"Three and Out is Three and out." Casey Stengel, Manager, N.Y. Yankees, 1949 - 1960
This week we'll put up some thoughts on what happens when the athlete, through over use (sound familiar?), trauma or just plain bad luck wears out a hip, knee, etc. Then said athlete expects the orthopedic community of 2019 to be able to "slip a new one in there" and he or she'll simply get back to long bike rides on Saturdays with the girls. Realistic? We'll see.
"Yeah I have some arthritis but I'll just push it until it wears out, get an artificial joint, and keep racing." This theme, or something like it has been the subject of blogs here in the past. The usual take home is that life doesn't work that way. Regardless how good a surgeon or artificial joint is, it does not equal the "original equipment from the manufacturer."
Let's see if the Orthopedic research community has refined the art of joint replacement arthroplasty to the point if, like changing a worn out tire on your car, the triathlete can have that worn out joint replaced, and return to triathlon the same athlete as before.
When I lecture to other physicians, I often use Floyd Landis as an example. Whether or not you agree with his tactics* to wear the Tour de France yellow jersey in Paris, for the purposes of this discussion he makes and excellent example. Briefly, while a member of USPS pro cycling and a domestique for Lance Armstrong, Floyd had a cycling accident, suffered a hip fracture and underwent surgical pinning of the hip. It worked relatively well for a while. But following the 2006 Tour, where Flloyd brought home the Maillot Jaune (yellow jersey) signifying the winner of the great stage race, he had an operation on the hip akin to replacement called resurfacing. The socket of the joint is replaced with a metal cup and the head with a metal ball. It's an operation frequently performed on the young, active population with end stage arthritis of the joint. Floyd is out there riding with the best of them for the time being, but is it wise. Or, more importantly, is it for you? History would tell us no.
In a recent edition of the Journal of Bone and Joint Surgery, Harlan Amstutz, M.D., a very experienced joint replacement surgeon, reported on an investigation at the Joint Replacement Institute at Saint Vincent Medical Center, Los Angeles, California where they studied 485 patients, mean age of 48.7 years, 74% male, averaging about ten years from joint replacement. Sadly, 23 patients had already undergone revision surgery (repeat hip replacement.)
There may be some hope, however, for the athletes that come behind us. Improvements in the polyethylene liners of both hips and knees, impregnating them with antioxidants, seems to significantly extend longevity. Frequently for knee arthritis, a complete knee replacement may not be needed. A half knee, or unicondylar replacement may be the ticket for those athletes with wear and tear in only half of the knee, a frequent occurance. For hips, "simple" resurfacing, after a very rocky resurgence including metal-on-metal hip law suits and personal injury claims, several orthopedic surgeons like Tom Gross, MD in Columbia, SC have done thousands of resurfacings, many in runners, and may be the pathway to the future. Three local athletes, all runners, have had this operation by Dr. Gross and are back on the roads. Smiling!
To further quote Dr. Amstutz "...both patients and surgeons should be aware of the fact that high-demand activities performed frequently are associated with reduced survivorship over time, and patients should be properly counseled with respect to high levels of sporting activity on the basis of the presence of additional risk factors." But as technology marches on, this will not always be the case, I'm certain of it. So if you are an athlete reading this, you are special and can't be lumped in with the Toms, Dicks and Harrys of the world. Do your homework, don't be in a rush, and you'll get what's right for you.
* Following the TdF, it was found that Floyd had some "problems" with his testosterone to epitestosterone ratio in a number of samples taken during the race. It was triple the WADA limit! Sorry Floyd, you're outta here!
Image, Google Images.