Total hip replacement in dancers
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- Buyls, I.R.A.E., Rietveld, A.B.M.(., Ourila, T. et al. Clin Rheumatol (2013) 32: 511. doi:10.1007/s10067-013-2189-3
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A case report of a professional contemporary dancer who successfully returned to the stage after bilateral total hip replacements (THR) for osteoarthritis is presented, together with her own commentary and a retrospective cohort study of total hip replacements in dancers. In the presented cohort, there were no post-operative dislocations or infections, the original pain had been relieved, rehabilitation was objectively normal and all resumed their dance (teaching) activities. Nevertheless, they were disappointed about the prolonged rehabilitation. Due to their high demands as professional dancers, post-operative expectations were too optimistic in view of the usual quick and favourable results of THR in the older and less physically active, general population. In all dancers with unilateral osteoarthritis, the left hip was involved, which may reflect the tendency to use the left leg as standing leg and be suggestive that strenuous physical activity may lead to osteoarthritis. Better rehabilitation guidelines are needed for dancer patients undergoing THR, especially drawing their attention to realistic post-operative expectations.
KeywordsDancingOsteoarthritis of the hips / coxarthrosisPerforming arts medicineTotal hip replacement / THR
A case report of a professional contemporary dancer who successfully returned to the stage after bilateral total hip replacements for osteoarthritis is presented, together with her own commentary and a retrospective review of hip replacement in dancers.
T. O. (date of birth is 16 June 1973), and also a co-author of this report, started dancing in her native Finland at the age of 7. She later moved to the Rambert School in the UK, to complete her training in Contemporary Dance. She then danced professionally with various companies for some 15 years, considering herself to have a very slight difference in leg length and a difference in turnout of about 5° between the two sides.
She had previously had keyhole surgery on the left knee at the age of 14, though the reason for this was not clear. At the age of 19, surgery was performed to shorten the ligaments at the ankle as an aid to dancing. There was no relevant family history of musculoskeletal disease though her father, who was sporty, had his first hip replacement at the age of 80.
Increasingly, the range of movement became restricted at the left hip, and pain there became more persistent. Plies became more difficult, and by 2008, symptoms also commenced in the right hip. An X-ray was taken (Fig. 1).
When first reviewed at a performing arts medicine clinic in July 2010, both hips were painful, and she demonstrated marked bilateral reduction of internal rotation in flexion. There was a stiff segment at the base of the spine, but the knees, ankles and hips appeared normal. Her general practitioner had already raised the possibility of further hip surgery, and she was now referred to an orthopaedic hip specialist. Total left hip replacement was offered, and after some considerations, she accepted this. The left hip was replaced with a large bearing ceramic-on-ceramic prosthesis (Note: Depuy Corail stem and Pinnacle 100 series socket with a 36 mm Biolox Delta ceramic liner and head) in September 2010, arguably as the prosthesis most likely to allow her to remain active. She was warned of the possible future need for a right total hip replacement and continued with intensive specialised rehabilitation.
The choice of this particular prosthesis by the surgeon in the UK, who selected it, remains a matter of debate, given the lack of formal controlled trials for this relatively new prosthesis. His rationale was that he was familiar with it and that its use had previously allowed sportspeople under his care, including skiers, to return to their sport at a national level. Moreover, the manufacture of ceramics has improved significantly, in the past decade, the large surface prostheses reducing the risk of dislocation in any dancer or sportsperson still requiring a large range of hip movement.
She was no longer dancing on the stage; although the left hip was now largely symptom free, the right hip was becoming increasingly painful and restrictive in terms of her teaching capacity. A large bearing ceramic-on-ceramic total hip replacement was now offered on the right side, and after some deliberations, she accepted this also. The second hip was replaced 1 year after the first. The post-operative X-ray is shown (Fig. 2).
The patient’s viewpoint (T. O.)
