1-How long have hip prostheses been used ?
 
The first trials started just after the war in 1947. It was two brothers by the name of Judet who had the idea of replacing the femoral head by a semi ball-bearing made of methacrylate. The halved ball was fixed in the femur by a small stem of about 6 or 7 cm. Later on the stem was lengthen to give a better fixation in the femur. The material was also changed and the methacrylate was replaced by metal(chrome cobalt or inox).
It was quickly noticed that in the case of hip arthritis not only did the femoral head need to be changed but also the receiving cup in the pelvis (acetabulum).
The hip prosthesis as we actually know it today was the work of John Charnley. It was Charnley who first had the idea to use a cup made of polyethylene fixed in the pelvis to the bone with an acrylic cement. At the beginning of the 1960’s he made several experiments with Teflon but the component wear in Teflon posed more problems than he was able to resolve. The utilisation of a metal stem against polyethylene acetabulum reveal itself to be a good compromise. The Charnley hip prosthesis, 30 years old, is still considered by a good number of surgeons as the « Gold standard ».[top]

2-Who needs to have a hip prosthesis ?
All illnesses that lead to a destruction of hip joint are susceptible to be treated by a THR (total hip replacement). The arthrosis of the hip, still often referred to as coxarthrosis, is the most frequent cause. [top]

3-What is arthrosis ?
 
Arthrosis is defined as a wearing out of the cartilage. This disappearance of the cartilage will lead to a procession of manifestations, the most frequent being pain.
The majority of hip arthrosis are primitive (or primary). The term primitive is used when speaking of an arthrosis of which the origin is not known. Certain think that not all of us have the same quality of cartilage….
Also it is known that using the hip a lot often favours arthrosis. Recent studies tend to show that in effect many of these primary arthrosis are in fact secondary to the problem of a femoral head that is not perfectly round.
There also exists a secondary arthrosis, whose origins are usually due to a malformation of the hip. These malformations are in general congenital. In which case one speaks of a dysplasia of the hip. The dysplasia can be corrected by surgery if the destruction is not too advanced. One can also practice a periacetabular osteotomy on the acetabulum if there is insufficient cover (acetabulum is too small). Actions taken on the femur have a tendency to be less feasible because they often modify, in an important way, the anatomy of the femur. Therefore placing a THR risks to be more difficult the one day when the damage progresses.
Secondary arthrosis can also show up because of the after-effects of a fracture. The fractures of the acetabulum (violent trauma) which mend badly can often be the origin of an arthrosis which will later be very difficult to treat.
That is the reason for which all fractures of the acetabulum (especially those concerning young patients) should be treated in highly specialised centres where there are surgeons who have a great deal of experience.
Certain rare illnesses can also be the origin of joint destruction: rheumatoid polyarthritis, system illnesses…etc.
Arthrosis means pain : first a stiffness then a limp that will end by imposing a limited perimeter - one walks less well and not as long.
Finally, in certain cases, it is the femoral head bone which supports the cartilage which is attained. The necrosis of the femoral head leads to a weakness of the bone structure that will later on be the origin of a cartilaginous lesion leading to arthrosis.
When consulting the X-rays, the first sign is narrowing of the « in between » space. The cartilage occupies the space between the femur and the acetabulum. If the cartilage deteriorates, the space between the two will diminish in height. In principle the narrowing takes place at the upper part of the joint. Other signs follow : osteophytes (the famous « parrot’s beak») , geodex (little cysts within the bone testifying an area overloading). In certain cases, the destruction of the joint might be also take place at the same time as the disappearance of the « in between » space.
On the other hand, it is paradoxical to notice that pain is not always correlated with the damage that is seen on the X-ray. Certain patients with hips that the radiograph shows as destroyed might experience very little pain. While others might suffer a great deal and at the same time have normal- appearing radiographs. [top]

4-What does an arthrosis hip pain feel like ?
 
