Total Hip Arthroplasty in Athletic Patients Under 55 Years Old: Functional Outcomes and Return to Sport at a 2-year Average Follow-up

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Improved implant durability has made it possible to offer this procedure to active patients, including athletes, with expectations of favorable outcomes and long-term survival. However, fear of not being able to return to sports often delays surgery. This study retrospectively analyzes functional outcomes and return to sport in patients under 55 years old who underwent THA following our rehabilitation protocol. Materials and Methods We evaluated 136 THAs in 117 athletic patients (mean age: 49 years; range: 23–55), with an average follow-up of 24 months. Preoperative diagnoses included 119 cases of hip osteoarthritis, 11 cases of avascular necrosis, 3 cases of necroarthrosis, and 3 sequelae of septic arthritis. Functional outcomes were assessed using the Harris Hip Score (HHS) and the High Activity Arthroplasty Score (HAAS). Results Average improvement was from 52.35 to 93.25 in HHS and from 7.43 to 15.18 in HAAS. Return to sport occurred at a mean of 4 months postoperatively (range: 1.5–6 months). Two patients experienced aseptic loosening of the acetabular component, which was resolved with revision surgery, and both returned to physical activity before 6 months. Conclusion THA in athletic patients under 55 years demonstrated favorable short-term functional outcomes, early return to sport, and satisfactory implant survival. These findings may influence future recommendations regarding postoperative physical activity. Level of evidence: III Young Patients Total Hip Arthroplasty Return to Sport INTRODUCTION Total hip arthroplasty (THA) is now a common procedure in young patients. Thanks to the modernization of surgical techniques, the understanding of friction surface interactions provided by tribology studies, and the improvement in prosthetic materials, the durability and survival of implants have significantly increased. This has given hip surgeons the confidence to operate on increasingly younger patients, including those with high functional demands, such as athletes, with the expectation of high success and long-term implant survival—even beyond 15 years¹. In young patients under 55 years of age who are physically active or participate in sports, the desire to return to physical activities after total hip replacement is significant. Many of them even postpone the decision to undergo surgery due to fear of being unable to resume physical activity afterward. The objective of this study is to conduct a retrospective analysis and evaluation of a cohort of patients under 55 years old, with high functional demands and athletic backgrounds, who followed our rehabilitation protocol after undergoing total hip arthroplasty. Our hypothesis is that early rehabilitation and return to sports can be achieved using this protocol, with a mean follow-up of two years after the surgery. MATERIALS AND METHODS Over the past five years, between 2018 and 2023, we performed 943 primary total hip arthroplasties (THA). For this retrospective study, we included patients younger than 55 years with diagnoses of hip osteoarthritis, avascular necrosis (AVN), post-septic arthritis sequelae, and hip necroarthrosis. All included patients had a minimum clinical and radiological follow-up of 6 months (up to 5 years) and participated in some form of sports activity. Exclusion criteria included older patients, partial hip replacements, other indications such as femoral neck fractures, sequelae of hip osteotomies in dysplasia, and sequelae of femoral fractures. Patients with low functional demand or incomplete postoperative follow-up were also excluded. All surgeries were performed using the same surgical technique by the same surgeon, via a direct anterolateral approach with the patient in the supine position, in laminar flow operating rooms following strict surgical antisepsis protocols. An intraoperative lavage with povidone-iodine solution was performed before closure. Spinal hypotensive anesthesia and peripheral nerve block were used, along with intravenous tranexamic acid administration (15 mg/kg) 20 minutes before skin incision. For infection prophylaxis, two doses of 1 g of cefazolin were administered—one during anesthesia induction and one in the immediate postoperative period. Thromboprophylaxis consisted of aspirin 325 mg daily for 30 days. All patients received uncemented implants with metaphyseal fixation, highly cross-linked polyethylene liners, and ceramic heads (mostly 36 mm in diameter), paired with 50 mm acetabular cups, or in some cases, smaller 32 mm cups. We implemented a progressive rehabilitation protocol aimed at returning to sports. This program, supervised by physiotherapists and the physical therapy team, began during hospitalization, which lasted between 48 and 72 hours post-surgery. Patients began sitting on the day of surgery and performed isotonic and isometric bed exercises based on tolerance, focusing on gluteal and lower limb muscle strengthening. Ambulation with walker assistance began within 12–24 hours, depending on the effects of the peripheral nerve block. Patients were discharged with a walker or crutches as needed and continued with at-home physical therapy. Between the second and third postoperative week, depending on patient progress, the protocol intensified with stationary cycling, progressive strength and resistance training, walking, and general locomotor strengthening focused on the lower limbs. Patients were allowed to resume driving and return to work depending on the physical demands of their occupation after the third week. Preoperative functional and imaging assessments were performed, followed by postoperative evaluations at 3 and 6 weeks, and subsequent follow-ups at 3 and 6 months, then annually. Functional outcomes were assessed using the Harris Hip Score (HHS), with the following classifications: excellent (90–100), good (80–89), fair (70–79), and poor (< 70). We also used the High Activity Arthroplasty Score (HAAS) to better evaluate physical performance in relation to sports. All data were collected retrospectively from perioperative consultations and patient medical records, in accordance with the inclusion and exclusion criteria. Bias Control, Variability Management, and Data Collection To minimize surgical variability and reduce potential biases, all procedures were performed by a single experienced hip surgeon using a standardized surgical technique and a uniform postoperative rehabilitation protocol. This approach ensured consistency in both the surgical procedure and postoperative care. Patient selection was based on strict inclusion and exclusion criteria. Individuals with comorbidities that could negatively influence functional outcomes or interfere with rehabilitation, as well as those with incomplete clinical records or less than six months