Being an MMA fighter is a challenging task, but doing it with a total hip replacement
is on another level. OR is it? Well in the next few minutes we are going to explore whether
it is in fact possible to do that and if so, what is required to make this a possibility.
BROLL knockout
Frankie Edgar is a professional MMA fighter currently working for the Ultimate Fighting
Championship. At 5’6” and 135 lbs, he currently competes in the bantamweight division.
In the past, he was the UFC lightweight champion who successfully defended his lightweight
title multiple times. He also competed at the featherweight division on a number of
occasions as well. Having just turned 40 years of age, he is presently ranked #12 in the
UFC bantamweight rankings. After an extended time away during the COVID pandemic, he returned
to competition on November 6, 2021 for UFC 268: Usman vs Covington. In his return, Edgar
fought Marlon Vera, the 13th ranked bantamweight. Edgar was defeated by knockout at 3:50 of
the third round.
After his loss, Edgar was interviewed on the Champ and the Tramp podcast. In his discussion,
he revealed that seven months prior to the contest, he had had his hip replaced. Not
only had he completed his normal post-operative rehabilitation following this major surgery,
but he had also successfully completed a full training camp for a mixed martial arts competition
with one of the top 15 welterweight fighters in the world. While he lost the competition
by knockout, Edgar was ahead on total strikes (138 vs 110), significant strikes (94 vs 88),
and takedowns (3 vs 0) at the moment he was knocked out. He looked for all intensive purposes,
just like a normal, able-bodied fighter, and there were not any indications that would
suggest that he were anything other than so/that. He added that the hip replacement had not
played a factor in his preparation or his loss, and that during his fight, his hip had
felt great.
Edgar went on in the interview to say that he had been dealing with progressive leg pain
and radiculopathy for the past four years. He stated that while comfortable when supine
or in a seated position, he was uncomfortable when standing with only a 20 minute activity
tolerance. Given the statements about his low back and radicular symptoms, it seems
like his low back would have been more of a factor in his fight than would have been
his hip. But having said that, what is the likelihood that an athlete could compete at
the highest level of professional mixed martial arts with an artificial hip?
Retired wrestler and MMA fighter Ben Askren was forced to retire from competition in November
2019 after his fight against Demian Maia, only his third UFC bout. He lost to Maia in
the third round by submission. In an interview with Ariel Helwani after his retirement, he
reported that he had been informed by his physician prior to the bout of an injury to
his hip. He had not previously mentioned it prior to the Maia fight because he did not
want anyone to think that it was the cause of his loss. After consultation with his physician,
Askren was informed that he would need a hip replacement and elected to retire in anticipation
of the procedure. After retirement he consulted with physicians so that he could assess potential
options, and come up with a game plan. In September 2020, Askren underwent a hip resurfacing,
or what is more commonly referred to as a partial hip replacement. When speaking of
the hip pain he had experienced prior to his surgery, Askren remarked that “the day after
surgery, it was gone. It was wild. I wasn’t anticipating that.”
In an interview with Mike Heck of MMA Fighting in November 2020, Askren stated that he was
not completely closed to the idea of a return to mixed martial arts. He even predicted that
he would wrestle again in 2021. Although he did face YouTube content creator Jake Paul
in April 2021, this was a boxing match, not an MMA match. And he certainly wasn’t successful
in this outing.
In the interview Askren stated that he did not believe that another professional athlete
had ever had a similar procedure and then returned to professional MMA fighting. However,
this is not actually the case. In 2016, professional MMA fighter Mark O’Mard was faced with the
prospect of having to give up professional MMA fighting after he was diagnosed with advanced
osteoarthritis of his hip. O’Mard, who had practiced martial arts since he was a child
was not happy with this prospect. He sought the advice of a second surgeon, from Northwell
Health’s Orthopedic Institute, orthopedic surgeon Sreevathsa Boraiah. Dr. Boraiah offered
to perform a total hip arthroplasty using an anterior approach. While conventional approaches
like the lateral or posterior approach, cut through muscle groups, the anterior approach
uses a path that goes in between muscle groups. Dr. Boraiah stated that, “Mr. O’Mard wanted
to return to his sport. I knew this technique would get him closes to his goal of returning
to high-level competition.”
O’Mard underwent surgery in August 2016. He was discharged home the day after his surgery.
