Athletic activity after total joint arthroplasty

New comprehensive score for predicting difficulties in revision total hip arthroplasty

BACKGROUND

Revision total hip arthroplasty (THA) can be complex, and assessing possible difficulties is important to predict the operative time. No simple score for predicting difficulties has been assessed prospectively. We therefore developed an original score for the pre-operative evaluation of extraction and reconstruction difficulties. The objectives of this prospective study were to (1) assess correlations between score values and operative time, (2) determine whether the score predicted the need for revision implants and/or filling material, (3) determine whether the score predicted intra-operative and post-operative complications, and (4) evaluate the inter-observer and intra-observer reproducibility of the score.

HYPOTHESIS

The score is reproducible and correlates well with the operative time, thereby allowing prediction of this parameter before surgery.

MATERIAL AND METHODS

A prospective study of 103 revision THA procedures performed between March 2018 and August 2023 was conducted. The primary outcome was operative time and the secondary outcomes were use of a revision implant, use of filling material, and intra-operative and post-operative complications. The score was determined by four observers to allow evaluation of inter-observer agreement. Intra-observer agreement was assessed by having one of the observers determine the score a second time after inclusion of the last patient. The score has a maximum value of 20 and allows classification of the procedure as very difficult, difficult, and moderately difficult.

RESULTS

Mean operative time correlated with the score value: 136.0 ± 33.9 min in the very difficult group, 102.0 ± 34.8 min in the difficult group, and 75.4 ± 65.5 min in the moderately difficult group (p = 0.0002). The score predicted the use of a reinforcement ring (40 procedures: 12/17 [70%], 11/25 [44%], and 17/61 [28%] in the very difficult, difficult, and moderately difficult groups, respectively; p = 0.01) and of a long stem (20 procedures: 8/17 [47%], 7/25 [28%], and 5/61 [8%] patients in the very difficult, difficult, and moderately difficult groups, respectively; p < 0.001). The score did not predict the use of filling material (42 procedures: 10/17 [59%], 9/25 [36%], and 23/61 [37%] in the very difficult, difficult, and moderately difficult groups, respectively; p = 0.250). The score predicted both intra-operative complications (5/17 [29%], 4/25 [16%], and 4/61 [6%] procedures in the very difficult, difficult, and moderately difficult groups, respectively; p = 0.028) and post-operative complications (4/17 [23%], 0/25 [0%], and 6/61 [9%] in the very difficult, difficult, and moderately difficult groups, respectively; p = 0.15). Inter-observer agreement was strong according to Landis-Koch criteria, with kappa values ranging from 0.70 to 0.79 [0.57-0.90]. The kappa value for intra-observer agreement was 0.74 [0.63-0.85].

DISCUSSION

This score predicts surgical difficulties by adding criteria to bone destruction, in contrast to widely used classifications for revision THA. Moreover, the score is reproducible and predicts the operative time, thus potentially playing an important role during pre-operative planning.

LEVEL OF EVIDENCE

IV; prospective observational non-comparative study.

Return to surfing following hip arthroplasty

BACKGROUND

To date, no previous studies have explored return to surfing after hip arthroplasty. The objective of this study is to analyse return to a risky activity following hip arthroplasty.

METHODS

A retrospective chart review was conducted on all primary total hip arthroplasties (THA) and hip resurfacing arthroplasties (HRA) performed by the senior author from 2014 to 2021. Patients identified as surfers were contacted to complete a survey including surfing history and patient-reported outcomes.

RESULTS

83 hips in 67 patients were contacted. There were 66 THAs and 17 HRAs. 81 hips were performed through a posterior approach and 2 through an anterior approach. At an average of 67 months, there were no dislocations and no patients reported hip pain while surfing. Time to resume surfing was a median of 16 (range 8-144) weeks. Among 13 patients who did not return to surfing, 8 cited new lifestyle restrictions, 4 attributed it to other arthritic joints, and only 1 patient attributed their limitation to the replaced hip. This group had taken significantly more time off from surfing prior to surgery.

CONCLUSIONS

Return to surfing following THA and HRA is common and safe in our study population with no complications and specifically no dislocations. Patients with other sites of arthritis and patients who have more extensive time away from surfing prior to surgery are less likely to return to sport. While surfing is clearly not without risk, patients can generally expect a high rate of successful return to surfing after hip arthroplasty.

Comprehensive evaluation of risk factors for aseptic loosening in cemented total knee arthroplasty: A systematic review and meta-analysis

Purpose

Aseptic loosening is the most common cause for revisions after total knee arthroplasty (TKA). Despite many studies exploring various risk factors associated with aseptic loosening, findings often present inconsistencies. To address this, we conducted a thorough review of the literature to identify and analyse these risk factors in cemented TKA. Additionally, we performed a meta-analysis to reconcile the divergent conclusions observed across studies.