of follow-up, were excluded. Data collection was conducted retrospectively using institutional digital medical records and assessments from scheduled preoperative and postoperative clinical evaluations. Harris Hip Score (HHS) and High Activity Arthroplasty Score (HAAS) were documented by the same medical team during routine follow-up visits, under standardized conditions and following the original guidelines of both scoring systems. An anonymized database was used for statistical analysis to ensure patient confidentiality and data traceability. Statistical Analysis Data were analyzed using SPSS software, version 18.0 (IBM Corp., Armonk, NY). Continuous variables were expressed as mean ± standard deviation (SD), as well as median and interquartile range (IQR) when appropriate. Ninety-five percent confidence intervals (95% CI) were calculated for the main functional outcomes. Comparisons between preoperative and postoperative results were performed using the paired Student’s t-test, with statistical significance set at p < 0.05. The complication rate was calculated as a percentage of the total number of cases. Functional outcomes were categorized according to the Harris Hip Score (excellent, good, fair, and poor) and reported in both absolute and relative frequencies. Ethical Considerations This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Patient confidentiality was ensured through the use of anonymized clinical databases. All patients signed an informed consent form prior to surgery, which included authorization for the use of their clinical data for scientific and academic purposes. The study protocol was reviewed and approved by the local institutional ethics committee. RESULTS We included a cohort of 153 athletic patients under 55 years of age who underwent total hip arthroplasty. Among them, 117 patients (76.5%) returned to sports, accounting for a total of 136 total hip replacements (Table 1). The mean age was 50 years (range: 23–55). The cohort included 38 women (20 right hips, 23 left hips) and 79 men (39 right hips, 54 left hips). Bilateral THRs were performed in 19 cases (15 men and 4 women). Preoperative diagnoses included: 119 cases of primary osteoarthritis, 11 cases of developmental dysplasia of the hip (DDH), 3 cases of avascular necrosis, and 3 sequelae of septic arthritis. Table 1 Sample Characteristics Variable Number Patients 117 Hips 136 Age Range 23 to 55 years (mean: 50) Female/Male 38 / 79 Right/Left Hip 59 / 77 Osteoarthritis 119 AVN 11 Necroarthrosis 3 Post-Septic Arthritis Sequelae 3 All patients engaged in sports activities before stopping due to hip pain; some practiced more than one discipline [Table 2]. The most commonly practiced sport was football (soccer), played by 46 patients two to three times a week. This was followed by cycling (35 patients, 10 to 25 km/week) and running (34 patients, 5–10 km/week). Twenty-six patients swam (sometimes as a complementary sport), 22 played tennis (about two to three times a week), 19 played golf (once or twice a week), and 6 practiced martial arts. Table 2 Sports Practiced Before Surgery Sport No. of Patients Frequency / Distance Cycling 35 10 to 25 km per week Tennis 22 Two to three times a week Football 46 Two to three times a week Golf 19 Once or twice a week Running 34 5–10 km per week Swimming 26 Two or three times a week Martial Arts 6 Twice a week Functional Outcomes : We observed an average improvement in Harris Hip Score (HHS) of 37.8 points: from a preoperative mean of 52.35 (range: 50.25–60.65) to a postoperative mean of 93.25 (range: 80.65–97) (Table 3). In the High Activity Arthroplasty Score (HAAS, 0–18 points), the average improvement was 7.75 points: from a preoperative mean of 7.43 (range: 3–12) to a postoperative mean of 15.18 (range: 7–18). Table 3 Functional Outcomes (HHS and HAAS) Scale Preoperative (Mean ± SD) Postoperative (Mean ± SD) 95% CI of Improvement Median (IQR) p-value (Student's t-test) HHS 52.35 ± 5.8 93.25 ± 6.3 [36.2–39.4] 53 (50–56) < 0.001 HAAS 7.43 ± 2.1 15.18 ± 1.9 [6.5–8.9] 7 (5–10) < 0.001 Return to Sport and Complications : Patients gradually returned to physical activity, starting intensive rehabilitation with physical therapists and kinesiologists at a mean of 1.5 months postoperatively. Initial activities included stationary cycling and strength training. Most patients resumed high-impact sports previously practiced before symptom onset and surgery at an average of 4 months. The highest levels of satisfaction were recorded from the sixth postoperative month onwards. We recorded 2 complications among the 117 patients: 2 cases of aseptic acetabular loosening, both resolved with acetabular component revision surgery after ruling out infection. Both patients returned to their preoperative sport before the sixth postoperative month following revision surgery. DISCUSSION Numerous scientific studies have addressed the issue of return to work and sports activities in young patients who previously engaged in high-impact sports following total hip replacement (THR). In our study group, we observed results consistent with the existing literature regarding low-, medium-, and high-impact sports activities in patients under 60 years of age. Given the relatively young age of our cohort, the outcomes regarding return to sport were highly encouraging, with some patients even resuming high-impact activities. In 2007, the recommendations issued by the Hip Society (HS) and the American Academy of Hip and Knee Surgeons (AAHKS), updated in 2017 and also endorsed by the British Hip Society (BHS), reflected a shift in the attitude and restrictions imposed by surgeons on patients undergoing joint replacement surgery³. These guidelines reported that 36.2% of surgeons allowed high-impact activities, and 23.8% permitted contact sports. Postoperative symptom improvement, pain management, and the implementation of early rehabilitation programs in THR have contributed to greater patient confidence in participating in such activities⁴. Zimmerer et al. (2021) reported that, among 36 patients under 40 years of age who underwent THR, 67% resumed sports activities within the first 3 postoperative months, 17% between 3 and 6 months, and another 17% after 6 months, with a significant increase in the diversity of sports practiced⁵. These results are consistent with those of our cohort, where patients returned to their preoperative sports within an average of 6 months, considering our patients had a slightly higher mean age of 50 years. In a recent study by Boettner et al. (2023) involving 3,828 patients (4,152 hips), most (52.9%) engaged in moderate physical activity, such as walking 1–2 blocks per day. Only 40% performed higher-level activities like running multiple times per week⁶. A systematic review by Stevens et al. (2022) concluded that low-impact activity can be resumed after joint replacement, discouraging contact sports and highlighting the importance of interventions