The most typical pain is one involving the groin fold. There is almost no other illness (or pathology) that manifests a pain in the inguinal fold while walking. A few rare vertebral disc hernias and inguinal hernias could manifest the same symptoms but there will be other signs which can not be mistaken. The external pain on the greater trochanter is one of them. It testifies of a fatigability of the hip muscles and is often a early sign whereas the groin fold pain often goes hand in hand with an advanced attack.
Certain hip pains will only be manifested by a pain in the knee. In almost all of these cases the stiffness of the hip is important but it is the knee that suffers. The moment a THR is placed the pain in the knee will disappear.
The pain in the buttock itself is rarely due to a pain in the hip. It is rather in the direction of the lumbar column that the problem should be investigated. Occasionally however a stiffness of the hip leads to bad positions of the spine and favours this type of pain. (During a normal walk, the hip works a lot by rotation !)
It is clear however that the surgeon often only see patients when they are already in an advanced stage. In nearly all these cases it is the loss of the rotation of the hip which will lead to a need for a THR. Flexion is very often conserved. It is the inside rotation that will be the first to disappear. When the outward rotation is also attained the need for a THR is not far away.. [top]

 
 
5-Do hip prostheses wear out ?
 
Alas yes ! But not all the THR models are the same concerning wear and tear. This is also true for patients.
One could compare a total hip prosthesis to the tires of an automobile. The more one drives the more often the tires have to be changed. It is not at all logical to refer to the wear and tear of a THR in terms of years. A « bad » THR placed in someone sedentary will last longer than a « good » prosthesis placed in a hyperactive young man.
It is important to understand the wear and tear mechanism of a classic prostheses ( friction pair of metal ball against polythene cup). With each step minuscule fragments of plastic are detached from the cup. (This is situated at a molecular level.) Certain researchers have even spoken of 350 000 fragments with every step. These fragments will then « fall » in the articulation and this will lead to a reaction by the organism. It has to do with a immunity reaction that takes place each time a foreign body is introduced in the organism. (the immune system is much more sensible to a microscopic fragment that to a piece the size of several centimetres) this immunity reaction will then stimulate all the immunity reaction cells: macrophages, lymphocytes… These cells will attempt to digest the plastic fragments but without success and these fragments will accumulate to form what is called a polythene granuloma. During certain repairs of the prosthesis the surgeon will have to « do some house cleaning » and sometimes will remove a full « bowl » of granuloma. It is this immunity reaction that causes a prosthesis to break. The granuloma cells will liberate toxic substances with regard to those cells within the immediate environment. These substances will lead to a demolition of bony cells (the osteocytes) and thus the support of the prosthesis. The usual origin of the breakdown is found at that point.[top]

6-Which pair of frictions should one choose ? (from hard/soft to hard/hard)
 
