The Athlete with a Total Joint Replacement
The Athlete with a Total Joint Replacement
Robert W. Engelen
Jennifer L. Reed
PREVALENCE AND OUTCOME
In 2003, a total of 202,500 primary total hip arthroplasties and 402,100 primary total knee arthroplasties were performed in the United States (
10).
By 2030, the demand for total hip arthroplasty (THA) is estimated to grow by 174% to 572,000, and the demand for total knee arthroplasty (TKA) is estimated to grow by 673% to 3.48 million procedures (
10).
The prevalence of shoulder arthroplasty in 1998 was 15,266, with 8,556 hemiarthroplasties and 6,710 total shoulder arthroplasties (
19).
On average, a modern total joint replacement has a > 90% chance of surviving 10-15 years (
1,
10).
Dislocation, periprosthetic fracture, and implant breakage are possible, but uncommon, complications of athletic activity. More salient concerns include implant loosening from periarticular osteolysis and excessive joint-bearing surface component wear.
Athletic activity increases stress on implant fixation, and several studies have suggested that use and activity levels contribute to loosening rates associated with total joint arthroplasty (
21).
Activity levels can vary tremendously from patient to patient. Implant wear has been shown to be related to use of the joint as opposed to duration of implantation (
21).
Active, high-demand patients place arthroplasty implants at increased risk for loosening and wear.
Patients under 60 years of age are 30% more active on average than patients 60 years of age or older (
24).
In the Swedish National Hip and Knee Arthroplasty Registers, 10-year revision rates among younger men were three to four times greater when compared to older patients (
9,
15).
Published guidelines concerning activity after total joint arthroplasty discourage high levels of activity (
2).
Prospective, randomized studies on athletic activity after joint replacement and its effect on implant survivorship are not available (
6).
Current recommendations are largely based on the opinions of orthopedic surgeons.
Tables 118.1,
118.2,
118.3,
118.4 and
118.5 represent revised recommendations from surveys of the Hip, Knee, and American Shoulder and Elbow Societies conducted in 1999 and from repeat survey completed in 2005 (
7).
A recently published review article by Kuster (
11) suggests that recommendations be made according to scientific knowledge including a biomechanical analysis of the joint loads during the sport in question.
The following sections discuss issues that should be taken into account for each patient and sporting activity.
WEAR OF TOTAL JOINT REPLACEMENTS
Up to 500,000 submicron-sized polyethylene particles are released with each step (
20). These small particles can activate macrophages that produce factors such as prostaglandins and interleukins thought to explain the progressive osteolysis and subsequent implant loosening.
Another major long-term problem is polyethylene wear itself. The total volume of wear particles produced strongly depends on the number of steps, the load applied, and the roughness of the joint surfaces (
13). Standard metal on polyethylene has shown elevated levels of wear, greater than 0.2 mm per year (
14).
In a study evaluating the results of 5,700 TKAs recorded in a community joint registry, polyethylene wear accounted for 15% of all revisions and 30% of revisions after the knee survived greater than 5 years (
13).
The most common reason for TKA revision in a community joint registry prospectively following 1,047 patients under the age of 55 was aseptic loosening, but the study showed a 14-year survival rate of 74.5% (
3).
A study by Gschwend et al. (
5) followed two cohorts of patients after THA, one cohort active in Nordic and/or Alpine skiing and the other cohort inactive. At 10 years, the wear rate was higher in the active group but loosening remained higher in the inactive group of patients (
5).