that promote physical activity⁷. Payo-Ollero et al. (2020), in their study of 46 patients, also reported changes in sports participation following surgery⁸. Preoperative physical activity⁹ and adherence to a structured postoperative rehabilitation protocol are undoubtedly prognostic factors for functional outcomes and sports reintegration¹⁰. Boettner also reported high survival rates without revision at 2, 5, and 7 years. However, some hips required revision due to issues such as dislocation/instability, periprosthetic fracture, femoral component loosening, periprosthetic joint infection, adverse local tissue reactions, and malposition of the acetabular component. In our series, we recorded two cases of aseptic acetabular loosening out of 136 hips (1.47%), both of which were successfully managed with component revision, with favorable outcomes and return to sport. The introduction of highly cross-linked polyethylene in recent years has provided surgeons with greater confidence in the durability of prosthetic implants by minimizing early wear 11 , 12 . The use of ceramic heads, combined with reduced wear, helps decrease the risk of corrosion at the taper junction between the head and the femoral stem 13 , 14 . Larger-diameter heads allow for improved range of motion with reduced risk of impingement and dislocation 15 , 16 . Total hip arthroplasty is increasingly being performed in younger patients 17 , 18 , 19 , 20 , who typically have higher physical demands both in the workplace and in sports. This trend places greater demands on both the implants and the surgeons 21 , 22 , 23 and may lead to evolving recommendations regarding postoperative sports participation in the coming years 24 , 25 . We recognize that our sample size, patient age range, and short-term follow-up may be considered limitations of the study, along with its retrospective design. However, one of the main strengths is that all surgeries were performed by the same surgeon, using the same surgical technique and rehabilitation protocol, ensuring procedural consistency throughout the study. CONCLUSION Total hip arthroplasty in young patients with high functional demands, both in the workplace and in sports, has shown very favorable short-term results. This success has led to a significant shift in the permissions and restrictions that were traditionally imposed on this patient population. However, it is essential to conduct medium- and long-term evaluations to assess implant durability and quality of life in these patients, particularly in physically demanding occupational and sports environments. These long-term analyses will be crucial for fully understanding the benefits and potential limitations of this procedure in this specific group of patients. Declarations Funding sources None. Generative AI and AI-assisted technologies in the writing process During the preparation of this manuscript, the author(s) used ChatGPT to improve readability and language. After using this tool, the author(s) reviewed and edited the content as needed and take full responsibility for the content of the publication. Conflicts of interest None. References Evans JT, Evans JP, Walker RW, Blom AW, Whitehouse MR, Sayers A. How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet. 2019 Feb 16;393(10172):647-654. doi: 10.1016/S0140-6736(18)31665-9. Epub 2019 Feb 14. PMID: 30782340; PMCID: PMC6376618. Talbot S, Hooper G, Stokes A, Zordan R. Use of a new high-activity arthroplasty score to assess function of young patients with total hip or knee arthroplasty. J Arthroplasty. 2010 Feb;25(2):268-73. doi: 10.1016/j.arth.2008.09.019. Epub 2008 Dec 3. PMID: 19056232. Bradley BM, Moul SJ, Doyle FJ, Wilson MJ. Return to Sporting Activity After Total Hip Arthroplasty-A Survey of Members of the British Hip Society. J Arthroplasty. 2017 Mar;32(3):898-902. doi: 10.1016/j.arth.2016.09.019. Epub 2016 Sep 28. PMID: 27889306. Lopreite, F. A., Garabano, G., Mana Pastrian, D., Robador, N., & del Sel, H. (2012). Satisfacción del paciente luego de una artroplastia de cadera o de rodilla.[Patient satisfaction after hip or knee arthroplasty]. Revista De La Asociaci ó n Argentina De Ortopedia Y Traumatolog ía , 77 (2), 112-117. https://doi.org/10.15417/64. L. Navas, Jasmin Faller, S. Schmidt, M. Streit, M. Hauschild & A. Zimmerer (2021). Sports Activity and Patient - Related Outcomes after Cementless Total Hip Arthroplasty in Patients Younger than 40 Years, J. Clin. Med. 10, 4644. https://doi.org/10.3390/jcm10204644 L. E. Streck, Y. Chiu, S. Braun, A. Mujaj, C. Hanreich & F. Boettner (2023). Activity Following Total Hip Arthroplasty: Which Patients Are Active, and Is Being Active Safe?. J. Clin. Med. 12, 6482. https://doi.org/10.3390/jcm12206482 Y. Mooiweer, M. Stevens, I. van den Akker - Scheek & PAIR study group (2022). Being active with a total hip or knee prosthesis: a systematic review into physical activity and sports recommendations and interventions to improve physical activity behavior. Mooiweer et al. European Review of Aging and Physical Activity. 19:7. https://doi.org/10.1186/s11556-022-00285-1 J. Payo - Ollero, R. Alcalde, A. Valentí, J. R. Valentí & J. M. Lamo de Espinosa (2020). Influencia de la artroplastia total de cadera y el consejo médico en la actividad deportiva realizada después de la intervención. Revista Español de Cirugía Ortopédica y Traumatología, 64 (4): 251 - 257. https://doi.org/10.1016/j.recot.2020.02.004 Vasta S, Papalia R, Torre G, Vorini F, Papalia G, Zampogna B, Fossati C, Bravi M, Campi S, Denaro V. The Influence of Preoperative Physical Activity on Postoperative Outcomes of Knee and Hip Arthroplasty Surgery in the Elderly: A Systematic Review. J Clin Med. 2020 Mar 31;9(4):969. doi: 10.3390/jcm9040969. PMID: 32244426; PMCID: PMC7231073. Papalia R, Campi S, Vorini F, Zampogna B, Vasta S, Papalia G, Fossati C, Torre G, Denaro V. The Role of Physical Activity and Rehabilitation Following Hip and Knee Arthroplasty in the Elderly. J Clin Med. 2020 May 9;9(5):1401. doi: 10.3390/jcm9051401. PMID: 32397459; PMCID: PMC7291199. Buckner BC, Urban ND, Cahoy KM, Lyden ER, Deans CF, Garvin KL. Long-term polyethylene wear rates and clinical outcomes of oxidized zirconium femoral heads on highly cross-linked polyethylene in total hip arthroplasty. Bone Joint J. 2024 Mar;106-B(Suppl A):38–43. Rames RD, Stambough JB, Pashos GE, Maloney WJ, Martell JM, Clohisy JC. Fifteen-year results of total hip arthroplasty with cobalt-chromium femoral heads on highly cross-linked polyethylene in patients ≤50 years. J Arthroplasty. 2019 Jun;34(6):1143–1149. Beckers G, Morcos MW, Lavigne M, Massé V, Kiss MO, Vendittoli PA. Excellent results of large-diameter ceramic-on-ceramic bearings in total hip arthroplasty at minimum ten-year follow-up. J Arthroplasty. 