115,000 Miles and Counting: Extraordinary Athletic Activity After a Historic Total HipArthroplasty with 39-year Follow-up

Abstract

We present an 81-year-old male who underwent a direct anterior approach total hip arthroplasty (THA) with a ceramic-on-ceramic bearing in 1986. Amazingly, the patient kept meticulous logbooks of his many athletic endeavors, which were tallied after 35 years in 2020. These included 20,797 miles of running, 2323 miles of swimming, 66,349 miles of bicycling, and at least 25,500 miles of walking, amounting to more than 114,969 miles of physical activity. As the average age of patients who undergo index THA decreases, the debate regarding physical activity recommendations after THA has become increasingly relevant for patients, but this topic is inadequately studied and thus remains an unanswered question.

Introduction

The evolution of total hip arthroplasty (THA) has revolutionized the quality of life for patients who suffer from osteoarthritis and other hip-related diseases. However, in the 1970s and 1980s, most doctors sought nonoperative methods to address osteoarthritis in younger and more physically demanding patients. At that time, hip implants were struggling to achieve long-term bone fixation, which resulted in high rates of implant loosening and failure [1,2]. The bearing surface materials that implants were composed of also had relatively high rates of wear, fracture, and occasionally caused toxic soft tissue reactions [3]. In addition, almost all early THAs had a small-diameter metal ball on conventional polyethylene (not cross-linked polyethylene [XLPE]) bearings with high associated linear wear rates and rapid development of periprosthetic osteolysis, especially seen in young, active patients. Since the longevity of replaced joints was variable, few doctors would perform hip replacements on these demanding patients, or on those under the age of 70 [1,4]. This led some surgeons of that era to explore the use of “alternative bearings” to circumvent these well-known modes of metal on conventional polyethylene failure [3].

The investigation into alternative bearing surfaces may not have demonstrated immediate benefits; however, the reduction in THA revisions over time has displayed the progress of components and their direct impact on implant survival. A 2022 study focusing on a 30-year survival of primary THA in patients under the age of 50 reported a revision-free survival rate of only 66.7% [5]. While the 66.7% survival of primary THAs included the utilization of early generation, conventional non-XLPE plastic liners, another study that focused on third-generation ceramic-on-XLPE THA bearings in 2020 showed 98% survival of the femoral component and 96% survival of the acetabular component at 18-year follow-up for patients younger than 30 years at the time of implantation [6]. The jump from a primary THA success rate from 66.7% to 96%-98% captures the evolution of ceramic components to a more durable fourth-generation material in 2003, which has also led to decreased implant fracture rates, combined with the development of XLPE, dramatically reducing poly wear rates [3].

As modern implant bearing surface composition has improved and implant materials have advanced, bone in-growth and stability are now more durable than at any previous point in time. This has also led to lower rates of revision surgeries and implant failures [3,7]. In addition, the direct anterior approach (DAA) to THA has helped to improve muscle preservation and reduce patient recovery time [8,9]. These improvements have enabled surgeons to feel more comfortable recommending THA for younger patients, facilitating a more expeditious return to work and lifestyle activities [[10], [11], [12]]. As a result, the age group of people who undergo THA has significantly decreased and is projected to decline further in upcoming years [4,12].

As younger, more active people undergo THA, a frequently asked question is what activities are considered “safe” after a hip replacement? Specifically, is running “physician approved?” Most physicians and online sources suggest that running is a high-impact sport because of repetitive stress-loading on the hip joint; therefore, it is usually discouraged due to concerns regarding implant fracture, dislocation, or failure [1,4,11,12]. However, the research on and guidelines for running post-THA are scarce and often conflicting [5,7,11,[13], [14], [15], [16]].

Due to the current lack of and growing need for information, increased efforts have been made to clarify exercise directives and document significant athletic activity after total joint replacement surgeries [11,13,17,18]. A recently published study focusing on returning to sports after total knee arthroplasty allowed patients to self-report their athletic activities after total knee arthroplasty [18]. While the majority of participants reported being “satisfied” or “very satisfied” by their return to sports overall, dissatisfaction remained highest among runners and joggers [18].

Concerning THA, the European Hip Society conducted a survey investigating physicians' activity recommendations for patients who underwent THA in 2020 [11]. The study's results report that most physicians recommend that swimming (88%), cycling (77%), jogging (75%), and running, on both the treadmill (67%) and otherwise (61%), be allowed 6 months after surgery [11]. Notably, the study also observed a tendency for surgeons utilizing the DAA to allow more sport activities after THA than surgeons practicing other approaches [11]. Given the rising interest in athletic activity after THA, we are aiming to supplement the current literature with a unique account.

