 pm: Yes. Cam impingement is common. I have it in my own left hip – but have lived with it – played college basketball, tennis – and I am still managing without any surgery.  9:57 pm: How quickly must you have surgery if AVN is detected ? [Dr.Schmalzried] 9:58 pm: You should only have surgery if the pain and disability out-weigh the risks of the proposed surgery. [tammy] 9:57 pm: The stress I feel from the knee down to the foot currantly- can that be caused by the bad hip? [Dr.Schmalzried] 9:59 pm: Pain below the knee is unlikely to be from the hip. [edgenowlin] 9:57 pm: I understand you prefer the posterior approach; while some others prefer anterior (Dr. Mont). I have seen positive and negative criticisms of both but nothing that clearly indicates one approach is better than the other. What is your view? [Dr. Schmalzried] 10:00 pm: Dr. Mont uses the antero-lateral approach. There are trade-offs – but the overall quality of the surgery is more important than the path into the hip joint. [Bionic] 9:58 pm: I just got my x-rays back and my right hip sure looks a lot like the drawing I saw online of cam FAI. [Dr. Schmalzried] 10:01 pm: Cam impingement is an issue on the femoral side. [Pat Walter] 10:02 pm: I want to Thank him for taking time to do the chat with us tonight. We all learned a lot. [Dr. Schmalzried] 10:02 pm: I did all the typing myself – and I am proud of it! [Dr. Schmalzried] 10:02 pm: It was my pleasure. Thank you for inviting me.