Lindsey, You Are Not Alone

Partial knee replacements in extreme athletes are becoming more common. Here is the evolution of our thinking.

When she retired in 2019, at 34, Lindsey Vonn was the most accomplished alpine skier of all time. She returned to downhill ski racing at age 40 after a partial knee replacement solved her severe lateral knee arthritic pain. She has received both admiration and scorn for doing so.

Ski racers, if they persevere from teenage years to World Cup success, endure on average three major, possibly career-ending injuries during their careers. These injuries often lead to surgical removal of their meniscus cartilage, reconstruction of their cruciate ligaments, and repair of their broken bones. As with other athletes, once the knee cartilage and ligaments are damaged arthritis ensues.

Many athletes receive standard care, with excision of their torn tissues in order to get back in the game as quickly as possible. Others pursue our biologic knee replacement techniques in which the meniscus is replaced, the ligaments reconstructed, and the articular cartilage regenerated in an effort to restore a more normal knee. 

Once the damage is so great that there is bone-on-bone visible on the X-ray, the surgical options are often limited to artificial partial or total joint replacement. Traditionally athletes under 60 years of age are told to live with the pain until they are older—often for decades—since the belief and some of the data indicate that the earlier the artificial replacement, the more revision surgeries and failures occur. 

What changed? First of all, every time I gave a lecture at a major orthopaedic meeting related to this topic, I would ask for a show of hands to indicate how many surgeons had seen a patient’s artificial joint replacement fail from sports activities. None ever raised their hands. Secondly, the introduction of robotics with 3D modeling of the knee joint before proceeding to surgery has dramatically changed the precision with which the implants can be placed. More precision has led to fewer errors in alignment and better balance of the ligaments around the knee. 

This gave us the confidence to place more partial replacements in more difficult knees than ever before. And younger knees. Very, very few have failed, despite our patient population returning to running, triathlons, tennis, weightlifting, and many other sports. One patient, after bilateral partial replacements, actually ran across the United States a year after his surgery. The plastic trays that sit between the metal femur and tibia are durable for 30 years—according to the companies that make them. We shall see if high-level sports changes that wear pattern. Fortunately, the trays are replaceable.

For patients with multiple-compartment severe arthritis, total knees are the definitive solution. Due to the accuracy of the robotic saws, we can now bond them with just a press fit, no longer requiring bone cement. Only the bone required to allow a perfect fit, and no more, is removed. The implants are porous on their undersurface and the adjoining bone grows into them. To loosen them, the patient would have to break their bones—unless some other disease sets in.

Given what our patients are doing, the admonitions “live with your knee pain until you are older” and “limit your activities to preserve the artificial components” seem outdated. For Lindsey Vonn, racing down a mountain at 60 miles an hour is just as crazy and exhilarating as it always was. Today, it is also an inspiration to all athletes. Don’t let knee pain get you down or keep you down. Listen to your own intuition and pursue your goals. Forty might not be the new 20, but it isn’t geriatric. Go, Lindsey. 

3200+ Miles on Two Partial Knee Replacements: Inspiration in Motion

Meet Ultra Runner Richard Donovan. Richard ran across the United States, starting at the Boston Marathon and finishing 3,200+ miles and 16 states later at the Santa Monica Pier in California. Running 40+ miles per day on his partial knee replacements, this phenomenal accomplishment challenges our conceptions of what is possible after knee replacement and serves as an inspiration to injured athletes everywhere.