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The World's Premiere Nordic Skiing Publication Volume 21, Issues 1

Spare Parts Included:
Skiing After Joint Replacement Surgery

Ron Caple was feeling, if not triumphant, then certainly proud when he crossed the finish line at the National Masters in Anchorage last February. Sure, he came in last of eleven in his age group of 65 and up. But with an artificial hip joint, Caple was simply glad to be doing what he loved, gliding through the snow. That three of the skiers who beat him also had spare parts only added to the Six Million Dollar Man moment.

Ron Cable age 66

It’s been five years since Caple, an organic chemistry professor at the University of Minnesota in Duluth, joined the growing league of Americans whose joints pivot on artificial parts. In 1999, replacement operations were performed on 541,245 hips and knees, a healthy increase since the operation became commonplace in the 1980s.

Similarly, the number of people receiving new shoulder balls and sockets has tripled since the early nineties. In 1998, more than 15,266 shoulder arthroplasties were performed, compared to 5,000 only five years earlier. Like those of the shoulder, hip and knee joint replacement rates are only increasing.

As Caple explained, his decision to undergo hip surgery involved a calculus of pain versus quality of life. Osteoarthritis in his left hip left him wincing. "I could probably walk 20 minutes before it would be unbearable," he remembered. "I could hardly handle stairs."

Worse still, his new wife was a champion Nordic skier, and he didn’t want to miss out on the fun. When his surgeon told him cross country skiing was not only permitted, but recommended as postoperative exercise, Caple leaped for surgical relief. Now he sees nothing but smooth trails ahead. "To be able to ski pain-free was such a pleasure," he stated. Call it a design flaw, but hips and other joints have a tendency to wear out before their warranties and we expire.

Arthritis, earlier injuries and age contribute to debilitating pain. When successful, joint replacements, which substitute high-tech cement, metal alloys and polyethylene parts for those of bone and cartilage, help restore proper movement. Slow walking begins the healing process; with physical therapy, recovery typically takes six to eight weeks.

At one time, joint replacements were reserved for only the creakiest of us. But now that’s changing.

As people live longer and anti-inflammatories fail, pain sufferers often turn to prostheses. People in their seventies and eighties once made up the bulk of orthopedic patients, whose implant life spans—10 to 15 years—matched their own with years to spare.

But today’s joint replacement patients, frequently baby boomers, expect more than a leisurely stroll through their later lives. Thanks to improvements in the operation and the quality of parts, not only are they having surgeries earlier, but they’re also intending to keep the implants longer and work them harder. They want to push and lift and grind and glide right up to the finish line.

"Ninety percent of joint replacements completed through the mid-90s died with the patient," explained Dr. Richard Iorio, a Burlington, Massachusetts-based orthopedic surgeon who specializes in joint replacements. He continued, "But as life expectancy increases, if we put them in younger people, the sooner they’re going to fail [with] the more wear they get."

Athletic activity increases the stresses on a new joint at the bone-cement-implant interface and at the joint-bearing surface. That’s why orthopedic specialists now worry that younger joint replacement recipients could literally wear out their parts. Meanwhile, the risk of complications grows with repeat operations.

"We’re restoring people’s joints so they can destroy them again," Dr. Iorio commented. "We’re doing this in active people who want to continue to do risky behavior."

According to surveys of The Hip Society, The Knee Society and The American Shoulder and Elbow Society, "risky" postoperative behavior includes jerky, joint-rattling high-intensity sports such as singles tennis, rock climbing, basketball and jogging. Along with swimming and bicycling, cross country skiing is listed among low-joint-load sports that are "allowed with experience" for those with prosthetic knees and hips.

"As a rule, high-impact sports are bad," Dr. Iorio reiterated. "Cross country skiing is not a high-impact sport." In spite of Nordic skiing’s low impact, Iorio described one danger, "On an icy trail when your skis get crossed, it can be high impact." Falls, which may cause loosening, dislocation or worse, can be catastrophic for a lone skier far from the trailhead.

Studies have shown that even regular use, though beneficial to muscles, ligaments and bones, eventually increases wear at the joint surface, raising risks for implant loosening, breakage and other complications. Sedentary people simply don’t tax their new joints in the way that active folks do.

As the February 2002 Harvard Health Letter stated: "Even ordinary activities like walking put a great deal of mechanical force on the hip: the ball is constantly rubbing up against the socket. Over time, that stress causes tiny bits of the replacement parts—particularly the plastic and ceramic lining of the acetabular component—to flake off. That causes inflammation. And inflammation has an erosive effect on bone tissue, which causes the components of the hip replacement to loosen."

But a recently published Swiss-led 10-year study of alpine and cross country skiers with hip prostheses found that the number of problems following total hip replacement was lower in active than inactive people. Greater joint loosening was detected among active patients, especially the extremely active, but the cardiovascular benefits and psychological gains of cross country skiing outweighed the risks.

"There is still no evidence to explain why activity affords a protective effect, but it can be said that a careful execution of sporting activities—including alpine and cross country skiing—is unlikely to damage the joint prematurely," the researchers wrote in Acta Orthopaedica Scandinavia 2000; 71 (3). However, they do not recommend taking up skiing post-surgery because of an increased chance of falls.

What does all this mean for seasoned skiers like Caple? Whether or not to resume sports hinges on several factors: the quality of the joint reconstruction, the condition of the athlete, his or her experience in the chosen sport and the intensity with which it is to be pursued.

Caple’s surgeon recommended diagonal skiing over skating style. "I much prefer the classic, so I’m sticking with that," Caple remarked.

Overall, the word is moderation. Recreational skiing along groomed trails is fine—four or five miles, say, once or twice a month—while competitive activity should be reserved for only those with the highest levels of skill and conditioning. Downhill skiing, especially on moguls, is to be avoided.

The main worry is wear for joint replacement recipients. Dr. Iorio explained, "If they remain very active, they may need to have another. They may not be able to cross country ski next time."

For Caple, the skiing rush is worth the risk. "There’s a risk factor involved," he tells those who ask his advice. "But this is one where the odds are in your favor."

    Dr. Richard Iorio’s suggestions to post-surgery skiers:
  • First get surgeon’s approval.
  • Get technique down on an indoor ski machine.
  • Always go with a cell phone.
  • Never go alone.
  • Use well-groomed trails.
  • Use trails frequented by others.

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