There are several types of prostheses. They are defined by the friction pairs that exist between the bearing of the femoral stem (component) and the acetabulum cup. Nowadays there are three different grand types of friction pairs.
The most classic is a metal ball lodged in a plastic polythene cup. The bearing is hard, the plastic is soft. The metal can either be in inox or chrome cobalt (very hard steel) - both of high quality and very pure. Factory precision is rigorous. Since the beginning of the 1980’s there is a tendency to replace the metal bearing with a ceramic one when it comes to treating younger patients. The surface finishing seemed better and the wear rate less. Above all the material was harder than steel and did not scratch. A metal bearing that scratches leads to much more wear. Ceramics made of alumina and zircon are employed. In principle ceramics made of zircon are theoretically a little better than alumina when it comes to solidity. Recent studies seem to show that prosthesis using « certain » heads of zircon experience more wear and tear. This risk is sufficiently important so that an ordinance was issued in August 2001 forbidding the use of this particular sort of ceramic head. ( but attention, not all heads in zircon pose this problem.) However, alumina is a little more fragile than zircon and fractures of the femoral bearing could occur. It is extremely rare (1/1000) but possible. The problems of wear and tear of the zircon heads do not seem to exist with alumina. Thus alumina is still authorised.
The size of the femoral bearing in the case of a metal/plastic prosthesis is also of importance. The small bearings seem to wear less than the bigger ones. Charnley perfection his first hip prosthesis using a 22,2 mm inox ball. The other surgeons thought it better to utilise bigger bearings of around 38 mm. It is now known that the bigger bearings lead to more wear in the case of the friction pair metal/ polythene. More debris and more wear signifies more breakage. Actually the consensus is to place bearings of 28 mm to 22,2 mm.
One should also know that in the case of a hip prosthesis the smaller the bearing the higher the dislocation risk. Which shows that nothing is perfect and a lot depends on finding a compromise.
The second pair of friction that is in actual used is alumine against alumine (hard bearing against hard acetabulum). Both the bearing and the acetabulum are in alumine. All the studies so far have shown that the wear and debris rate is close to zero. This type of friction pair was invented by a French doctor named Bouttin who worked in the south west of France at the beginning of the 1970’s. The biggest problem of this pair of friction comes from the cotyloid piece. First of all, it is imperative that the adjustment between the two components be absolutely perfect. At the beginning of the 1970’s, each prosthesis was paired.
Now due to the progress of digital manufacturing, this is no longer necessary. It was then necessary to find the best way to fix the bone to this block of ceramic. The rigidity of the ceramic is much higher than that of the bone. A fixation with cement was first tried but that resulted in frequent detachments. The detachment is not due to ceramic debris
( there are not any ) but to a too great rigidity difference between the ceramic, the bone and the cement. When the surgeon operates a detachment, he almost always has the pleasant surprise of discovering the absence of granuloma. Thus revision surgery is much more simple.
To relieve this problem, a ceramic cup was placed in a second cup made out of metal which was then impacted or screwed down into the bony acetabulum. But there also, were problems. The design problems of these particular types of prostheses lead to important failures. These problems seem at the moment to be resolved but twenty years of « average » results have left their mark and even now many surgeons are still reluctant to use this type of friction pair. It is nevertheless a future path to consider for the debris rate is extremely low.
The third pair of friction, that is taking on greater importance, is the metal against metal prostheses (hard bearing against hard acetabulum). It is not really new, for in the 1960’s the English surgeons, Doctors Mac Kee and Farrar had realised a large bearing prosthesis (46 mm) that articulated in a cemented metal cup. The results were variable. In many cases, it was necessary to re-operate these patients after a few years because the prosthesis had loosen up. But in other cases, on the contrary, the prosthesis was as perfectly anchored after twenty-five years as it was on the first day. It took twenty years in order to understand that the problems depended upon the quality of the construction and the manufacturing of the two components. The prostheses that « grabbed » did not hold. Those who adjusted perfectly gave the most reliable results in the long run and without a trace of loosening up or wearing. It was a Swiss surgeon, Doctor Weber, who re-launched this friction pair in the middle of the 1980’s. He also had the idea of placing a metal cup in a block of polythene. The polythene plays the role of a shock absorber and permits the cotyloid piece to be cemented without a problem.
Like with the ceramic/ceramic prostheses, the wear and debris rate is almost zero. Thus one can perhaps consider perfectioning prostheses whose life span will go beyond « 20 years » even when they are used in young and active patients.
In the case of metal to metal implants, some surgeons prefer to augment the diameter of the femoral bearing. This does not seem to raise the risk of wear and permits to diminish the risk of dislocation. One is able to approach the anatomy of a normal hip which is makes this very interesting. [top]

7-Cemented or cementless ?
 
One only has to attend a Hip Prostheses Congress to discover that there are no clear answers. And one finally ends up by saying that this does not really pose a problem.
Cementing dates from the first prostheses by Charnley, who fixed the femur stem in the plastic acetabulum with an acrylic cement. At that time he was only able to work with a prosthesis which was of one size therefore when the femur was very large he used a lot of cement and when the femur was small he put in very little. Since then the situation has evolved and the surgeon now disposes of different sizes and is able to adapt to each case. The manner of preparing the cement and put it in place has also changed. This is now referred to as third generation cementing.
The first generation of the femoral stem were in inox or chrome cobalt. This has never really posed any problems. In the 1980’s a titanium prostheses was perfectioned because the metal appeared much closer to a bone’s elasticity. There were quite a few problems due to the nature of titanium itself and the cement used. Currently the problem is solved but it is known that it is preferable to utilise stems in inox that are perfectly polished and a section more or less square.
Cementless prostheses date from the beginning of the 1970’s. It was Robert Judet who had the idea of fabricating stems presenting the same asperities as the bone in which it would be placed and colonising the prosthesis fixing it solidly to the bone. Having a prosthesis completely integrated with the bone got rid of cement, which had been the motivations of the first designers. The idea was good but the first realisation did not have the success expected. Probably because the technical leap was too great. If the femoral stem had given fairly good results, the acetabulum and more particularly the tear of the polythene was the origin of the bad results. Actually it is now proven that an acetabulum in polythene blocked in a metal piece wears more quickly than acetabulum in polythene sealed with cement.
On the other hand the hanging of the stem and the metal acetabulum is more or less resolved. Certain cementless prostheses now have a 20 year perspective behind them and the breakage rate is identical or even better than a cemented stem.
Since over a little more than ten years certain cementless prostheses have been coated with hydroxyapatite. Hydroxyapatite is a form of mineral that takes calcium in the bone. This facilitates the osteointergration of the prosthesis on the short term. On the long term the results seem identical with a classic cementless stem.
The placing of a cementless prosthesis requires a surgeon who has a certain amount of experience for he must feel the quality of bone and find the size for which it is best adapted. That is without a doubt the reason for which one finds cementless prostheses for both the right and left side.
However it is certain that more and more surgeons are using cementless prostheses. Finally, one should be aware that in certain cases which concern fragile patients there will be an important drop in tension during the operation the moment when pressure is used to apply the cement. [top]

