THR = Running – Surgeons Response

Hi Rob – this looks like bad news.

On the other hand, we now know the stem is cemented (and we need someone on here with a cemented stem to join the conversation) and the bearing is the expected plastic on ceramic, like most hiprunners I suspect. Your surgeon suggests the device is not designed to take large axial loads but I found a testing site that quotes stem fatigue tests at 517 pounds/5 million cycles and neck fatigue loads of 1200 pounds/10 million cycles as standard. For me, those figures equate to 3.5g and over 8g shocks respectively, ten million cycles could be 10,000 km or 6,000 miles or more. I have a very gentle running style, low shock loads, and I only have another 10 years or so of running left so I am happy to continue to test my devices. I am a little worried by your cemented stem and you have to worry about revisions in your future and I don’t know your weight/running style – but I would still encourage you to give it a go when you feel ready, if it does not feel right at least you will have tried…

Good luck
Pete

Hi Rob

Your hip surgeon has probably always held that view and it’s probably not surprising that his view hasn’t changed and that he has expressed the reply the way he has. He does end with “ultimately the decision is up to you” so it comes down to your view of risk versus benefit.

If you do decide to try, much of the advice I have seen includes the following
– being as strong as you can before you start. So being sure the muscles are in the best possible condition through gym work, cycling, swimming, trekking poles etc
– easing in gently through run / walk and through making sure running is not the only way you train
– focusing on mid or forefoot striking, not heel striking.

Interesting to see you have a hybrid THR. It would be worth seeing if you can find others with the same.

• This reply was modified 1 year, 9 months ago by Coddfish.

I’ll share the thinking, as I understand it, of the surgeons who think running is fine on a hip replacement.

There are several parts to their thinking. One, there are studies of younger active patients, people under 50 and so on, and over time, top surgeons at least have not found a high rate of failure in these “younger” patients. Those studies of people under 50 are one source of evidence. In other words, the theory propounded by your surgeon would hold that that people under 50 would have much higher revision rates because people under 50 are going to be more active than people over 50, impact or not.

Well with the cross-linked polyethylene liners, they aren’t seeing higher revision rates among the younger people who are presumed to be more active.

Second, the way hips break down (even on old materials) is NOT by some big crack. Your surgeon’s sense is off base here. They break down overwhelmingly by a process called osteolysis … which is particles falling into the bone where the femur is and over time those particles weakening the bone and the femur comes loose. Cracked hips, even in the cup or the femur device, isn’t where hips typically fail–absent falls or car accidents of the type that would fracture a “natural” hip.

Note that your surgeon points to no evidence in his assessment. He’s using all intuition. And look, a surgeon’s intuition isn’t to be disrespected for sure. But surgeons are starting to track what they call “high activity” patients vs low activity patients … and there’s not any strong evidence apparently that high activity shortens the lifespan of the device.

Let me pause and say I get how strange it can be that a total hip can support running or basketball. I get how strange that seems. But keep in mind that manufacturers have been building total hips for what 50 to 100 years now … and manufacturers have been constantly tweaking those devices with the impact of research and the imput of surgeons. And surgeons have been learning to operate in ways that stabilize the devices. And again, the main way hips fail is not through cracks/breaks … but through loosening of the device as a result of wear particles. The breakthrough of cross linked and highly cross-linked polyethylene liners has reduced particle falloff to close to nill going on 15 years of monitoring.

The way my surgeon (and his practice) reads the research: they are not seeing more failures about people with high activity.

BTW: the way I read your surgeon’s note, the last line is the give-away. He doesn’t want the responsibility to have OK’ed you to run, but that last line saying the choice is up to you–no heart surgeon would say that for an activity that was seriously deadly to a heart patient. That last line seems to me to be his way of saying, “You might be ok, but you’re on your own there.” I don’t read your surgeon’s note as a strong recommendation against running. I read it as he wants to be cautious.

BTw: here’s one link to a study that found that in fact high activity people had lower failure rates than low activity people about 5 years after surgery.
https://www.arthroplastytoday.org/article/S2352-3441(21)00123-0/fulltext

I think @cityofsmokimgjoe is spot on when he says the surgeon doesn’t want the responsibility of OKing you. Whilst my surgeon was supportive, it’s quite daunting getting started and am treading super carefully at the moment. Good luck whichever way you decide.

