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joint replacements

Joint replacements

Advances in surgery Can a new joint put a spring in your step? Diane Back and Angus Lewis outline sporting possibilities and cautions for replacement hips and knees

In the past 20 years there has been an explosion in the number of total joint replacements performed throughout the world(1). Hips and knees are the most commonly replaced joints, but shoulders, elbows and ankles can all be done, too.

Hip and knee replacements were originally designed for elderly people, generally over the age of 70, who led relatively sedentary lives and who were not expected to outlive the lifetime of the prosthesis. The ability of these artificial joints to relieve pain and maintain everyday mobility has been a revolution in the treatment of arthritic conditions, and we would expect a new hip joint in these elderly patients to be good for 15 to 20 years.

With increasing confidence, hip and knee replacements are being given to an ever younger population, who are much more likely to outlast the expected life of their replacement joint and who also place demands on the implants that the original designers would not have considered. Although the technology behind joint replacement surgery continues to evolve, people are pushing the implants to the limit and causing them to fail earlier – after 10 years or less in the case of hips. Because knee replacements are more recent, we can be even less certain about their longevity and what might influence it. While we have data giving more than 95% ‘survivorship’ of knee implants at five to 10 years’ follow-up, this is among the more elderly and less active population(2). For younger patients, we simply do not yet know how they will fare.

Aware as we are in the medical profession of the need to encourage people to pursue healthy lifestyles, what advice should we all be giving to people who have undergone a total joint replacement? Should we advise them to cease all exercise, or do we tell clients and patients to undertake only certain types of exercise and avoid others?

While there are numerous published guidelines on what types of activity people should do after joint replacement surgery, none of them are based on proper randomised control trials. Nevertheless, there is plenty of evidence that the more activity you do, the quicker you will wear out your implant(3). What we’re less clear about is whether impact in particular makes much difference. Most studies recommend a reduction in impact sports to minimise the likelihood of wear on the bearing surface and decrease the chances of loosening the implant(4-6).

There is no doubt that patients who participate in sport after knee and hip replacements are at higher risk of traumatic complications, including dislocation, fracture around the prosthesis and even failure of the implant. The likelihood of doing serious injury to the replacement joint while playing rugby is far greater than if you restrict your activity to playing a sedate round of golf!

While clients and patients need to be aware of the relative risks involved, the current literature does not offer a great deal by way of helpful advice, with opinion, even among orthopaedic surgeons, divided as to what exactly we should be recommending as harmless or beneficial.

Hips

For total hip replacement, there is general consensus that impact sports should be avoided:

  • running
  • water skiing
  • football
  • basketball
  • hockey
  • handball
  • karate
  • rugby
  • squash.

The materials used in total hip replacement vary but these days most implants consist of a metal head articulating on a polyethylene cup. The polyethylene has been shown to wear more with increased weight-bearing activities. Work has been done on other kinds of bearing surfaces, such as ceramic heads articulating with ceramic cups.

Also in the past 10 years there has been a resurgence of interest in ‘hip resurfacing’, a procedure that aims to preserve a significant proportion of the femoral head and leaves the femoral canal intact. This produces a bigger ball and socket joint, which holds out much better prospects for the stability of the joint. The new generation of hip resurfacings tend to incorporate a metal head with a metal cup articulation in the belief that this will produce less ‘wear debris’ and reduce the chances of loosening of the implants.

Studies have shown that after hip resurfacing, people are able to undertake sports that would have been on the banned list for a total replacement, including downhill skiing, squash, football, judo, horse riding, triathlon and running.

There is a big proviso, however: we still have only three years’ worth of evidence of joint performance among hip-resurfacing patients, so it is too early to tell whether these dramatically increased levels of activity involving high impact sports will also cause a decrease in the durability of the prostheses. Likewise, we have no long-term follow-up studies yet on how the new materials affect the longevity of resurfacings.

Knees

With the exception of cross-country skiing the general advice about avoiding impact sports is much the same as for hip replacements. But the reality is that total knee replacement seems to be far less forgiving with regard to sporting activities. Several studies show that a significant number of patients do not return to their pre-replacement sporting activity(7,8). At present artificial knee joints don’t seem to be able adequately to reproduce the complex twisting mechanism of the natural knee and many enthusiasts find they are unable to maintain their chosen sports.

Ankles, elbows and shoulders

Total shoulder and elbow replacements are less common. There are fewer problems about weightbearing surface but joint stability can be an issue. One study did show that after shoulder replacement, significant numbers of golfers did return to their sport and even improved their handicaps.(9)

Total ankle replacement is very much in its infancy. There have been numerous problems with fixation of these implants and there is nothing in the literature to guide us about sporting activity, although the general recommendation for no impact sport would probably be appropriate.

Joint disease: what the surgeons advise

For hip arthritis

If your arthritic client is keen to continue their sporting activities, hip resurfacing might be the best option for:

  • women who are less than 55 years old and have good bone density;
  • men under the age of 70.

Note that there are no long-term results for this partial replacement procedure. Note, also, that if a resurfacing fails the individual can still have a conventional total hip replacement.

For knee arthritis

Clients should be warned that they may lose some flexion and that kneeling is often not possible after replacement surgery.

For anyone considering replacement surgery

These operations are done to relieve people’s pain. They cannot be guaranteed to improve function or enable someone to maintain their sporting activities. Younger people should understand that, especially if they are very active, their first implant will probably not last the rest of their lifetime and they will probably need further surgery at some stage.

References

  1. Mendenhall S (2000), Editorial. Orthopedic Network News 11 (January) 7.
  2. Back DL, Cannon SR, Hilton A, Bankes MJ, Briggs TW (2001 ), The Kinemax total knee arthroplasty. Nine years’ experience. J Bone Joint Surg Br. Apr;83(3):359-63.
  3. Schmalzried TP, Shepherd EF, Dorey FJ, et al( 2000), Wear is a function of use, not time. Clin Orthop381:36 –46.
  4. American College of Sports Medicine Physicians Statement (1990), The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults. Med Sci Sports Exerc 22: 265 –274.
  5. Cirincione RJ (1996), Sports after total joint replacement. Md Med J 45:644 –647.
  6. Engh EA, Ing CA (1999), Activity after replacement of the hip, knee or shoulder. Orthopaedic Special Edition 5:61 –65.
  7. Bradbury N, Borton D, Spoo G, et al (1998), Participation in sports after total knee replacement. Am J Sports Med26: 530–535.
  8. LaPorte DM, Mont MA, Hungerford DS, et al (1999) Characterization of tennis players who have a total knee arthroplasty. Proceedings of the 66th Annual Meeting of the AAOS, p171.
  9. Jensen KL, Rockwood CA Jr (1998), Shoulder arthroplasty in recreational golfers. J Shoulder Elbow Surg7:362 –367.

joint replacements