8-Where will the scars be ?

In fact more than a question of a scar, it is the surgical approach that one should be concerned about. The surgical approach is the pathway that will be used to reach the hip joint in order to place the prosthesis. The hip is an very deep articulation « drowned » in an important mass of muscles. These muscles are precious for they are the ones who will later permit the proper functioning of the prosthetic joint. Without muscles no prosthesis !
Thus it is important that the surgeon does not damage the muscular system while implanting the prosthesis.
The anatomical path that he will take that starts from the skin all the way to the articulation is commonly referred to as the surgical « approach ».
In France the large majority of surgeons use a posterior approach. The scar is found in the buttock, and is about fifteen to twenty centimetres long. It is necessary to cut the small muscles that permits the outwards rotation of the hip. The sectioning of these muscles is not serious because the hip contains a large number of internal rotating muscles. Technically speaking this is the approach that is the easiest for the surgeon. However, the risk of dislocation is more likely than with the other approaches. If all goes well, the result is fairly simple and quick, and the use of an support is possible immediately.
There are three anterior approaches : the trochanterotomy, the Hardinge approach, and the Hueter approach. One can also add the Watson Jones approach and the Mueller approach. Each surgeon has his own personal habits and numerous ways of approaching the hip, have been and continue to be described. For example there are at least three methods of practising a trochanterotomy.
There is very little direct muscular damage during a trochanterotomy. Instead of sectioning a muscle to enter into the hip, a bone chisel is used to section the greater trochanter. The bone has a capacity of cicatrization that is far beyond that of the muscle. It is probably the only tissue that is able to mend without a scar. The only problem is that complete support is only allowed after forty-five days. Trochanterotomy is of immense value for the hip. It is the surgical approach for difficult cases. Surgeons use this method less and less for first intention surgery. That is to say for a prosthesis on a hip that has never been operated on.
The anterolateral approach like the Hardinge approach is very popular in certain regions of France. It is also the approach chosen in Germany where the surgeons do not like to use the posterior approach because of it’s dislocation risk.
Nonetheless the follow-up is a little more delicate and the musuculaire recuperation is somewhat slower than after a posterior approach.
What remains is the pure anterior approach or the Hueter approach. It is an approach that has many advantages, one of them being that it does not touch the muscles, also recuperation is rapid to the point of being amazing but however does require a specific installation system for carrying out the operation. The patient needs to be placed on a special orthopaedic table that not all centres are equipped with. And last but not least, it is an operation that is a technically delicate operation for surgeons to perform. For those surgeons who have mastered this technique, they would not use any other because the follow-up is quick and the pain level is relatively low. And with experience the scar can even go under the ten centimetre bar. And sometimes for a thin person be only five to six centimetres.
Of course there is one flaw : there exists a tiny - but only sensitive - nerve branch that can be damaged by the spreaders. This involves a very localised zone of hypoesthesia (diminution of the sensation of feeling) atop the external face of the thigh. In general this will disappear after several months. You must have understood by now that this is the surgical approach that I use with most of my patients. [top]

9-What is a dislocation ?