No, the recommendations on running are not based on surgeons using particular devices vs othrs. No, the devices are basically all the same. The tools surgeons use to insert the devices, the steps for inserting the device, the feel, the subjective experience–those are why surgeons choose certain devices.

You’re barking up the wrong tree looking for registry information on different devices. Keep in mind that some surgeons cut from the front, some from the back, some from the side … That’s all personal preference and comfort level and confidence … No one approach is better than the other (despite all the hype about the anterior approach) …..

But maybe you mean materials … again, registries don’t break out info like this from when I last checked. But yes, there are academic studies on various materials … and the materials used by many surgeons these days is ceramic head on cross-linked polyethylene liner, uncemented cub and uncemented femoral stem … though as I mentioned earlier, i don’t think cement or not is the big deal here …All the surgeons I encountered who were fine with running were using ceramic on highly cross-linked polyethylene. This is easy info to find out. Don’t worry about other details–the details are ridiculously similar and NONE has some great and noticeable advantage in survivorship than the others or else all surgeons would be using that particular device.

I did go looking for surgeons who are comfortable with running because I wanted not to have to contradict a recommendatin. I wanted the full placebo effect, as it were, for running afterwards … But I admit I got lucky. Surgeons don’t loudly advertise this recommendation. Often I would have to go to a website or read a review and see that a patient was running. My surgeon has no information endorsing running out there in public, but I found an obscure interview with him in an orthopedic journal where he disclosed his view on running. His practice’s website has testimonies from a few runners who were patients, but no officials works (other than one younger surgeon in the practice) endorsing running. Really good surgeons do not want to over promise. And in fact, my surgeon said he could not guarantee that I would enjoy running after surgery. He said some patients just feel funny or awkward running after the surgery.

I learned that the surgeons comfortable with running were not rebels … They were just confident in the results and survivorship rates in their active patients and they looked closely at research … Once I got all this, I was able to find a number of surgeons who were OK with running. It was like I decoded the modest lingo to figure out who was ok with running.

BTW: a surgeon at my surgeon’s practice actually talked about something that is relevant to you. Are you really going to exercise at the same level you would in running? If you are going to skip running, you really want to find a new activity you LOVE! … For your overal health. You don’t want to be out there moping around feeling sorry for yourself, doing some exercise that reminds you of tasteless food. You need to find something challenging and juicy. You will need to experiment. This thinking was one of the reasons that one of my surgeon’s partners gave for being OK with running–overall health, physical and mental!

• This reply was modified 1 year, 9 months ago by Cityofsmokingjoe.

Hi Rob

I tend to agree with @cityofsmokingjoe. I found a surgeon who likes to work on active people, basically because the physio who referred me to him is from the practice that supports Ben Ainslie’s americas cup racing set up. He did lead me to believe I wou¿d have a better outcome through my uncemented solution but he went into the surgery intending to make the final decision once he saw the health of my bones. Only you can decide what to do next.

Fantastic reading guys. I am learning more about my posterior THR then when I made the decision. I have an uncemented titanium post and socket with ceramic head. My doctor told me that the ceramic head allowed for a much larger joint that alleviates most of the dislocation and wear issues of previous replacements. He said that with the new technology the hips are predicted to last 30 years with normal use but that all tests have been outside the body so it will take a number of years to know the real results inside the body.

The end of December I will be 18 months post op. My surgeon gave me full go ahead to run….but said he wouldn’t recommend marathons….which I am okay with since I have “been there-done that”. He said at my age when I had my surgery 64, I wouldn’t wear it out. I find it interesting that he said “wear it out” verses “break it”. “Break it” never entered any of our conversations which leads me to believe that he has zero concerns with it breaking.

I have several friends who are lifelong runners….Todd ran a 2:16 marathon when we were younger….who have had hips replaced. Some choose not to run, some like Todd run up to 20 miles per week on three runs plus bike, others like myself continue running/racing. It is a matter of what is important to keeping your active lifestyle and mental approach to life healthy.