Methods

We searched PubMed, Web of Science and Embase from 1996 up to 2024 and evaluated the quality of the included literature. Seventy-four studies were included to assess the association of BMI, diabetes, high physical activity (HPA), osteoporosis, rheumatoid arthritis (RA), cement material and implant design. Twenty-nine studies were used to calculate relative risk and CIs (using the random effects theory) and study heterogeneity for six different risk factors (BMI, diabetes, HPA level, cement material, polyethylene and implant design).

Results

Patients with diabetes are eight times more likely to experience aseptic loosening compared to those without diabetes (RR = 9.18, 95% CI: 1.80-46.77, p < 0.01). The use of tibial stem extension or highly crosslinked polyethylene can help reduce the incidence of aseptic loosening. However, we did not identify BMI, HPA, osteoporosis, RA, the use of high-viscosity cement and the utilization of mobile-bearing designs as risk factors for aseptic loosening post-cemented TKA.

Conclusions

Patients with diabetes undergoing TKA should be counselled regarding their potential increased risk of aseptic loosening. The use of tibial stem extensions and HXLPE can mitigate the incidence of aseptic loosening in cemented TKA. However, given a limited number of studies were included in the meta-analysis, we believe that higher-level studies are necessary to clearly identify other risk factors.

Level of Evidence

Level III.

Clinical outcomes and return to dance after total hip arthroplasty or hip resurfacing in professional dancers

Aims

Professional dancers represent a unique patient population in the setting of hip arthroplasty, given the high degree of hip strength and mobility required by their profession. We sought to determine the clinical outcomes and ability to return to professional dance after total hip arthroplasty (THA) or hip resurfacing arthroplasty (HRA).

Methods

Active professional dancers who underwent primary THA or HRA at a single institution with minimum one-year follow-up were included in the study. Primary outcomes included the rate of return to professional dance, three patient-reported outcome measures (PROMs) (modified Harris Hip Score (mHHS), Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR), and Lower Extremity Activity Scale (LEAS)), and postoperative complications.

Results

A total of 49 hips in 39 patients (mean age 56 years (SD 13); 80% female (n = 39)) were included. Mean follow-up was 4.9 years (SD 5.1). Of these 49 hips, 37 THAs and 12 HRAs were performed. In all, 96% of hips returned to professional dance activities postoperatively. With regard to PROMs, there were statistically significant improvements in mHHS, HOOS-JR, and LEAS from baseline to ≥ one year postoperatively. There were complications in 7/49 hips postoperatively (14%), five of which required revision surgery (10%). There were no revisions for instability after the index procedure. Two complications (5.4%) occurred in hips that underwent THA compared with five (42%) after HRA (p = 0.007), though the difference by procedure was not significantly different when including only contemporary implant designs (p = 0.334).

Conclusion

Active professional dancers experienced significant improvements in functional outcome scores after THA or HRA, with a 96% rate of return to professional dance. However, the revision rate at short- to mid-term follow-up highlights the challenges of performing hip arthroplasty in this demanding patient population. Further investigation is required to determine the results of THA versus HRA using contemporary implant designs in these patients.

Return to Sports and Recreational Activities Following Arthroplasty of the Basal Joint of the Thumb: A Retrospective Review

Purpose

Arthroplasty of the basal, or carpometacarpal, joint of the thumb has been shown to decrease pain, improve strength, improve range of motion, and allow return to work. This study sought to assess whether basal joint arthroplasty also allows for a return to sports and recreational activities.

Methods

A survey assessing participation in sports and recreational activities, timing of return to play after surgery, enjoyment, and the presence of pain and limitations was mailed to patients who had undergone an arthroplasty of the basal joint of the thumb over a 3-year period.

Results

Of the 333 patients who underwent thumb carpometacarpal arthroplasty, met the criteria, and responded, 73% were able to successfully return to sports and recreational activities, with decreased pain and at the same or increased level of play, frequency of participation, and level of enjoyment for their sport or recreational activity. Patients were more likely to successfully return to sports and recreational activities if they had undergone surgery on their nondominant hand, did not stop their sport or recreational activity before surgery, were able to return within 9 months of surgery, and reported no postoperative limitations. Successful return to sports and recreational activities was not related to age, sex, surgeon, level of play, or the type of sport or recreational activity.

Conclusions

Most patients who replied to our survey reported successful return to sports and recreational activities after arthroplasty of the basal joint of the thumb.

Type of study/level of evidence

Prognostic IV.

Angle Stable Plate Fixation vs Hemicallotasis in Medial Opening Wedge High Tibial Osteotomy: A Comparative Study

Background

Varus alignment associated with medial compartment degeneration is the most common presentation of knee osteoarthritis and often presents in young active adults where arthroplasty might be unsuitable.

Purpose

To compare the accuracy of the angle stable medial high tibia plate and self-adjusting HTO (high tibial osteotomy) fixator in achieving correction of varus deformity of the knee by medial opening wedge HTO and to evaluate functionality between the groups.

Study Design

Prospective randomized control study.

Methods

Forty patients each underwent medial opening wedge high tibial osteotomy with acute correction and stabilization using the angle stable plate (ASP group) or with the hemicallotasis technique using the self-adjusting HTO external fixator (HCO group). Anatomical and functional outcomes were compared to the pre-operative values at the 6th and 12th month.