2024 Dec;39(12):3028–3035. Eichler D, Barry J, Lavigne M, Massé V, Vendittoli PA. No radiological and biological sign of trunnionosis with Large Diameter Head Ceramic Bearing Total Hip Arthroplasty after 5 years. Orthop Traumatol Surg Res. 2021 Feb;107(1):102543. doi: 10.1016/j.otsr.2019.12.015. Epub 2020 Apr 7. PMID: 32276843. Fransen BL, Bengoa FJ, Neufeld ME, Sheridan GA, Garbuz DS, Howard LC. Thin highly cross‑linked polyethylene liners combined with large femoral heads in primary total hip arthroplasty show excellent survival and low wear rates at mean follow-up 12.8 years. Bone Joint J. 2023 Jan;105-B(1):29–34. Neupane G, Madhusudhan R, Shrestha A, Vaishya R. Large Diameter Head in Primary Total Hip Arthroplasty: A Systematic Review. Indian J Orthop. 2020 May 29;54(6):784-794. doi: 10.1007/s43465-020-00146-y. PMID: 33133401; PMCID: PMC7573004. Kumar A, Bloch BV, Esler C. Trends in total hip arthroplasty in young patients - results from a regional register. Hip Int. 2017 Sep 19;27(5):443-448. doi: 10.5301/hipint.5000485. Epub 2017 May 10. PMID: 28497453. Swarup I, Lee YY, Chiu YF, Sutherland R, Shields M, Figgie MP. Implant Survival and Patient-Reported Outcomes After Total Hip Arthroplasty in Young Patients. J Arthroplasty. 2018 Sep;33(9):2893-2898. doi: 10.1016/j.arth.2018.04.016. Epub 2018 Apr 19. PMID: 29754980. Mei XY, Gong YJ, Safir O, Gross A, Kuzyk PR. Long‑term outcomes of total hip arthroplasty in patients younger than 55 years: a systematic review of the contemporary literature. Can J Surg. 2019;62(4):249‑58. Drobniewski M, Gonera B, Olewnik Ł, et al. Challenges and long‑term outcomes of cementless total hip arthroplasty in patients under 30: a 24‑year follow‑up study with a minimum 8‑year follow‑up, focused on developmental dysplasia of the hip. J Clin Med. 2024;13(21):6591. Schwarzkopf R, Jain R, Abdel MP. Trends in complications and outcomes in patients aged ≤ 65 years undergoing total hip arthroplasty: data from the American Joint Replacement Registry. J Arthroplasty. 2023. Clohisy JC, Oryhon JM, Seyler TM, et al. Function and fixation of total hip arthroplasty in patients 25 years of age or younger. Clin Orthop Relat Res. 2010;468:3207–3213. Tsukanaka M, Halvorsen V, Nordsletten L, et al. Implant survival and radiographic outcome of total hip replacement in patients less than 20 years old. Acta Orthop. 2016;87:479–484. Mei XY, Gong YJ, Safir O, Gross A, Kuzyk PR. (Ver el ítem 1; análisis de supervivencia de 5 y 10 años con tasa del 98,7% y 94,6%). Wangen H, Lereim P, Holm I, et al. Hip arthroplasty in patients younger than 30 years: excellent ten‑ to 16‑year follow‑up results with a HA‑coated stem. Int Orthop. 2008;32:203–208 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7222780","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":492554539,"identity":"086e15fe-8dd3-40e2-baab-6c0bc4c95739","order_by":0,"name":"Walter Fabian Martinez","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYDAC5gPMDz78sJEDsQ88IEoLWwKb4cyeNGOwlgQitTBI87AdTmwAcYjSYnCMO8GAh4c5fX7Y4YdAW+zkdBsIauHd8EDCgi134+00A6CWZGOzAwS0mN3v3WAAtCZ34+wEkJYDidsIagHaIpHAJpFuODv9AwlaDrAZJMhL5xBpi/0x3m2GjT0JhhukcwoOJBgQ4RfJNt7Nj//8+C8vPzt984cPFXZyBLXAgQFYpQGxykFAvoEU1aNgFIyCUTCiAADZYkhN9NswNAAAAABJRU5ErkJggg==","orcid":"","institution":"Pontifical Catholic University of Argentina","correspondingAuthor":true,"prefix":"","firstName":"Walter","middleName":"Fabian","lastName":"Martinez","suffix":""},{"id":492554542,"identity":"795a15dc-c095-4f67-a89e-6714316bf833","order_by":1,"name":"Florencia garbini","email":"","orcid":"","institution":"GRECARO TEAM","correspondingAuthor":false,"prefix":"","firstName":"Florencia","middleName":"","lastName":"garbini","suffix":""},{"id":492554543,"identity":"ad5f818d-a428-4912-8c3a-763215c0b61e","order_by":2,"name":"eduardo javier bochatey","email":"","orcid":"","institution":"Pontifical Catholic University of Argentina","correspondingAuthor":false,"prefix":"","firstName":"eduardo","middleName":"javier","lastName":"bochatey","suffix":""},{"id":492554545,"identity":"bb805191-2887-45b3-875b-641d5fea676d","order_by":3,"name":"fernando adrian lopreite","email":"","orcid":"","institution":"Pontifical Catholic University of Argentina","correspondingAuthor":false,"prefix":"","firstName":"fernando","middleName":"adrian","lastName":"lopreite","suffix":""}],"badges":[],"createdAt":"2025-07-26 18:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7222780/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7222780/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88666797,"identity":"0a902a90-f641-42da-a98d-a32bf02ccf49","added_by":"auto","created_at":"2025-08-09 01:31:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":548653,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7222780/v1/eeae3cd2-6544-4a48-a43a-cc240ffa0825.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTotal Hip Arthroplasty in Athletic Patients Under 55 Years Old: Functional Outcomes and Return to Sport at a 2-year Average Follow-up\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eTotal hip arthroplasty (THA) is now a common procedure in young patients. Thanks to the modernization of surgical techniques, the understanding of friction surface interactions provided by tribology studies, and the improvement in prosthetic materials, the durability and survival of implants have significantly increased. This has given hip surgeons the confidence to operate on increasingly younger patients, including those with high functional demands, such as athletes, with the expectation of high success and long-term implant survival\u0026mdash;even beyond 15 years\u0026sup1;.\u003c/p\u003e\u003cp\u003eIn young patients under 55 years of age who are physically active or participate in sports, the desire to return to physical activities after total hip replacement is significant. Many of them even postpone the decision to undergo surgery due to fear of being unable to resume physical activity afterward.\u003c/p\u003e\u003cp\u003eThe objective of this study is to conduct a retrospective analysis and evaluation of a cohort of patients under 55 years old, with high functional demands and athletic backgrounds, who followed our rehabilitation protocol after undergoing total hip arthroplasty. Our hypothesis is that early rehabilitation and return to sports can be achieved using this protocol, with a mean follow-up of two years after the surgery.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eOver the past five years, between 2018 and 2023, we performed 943 primary total hip arthroplasties (THA). For this retrospective study, we included patients younger than 55 years with diagnoses of hip osteoarthritis, avascular necrosis (AVN), post-septic arthritis sequelae, and hip necroarthrosis. All included patients had a minimum clinical and radiological follow-up of 6 months (up to 5 years) and participated in some form of sports activity. Exclusion criteria included older patients, partial hip replacements, other indications such as femoral neck fractures, sequelae of hip osteotomies in dysplasia, and sequelae of femoral fractures. Patients with low functional demand or incomplete postoperative follow-up were also excluded.