sculling after a hip replacement.

[Steve Giddings]

I am wondering if there is anyone who frequents this group has has expertise in this area and is willing to comment.

I had a total hip resurfacing (Birmangham hip) performed in mid 2010. Recovery was uneventful and after 3 months I went back to sculling without any difficulty.

The hip worked well until late 2014, when I developed a large mass on my outer thigh which became painful and limited movement. It was a "pseudotumor", an inflammatory mass that communicated with the hip joint, now recognized as a relatively frequent complication of metal on metal hip prostheses of all types. My cobalt levels were also elevated.

I had a revision surgery in April 2015. After some discussion, the orthopedist and I decided to go with a "hybrid" solution, to keep the metal acetabular cup that sits in the pelvis, and to replace the metal femoral head with a Stryker modular stem, pin and two component head, which has an outer lining of polyethylene and an inner ball of ceramic material.

Three months after the surgery and after being taken off posterior hip precautions, I dislocated the hip while on my hands and knees trying to retrieve an object that had rolled under my bed.
I had a closed reduction and did extensive rehab to strengthen the muscles surrounding the hip, did the exercises daily for at least an hour. Four months later, the hip dislocated again , this time while bending over to pick an object off the floor. The hip once again dislocated less than 2 weeks later, and this time the closed reduction was not successful. The two components of the ball separated and only the ceramic component went back into the cup.

I had emergent surgery 3 days later. This time the orthopedist replaced the cup and ball, using a larger diameter cup and ball (70mm), and components designed to be used together. This cup also has a greater depth, it fits 180 degrees of the ball. The previous cup was shallower, fitting only 160 degrees of a smaller ball. On my 2 month follow up visit, again with extensive and continuing rehab, the orthopedist told me that I should never row/scull again.

This did not make for a happy camper, as I have sculled and rowed almost daily for more than 20 years, and it has also been a large part of my social life as well.

I know that there are a fair number of masters rowers out there with artifical hips who continue to row/scull. Now that I have an appropriate prosthesis, why would I be any different, once the torn tissues/muscles have healed and strengthened with time and exercise?

The hip is in near anatomic position with 42 degrees of vertical arc and appropriate anterior posterior orientation.

[jhmb...@gmail.com]

Steve

Sorry to hear about the problem you are having. It is increasingly common.

First off, it sounds as though the initial hip resurfacing was not in fact a Birmingham (which has a 180 degree cup), but instead one of the imitators, most of which have a less-than-180 degree cup. Many of these have been withdrawn from the market. All large head hip replacements, with a standard stem, trunnion, and large metal head articulating with a metal cup, have been withdrawn. Metal debris can originate either from the trunnion or from the top outer edge of the head / cup articulation (especially if the cup was implanted a little 'vertical', or if the cup was less than 180 degrees.)

The Birmingham Hip Resurfacing itself has a good reputation, if implanted in a surgical unit which is doing a reasonable number of them.

So, where to go from here? Patients who have a revision hip are at higher risk of dislocation. You have to take the decision yourself whether you are prepared to take the risk for any given activity.

If it was me, I would want to know more details about the arc of stability that your personal hip has. Your surgeon will have documented this at the time of the revision. Or, you could ask your surgeon to 'screen' your hip, moving it under the view of an image intensifier.

Dislocation is either posterior or anterior. Yours sounded as though it was posterior. It is usually the combination of hip flexion (bending over) with adduction (leaning or twisting towards the affected hip) that leads to dislocation. The highest risk of this occurring while sculling will be while entering / exiting the boat. You can reduce the risk by lowering the area of deck which you stand on. Boating from a shelving bank is probably also safer than using a landing stage. I think sculling is relatively safer than rowing.

Hope this is of use.
James

[Steve Giddings]

Thanks for weighing in. You are correct, my original prosthesis was manufactured by Smith and Nephew, which was to my knowledge the only total hip resurfacing prosthesis actually approved by the (US) FDA.

I have not been able to get a direct answer concerning the arc of stability. I know my surgeon is very competent. He does 3-4 or more hips on two separate OR days each week, has stirling credentials and is highly respected by his peers. I believe he is a bit "gun shy" for me after the three succcessive dislocations, each occurring with less provocation. The reductions were not easy. The first required 14 attempts. Evidently the drug interactions did not go as expected and I did not relax. I did not lose consciousness and remember the entire process. After the third, I was discharged home with the unstable hip and was not told what had happened until I saw my orthopedist 2 days later.

[jhmb...@gmail.com]

That cannot have been fun.

Its not relevant now, but Derek McMinn sold his Birmingham design to Smith and Nephew. So I guess that when you mentioned that the cup arc was less than 180 degrees, this was regarding the liner that was implanted into the BHR cup (which was left in place). Water under the bridge.

For scullers who are thinking about having a hip replacement, a resurfacing is still probably the best option regarding the dislocation risk. And who would want to capsize into cold water with a dislocated hip.

I am an orthopaedic surgeon, and every single clinic brings people who want to keep on playing their sport, and enjoying life to the full. So I should think that there must be quite a few scullers out there who have had hips replaced, and perhaps had problems with the replacement.

Entering the boat while standing in shallow water, instead of using a landing stage, might help. You can sit down and swing your lower limbs into the shell while keeping them in line with your pelvis - in a similar manner to the way physios will tell you how to approach getting in and out of a car.

Presumably your first steps would be to clear it with your surgeon, and try an ergo session.

[Steve S]

My experience, in brief.

With no cartilage left in the right hip and little in the left, I had a double hip replacement in mid-2014, at age 71. The procedure was anterior, and the components were the standard for the institution, Kaiser Health Care. The ball size was 36mm.

