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101 THE ATHLETE WITH A TOTAL

JOINT REPLACEMENT

Jennifer L Reed, MD

BACKGROUND

•Over 594,000 hip and knee replacement operations
were performed in the United States in 2000
(American Academy of Orthopedic Surgeons, 2003).

• The prevalence of shoulder arthroplasty in 1998 was
  15,266 with 8556 hemiarthroplasties and 6710 total
  shoulder athroplasties (Mendenhall, 2000).
  •Pain remains the primary indication for joint replace-
  ment operations; however, disability and reduced
  function associated with a painful or stiff joint is
  increasingly seen as an appropriate indication for joint
  replacement.


• On average, a modern total joint replacement has a

  
  

  90% chance of surviving 10 to 15 years (Diduch
  et al, 1997; Knutson et al, 1994).

  
  

  
  


• 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 activ-

ity levels contribute to loosening rates associated with

total joint arthroplasty (Schmalzried et al, 2000).

• 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 (Zahiri
  et al, 1998).


• In the Swedish National Hip and Knee Arthroplasty
  Registers, 10-year revision rates among younger men
  were 3 to 4 times greater when compared to older
  patients (Knutson et al, 1994; Malchau, Herberts, and
  Ahnfelt, 1993).


• Published guidelines concerning activity after total
  joint arthroplasty discourage high levels of activity
  (Engh and Ing, 1999).


• Prospective, randomized studies on athletic activity
  after joint replacement and its effect on implant sur-
  vivorship are not available (Healy, Iorio, and Lemos,
  2001).


• Current recommendations are largely based on the
  opinions of orthopedic surgeons. Tables 101-1 to 101-3
  represent activity recommendations compiled from sur-
  veys of the Hip, Knee, and American Shoulder and
  Elbow Societies conducted in 1999 (Healy, Iorio, and
  Lemos, 2001).
  •A recently published review article by Kuster sug-
  gests that recommendations be made according to sci-
  entific knowledge including a biomechanical analysis
  of the joint loads during the sport in question (Kuster,
  2002).


• Issues that should be taken into account for each
  patient and sporting activity include:

WEAR OFTOTALJOINTREPLACEMENTS

• Up to 500,000 submicron-sized polyethylene particles
  are released with each step (Schmalzried and
  Callaghan, 1999). These small particles can activate
  macrophages that produce factors such as
  prostaglandins and interleukins thought to explain the
  progressive osteolysis and subsequent implant loosen-
  ing.


• Another major long-term problem is polyethylene
  wear itself. The total volume of wear particles pro-
  duced strongly depends on the number of steps, the
  load applied, and the roughness of the joint surfaces
  (Kuster and Stachowiak, 2002).


• Activity levels can vary tremendously from patient to
  patient. At least one study has shown that wear is
  clearly a function of use and not time (Schmalzried
  et al, 2000).

594 SECTION 7 • SPECIAL POPULATIONS