\u003c/p\u003e\u003cp\u003eAll surgeries were performed using the same surgical technique by the same surgeon, via a direct anterolateral approach with the patient in the supine position, in laminar flow operating rooms following strict surgical antisepsis protocols. An intraoperative lavage with povidone-iodine solution was performed before closure. Spinal hypotensive anesthesia and peripheral nerve block were used, along with intravenous tranexamic acid administration (15 mg/kg) 20 minutes before skin incision. For infection prophylaxis, two doses of 1 g of cefazolin were administered\u0026mdash;one during anesthesia induction and one in the immediate postoperative period. Thromboprophylaxis consisted of aspirin 325 mg daily for 30 days.\u003c/p\u003e\u003cp\u003eAll patients received uncemented implants with metaphyseal fixation, highly cross-linked polyethylene liners, and ceramic heads (mostly 36 mm in diameter), paired with 50 mm acetabular cups, or in some cases, smaller 32 mm cups.\u003c/p\u003e\u003cp\u003eWe implemented a progressive rehabilitation protocol aimed at returning to sports. This program, supervised by physiotherapists and the physical therapy team, began during hospitalization, which lasted between 48 and 72 hours post-surgery. Patients began sitting on the day of surgery and performed isotonic and isometric bed exercises based on tolerance, focusing on gluteal and lower limb muscle strengthening. Ambulation with walker assistance began within 12\u0026ndash;24 hours, depending on the effects of the peripheral nerve block. Patients were discharged with a walker or crutches as needed and continued with at-home physical therapy.\u003c/p\u003e\u003cp\u003eBetween the second and third postoperative week, depending on patient progress, the protocol intensified with stationary cycling, progressive strength and resistance training, walking, and general locomotor strengthening focused on the lower limbs. Patients were allowed to resume driving and return to work depending on the physical demands of their occupation after the third week.\u003c/p\u003e\u003cp\u003ePreoperative functional and imaging assessments were performed, followed by postoperative evaluations at 3 and 6 weeks, and subsequent follow-ups at 3 and 6 months, then annually. Functional outcomes were assessed using the Harris Hip Score (HHS), with the following classifications: excellent (90\u0026ndash;100), good (80\u0026ndash;89), fair (70\u0026ndash;79), and poor (\u0026lt;\u0026thinsp;70). We also used the High Activity Arthroplasty Score (HAAS) to better evaluate physical performance in relation to sports.\u003c/p\u003e\u003cp\u003eAll data were collected retrospectively from perioperative consultations and patient medical records, in accordance with the inclusion and exclusion criteria.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBias Control, Variability Management, and Data Collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo minimize surgical variability and reduce potential biases, all procedures were performed by a single experienced hip surgeon using a standardized surgical technique and a uniform postoperative rehabilitation protocol. This approach ensured consistency in both the surgical procedure and postoperative care. Patient selection was based on strict inclusion and exclusion criteria. Individuals with comorbidities that could negatively influence functional outcomes or interfere with rehabilitation, as well as those with incomplete clinical records or less than six months of follow-up, were excluded.\u003c/p\u003e\u003cp\u003eData collection was conducted retrospectively using institutional digital medical records and assessments from scheduled preoperative and postoperative clinical evaluations. Harris Hip Score (HHS) and High Activity Arthroplasty Score (HAAS) were documented by the same medical team during routine follow-up visits, under standardized conditions and following the original guidelines of both scoring systems. An anonymized database was used for statistical analysis to ensure patient confidentiality and data traceability.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using SPSS software, version 18.0 (IBM Corp., Armonk, NY). Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), as well as median and interquartile range (IQR) when appropriate. Ninety-five percent confidence intervals (95% CI) were calculated for the main functional outcomes. Comparisons between preoperative and postoperative results were performed using the paired Student\u0026rsquo;s t-test, with statistical significance set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The complication rate was calculated as a percentage of the total number of cases. Functional outcomes were categorized according to the Harris Hip Score (excellent, good, fair, and poor) and reported in both absolute and relative frequencies.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthical Considerations\u003c/b\u003e\u003c/p\u003e\u003cp\u003e This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Patient confidentiality was ensured through the use of anonymized clinical databases. All patients signed an informed consent form prior to surgery, which included authorization for the use of their clinical data for scientific and academic purposes. The study protocol was reviewed and approved by the local institutional ethics committee.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eWe included a cohort of 153 athletic patients under 55 years of age who underwent total hip arthroplasty. Among them, 117 patients (76.5%) returned to sports, accounting for a total of 136 total hip replacements (Table 1). The mean age was 50 years (range: 23\u0026ndash;55). The cohort included 38 women (20 right hips, 23 left hips) and 79 men (39 right hips, 54 left hips). Bilateral THRs were performed in 19 cases (15 men and 4 women).\u003c/p\u003e\n\u003cp\u003ePreoperative diagnoses included: 119 cases of primary osteoarthritis, 11 cases of developmental dysplasia of the hip (DDH), 3 cases of avascular necrosis, and 3 sequelae of septic arthritis.\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eSample Characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHips\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e136\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge Range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 to 55 years (mean: 50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale/Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 / 79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRight/Left Hip\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59 / 77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteoarthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e119\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAVN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNecroarthrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePost-Septic Arthritis Sequelae\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAll patients engaged in sports activities before stopping due to hip pain; some practiced more than one discipline [Table 2]. The most commonly practiced sport was football (soccer), played by 46 patients two to three times a week. This was followed by cycling (35 patients, 10 to 25 km/week) and running (34 patients, 5\u0026ndash;10 km/week). Twenty-six patients swam (sometimes as a complementary sport), 22 played tennis (about two to three times a week), 19 played golf (once or twice a week), and 6 practiced martial arts.