Though I had trouble standing and walking immediately prior to the operation, I was still sculling and had raced 7 days before the operation.

Recovery was smooth though I took my time. Six months afterwards I began to train seriously and by ten months I was racing again, quite successfully: sculling, not rowing. I'm now training about 10k/day, and rowing faster than one year prior to the operation.

My range of hip flexibility is at least what is was on the damaged hips. I've been told that both the anterior rather than the posterior and the 36mm rather than 32mm contribute to the flexibility I enjoy.

I'm lifting light, but doing no running or jumping at all.

I suspect that I'm wearing the plastic liner more rapidly than I would have were I not training and I face a revision in the distant future. That's a trade-off I'm comfortable with.

In my Berkeley, California, rowing and paddling club of about 150 members there are two other double-hips and two singles, three of whom are training seriously. Of these, one single and one double had complications and revisions, in both cases due to problems with the initial procedure, not with training.

Both of the members with revisions are paddlers not rowers. Canoeing and kayaking are more congenial to limited hip flexibility than rowing.

[Steve Giddings]

Thanks to all of you. I am a physician, an endocrinologist with a prior PhD with a n emphasis inexercise physiology. Right now, after being nonweightbearing for the first month after surgery, and 50% for the second, I am both weak and reconditioned. So nothing anytime soon. I am walking now about 55 minutes at a risk pace and get out of breath with four fights of stairs. My legs show significant atrophy just by inspection, so I have bit of work to do before I get back in a boat. But hopefully with guidance and support I will get there

[Henry Law]

On 30/01/16 01:13, Steve Giddings wrote:
> I am ... reconditioned

Oh, I could do with being reconditioned. You know, new bearings, oil
filter changed ... :-)

Seriously though, I've been reading this thread with a mixture of alarm
and amazement at modern technology. All I can do is wish you all the
best and hope fervently (as you do) that you can return to the sport we
all love.

--

Henry Law Manchester, England

[ben]

I"m also an orthopaedic surgeon, do about 100 total hips/year and have won the Master's 40+ 8+ at the Charles a couple of times over the last few years with a guy in the boat who raced with a total hip replacement (not a Birmingham). Your situation is probably a bit different than most people with a hip replacement because of the recurrent dislocations. Despite the good position of the components now and the strengthening you've done around your hip, your risk is way, way higher given three surgeries and previous dislocations. The ligaments and capsule around the hip would be quite damaged in a way that you just can't strengthen and would make your risk lifelong.

That being said, you might be ok. If you've never actually dislocated rowing and you feel comfortable erging and it's that important to you then , well...it's your hip. I'd agree with what was mentioned before about being careful getting in and out more than actually rowing, and you could have it examined for stability to give you some idea but you could probably never be 100% one way or the other anyway. The proof will be in the pudding. Keep your feet lower too, will probably give you less flexion.

Seeing as this thread might get looked up again by people looking for hip replacements, it does serve as a cautionary example of the metal-on-metal hips such as the Birmingham. If everything goes well, it's a great operation but certainly there is the complication you experienced with the pseudotumour and subsequent revision.

In my experience, the regular old hip stemmed hip replacements are so good, with much larger heads and lower wear rates now (or the very large dual mobility heads that you went through at some point), that I"m not sure getting a "Birmingham" would be worth the risk for rowing. Maybe for downhill skilling or hockey or something, but rowing is a pretty controlled motion and I've seen firsthand that you can row and train at even a pretty high level with a so called "standard" hip replacement.

[Steve Giddings]

[Steve Giddings]

On Thursday, January 21, 2016 at 5:28:20 PM UTC-6, Steve Giddings wrote:

Wnated to add a follow up as it is positive. Several months and after not getting answers concerning potential causes of my recurrent hip dislocations, I went to the orthopedic literature and found several series on recurrent dislocations and associated findings. The two most common factors appeared to be soft tissue disparity, primarily weak abductors, and a low degree of anteversion. I had been doing regular abductor strengthening exercises since the last surgery, and prior, and my abductor strength is just fine. I got copies of my various xrays and used them to caclulate the degrees of inclination and anteversion for both the first and the second cup. The inclination for both cups was about the same, 40-45%, but the first cup had less than 10% of anteversion. The second cup is right around 30%.

Buoyed by this new knowledge, I went to another orthopedist with my written calculations and my xrays. Hed reviewed them both, made the comment "You certainly have done your homework" and then said that he could not see any reason that I couldn't row.

I have been back on the water since that day and have had no trouble getting in and out of the boat on one leg or up the the catch. Happy camper.

[rosw...@gmail.com]

Hi Steve - Im a rower in Davis CA, looking at hip replacement at 55yo. Am curious to find a surgeon in Bay Area- Sacramento area who is fluent in hips and rowing. Would your hipster members be willing to give me recommendations/advice/ warnings?
my story: labral tear with subsequent arthroscopy debridement in 2015. Took up rowing in 2017, then more labral tearing in 2018 and now osteoarthritis. Specialist has ruled out labral reconstruction due to the cartilage degeneration)

[Steve S]

My surgeon was Christopher Grimsrud. He is on the Kaiser staff. They build him a new operating theatre every couple of years, it seems. I think he operates out of the newish hospital in San Leandro these days and probably sees patients in Oakland as well. He has substantial experience with masters athletes. He is a specialist in the anterior procedure that I think is essential for easy rapid recovery and maximal post operative flexibility. He is one of the very few Kaiser surgeons who does double hips regularly. I know several of his other patients and they are as positive about their experience as I.

BTW, I'm still training and racing a lot.