Alpine Skiing With total knee ArthroPlasty (ASWAP): study design and intervention

Total knee arthroplasty improves sports activity and the patient-reported functional outcome at mid-term follow-up

PURPOSE

The purpose of this study was to assess (1) sports participation and preference for the type of sports activity after TKA, (2) mid-term functional outcome and activity level, (3) correlation of different age groups with activity level and functional outcomes, and (4) mid-term survivorship of the prosthesis.

METHODS

A retrospective review of prospectively collected data was performed. 182 patients were included who underwent primary TKA between January 2010 and December 2016. Inclusion criteria were symptomatic knee osteoarthritis, age 50-90 years, and with a minimum of 5-year follow-up after TKA. Patients with rheumatoid arthritis and revision TKA were excluded. Sports participation and sports preference, Oxford Knee Score (OKS), Tegner Activity Level, and Visual Analogue Scale (VAS) for pain were recorded pre- and postoperatively at 6 months, 1 year, 2 years, and 5 years. The patient cohort was subdivided according to age groups; activity levels, patient-reported outcomes, and improvement in knee pain were correlated with these age groups. Kaplan-Meier curves were used to investigate survivorship at a minimum of 5 years.

RESULTS

The mean age of the cohort was 75.6 ± 7.2 years (range 52-89). Significant improvement was noted in sports participation (p < 0.003). After TKA, there was no change in the preference for sports and none of the patients had to discontinue their sporting activity. OKS improved significantly at all follow-up time points compared to the preoperative score (p < .0001). Patients' sports and physical activity improved significantly at 1 year compared to the preoperative activity level (p < 0.001). Although the Tegner activity level improved over time, this improvement was not significant (NS), while it was significantly higher in males than in females (p < 0.004). Significant improvement was found in the VAS for pain at all follow-up time points compared to the preoperative score (p < .0001). Survivorship was found to be 100% at a 5-year follow-up.

CONCLUSION

After TKA, patients can be able to return to sporting activity or even perform better than before surgery. Maximum improvement was noted in the first post-operative year. The male and younger groups perform better than the female and older groups. Sports and physical activity do not negatively impact survivorship of the knee prosthesis at mid-term follow-up and all patients are encouraged to take up sports participation after their TKA.

LEVEL OF EVIDENCE

Level 3.

Can I Ski Doc?: Return to Skiing Following Total Joint Arthroplasty

BACKGROUND

Currently, there are little data on performance, safety, or return to downhill skiing after total joint arthroplasty (TJA). This leaves surgeons with little information for patient counseling regarding skiing.

METHODS

An online survey was sent to 4360 patients who had undergone at least 1 primary TJA at a single academic center over the past 10 years (4 surgeons). The survey asked patients about their prior and current skiing activity including ability level, limitations, and reoperations. Demographics, patient-reported outcomes, and reoperations were also captured through chart review. Chi-squared, analysis of variance, and t-tests were used to compare demographics and outcomes. Paired t-tests were used to compare preoperative and postoperative skiing levels.

RESULTS

Of the 763 survey respondents, the average follow-up was 4.4 years (range 0.5-10.3). In total, 35.6% had never skied, 26.5% had not skied in the 5 years prior to surgery (remote), and 37.9% had skied in the 5 years prior to surgery (recent). Seventy percent of recent skiers returned to skiing after surgery, compared to 11.9% of remote skiers. The majority of skiers, mostly advanced, returned to their prior level. There was no difference in return rates in those with a single total hip arthroplasty vs total knee arthroplasty vs multiple TJAs. Rates of reoperation were not significantly different between patients who did and did not return to skiing.

CONCLUSION

The majority of recent skiers were able to return to skiing after TJA at their same level without an increase in reoperation rate. Further studies are needed to determine long-term consequences of skiing after TJA.

Quantitative Analysis of Patellar Tendon After Total Knee Arthroplasty Using Echo Intensity: A Nonrandomized Controlled Trial of Alpine Skiing

BACKGROUND

Despite the knee extensor weakness, less attention has been paid to the evaluation of patellar tendon after total knee arthroplasty (TKA). We previously observed patellar tendon hypertrophy after TKA. The purpose of this study is to reanalyze these ultrasound data to detect whether brightness mode ultrasound imaging reflects pathological changes of the patellar tendon after TKA.