\u003c/p\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eSports Practiced Before Surgery\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSport\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo. of Patients\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency / Distance\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCycling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 to 25 km per week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTennis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwo to three times a week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFootball\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwo to three times a week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGolf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOnce or twice a week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRunning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u0026ndash;10 km per week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSwimming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwo or three times a week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMartial Arts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwice a week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eFunctional Outcomes\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eWe observed an average improvement in Harris Hip Score (HHS) of 37.8 points: from a preoperative mean of 52.35 (range: 50.25\u0026ndash;60.65) to a postoperative mean of 93.25 (range: 80.65\u0026ndash;97) (Table 3).\u003c/p\u003e\n\u003cp\u003eIn the High Activity Arthroplasty Score (HAAS, 0\u0026ndash;18 points), the average improvement was 7.75 points: from a preoperative mean of 7.43 (range: 3\u0026ndash;12) to a postoperative mean of 15.18 (range: 7\u0026ndash;18).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eFunctional Outcomes (HHS and HAAS)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eScale\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePreoperative (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePostoperative (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI of Improvement\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value (Student\u0026apos;s t-test)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e52.35\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e93.25\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e[36.2\u0026ndash;39.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53 (50\u0026ndash;56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHAAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.43\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.18\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e[6.5\u0026ndash;8.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (5\u0026ndash;10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eReturn to Sport and Complications\u003cspan style='text-align: start;color: rgb(0, 0, 0);background-color: rgb(255, 255, 255);font-size: medium;font-family: \"'\u003e:\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003ePatients gradually returned to physical activity, starting intensive rehabilitation with physical therapists and kinesiologists at a mean of 1.5 months postoperatively. Initial activities included stationary cycling and strength training. Most patients resumed high-impact sports previously practiced before symptom onset and surgery at an average of 4 months. The highest levels of satisfaction were recorded from the sixth postoperative month onwards.\u003c/p\u003e\n\u003cp\u003eWe recorded 2 complications among the 117 patients: 2 cases of aseptic acetabular loosening, both resolved with acetabular component revision surgery after ruling out infection. Both patients returned to their preoperative sport before the sixth postoperative month following revision surgery.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eNumerous scientific studies have addressed the issue of return to work and sports activities in young patients who previously engaged in high-impact sports following total hip replacement (THR). In our study group, we observed results consistent with the existing literature regarding low-, medium-, and high-impact sports activities in patients under 60 years of age. Given the relatively young age of our cohort, the outcomes regarding return to sport were highly encouraging, with some patients even resuming high-impact activities.\u003c/p\u003e\u003cp\u003eIn 2007, the recommendations issued by the Hip Society (HS) and the American Academy of Hip and Knee Surgeons (AAHKS), updated in 2017 and also endorsed by the British Hip Society (BHS), reflected a shift in the attitude and restrictions imposed by surgeons on patients undergoing joint replacement surgery\u0026sup3;. These guidelines reported that 36.2% of surgeons allowed high-impact activities, and 23.8% permitted contact sports. Postoperative symptom improvement, pain management, and the implementation of early rehabilitation programs in THR have contributed to greater patient confidence in participating in such activities⁴.\u003c/p\u003e\u003cp\u003eZimmerer et al. (2021) reported that, among 36 patients under 40 years of age who underwent THR, 67% resumed sports activities within the first 3 postoperative months, 17% between 3 and 6 months, and another 17% after 6 months, with a significant increase in the diversity of sports practiced⁵. These results are consistent with those of our cohort, where patients returned to their preoperative sports within an average of 6 months, considering our patients had a slightly higher mean age of 50 years.\u003c/p\u003e\u003cp\u003eIn a recent study by Boettner et al. (2023) involving 3,828 patients (4,152 hips), most (52.9%) engaged in moderate physical activity, such as walking 1\u0026ndash;2 blocks per day. Only 40% performed higher-level activities like running multiple times per week⁶. A systematic review by Stevens et al. (2022) concluded that low-impact activity can be resumed after joint replacement, discouraging contact sports and highlighting the importance of interventions that promote physical activity⁷. Payo-Ollero et al. (2020), in their study of 46 patients, also reported changes in sports participation following surgery⁸. Preoperative physical activity⁹ and adherence to a structured postoperative rehabilitation protocol are undoubtedly prognostic factors for functional outcomes and sports reintegration\u0026sup1;⁰.