Riding after Joint Replacement

There may be life after joint replacement surgery.but is there riding? For most horsemen and horsewomen, the answer is yes.
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There may be life after joint replacement surgery.but is there riding? For most horsemen and horsewomen, the answer is yes.
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For grand prix dressage rider pam goodrich, riding without pain was almost unimaginable. Degenerative arthritis had virtually destroyed her hip joint by the time she was 35. "My hip had started to fuse, probably from having injured it when I was a kid. I couldn't ride and I couldn't walk," she remembers.

Cindy Schlener's experience was much the same.

"Because of my arthritis, it would take about 20 minutes just to stretch my hip muscles when starting to ride," Cindy recalls. "I had problems opening my hip angle for the trot and especially the canter. I'd have to get off my horse and re-adjust my hip. I wasn't able to ride consecutive days, and I wasn't able to ride my husband's horse because she was wider than I could handle. Painkillers didn't work after the first few months. I rode through the pain, but I never looked forward to it."

For both Schlener and Goodrich, the solution was hip replacement surgery, now one of the most common orthopedic procedures performed in the United States. Some 220,000 people have an artificial hip joint installed annually, and more than a quarter of a million get a new lease on life by getting one or both knee joints replaced.

Joint replacements are complex, but highly successful surgeries, which can restore mobility and quality of life to patients suffering the effects of degenerative joint disease. But can a prosthetic joint allow you to do what you most dearly love-ride?

For Goodrich, the answer was an unqualified yes.

"Four months after my surgery I was back in the saddle. I had ridden at the Grand Prix level before the surgery, and one year later I was riding Grand Prix again," she shares. "Whatever you did before, you can do again [with an artificial joint]. In fact I was so much better afterwards, because I was riding without pain for the first time in years!"

Sally Sparrell underwent a knee replacement in March, 2002.

"My knee had deteriorated to the point where I was barely able to walk, and riding was put on hold," Sparrell recalls. "When I agreed to the surgery, my real concern was whether I would even be able to walk afterwards, my age [59] and bone condition being predominant factors. I was pleasantly surprised. I no longer ride much over fences, and have no desire to show anymore, but that really has nothing to do with the knee. I would be completely confident to ride the flat classes, both hunter and western, and since the surgery, I have on occasion ridden my students' horses over schooling fences and trained some green western horses, though my risk-taking days are pretty much over now.

"I have found that my new knee has made it a little difficult to pick up the right stirrup, as I can't turn my toe in as far as before. The surgery changed the leg bone alignment slightly. But other than that, I have few complaints," says Sparrell.

Riding with Replacement Parts

• Find an orthopedic surgeon who understands your horse-centric lifestyle and the physical aspects of riding.
• Follow your doctor's advice about rest and recovery.
• Although you may not return to the same level of riding, revel in the fact that you will return.
• Consider riding a breed known for having smooth gaits.
• Avoid riding situations that put you at high risk of falling.
• Use caution when mounting and dismounting to protect your new joints.
• Ride with a longer stirrup to help relieve pressure on your artificial joints.

Encouraging Words
Are you a candidate for joint replacement surgery? If chronic pain in your hip or knee is starting to keep you from doing the things you want to do, then the answer may be yes.

Improvements in the design of artificial joints, and advances in surgical techniques which make the procedures less invasive and less painful than in the past, allow for faster recovery times, and have taken the expectations for joint replacement surgery sky-high. It is now a viable option for far younger patients with much more athletic ambitions. Cyclists, swimmers, mountain climbers-and yes, riders-are looking at joint replacement, and they're not waiting until they're incapacitated to investigate.

"Ten or 15 years ago, orthopedic surgeons in general would recommend waiting until the age of 65, or until the pain was so debilitating that the patient couldn't walk, before agreeing to joint replacement surgery," says Dr. Jess Lonner, director of knee replacement surgery at Pennsylvania Hospital in Philadelphia. "We recognized that artificial joints had a finite lifespan, which was the main reason we didn't recommend undertaking the surgery sooner. But by doing so, we were condemning a lot of 40- to 50-year-old patients to debilitating pain.