I wrote a detailed blog earlier in this forum about my return from surgery. An update to my slow build back, I am now running between 55 to 65 miles per week, biking 75 to 100 per week and swimming 3 to 4k per week. I am utilizing the 80/20 training book written by Matt Fitzgerald to train for the Atlanta half marathon the end of February with a goal of sub 2 hours….I ran 1:09 in the 1980s for reference. I will then use my return to running as a launch to the 70.3 triathlon season and an attempt to qualify for the age group world championships, which I have done each 5 years since turning 50. Pending my results this year….I may attempt to again try to qualify for the full Ironman distance world championships when I turn 70. I was trying to qualify for this when I twist broke my leg back in 2011 and lead to my THR in 2020.

I mention all of the above because it is what gets me excited, keeps me focused and healthy and young to chase my grandkids around…..as the guys mentioned above it is all about what keeps you healthy, motivated and active. It is all about choices.

Lastly I have had zero hip issues, other than mobility which is a result of years of favoring it and tightness from the return after surgery. But even without the surgery mobility is something we all need to be aware of and work as we age.

Good luck, great discussion and as my surgeon said….let pain be your guide whatever you choose to do after the replacement.

Oh one last thing….my neighbor who had hip replacement surgery 30+ years ago with the old technology had to have revision surgery last year because the post in his femur became loose and started to move sideways. Prior to revision surgery he was active but only walking and doing yard work. He is 80 years old and is doing fine since his revision surgery. None of my friends who have had the new type of hips have had revisions, but that should be expected since they have only had them done in the last 5 to 10 years.

Hi Rob

I am not personally aware of anyone having issues after hip surgery through activity, although I don’t directly know anyone who runs on one. I do know people who do other fairly high impact things on them. My cleaner’s mother dislocated hers on the day she got home from hospital by ignoring the don’t cross the mid line restriction to get into her favourite seat. My niece is a doctor and although her specialism is paediatrics, she does a lot of locum shifts in a busy A&E. She says the post-hip surgery problems that present in A&E are always in frail, elderly people, usually fractures resulting from falls. I don’t think you can easily wear a modern hip replacement out. I don’t think you can easily break it. It’s possible for it to loosen / come out of alignment / have an issue as a result of a break elsewhere in the femur. Loosening is often down to infection and you haven’t had any sign of that so far. Other than infection, I would imagine all of these are less likely in someone who is structurally in good shape for their age. Load bearing should theoretically help keep bones strong and healthy. At 64, I would rather spend whatever healthy years I have left doing the things I love. If I somehow compromise the hip and have to have a revision, then so be it.

Bluebirds

Of course I’m sure there are people who there who had problems with hip and who ran. So what? There are people out there who barely move and end up having revisions. People who midly move and need revisions and people who moderately move who need revisions.

You have all the information you’ll ever get on this subject. You will have to take the leap or not. Asking for more details–you’re not going to get to any information that definitely or overwhelmingly favors one side or the other. We don’t have that level of clarity. YOU have to step up and decide. I will say that most revisions have nothing to do with patient activity. Nothing. And when I say I’m thinking 99 percent of them, not 51 percent.

You know you can try out running for a year or so … or for a few months. I don’t think any claims that a few months of running or a few years will ruin a device. The ruin the device would be after years and years (for those who have that view).

You are the one who has to decide–there is no data or study out there that will decide this for you. And btw: I’m someone who did indeed look for such data before I had surgery.

Fantastic Rob. You are ahead of me – I am still walking parkrun with trekking poles – whilst slowly working myself back into running through C25K. I hope to be running parkrun by the time my hip is 6 months old.

Yes Rob – the brain is the biggest obstacle to any of this. I am dealing with the same issue, despite my surgeon’s relative positivity. Done 2 run/walks now, spaced them a week apart. Next challenge is 2 in a week. If that’s ok I will do C25K properly next year with an aim to be running properly again at 6 months. Have to say it feels great to even get this far, and we’ll done on your parkrun today. I stalled on 179 before lockdown and have restarted recently with walking. I don’t have enough available weeks to complete my 250 next year but it will happen in 2023. If I am ever a tourist in Cardiff I will let you know.