METHODS

Twenty-eight participants with post unilateral TKA were assigned to an intervention group or control group. The intervention group underwent a 12-week skiing program. Patellar tendon mechanical properties were obtained by combining isometric dynamometry, ultrasound imaging, and electromyography in operated knee and nonoperated knee. Luminosity ratio (LR) was measured using echo intensity in a relaxed and maximally loaded phase.

RESULTS

Baseline comparisons revealed significant effects of the surgical side (P < .001) and loading phase (P = .017), but no interaction between leg and phase (P < .149). LR of the operated knee was significantly lower than LR of the nonoperated knee in relaxed (P < .001) and maximally loaded phases (P = .003). In addition, there was a significant correlation between LR of maximum phase and isometric knee extension torque (r² = 0.156, P = .038). However, LR was not related to patellar tendon stiffness, Young's modulus, or strain. There was a significant time effect in knee extension torque, but no time effects on LR and tendon force.

CONCLUSION

Patellar tendon LR is decreased along with degenerative change after TKA. Ultrasound imaging provides a promising metric to acquire in vivo patellar tendon pathological assessment after TKA.

Feasibility of Ski Mountaineering for Patients Following a Total Knee Arthroplasty: A Descriptive Field Study

Background: Total knee arthroplasty (TKA) is socially relevant due to its high prevalence, high incidence and the affected population. A subpopulation of TKA patients exists that strives to be active and also return to sports after total joint replacement. In this context, a further group of TKA patients is interested in high-impact physical activities and want to proceed with such activities even after surgery. Focusing on winter sports, there is still a lack of evidence on whether ski mountaineering is feasible for this subgroup of patients. Therefore, this feasibility study examines the effects of moderate ski mountaineering on strength, balance, functional abilities and mental health in persons following a TKA. Methods: Eight patients (six males, two females; median age, 63 ± Interquartile range 9 years) with TKA were included in this study. The volunteers, who were pre-selected for a 7-day holiday in Sankt Johann (Tyrol, Austria), participated in five guided ski mountaineering tours. Statistical analyses of non-parametric longitudinal data were performed using analysis of variance. For gait parameters and the Feeling Scale, one-factor longitudinal models were used. Statistical significance was set at the level of p < 0.05. Results: A significant decrease in the S3-Check MFT stability index (p = 0.04), a significant increase in general well-being (p = 0.05), and a trend towards a decrease in general stress (p = 0.1) were detected, while all other parameters were unaffected. Conclusion: A 7-day recreational ski mountaineering holiday had no negative effects on ski-experienced patients with TKA and seemed to increase well-being. Further studies should focus on larger groups and use controlled designs. Additionally, long-term effects should be evaluated.

Effect of aging on muscle and tendon properties in highly functioning elderly people

This study analyzes long-term changes in muscle strength, muscle architecture, and patellar tendon mechanical properties in a specific sample of physically active elderly people. Twenty-two participants were re-examined from a former 12-week-long skiing intervention study: 11 from the intervention group (IG: 7 ♀, 4 ♂; 67 ± 3 years) and 11 from the control group (CG: 6 ♀, 5 ♂; 66 ± 4 years). Muscle architecture, strength endurance, maximum torque, and tendon properties were analyzed three times within 6 months, and again 6 years later in a follow-up test. No changes in either group could be observed between June 2009 and April 2015 in any parameter. This can be interpreted positively because no age-related decreases were found. Although our participants were physically active from the very beginning (>150 min/wk), it must be noted that the intensity of the physical activity was too low to provoke physiological improvements in leg strength or muscle/tendon morphology.