A dislocation of the prosthesis is when the femoral head leaves the acetabulum. This is of course very painful and one is completely helplessness. As a rule this ends with a brief general anaesthesia during which time the head is replaced in its usual habitation which is the prosthetic acetabulum.
There are two types of dislocation to differentiate. The first one concerns a dislocation during the decrement of the operation ( within the first two or three months ). If however, everything goes well after that time then nothing more should arrive. The second concerns a recurrence that could reveal to be a real problem of stability which in certain cases will require another surgical intervention.
In the majority of cases a dislocation occurs following a extreme false movement; outward hyper-rotation with extension or a massive flexion of the hip with adduction (knee inwards). For this reason your surgeon will explain the famous movements to be avoided at the beginning just after the operation. In principle if there has been no dislocation at the end of three months the risks strongly diminishes and becomes almost non-existent ; the cicatrising tissues preventing a dislocation.
Certain approaches cause more dislocations than others. This explains why the use of the posterior approach does not have a good reputation. In general, the anterior approach causes fewer dislocations. The size of the bearing is also important : the larger it is the more stable the hip. The famous Charnley prostheses with their tiny 22 millimetre bearings are fairly exposed to dislocation problem.
But it is probably the position of the prosthesis in the femur and the pelvis that can more easily explain recurrent dislocations. Certain persons because of the rigidity of their lumbar column will submit their prosthesis to more important movements and a prosthesis that is perfect in a standing position can pose serious problems in a sitting position.
There exists specific prostheses which seem to prevent dislocations. These can be quite interesting in the case of frail patients with a deficient musculature, a rigid back or inclined towards using those movements forbidden during the first weeks after the operation. Many surgeons no longer hesitate to systematically use these prostheses with patients who are 70 years old and older. Moreover these prostheses designed by Professor Bousquet at Saint Etienne, seem to give few wearing problems even after a long term. Research to confirm this impression are still being studied. [top]

10-What is to be done before the operation ?

Before talking about the actual operation itself, there are certain precautions that might have to be under taken. For example, your surgeon might ask you to visit your dentist and if you are a woman to have a cytobacteriological urine test done. The purpose of these tests is to find out if there might be any unknown infections lurking. For this could reveal to be disastrous in the case of prosthetic surgery. It is in effect dangerous to place a prosthesis if there might be any risk of infection.
Your surgeon will also take in consideration the state of your leg veins. If he thinks necessary, just after the operation, he will prescribe support stockings for you to wear. These support stockings will help limit the risk of a phlebitis.
Finally you will visit the an aesthetist. This consultation is compulsory from the medical- legal view. The anaesthetist will ask you a certain number of questions concerning your general state of health. Perhaps, he may even ask the advice of another specialist, in particular, a cardiologist. In order to simplify his work, it is important that you bring all the recent examinations that you have in your possession. He might even propose an autotransfusion, which would then mean that you would have to go two or three times to a transfusion centre to donate your blood. This will be the blood that will be restored to your body after the operation. Thus blood transfusions other than your own will only be necessary under exceptional cases.
In most cases you will be asked to check in to your place of hospitalisation the day before the operation. Of course, do not forget to bring all the papers, and above all the X-rays, that you have in your possession. And remember to bring your crutches. The hospitals are not pharmacies and in general they will not be able to furnish crutches.
You will then see the anaesthetist a second time. And an electrocardiogram will be done. Another set of X-rays might also be taken if the quality of the one you brought were not good enough or too old.
Before the operation your epiderm will be prepared and this consists of shaving the area that will be operated on and taking a shower using an antiseptic product. If there happens to be skin lesions of any kind you must point them out to the doctor. You will be given a premedication one or two hours before the operation. In general this is a medication to help you to relax and eliminate the stress. [top]

11-Concerning the operation itself.
 
It goes without saying that the operation will take place in operating block. It is almost always a specific room set aside just for orthopaedic surgery. It is often equipped with a laminar flow ( a sophisticated ventilation system) that very efficiently eliminates all the germs and particles in the operating room. The anaesthetist will be the first to take care of you. He will pose one or two intravenous lines in your vein. Electrodes will be placed in order to follow your cardiac rhythm and a saturometer placed either on the finger or ear will keep track of the amount of oxygen in your blood. After this you will be placed on the operating table.
If you have chosen to have a peridural anaesthesia, the anaesthetist will give you an injection just at the contact of the nerve roots between the two lumbar vertebra. Thus you will be awake during the entire operation. You can also be put into a light sleep if the idea of remaining totally awake bothers you.
In the case of a general anaesthesia the product passes through the veins. A tube is placed in the larynx or trachea and a very sophisticated apparatus will breath for you during the entire operation. An entire battery of apparatus will permanently monitor your vital functions. Anaesthesia is not completely risk free but these risks are really very small.
The operating zone is whitewashed once or twice with a powerful antiseptic product and then a protection system is set up. This is the operating area. In orthopaedics, this will englobe the entire patient and the setting up is very precise. Only a area of several centimetres square is left to the open air and it is there that the surgeon will make an incision. Generally this cutaneous area is recovered with a sticky supple plastic saturated with an antiseptic product. The surgeon will make the incisions through this plastic film. The skin and the numerous germs that reside will thus never be in contact with the operation wound itself.
The installation time can sometimes be a little long because during this same time all the specific instruments for this particular operation must be taken out and placed. It is at this time that the anaesthetist gives the surgeon the blood recovery system (called cell saver) which will aspire the blood during the operation, clean it and restore it to your body at the end of the operation.
The operation itself lasts between 45 minutes and 2 hours. A lot depends on the parameters.
At the end of the operation, the surgeon places 1 or 2 drains (called Redons -suction drains) that you will keep for 2 to 4 days. They permit the evacuation of an eventual haematoma. The dressing is put in place, verification radiographs are done and then you will be placed in a recovery room where you will be kept for 1 to 3 hours. When your condition is stabilised you will be returned to your own room. [top]