This case report presents a patient who underwent THA in 1986, whose hip has since withstood 39 years and over 115,000 miles (mi) or 185,074.5 kilometers (km) of well-documented physical activity. This patient's ceramic-on-ceramic (CoC) THA has been a living tribology laboratory that has endured 39 years of intense physical activity. This has included multiple Ironman events (distinguished as the longest standard triathlon, consisting of a 2.4 mi [3.9 km] swim, a 112 mi [180.2 km] bike ride, and a 26.2 mi [42.2 km] run), as well as marathons (26.2 mi or 42.2 km run) and other endurance events, with no reported patient pain or need for revision. Written informed consent was obtained from the patient for publication of this report and for publication of the associated images.

Case history

In 1985, an active, healthy 43-year-old male presented after experiencing a burning sensation in his right hip that occurred while lifting weights. The patient's past medical history was unremarkable, with no family history of arthritis or other hip-related conditions. He was advised to follow a standard, nonoperative regimen and to later return for a follow-up visit. The patient continued to jog, swim, and bike but continued to experience consistent and progressive pain. The patient denied that the pain ever debilitated him from performing daily tasks, like putting on his own socks or tying his own shoes; however, the pain had started to disrupt his sleep. He had also developed a severe limp.

He returned and was reassessed in 1986. His radiographs (Fig. 1) showed moderate flattening of the femoral head, obliteration of the joint line, slight lateral displacement of the femoral head, and cysts in the acetabular weight-bearing region. All these radiograph findings were consistent with moderate to advanced osteoarthritis. The left hip was normal in appearance. After assessment of his progressive clinical symptoms and radiological changes, the plan was to proceed with a right total hip replacement.

Figure 1.

Anteroposterior radiograph upon presentation in May of 1986 about a year after the initial presentation.

The patient underwent right THA in the fall of 1986. His femoral component was the Richards cobalt chromium, noncemented “Biofit” stem, designed by Indong Oh (Fig. 2) [19,20]. The acetabulum and femoral head were those of the Mittelmeier threaded cup with a 32-millimeters (mm) inner-diameter CoC design, which was first introduced by CeramTec in 1974 and updated to a second-generation ceramic in 1985. His surgeon elected to use the DAA, and the operation went smoothly. Afterward, the patient was able to walk around the hospital that same day.

Figure 2.

Cover image from the original Richards BioFit technique Guide, January 1987 [19].

Within the next 3 days, he recorded in his logbook a walk of 1.5 mi (2.4 km) around the hospital with a time of 19 minutes (min) and 28 seconds (sec). He was discharged 6 days after the operation. His first day home was spent walking at his local track. He was curious to see if he could run, so he jogged for a few steps. Encouraged by no pain, every time he returned to the track, he would incorporate a little more jogging into his laps. After 6 weeks, he participated in a sprint biathlon, 0.25 mi (0.40 km) swim and a 3.1 mi (5.0 km) run, with a finishing time of 31 min and 15 sec.

Four months after surgery, he participated in his first race recorded in his logbook, a 6.2-mi (10 km) run (55 min and 35 sec). As time passed with daily training, his speed started to improve. At the end of his first postoperative year, he had participated in a total of 13 races, one of them a full-distance triathlon (swim 2.4 mi [3.9 km], bike 112 mi [180.2 km], run 26.2 mi [42.2 km]), which he finished with a time of 12 hours (hr), 3 min, and 2 sec. The patient and his results from this triathlon were presented at a Yale Orthopedic arthroplasty conference, where many of the doctors strongly advised him to stop running because of risks regarding hip-bearing surface wear, dislocation, or fracture.

However, the patient reported that their concerns did not change his training regimen. Along with his triathlon, the patient noted a 4 mi road race that he finished with a time of 29 min and 40 sec (7:35 min/mi) in the fall of 1987, which was growing closer to the times he achieved before his arthroplasty. Notably, he had his fastest recorded marathon time only 2 years after surgery and continued with other endurance events. At age 70, he even achieved a first-place finish in his age division after completing a half-triathlon (1.2 mi [1.9 km] swim, 56 mi [90 km] bike, and 13.1 mi [21.1 km] run).

Over 39 years of his hip use and 58 endurance races, he recorded 20,797.0 mi of running, 2323.2 mi of swimming, 66,349.0 mi of bicycling, and at least 25,500 mi of walking in his logbooks (Fig. 3). Of note, these are all his recorded races, events, and training. He reports additional training and races not accounted for within the logbooks, which makes this an underestimation of his true mileage (Fig. 4a and b).

Figure 3.

Patient sitting in the office, holding all his logbooks that document his athletic training, mileage, and competitions since his total hip replacement in fall of 1986.

Figure 4.

Examples of daily documentation in his logbooks: (a) documentation from the month of replacement; (b) training from week of April 1987.