He completed an initial 2-week course of Physiotherapy at home and then returned to his dojo where
he slowly began to resume training. After a few months, he began to run again, and sometime
after that began kicking again. Soon after he began to compete again and Eventually,
in 2017, he even took first place in a karate tournament. He subselquently returned to kickboxing
and MMA competition winning the main event at Fall Brawl VII. O’Mard continues to remain
active in MMA today as the owner and head instructor of O’Mard Mixed Martial Arts
centre.
So now that we know that someone has done this with some success, how exactly is this
possible, what does this mean for the hip replacement itself, and what are the long
term effects of this type of activity on the implant and the patient?
Generally speaking, a joint replacement is viewed as the end of impact activities or
physical activity of a vigorous nature. But for some, it is not the end, but rather merely
a transition from one state to another. For those people in this camp there are several
considerations that are important for the patient and the surgeon to consider if vigorous
activity is the desired outcome. These include the surgical approach, the implants used,
and the implantation technique.
There are several surgical approaches that can be used for total hip arthroplasty, lateral,
posterior, and anterior. All three are valid, but each has its own advantages and disadvantages.
The two approaches most commonly used are the lateral and the posterior approaches,
with each type equally represented among surgeons. Both of these approaches require muscle to
be divided to allow access the hip joint; the gluteus Maximus and the short external
rotators for the posterior approach, and the gluteus medius, minimus, and the plane between
the IT band and the tensor fascia lata for the lateral approach. The posterior approach
is less likely to result in a persistent limp post-operatively, but is more likely to result
in dislocation when sitting or bending forward. The lateral approach is less likely to result
in dislocation when sitting or bending forward, but is more likely to result in a persistent
limp post-operatively. Six of one, half dozen of the other. None of these outcomes is guaranteed,
but each is associated with its own risks and complications.
The anterior approach is a newer technique that does not require muscle to be divided.
Instead, the anterior approach takes advantage of the muscle plane between the tensor fascia
lata and the sartorius superficially, and the rectus femoris and gluteus medius deeply.
Because the muscles are not cut, this surgical approach does not cause a limp post-operatively,
and it is less likely to cause instability of the hip. Patients who undergo a hip replacement
using the anterior approach tend to rehabilitate faster, have less post-operative restrictions,
and be able to do more in the immediate post-operative period. For these reasons, a patient looking
to return to vigorous activity like MMA after a hip replacement, would be best suited to
have this surgical approach for their surgery. However, regardless of what approach was used,
instability of the hip and dislocation, particularly at the end ranges of motion would always be
a concern.
The next consideration is the type of implant used. In North America, the typical implant
used for a hip replacement has several components, the femoral stem, the femoral head, the acetabular
shell, and the acetabular liner. Normally, the femoral stem and acetabular shell are
fabricated from titanium, the femoral head from cobalt chrome, and the acetabular liner
from polyethylene plastic. This combination, nicknamed metal-on-poly, is implanted by one
of the approaches discussed previously, and is typically expected to have a lifespan of
between 15-20 years…..under normal use. MMA is NOT considered normal use. Of course,
there are other materials that can be used that are more durable, that will improve the
lifespan of the implants. Although more costly, these materials can be independently selected
for use at the discretion of the surgeon. Depending on the combination used, the lifespan
may be extended out to as much as 30 years. Obviously, if you wanted to return to vigorous
activity such as MMA, you would want to use these more durable materials. The combinations
that might be used would include ceramic-on-ceramic, ceramic-on-poly or metal-on-metal. The longest-lasting
combination, ceramic on ceramic, would not be suitable for use here because of its increased
brittleness. It might last long, but it might catastrophically fail when subjected to the
impacts associated with MMA fighting. Metal-on-metal is favourable because of its durability and
its stability with extreme ranges of motions. However, it is associated with increased systemic
levels of circulating metal ions and possible pseudotumors that might cause premature failure
of the implants. Improved impact tolerance and better stability, but possibly dangerous
levels of metal ions in the bloodstream. Better for MMA, but not so hot for the patient. Ceramic-on-poly
is likely the combination that offers the best durability with the least amount of associated
side effects.