\u003c/p\u003e\u003cp\u003eBoettner also reported high survival rates without revision at 2, 5, and 7 years. However, some hips required revision due to issues such as dislocation/instability, periprosthetic fracture, femoral component loosening, periprosthetic joint infection, adverse local tissue reactions, and malposition of the acetabular component. In our series, we recorded two cases of aseptic acetabular loosening out of 136 hips (1.47%), both of which were successfully managed with component revision, with favorable outcomes and return to sport.\u003c/p\u003e\u003cp\u003eThe introduction of highly cross-linked polyethylene in recent years has provided surgeons with greater confidence in the durability of prosthetic implants by minimizing early wear \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. The use of ceramic heads, combined with reduced wear, helps decrease the risk of corrosion at the taper junction between the head and the femoral stem\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Larger-diameter heads allow for improved range of motion with reduced risk of impingement and dislocation\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTotal hip arthroplasty is increasingly being performed in younger patients\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, who typically have higher physical demands both in the workplace and in sports. This trend places greater demands on both the implants and the surgeons\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e and may lead to evolving recommendations regarding postoperative sports participation in the coming years\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eWe recognize that our sample size, patient age range, and short-term follow-up may be considered limitations of the study, along with its retrospective design.\u003c/p\u003e\u003cp\u003eHowever, one of the main strengths is that all surgeries were performed by the same surgeon, using the same surgical technique and rehabilitation protocol, ensuring procedural consistency throughout the study.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eTotal hip arthroplasty in young patients with high functional demands, both in the workplace and in sports, has shown very favorable short-term results. This success has led to a significant shift in the permissions and restrictions that were traditionally imposed on this patient population.\u003c/p\u003e\u003cp\u003eHowever, it is essential to conduct medium- and long-term evaluations to assess implant durability and quality of life in these patients, particularly in physically demanding occupational and sports environments. These long-term analyses will be crucial for fully understanding the benefits and potential limitations of this procedure in this specific group of patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding sources\u003c/strong\u003e\u003cbr\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGenerative AI and AI-assisted technologies in the writing process\u003c/strong\u003e\u003cbr\u003eDuring the preparation of this manuscript, the author(s) used ChatGPT to improve readability and language. After using this tool, the author(s) reviewed and edited the content as needed and take full responsibility for the content of the publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003cbr\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEvans JT, Evans JP, Walker RW, Blom AW, Whitehouse MR, Sayers A. How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet. 2019 Feb 16;393(10172):647-654. doi: 10.1016/S0140-6736(18)31665-9. Epub 2019 Feb 14. PMID: 30782340; PMCID: PMC6376618.\u003c/li\u003e\n\u003cli\u003eTalbot S, Hooper G, Stokes A, Zordan R. Use of a new high-activity arthroplasty score to assess function of young patients with total hip or knee arthroplasty. J Arthroplasty. 2010 Feb;25(2):268-73. doi: 10.1016/j.arth.2008.09.019. Epub 2008 Dec 3. PMID: 19056232.\u003c/li\u003e\n\u003cli\u003eBradley BM, Moul SJ, Doyle FJ, Wilson MJ. Return to Sporting Activity After Total Hip Arthroplasty-A Survey of Members of the British Hip Society. J Arthroplasty. 2017 Mar;32(3):898-902. doi: 10.1016/j.arth.2016.09.019. Epub 2016 Sep 28. PMID: 27889306.\u003c/li\u003e\n\u003cli\u003eLopreite, F. A., Garabano, G., Mana Pastrian, D., Robador, N., \u0026amp; del Sel, H. (2012). Satisfacción del paciente luego de una artroplastia de cadera o de rodilla.[Patient satisfaction after hip or knee arthroplasty]. \u003cem\u003eRevista De La Asociaci\u003c/em\u003e\u003cem\u003eó\u003c/em\u003e\u003cem\u003en Argentina De Ortopedia Y Traumatolog\u003c/em\u003e\u003cem\u003eía\u003c/em\u003e, \u003cem\u003e77\u003c/em\u003e(2), 112-117. https://doi.org/10.15417/64.\u003c/li\u003e\n\u003cli\u003eL. Navas, Jasmin Faller, S. Schmidt, M. Streit, M. Hauschild \u0026amp; A. Zimmerer (2021). Sports Activity and Patient - Related Outcomes after Cementless Total Hip Arthroplasty in Patients Younger than 40 Years, J. Clin. Med. 10, 4644. https://doi.org/10.3390/jcm10204644 \u003c/li\u003e\n\u003cli\u003eL. E. Streck, Y. Chiu, S. Braun, A. Mujaj, C. Hanreich \u0026amp; F. Boettner (2023). Activity Following Total Hip Arthroplasty: Which Patients Are Active, and Is Being Active Safe?. J. Clin. Med. 12, 6482. https://doi.org/10.3390/jcm12206482\u003c/li\u003e\n\u003cli\u003eY. Mooiweer, M. Stevens, I. van den Akker - Scheek \u0026amp; PAIR study group (2022). Being active with a total hip or knee prosthesis: a systematic review into physical activity and sports recommendations and interventions to improve physical activity behavior. Mooiweer et al. European Review of Aging and Physical Activity. 19:7. https://doi.org/10.1186/s11556-022-00285-1\u003c/li\u003e\n\u003cli\u003eJ. Payo - Ollero, R. Alcalde, A. Valentí, J. R. Valentí \u0026amp; J. M. Lamo de Espinosa (2020). Influencia de la artroplastia total de cadera y el consejo médico en la actividad deportiva realizada después de la intervención. Revista Español de Cirugía Ortopédica y Traumatología, 64 (4): 251 - 257. https://doi.org/10.1016/j.recot.2020.02.004\u003c/li\u003e\n\u003cli\u003eVasta S, Papalia R, Torre G, Vorini F, Papalia G, Zampogna B, Fossati C, Bravi M, Campi S, Denaro V. The Influence of Preoperative Physical Activity on Postoperative Outcomes of Knee and Hip Arthroplasty Surgery in the Elderly: A Systematic Review. J Clin Med. 2020 Mar 31;9(4):969. doi: 10.3390/jcm9040969. PMID: 32244426; PMCID: PMC7231073.\u003c/li\u003e\n\u003cli\u003ePapalia R, Campi S, Vorini F, Zampogna B, Vasta S, Papalia G, Fossati C, Torre G, Denaro V. The Role of Physical Activity and Rehabilitation Following Hip and Knee Arthroplasty in the Elderly. J Clin Med. 2020 May 9;9(5):1401. doi: 10.3390/jcm9051401. PMID: 32397459; PMCID: PMC7291199.