Prior to the onset of symptoms, I had danced with the Phoenix Dance Theatre, a company famous for their dancer’s athleticism and physical power as well as enjoying all forms of movement with activities such as yoga and Pilates in my spare time. It was difficult to understand what was causing the pain when it first appeared. I had no previous experience in dealing with injury, and it became increasingly difficult to lift my left leg to the side. I tried osteopathy, cranial osteopathy, Rolfing and Feldenkreis with varying degrees of success. When things suddenly got worse in the left hip around 2009, I had left the company and was teaching full time though found it increasingly hard to demonstrate and my leg would often give way when I was dancing. It was especially hard to understand why this should have been happening to me.
After the operation it has taken a full 2 years for the left hip to regain its many complex functions, although throughout that period, I have been pain free. My right side is also now getting stronger, also pain free. By the standards of conventional physiotherapy and function in non-dancers, I was probably back to normal within 3 months of each operation. But that does not take into account the complex and intricate demands dancers make on their bodies, turnout, leg lifts and twisting all especially hard to regain.
Turn-out positions are still easier to achieve with the left rather than with the right leg, especially when it is raised, but my surgeon suspects this is due to the slightly different position of the two prosthetic sockets. My life is now much happier. It was a challenge to return to a stage performance earlier this year, and I really enjoyed the challenge. It provided an opportunity to prove to myself that I had overcome the problem and that I had not been beaten by it.
Although I may never quite have my previous elevation, it is lovely to be able to jump and to walk as much as I want without any pain, even though I cannot quite do the splits. My return to the stage was in a work that required considerable physical and emotional effort but which did not require high elevations or difficult lines.
In a previous study, no significant differences were found in the degenerative changes in the hip joints between former professional female dancers and pair-matched controls . Hip complaints are, however, common (21 %; 14/66) in dancers of >45 years of age and older; 43 % (n = 6/14) of these hip problems were due to degenerative changes in the hip joints . Of this group, only three had had a total hip replacement (THP). These three are included in this study.
Two of us (I.B.; A.R.) reviewed eight other active dancers and dance teachers who had a total hip replacement between July 1993 and March 2001. There were seven female dancers and one male; the mean age was 53 (49–59) years. There were no dysplastic hips or cases of epiphysiolysis. Seven had a unilateral osteoarthritis of the left hip, which is significant even in this small group. One female dance teacher who had bilateral osteoarthritis was the youngest in the group, and THP was performed on the right side in 2000 and on the left in 2002. The mean follow-up was 3 years (9 months to 8.4 years). There were no post-operative dislocations or infections. All have resumed their dance (teaching) activities.
A problem encountered in this group was a leg length discrepancy in the absence of an adduction contracture, and in favour of the operated leg, this may be caused by the combination of hypermobility and the orthopaedic surgeon trying to achieve the proper tension between the hip components during operation, in order to avoid post-operative luxation. Although the original pain had been relieved in all, there were some subjective disappointments in the speed of the post-operative rehabilitation, even though this was objectively normal and often faster in comparison to non-dancer patients. This disappointment may be due to their high demands as dancers and a too optimistic expectation in view of the very favourable results of THP in the, usually much older, general population.
It comes as no surprise that the number of total hip replacements in active dancers and dance teachers is relatively low, even in a dedicated Medical Centre for Dancers and Musicians. In a review of 69 retired dancers, hip and knee complaints were more common than in matched controls, though they reported being more content with their lives and experienced being healthier than the controls . No THP replacements were reported.
Although our group was very small and can only serve as a retrospective clinical pilot study, there were some interesting observations relating to post-operative expectations and to which leg was involved. In all dancers with unilateral osteoarthritis, the fact that the left hip was involved may reflect the tendency to use the left leg mainly as standing leg. This may be circumstantial evidence that strenuous physical activity may lead to osteoarthritis, but then only in predisposed individuals, given the low numbers overall in dancers.
It would appear that better rehabilitation guidelines are needed for dancer patients undergoing THP, especially drawing their attention to the fact that due to their high demands and expectations as dancers, their rehabilitation will take over a year, much longer than in the general population. More research on the results of THP in the relatively young dancers and dance teachers would be welcomed, preferably in a multi-centre prospective survey.