"We now advise patients not to wait until they're wheelchair-bound. If their pain is limiting their mobility and/or their livelihood, they should be looking at [joint replacement] The technology and the techniques have improved considerably, and so has our ability to sterilize the joint, which in the past often made the material brittle and limited the amount of activity a patient could expect to do post-surgery."

Doug Unis, MD, a specialist in hip-replacement surgery at Roosevelt Hospital in Manhattan, agrees.

"The surgery is far more accessible and appropriate now for young, active patients," he says. "In the past, the bearing surfaces of the artificial joints weren't as good as they are today. They tended to be metal on plastic, and the plastic would eventually wear out, generating debris and particles which would cause the patient's body to react. Constant inflammation would eventually lead to osteolysis (bone deterioration) around the implant and the joint would wear out. The early metal-on-metal types weren't all that successful either.

"Over the last several years, though, the options for bearing surfaces have improved tenfold," Dr. Unis continued. "We can now operate on patients we would not have considered before, and get them back to doing higher-level activities post-surgery."

Dr. Lonner added, "We also recognize now that well-conditioned patients recover better, especially with knee replacements. Strong quadriceps muscles help a great deal. We find we have the best results with patients who lead active lives and are committed to their recovery.

"In that regard, riders are ideal candidates for joint replacement, because they're fit, motivated, and have good leg strength," he observed.

Overnight Sensations

It's been said that you never really know someone until you live with them. Horse-camping is a bit like that. It provides a unique opportunity for you and your horse to get to know one another-perhaps better than you ever have before. You'll eat together, drink together, wake together, and traverse the trails together, enjoying the sights, sounds and sensations that go along with discovering new places.

Be aware, though, that your horse may not appreciate the outing quite as much as you do-at least not at first. He may be nervous and distracted on the trail. He may fidget and fuss in camp. He may stamp and whinny throughout the night, and act like a far different animal than his usual, confident self.

But whether you're out for a night or the weekend, be considerate. Pay special attention to your horse's physical and emotional needs, and try not to ride him too long or too hard. And whether you're on the trail or tending to him back at camp, be calm and consistent in how you apply your cues. Use the language he knows and respects to refocus his attention and reinforce his good manners.

By keeping your side of the relationship bargain, you'll confirm that you're worthy of your horse's trust-and he'll learn to relax and look to you for security, no matter where your travels take you.

Going Shopping
If you're considering joint replacement surgery, patients agree it's crucial to find an orthopedic surgeon who either already understands the demands of riding, or is willing to listen. Most horse people won't be satisfied with a promise to return them to enough mobility to have a gentle stroll through the mall. They want to be back in the saddle, and be able to wield a muck-fork, and maneuver through a muddy paddock.

"Riding is non-weight-bearing (on the affected joint), which helps," points out dressage enthusiast Pam Goodrich. "But if you are any kind of athlete, it's important to go to someone who understands athletes. For us, it's about more than just comfort. It's about getting a lifestyle back."

There are dozens of implant options available, each with its own set of advantages and disadvantages. Range of motion and durability are priorities for horse people.

"But just because someone claims the 'Jack Nicklaus' implant, for example, is the best one to have, doesn't mean it will be the best one for you," Dr. Lonner notes. "So it's important to discuss all the options with your orthopedist."

In many cases, it might be better to go with the implant style with which your surgeon is most familiar. After all, would you prefer to be the guinea pig on which he or she performs a procedure for the very first time, or would you rather capitalize on the experience that comes with installing dozens of the very same implant you're getting?

Full joint replacement might not be the only option your surgeon discusses with you. Fifteen to 30% of hip replacement patients are candidates for a new procedure called "hip resurfacing," in which the original joint is left in place, but both the ball and socket are given a new, smooth surface.

Replacement Risks
Dr. Unis notes that one of the risks of having an artificial joint is that it might dislocate when you hyper-flex the leg. This is particularly true of some of the older-style artificial hips, which featured a ball-and-socket construction considerably smaller than that of a natural, flesh-and-bone hip joint.

We've already alluded to another risk of joint replacement-that the artificial joint will wear out before you do. According to Dr. Lonner, an artificial knee will last 10 to 15 years for 94% of patients, while a prosthetic hip lasts more than 20 years in 90% of patients.