\u003c/li\u003e\n\u003cli\u003eBuckner BC, Urban ND, Cahoy KM, Lyden ER, Deans CF, Garvin KL. Long-term polyethylene wear rates and clinical outcomes of oxidized zirconium femoral heads on highly cross-linked polyethylene in total hip arthroplasty. \u003cem\u003eBone Joint J.\u003c/em\u003e 2024 Mar;106-B(Suppl A):38–43. \u003c/li\u003e\n\u003cli\u003eRames RD, Stambough JB, Pashos GE, Maloney WJ, Martell JM, Clohisy JC. Fifteen-year results of total hip arthroplasty with cobalt-chromium femoral heads on highly cross-linked polyethylene in patients ≤50 years. \u003cem\u003eJ Arthroplasty.\u003c/em\u003e 2019 Jun;34(6):1143–1149. \u003c/li\u003e\n\u003cli\u003eBeckers G, Morcos MW, Lavigne M, Massé V, Kiss MO, Vendittoli PA. Excellent results of large-diameter ceramic-on-ceramic bearings in total hip arthroplasty at minimum ten-year follow-up. \u003cem\u003eJ Arthroplasty.\u003c/em\u003e 2024 Dec;39(12):3028–3035. \u003c/li\u003e\n\u003cli\u003eEichler D, Barry J, Lavigne M, Massé V, Vendittoli PA. No radiological and biological sign of trunnionosis with Large Diameter Head Ceramic Bearing Total Hip Arthroplasty after 5 years. Orthop Traumatol Surg Res. 2021 Feb;107(1):102543. doi: 10.1016/j.otsr.2019.12.015. Epub 2020 Apr 7. PMID: 32276843.\u003c/li\u003e\n\u003cli\u003eFransen BL, Bengoa FJ, Neufeld ME, Sheridan GA, Garbuz DS, Howard LC. Thin highly cross‑linked polyethylene liners combined with large femoral heads in primary total hip arthroplasty show excellent survival and low wear rates at mean follow-up 12.8 years. \u003cem\u003eBone Joint J.\u003c/em\u003e 2023 Jan;105-B(1):29–34.\u003c/li\u003e\n\u003cli\u003eNeupane G, Madhusudhan R, Shrestha A, Vaishya R. Large Diameter Head in Primary Total Hip Arthroplasty: A Systematic Review. Indian J Orthop. 2020 May 29;54(6):784-794. doi: 10.1007/s43465-020-00146-y. PMID: 33133401; PMCID: PMC7573004.\u003c/li\u003e\n\u003cli\u003eKumar A, Bloch BV, Esler C. Trends in total hip arthroplasty in young patients - results from a regional register. Hip Int. 2017 Sep 19;27(5):443-448. doi: 10.5301/hipint.5000485. Epub 2017 May 10. PMID: 28497453.\u003c/li\u003e\n\u003cli\u003eSwarup I, Lee YY, Chiu YF, Sutherland R, Shields M, Figgie MP. Implant Survival and Patient-Reported Outcomes After Total Hip Arthroplasty in Young Patients. J Arthroplasty. 2018 Sep;33(9):2893-2898. doi: 10.1016/j.arth.2018.04.016. Epub 2018 Apr 19. PMID: 29754980.\u003c/li\u003e\n\u003cli\u003eMei XY, Gong YJ, Safir O, Gross A, Kuzyk PR. Long‑term outcomes of total hip arthroplasty in patients younger than 55 years: a systematic review of the contemporary literature. \u003cem\u003eCan J Surg.\u003c/em\u003e 2019;62(4):249‑58. \u003c/li\u003e\n\u003cli\u003eDrobniewski M, Gonera B, Olewnik Ł, et al. Challenges and long‑term outcomes of cementless total hip arthroplasty in patients under 30: a 24‑year follow‑up study with a minimum 8‑year follow‑up, focused on developmental dysplasia of the hip. \u003cem\u003eJ Clin Med.\u003c/em\u003e 2024;13(21):6591.\u003c/li\u003e\n\u003cli\u003eSchwarzkopf R, Jain R, Abdel MP. Trends in complications and outcomes in patients aged ≤ 65 years undergoing total hip arthroplasty: data from the American Joint Replacement Registry. \u003cem\u003eJ Arthroplasty.\u003c/em\u003e 2023. \u003c/li\u003e\n\u003cli\u003eClohisy JC, Oryhon JM, Seyler TM, et al. Function and fixation of total hip arthroplasty in patients 25 years of age or younger. \u003cem\u003eClin Orthop Relat Res.\u003c/em\u003e 2010;468:3207–3213. \u003c/li\u003e\n\u003cli\u003eTsukanaka M, Halvorsen V, Nordsletten L, et al. Implant survival and radiographic outcome of total hip replacement in patients less than 20 years old. \u003cem\u003eActa Orthop.\u003c/em\u003e 2016;87:479–484. \u003c/li\u003e\n\u003cli\u003eMei XY, Gong YJ, Safir O, Gross A, Kuzyk PR. (Ver el ítem 1; análisis de supervivencia de 5 y 10 años con tasa del 98,7% y 94,6%).\u003c/li\u003e\n\u003cli\u003eWangen H, Lereim P, Holm I, et al. Hip arthroplasty in patients younger than 30 years: excellent ten‑ to 16‑year follow‑up results with a HA‑coated stem. \u003cem\u003eInt Orthop.\u003c/em\u003e 2008;32:203–208\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Young Patients, Total Hip Arthroplasty, Return to Sport","lastPublishedDoi":"10.21203/rs.3.rs-7222780/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7222780/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e\u003cp\u003eTotal hip arthroplasty (THA) has become a viable option in younger patients due to advances in surgical techniques, tribology, and prosthetic materials. Improved implant durability has made it possible to offer this procedure to active patients, including athletes, with expectations of favorable outcomes and long-term survival. However, fear of not being able to return to sports often delays surgery. This study retrospectively analyzes functional outcomes and return to sport in patients under 55 years old who underwent THA following our rehabilitation protocol.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e\u003cp\u003eWe evaluated 136 THAs in 117 athletic patients (mean age: 49 years; range: 23\u0026ndash;55), with an average follow-up of 24 months. Preoperative diagnoses included 119 cases of hip osteoarthritis, 11 cases of avascular necrosis, 3 cases of necroarthrosis, and 3 sequelae of septic arthritis. Functional outcomes were assessed using the Harris Hip Score (HHS) and the High Activity Arthroplasty Score (HAAS).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAverage improvement was from 52.35 to 93.25 in HHS and from 7.43 to 15.18 in HAAS. Return to sport occurred at a mean of 4 months postoperatively (range: 1.5\u0026ndash;6 months). Two patients experienced aseptic loosening of the acetabular component, which was resolved with revision surgery, and both returned to physical activity before 6 months.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eTHA in athletic patients under 55 years demonstrated favorable short-term functional outcomes, early return to sport, and satisfactory implant survival. These findings may influence future recommendations regarding postoperative physical activity.\u003c/p\u003e\u003ch2\u003eLevel of evidence:\u003c/h2\u003e\u003cp\u003eIII\u003c/p\u003e","manuscriptTitle":"Total Hip Arthroplasty in Athletic Patients Under 55 Years Old: Functional Outcomes and Return to Sport at a 2-year Average Follow-up","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-04 09:33:57","doi":"10.21203/rs.3.rs-7222780/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5052a139-dc95-4144-bac5-dcc7a28b9d62","owner":[],"postedDate":"August 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-09T01:23:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-04 09:33:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7222780","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7222780","identity":"rs-7222780","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}