Another consideration is the technique with which the prostheses are implanted. Prostheses
are implanted by either a cemented or an uncemented technique. In North America, surgeons tend
to use primarily an uncemented, press-fit technique. Surgeons make a socket of a particular
size and then insert an implant that is 1 mm larger into that socket. The implant has
a special coating that encourages bone growth, and over time the bone grows onto the implant
so that eventually, they are bonded to one another. In other regions around the world,
cemented fixation is more popular. With this technique a specialized type of cement is
injected into the socket and then the stem is placed into the socket and held in position
until the cemented has hardened and secured the stem in place. With this technique, there
is not direct bond between the implant and the bone. While both techniques offer excellent
stabilization of the implant, the cemented technique is more favourable with more elderly
patients and does not allow evolution of the bone-implant interface over time.
So with all of these considerations in mind, my optimal combination would include a ceramic-on-poly
construct, inserted with a press-fit technique by way of an anterior approach. It is not
clear whether this is the combination utilized by Frankie Edgar. The implant utilized Askren’s
surgeon, although more stable, was inserted using a lateral or posterior approach, and
carries with it the risk of metal ions in the bloodstream. Although we don’t know
what implant was used for O’Mard, we do know it was implanted through an anterior
approach and is stable enough to allow a full return to MMA competition.
So what does the literature say about returning to MMA after hip replacement? There is not
much literature on this topic which means that it is not something that happens with
significant frequency. Two articles look at the ability of high level judokas to return
to judo after either hip replacement or hip resurfacing. The most recent of which looked
at 67 hip replacements in 60 patients. Within this group, there were 11 international and
3 international competitors. Of the 60 study participants, 53 had resumed judo after a
mean of 4-7 months. The longest time to return to activity was associated with combat judo.
Only 2 did not return to judo for pain-related reasons. There were no short-term complications
such as fractures, dislocations, or loosening of the implants.
A recent European survey of return sports after hip replacement showed that surgeons
generally did not recommend a return to impact activities such as handball, soccer, football,
or basketball, and particularly contact sports or martial arts. The survey did note that
surgeons are progressively mitigating restrictions to sports after hip replacement. The complications
listed in the judoka study illustrate why surgeons are concerned.
Although the implants themselves are unlikely to fail, there is always the possibility of
fractures around the implants, dislocations of the implants, or loosening of the implants
may occur, should adequate bonding between the implant and the bone not occur. In addition,
higher levels of activity are associated with increased levels of wear of the liner of the
implant. Read, shorter lifespan of the implant. The more active you are, the quicker you will
need a revision surgery. Speaking of which, what’s the problem with just putting in
a new set of implants when they wear out?
Replacing a primary implant with a new implant is called a revision procedure. When a revision
is performed we first need to take out the original implants. If they are loose, then
out they come, easy peasy, no loss of bone. However, if they are well fixed, then we need
to cut them out. Bone is lost when this occurs, and bone is a limited resource that eventually
we will run out of. Meaning that every person has a limited number of revisions available
to them that is determined by the amount of bone stock they present with. Not to mention
that on every occasion other than the first surgery, the tissues are no longer virgin
with an ever increasing amount of scarring and a reduced blood supply. This means the
surgery is more difficult with an increasing risk profile every time we perform it. Consequently,
you want to minimize the number of revisions that you might undergo in a lifetime. One
primary procedure and one revision procedure are the optimal number of procedures. As activity
level increases, so too does the likelihood of revision procedures so for athletes returning
to MMA competition, this is certainly an issue of concern.
And most importantly, with each operation, there is a risk of infection. Overall the
risk is approximately 1%, but with more exposures to this risk, the opportunity for infection
increases. This is a severe complication that we want to avoid at all costs. The best way
to do this is to minimize the number of times we access the joint operatively. This means
avoiding situations that might force us to revise the construct, namely fractures, dislocations,
or loosening. Did I mention yet that the risk of these complications is increased with contact
sports and impact activities….like MMA fighting? Which also happens to shorten the lifespan
of the implants? So you see the problem.
So, is it possible to return to MMA fighting after total hip replacement or resurfacing.
Apparently so. Is it a good idea? That remains to be seen. What are your thoughts about Frankie
Edgar returning to MMA after hip replacement? Is it a good idea? Would you do it? Be sure
to let me know in the comments.
As always, that’s been a word from Dr. Chris, not your everyday ortho.