However, many of the newer implants haven't been on the market long enough for anyone to say for sure how long they will last.

Using caution when mounting and dismounting, which are the most likely times for the hip joint to hyper-flex, is good advice for riders with artificial hips.

"There's a very low risk with an anterior (front of hip) incision as opposed to the more common posterior approach. With some of the newer implants, there's a larger ball, which also reduces the risk of dislocation," says Dr. Unis.

Another risk is that you might end up with legs of slightly different lengths after a hip replacement. With knee joints, the challenge is aligning them correctly so you don't end up with your range of motion compromised. Here's where the experience of your surgeon can be critical.

You need to do your homework. Ask questions. How many of these surgeries does your orthopedist do? If he says he's only done a dozen or so, keep looking. Ask if your orthopedist is fellowship-trained in joint replacement-if he is, that means he'll have done the procedure over and over.

Great Expectations
Moderation should be your goal, post-surgery. Riders have considerably better odds of returning to their passion than athletes in "impact loading" sports such as running or skiing, according to Dr. Unis. "But you need to be careful about impact on the artificial joint, which can accelerate wear." In other words, he says, you can ride, but try not to fall off!

For horsewoman Lisa Caylor, multiple joint replacement surgeries have meant the difference between spending life in a wheelchair or walking, so protecting her new joints is important to her.

"I started out slow after my surgeries, on horses that were mellow and very well trained," explains Caylor, who drives horses as well as rides. "My surgeons have worked so hard to give me my new joints-I don't want to jeopardize my safety or their work."

Caylor has modified her tack and harness, as well as how she works with horses. Incidentally, Caylor is a student of the John Lyons' training methods, and has attended two Lyons riding clinics in Parachute, Colorado. She completed her second one last summer. She's careful about how long she spends in the saddle at any one stretch, uses a mounting block, and utilizes ground work exercises to instill patience, responsiveness and good manners in her horses. She wants them to be mentally and physically prepared before she climbs aboard or harnesses up for a drive. She adapts John's techniques to suit her own body's abilities to apply them, adjusting as she goes to take care of her joints, She has no intention or desire to give up her horse activities, an interest she shares with her husband, Rick.

"Knee replacement patients tend to experience a lot of irritation of the soft tissues around the joint when the knee is hyperflexed in the saddle," Dr. Lonner observes, "so I discourage patients from work which requires short stirrups, like galloping and jumping. Yes, you can return to riding, but you might want to make a minor lifestyle change and take up dressage, or consider switching to a gaited horse," he suggests.

How long will you be laid up? With the minimally invasive techniques, the main advantage is rapid recovery.

"The first two weeks after surgery are very uncomfortable, but it improves quickly," observes Dr. Lonner. "You might be walking without a cane two weeks after (a minimally invasive hip replacement). With a more conventional surgery, it might be up to three months. Remember that this recovery period doesn't mean you'll be back on a horse, either. That might be several months down the road, depending on how well your rehab routine goes."

It goes without saying that diligence with your rehab exercises will have long-term benefits. However, Cindy Schlener's orthopedic surgeon seriously under-estimated her dedication to the post-surgical rehabilitation program he assigned.

"Based on what my doctor said, the first month post-surgery you don't do anything but mild stretching exercises with a physical therapist. I did that at home three times a week. It was after my first follow-up check, a month later, that the doctor said I could lose one of the crutches and I could start exercising.

"The problem was that he never actually said how long I was supposed to bike for!" Schlener recalls with a smile. "What he meant was 10 to 15 minutes a day. But being very committed to my recovery and to getting back in the saddle, I was doing 45 minutes on the bike with far too much resistance! When I told him about it, he was horrified! I was ordered to stop biking for a week and then to start back slowly."

Pam Goodrich points out another hurdle you'll have to clear in order to be safe in the saddle after joint replacement surgery.

"The rehab exercises don't necessarily get you fit to ride. I found that because I hadn't really used my leg correctly for about three years, the muscles had atrophied. It's so important not to ride anything spooky in those first few months while the muscles are still weak."

I think there are two things that are very important," she adds. "The first is to make sure you have a good surgeon. The other is to follow the rehab instructions implicitly. It will feel like it's taking forever, but don't worry-you will ride again."