Throughout all his years of athletic activity, he has noted a gradual shortening of his right leg, which appears to have begun within 5 years after the operation according to a radiograph taken in November of 1991, which first displayed objective evidence of stem subsidence. He now wears a shoe lift to compensate for the difference (approx. 1.25 inches (in) or 31.75 mm). The lift has not interfered with his daily tasks or exercise. Physical assessment in 2022 revealed that the patient has a mild to moderate limited range of motion (approx. 90° flexion, 45° abduction, 20° internal rotation, 70° external rotation, and 40° adduction) (Fig. 5a-c), with painless loosening and subsidence of the femoral stem. He has a height of 69 in. (1.75 meters (m)), a weight of 77.1 kilograms, and a body mass index of 22.89 and has maintained his general physique over the years. He has not had any hip symptoms such as pain, squeaking, clicking, or loss of motion. Today, he still goes on long bike rides (14 mi) twice a week, plays tennis, and consistently walks 8-12 miles per week.

Figure 5.

Sequential hip radiographs: (a) Anteroposterior (AP) right hip radiograph 1 year after operation in 1987. (b) AP right radiograph upon presentation in July 2022 approximately 35 years after operation. (c) AP pelvis radiograph in July 2022.

Discussion

There is a notable lack of prospective scientific studies that have investigated which athletic activities are considered safe and feasible for patients after THA. As a result, exercise guidelines for total hip patients have been almost wholly generated based on expert opinion and recommendations of total joint surgeons collected via surveys [7,11,15,16].

While there seems to be a general consensus allowing certain “low-impact” exercises without limitation, like swimming and biking, discrepancies arise when evaluating “high-impact” sports, such as running [4,11,15]. In recent surveys, jogging has reportedly gained more support from physicians; however, few surveys have explored physician opinions on long-distance, intensive running [11]. One case report followed a 20-year-old who successfully competed in collegiate long-distance events, like the metric mile (1500 m), but the aftermath of his sport is yet to be reported [17]. Even as restrictions after THA are reduced, physician hesitancy remains concerning high-intensity activity due to concerns regarding periprosthetic failure, dislocation, and polyethylene wear [4].

One factor that has likely contributed to our patient's clinical success is the CoC bearing surface of his total hip. His ceramic, screw-in acetabular cup was designed by Mittelmeier after years of meticulous research; however, despite his diligent studies, the cup was deemed too difficult and unforgivable for placement by many American surgeons. While the unpopular screw-in design was eventually retired, CoC joints gained traction as they displayed good outcomes due to their excellent durability and resistance to wear properties [3,16,21]. Ceramic wear particles are also biologically inert, unlike the wear particles of polyethylene and metals, which are known to be associated with osteolysis, adverse tissue reactions, and pseudo-tumors [1,3].

With regard to the femoral component, the cobalt chrome stem incorporated scalloped shelves in the otherwise smooth surface, which were carved out in an attempt to encourage focal bone ingrowth and achieve subsequent implant fixation. However, due to aseptic loosening and subsidence, the Richards' Bio-Fit stem was ultimately observed to have a poor survival rate. In fact, a study from the Norwegian Arthroplasty Registry in 1995 reported that 4.5 years after placement, the estimated probability of revision for aseptic loosening for all uncemented implants was 4.5%, but a failure rate of 18.6% was observed for the Bio-Fit stem [22]. Modern uncemented implants have sought to improve both initial stability in the bone and durable long-term fixation through implant coatings, stem geometry, and surface textures that offer better coefficients of friction and rotational stability.

On evaluation of weight-bearing radiographs from 2022, there was negligible wear. There are subtle radiolucent lines along the superior lateral and inferior medial portions of the acetabular component with minimal proximal migration of the acetabulum; the acetabular component flattened (to approx. 20°) without any instability, dislocation, or impingement events. His collared femoral component, the Richards' Bio-Fit stem, has settled significantly (approx. 1.25 in or 31.75 mm), which has resulted in our patient wearing a shoe lift regularly (Fig. 6a-c). The overall preservation of his hip is significant in light of how many gait cycles it has withstood after 20,787 miles of running.

Figure 6.

Weight-bearing radiographs from 2022: (a) Standing AP of right hip, (b) standing with maximum abduction, (c) standing lateral of right hip.

While the hip remains surprisingly painless for the patient, if future revision were ever to be considered, it would most likely be indicated for worsening pain with weight bearing and involve removal and revision of the femoral component. A splined tapered femoral revision component could then be used to restore contact with the femoral cortices and facilitate re-gaining leg length, with the use of an identically sized ceramic head placed into the existing all-ceramic socket. Revision of the threaded ceramic acetabular component could also be considered but would most likely not be needed.