12-Postoperative follow-up
 
You will be under perfusion for 24 or 48 hours. This perfusion will pass the different molecules - not only the antibiotics, and antalgics - but also the blood that you had given before the operation.
The day after the operation, you will be place in a armchair for several hours and eventually for the more sturdy patients several steps will be attempted.
Two days later after the operation, sturdy or not, one must make an effort to take several steps. Generally this does not pose much of a problem. A support is authorised and crutches are there to aid the musculature. The physical therapist will help you and will also explain how to figure things out concerning the « extensions » that perhaps you are using for the first time.
On the third or fourth day, in principle, the Redon drains that served to drain the operation wounds are removed. This will considerably simplify your movements. It is not unusual that the physical therapist will give you permission to move around on your own.
Generally at this time he will explain the movements that you should avoid during the first weeks. As long as the
musculature has not recovered all of its force, there is a always a risk of dislocation. A dislocation is generally produced while making extreme movements. And it is these movements that one should avoid. For some this will not pose a problem but for others it could correspond to correcting long acquired habits that are not easy to break.
The dislocations will also depend upon which approach your surgeon used during the operation.
Thus in the case of a posterior approach, the maximum risk of dislocation will occur during the movements of massive flexion of the hip, the knee finding itself towards the interior. In the case of a anterior approach, the risk of dislocation is much rarer and occurs if the hip is in extension, the foot in a large outward rotation.
On the fourth or fifth day you undergo a radiographic control. The surgeon will use it as an initial reference point. Thus it is important not to lose this X-ray.
If all goes well, and the pain is not too important, one can hopefully leave between the fifth and eight day. [top]

13-Does one have to go to a rehabilitation centre ?
 
It varies. In principle, it is not necessary unless your personal surrounding are somewhat difficult. For example, if you live on the fifth floor without an elevator and have no one to help you, it is better that you rest three to five weeks in the centre. If on the contrary, you are well looked after by family or friends and your home passage ways are not too crowded with obstacles, the easiest thing is to go home. Contrary to what one might think, the presence of a few stairs is not an obstacle. It is only necessary to get rid of chairs, low couches and slippery areas ( rugs !). [top]

14-How long will physical therapy last ?
 
This also varies, but in general six to eight week should be enough. One must realise that in the meantime the best rehabilitation is walking. At the beginning with two crutches, then with only one( the opposite side of the operation) then without. Start by abandoning the crutches in a familiar surroundings, such as at home, then later when in the street.
Some patients are able to get rid of their crutches in ten days where as others need to use them for six weeks. One should not panic, we are all different and each of us will need to advance according to our own rhythm. [top]

15-How long before one can go back to work ?
 
There again, that varies. If you are an intellectual, working behind a desk, and with little transport, you can return to work in about fifteen days. Other patients will need three to four months. (difficult cases, jobs which take a lot of strength, difficult transportation problems, individual sensitivity).
In general you should be able to drive your car in three to four weeks and walk one kilometre after the fifth week. [top]

16-Return to Sports ?
 
One can imagine taking up sports again after six months, Certain patients can even attain their professional level again. The only sports to avoid are those which risk to cause a dislocation, such as skiing, the martial arts and football. Strictly speaking, nothing is forbidden but all should be done with measure. One « Homo sapiens » warned is worth two! [top]