The effects of a 3-month controlled hiking programme on the functional abilities of patients following total knee arthroplasty: a prospective, randomized trial

PURPOSE AND HYPOTHESIS

Improvements in pain, function and sports activity are the main goals of patients following total knee arthroplasty (TKA). Participation in sports has become an increasingly important contributor to patients' quality of life (QoL). Hiking is one of the most popular summer activities among elderly people in alpine regions. Consequently, this randomized controlled trial investigates the impact of a 3-month guided hiking programme on patients' functional abilities and QoL following TKA. It was hypothesized that patients who participate in this programme would demonstrate improvements in functional and QoL parameters compared with a control group.

METHODS

Forty-eight TKA patients were included and randomized into either the intervention group (IG; n = 25) or the control group (CG; n = 23). The IG participated in a 3-month hiking programme (2-3 times a week), whereas the CG performed activities of daily living. The stair climb test (SCT), QoL questionnaires and isokinetic force measurements were completed at three time points (i.e. pre-test, post-test, retention-test). ANOVAs for repeated measurements were conducted for the SCT results. The Friedman test and the Mann-Whitney U test were performed for the QoL parameters.

RESULTS

After the 3-month hiking programme, the IG achieved faster overall walking times on the SCT. The time decreased from 4.3 ± 0.6 s (pre-test) to 3.6 ± 0.4 s (post-test) for the stair ascent (p = 0.060) and from 3.6 ± 0.6 s (pre-test) to 3.2 ± 0.5 s (post-test) for the stair descent (p = 0.036). The IG showed significant improvement on some of the subscales of the Knee Injury and Osteoarthritis Outcome Score from pre-test to retention-test (p < 0.01). In the CG, no significant changes were observed (n.s.).

CONCLUSIONS

The results indicate moderate improvement in the functional abilities and QoL of TKA patients who participated in a 3-month guided hiking programme compared with the patients in the CG. Hiking did not have any acute detrimental effects on the TKA patients during this study period.

LEVEL OF EVIDENCE

II.

Alpine Skiing With total knee ArthroPlasty (ASWAP): physical self-concept, pain, and life satisfaction

Physical self-concept in the elderly is assumed to be structured in terms of different domains and to contribute substantially to life satisfaction. However, little is known about the role of the physical self-concept in older persons that are engaged in physical activity while suffering from typical age-related impairments or chronic diseases. The present study aimed to investigate the structure of physical self-concept in a group of older persons with total knee arthroplasty (TKA), its development throughout a 12-week skiing intervention, and its importance to life satisfaction. Factor analyses of the present data reveal that the physical self-concept consists of four dimensions addressing strength, flexibility/coordination, endurance, and sportiness. One higher order factor extracted by hierarchical factor analyses reflects a global physical self-concept. The 12-week skiing intervention had no substantial impact in terms of an improvement of self-concept. Life satisfaction is best predicted by positive changes in the subjective ratings between pre- and post-test (i.e., global physical self-concept, flexibility and coordination, and perceived sportiness) and not by objective physical performance (isokinetic strength, endurance, or coordination). Results support the assumption that physical self-concept of older people with TKA is only marginally sensitive to a 12-week skiing intervention.

Alpine Skiing With total knee ArthroPlasty (ASWAP): effect on tendon properties

The aim of this study was to investigate the effect of alpine skiing on patellar tendon properties in patients with total knee arthroplasty (TKA). Thirty-one adults (70.4 ± 4.7 years) with unilateral TKA were recruited 2.7 ± 0.9 years after surgery and assigned to an intervention (IG) or a control group (CG). The IG underwent a 12-week guided skiing program. Tendon stiffness, Young's modulus, and cross-sectional area (CSA) were measured before and after the intervention. In both groups, mean tendon CSA was 28% (P < 0.001) larger in the operated (OP) than in the non-operated (NOP) leg at baseline, without any difference in other tendon properties. After training, stiffness increased in the IG by 5.8% and 15.8%, respectively, in the OP and NOP legs. Likewise, mean CSA increased in the IG by 2.9% in the OP and 3.8% in the NOP leg, whereas no significant changes were found for the Young's modulus. None of the tendon parameters changed in the CG. Results indicate that patellar tendon structure and/or loading pattern are altered following TKA, but this tissue seems to retain its adaptation capacity. Further, alpine skiing appears to offer a suitable rehabilitation strategy for TKA patients.