While our case displays an overall smooth recovery and return to sport despite his above-average number of gait cycles, literature regarding elite athletics, specifically those classified as “high-impact,” suggests that such sports may increase the risk of osteoarthrosis and subsequent THA [23]. A Norwegian study investigating the link between elite athletics and later-life osteoarthritis leading to THA found that elite athletes have double the risk of osteoarthritis-induced THA compared to the general population for both sexes [23]. Notably, male participation in sports deemed to be “high-joint-impact” activities, such as running both long and medium distances, was associated with subsequent THA, which is consistent with our case [23]. A Japanese study explored the influence of jogging on overall implant durability and the participation rate of postoperative jogging [24]. Although this study concluded that hip implants in the joggers displayed no excessive wear at short-term follow-up compared to nonjoggers, the small sample size and lack of long-term follow-up support the need for further investigation on this topic. The study also reports a very low participation rate of jogging after hip replacement, with anxiety cited as the most common reason given for not jogging after THA among the people interested in doing so [24].

Studies examining the feasibility of returning to sports after a hip replacement surgery are attempting to address this patient anxiety. For instance, a 2021 case series aimed to report on elite athletes in a variety of disciplines who underwent hip resurfacing arthroplasty (HRA) and returned to their sport [25]. Interestingly, an ultramarathoner and a professional Ironman triathlete were 2 of the 8 athletes included in the report. While all 8 elite athletes reportedly returned to their sport after HRA for varying amounts of time, the ultramarathoner and the Ironman triathlete were the only 2 still actively competing at the time of the study's publication [25]. A different 2021 study focused on systematic review of patients' return to athletic endeavors after THA; unlike the HRA study, post-THA articles reported that returning to jogging and running after THA was generally not surgeon recommended and that athletes' return to “high-impact” sports was low overall [26]. They also reported that previous experience in that sport was a significant prognostic factor for returning to the sport, and that these athletes, with physician counseling, may be more able to return to sport after THA [26].

Studies on intensive athletic activity after THA are warranted to further our understanding of how a patient's implant and clinical outcome will be impacted during various sports, especially with the use of modern arthroplasty implants in combination with minimally invasive surgical techniques. There have been few long-term studies on the results of “high-impact” sports because surgeons only recently started to perform THA on younger, more active patients [4,10]. We hypothesize that newer and more durable implant biomaterial surfaces, improved liner-locking mechanisms, and improved bone-prosthesis osteointegration will pair with the minimally invasive, direct anterior-approach surgical approach to preserve native periarticular muscle function and thus allow modern THA implant constructs to withstand more physical stressors.

Amazingly, even without modern femoral or acetabular components, our patient has still had an excellent initial outcome that has been sustained over the ensuing 4 decades, long outlasting an era of metal-on-conventional polyethylene THA whereby most other THA implants failed in similarly young, high-demand patients. His objectively recorded mileages and radiographs are truly a rare and impressive testimonial of the potential capabilities of THA for young, high-demand patients who also desired to return to high levels of athletic training and competition, especially in that early era of hip replacement. Even if doctors do not currently advise running after THA, we encourage surgeons to be proactive in learning about what athletic activities their patients are participating in and believe that research is needed to investigate high-impact sports on the outcomes of modern THA. These considerations will ultimately provide more insight into which limitations for THA patients may be outdated, or perhaps unnecessary.

Summary

As the age of THA patients at index implantation continues to decline, the physical demands placed on implants will continue to increase. Running is generally considered a high-impact activity that has rare long-term data. We have presented the remarkable THA case of a patient who utilized their index CoC implant for over 39 years and 115,000 recorded miles of activity without needing a revision. Radiographic analysis reveals that the patient has experienced shortening of his right leg due to femoral stem subsidence; however, the patient has had never experienced problems such as hip pain, squeaking, or dislocation. After 39 years of hip use, the patient remains active and satisfied with his implants. Despite his clinical success, more long-term studies on intensive athletic activity after THA are still warranted.

Conflicts of interest

LER reports consulting for DePuy Synthes, Innovative Medical Products, and Thompson Surgical Instruments, with publication royalties from SLACK, Inc., Johns Hopkins University Press, and Wolters Kluwer. All other authors declare no potential conflicts of interest.

For full disclosure statements, refer to https://doi.org/10.1016/j.artd.2025.101711.

Informed patient consent

The author(s) confirm that written informed consent has been obtained from the involved patient(s) or if appropriate from the parent, guardian, power of attorney of the involved patient(s); and, they have given approval for this information to be published in this case report (series).

CRediT authorship contribution statement

Marguerite L. Gilmore: Writing – original draft, Visualization, Investigation, Conceptualization. Ansab Khwaja: Writing – review & editing, Supervision. Daniel H. Wiznia: Writing – review & editing, Supervision. Lee E. Rubin: Writing – original draft, Visualization, Supervision, Investigation, Conceptualization.