Great to see you back in the fold Rob! Not done Cardiff but I have run Pontypool, and got a pretty decent time there. Since our last correspondence I have been looking at specific devices and their failures and it is interesting that the Exeter cemented hip has failures in fatigue fracture of the stem – in inactive, heavy people who probably hardly use their hips, and the Furlong Evolution device had a couple of peculiar failures where the ceramic ball had worn through the polythene liner and the titanium cup – but Michael Rix on this site has run sub-16 minute 5k and raced triathons for at least 7 years on one of these devices. I personally know an inactive lady who broke a ceramic hip doing nothing particular, and heard of a titanium stem breaking whilst sitting. Shit happens, as they say, but it does not seem to happen so much in the active community. Best of luck going forward – I have just come back from a glorious couple of days in Snowdonia, walking up big hills and waking up muscles that don’t get used on the road, and despite aggravating my sciatica do not regret a minute of the temporary pain of recovery as a price to be paid for a great time in the hills with my son. We are all experiments, it would be good if the profession could collate our experiences to allow others to base their decisions on good data rather than hearsay/anecdote. I have recorded everything on Garmin since 2014, walking, biking, running, mountaineering and I guess others will have done so as well. Surgeons need to realise just how good their devices can be in the proper hands…

First runs (after a long break) are always awkward. You feel so excited to be running and yet your body is out of practice and with the new hip your body hasn’t had practice with a reliable hip. The entire body has to adjust now that your hip is reliable.

Think about doing glute exercises and some quads exercises as time goes on.

Whilst most surgeons are reluctant to approve of running as they are concerned about being blamed for acute hardware failure, if you ask them what is the most frequent cause leading to revision surgery they will admit that it is not injuries/acute trauma/sudden failure. Rather, it is recurrent pain/progression of arthritis/degeneration of the biological interface. In the absence of large studies (a few small studies suggest that running does not result in worse outcomes of THJR at least after 5 years or longer) the next best available evidence (from larger studies) is that running does not accelerate arthritis (in fact there is a good chance it may stave it off). Biologically, mobilisation and weight bearing results in stronger bone structure/density, so to me it make sense to run. Additionally, one needs to put on the scale the long term cardiovascular benefits of running as aerobic, weight-loss exercise. I have been running more than 4,000 km on my artificial hips now, and 3 years after surgery my mobility, strength and running times are still improving (parkrun in 21:45 today, age grade 70.02%).

Hi Pietro, glad to see you are running well again – I use 70% as my benchmark and was chuffed to bits to get 71% as a Christmas present at parkrun, although considerably slower than you due to my advanced years (and missing training due to sciatica in the summer).
It gives us experimenters more confidence when a medical professional like yourself is prepared to take advantage of a surgical procedure like THR to continue active sport, having weighed up the evidence.

Pete

Hi Rob, Pietro is a neurologist, I believe, working in a hospital in New Zealand so has ready access to orthopaedic surgeons opinions, possibly of the kind that are not freely given to the general public. Hope I am not treading on his toes by mentioning this.
In other news, Saturday’s parkrun was number 400 for me. Natural hips lasted to 170-odd and 250-odd so I have done about 140 on my Zimmer THR. It was a miserable wet day, cold and windy, and I wore a waterproof under my modified 100 (to indicate 400) parkrun shirt. Despite all that I managed 25:03 for 71.2%, a best time since parkrun restarted, and my RunBritain handicap has taken a leap in the right direction as a result. 4 seconds faster and I would have been ecstatic!

Pete

Our parkrun is a tarmac and paved seafront promenade, so whilst it might suffer from extreme winds, it’s only treacherous underfoot on the handful of days we have ice down here on the south coast. But it was awfully wet, not the best day to be the timekeeper. Happy parkrunning all, such a wonderful thing.

Hi Pete, no, not stepping on any toes, all cool. Of course as neurologist I have no expertise whatsoever in joints and ortho surgery, but I have at least some familiarity with weighing up evidence from the scientific literature, and I have a few chats with orthopaedic surgeons – though they are not the ones who encourage me to run!