Results

The FTA (femoro-tibial axis), mechanical axis, and functional scores improved significantly in both groups. There was also a significant change in the patellar height and tibial slope. Except for a better KOOS (Knee Injury and Osteoarthritis Outcome Score) in the angle stable plate group at the 6-month follow-up, there were no significant differences between the groups.

Conclusion

Both methods of performing a medially based proximal tibial osteotomy gave equivalent outcomes at the 1-year follow-up.

Activity Following Total Hip Arthroplasty: Which Patients Are Active, and Is Being Active Safe?

BACKGROUND

Younger and physically active patients demand a return to sport after total hip arthroplasty (THA). However, because of the risk of implant wear and loosening, high-impact activities are often not recommended. The current study evaluates predictive factors and revision rates in patients with higher activity levels.

METHODS

This retrospective study included 4152 hips in 3828 patients aged 45-75 that underwent primary THA for primary osteoarthritis between 2009 and 2019 with a minimum follow-up of 2 years. Pain and Lower Extremity Activity Scale (LEAS) were assessed before and 2 years after surgery. Activity was classified as low (LEAS 1-6), moderate (LEAS 7-13), or high (LEAS 14-18).

RESULTS

Pain and LEAS improved from preoperative to 2-years postoperative (p < 0.001). The activity level was low in 6.2%, moderate in 52.9%, and high in 40.9% of the patients. Younger age, lower BMI, ASA, and CCI, male sex, and higher preoperative LEAS correlated with higher activity at 2 years (p < 0.001). The predicted revision-free survival rates between the activity groups were better for more highly active patients (p < 0.001).

CONCLUSIONS

High physical activity 2 years following THA, with participating in sports like jogging several times a week, did not increase the risk of revision surgery. THA patients should not be prevented from a highly active lifestyle.

Does high activity after total and unicompartmental knee arthroplasty increase the risk for aseptic revision?

INTRODUCTION

It has been suggested that high activity might negatively impact implant survival following total and unicompartmental knee arthroplasty (TKA/UKA) and many surgeons advise their patients to only participate in moderate level sport activities. To date, it remains unclear whether such restraints are necessary to assure longevity of the implants.

MATERIALS AND METHODS

We conducted a retrospective study on 1906 knees (1745 TKA, 161 UKA) in 1636 patients aged 45-75 years who underwent primary arthroplasty for primary osteoarthritis. Lower extremity activity scale (LEAS) at a two year follow-up was assessed to define the activity level. Cases were grouped in low (LEAS ≤ 6), moderate (LEAS 7-13) and high activity (LEAS ≥ 14). Cohorts were compared with Kruskal-Wallis- or Pearson-Chi2-Test. Univariate logistic regression was conducted to test for association between activity level at two years and later revisions. Odds ratio was reported and converted to predicted probability. A Kaplan-Meier curve was plotted to predict implant survival.

RESULTS

The predicted implant survival for UKA was 100.0% at two years and 98.1% at five years. The predicted implant survival for TKA was 99.8% at two years, 98.1% at five years. The difference was not significant (p = 0.410). 2.5% of the UKA underwent revision, one knee in the low and three knees in the moderate activity group, differences between the moderate and high activity group were not significant (p = 0.292). The revision rate in the high activity TKA group was lower than in the low and moderate activity groups (p = 0.008). A higher LEAS two years after surgery was associated with a lower risk for future revision (p = 0.001). A one-point increase in LEAS two years after surgery lowered the odds for undergoing revision surgery by 19%.

CONCLUSIONS

The study suggests that participating in sports activity following both UKA and TKA is safe and not a risk factor for revision surgery at a mid-term follow-up. Patients should not be prevented from an active lifestyle following knee replacement.

Sport after Knee Replacement Surgery - a Review of Sport Habits and Key Surgical Aspects

As an increasing number of younger patients are undergoing total knee replacement (TKR) surgery, many wish to participate in sport, but still expect that the implant will survive for a extended period. Most of the current literature shows that patients predominantly participate in low impact activities, both before and after surgery. A few studies show that with appropriate previous experience, high-impact sports are possible and might not result in increased implant failure rates. These include a decrease in point loads on the polyethylene by using more conform bearing surfaces, avoidance of varus component alignment to minimise stresses at the implant bone interface and avoiding patella resurfacing to facilitate activities in deep knee flexion.A TKR is no longer an absolute contraindication for higher impact activities such as golf, tennis and ski. What is more important than implant specific factors seem to be patient specific factors, including preoperative activity level, and preoperative sport skills.The current review paper reports on the current sport habits of TKR patients, analyses biomechanical loads on the knee during different sport activities and reports on implant selection and technical considerations for the active patient undergoing TKR.

Projections and Epidemiology of Revision Hip and Knee Arthroplasty in the United States to 2040-2060

Background

National projections of future joint arthroplasties are useful in understanding the changing burden of surgery and related outcomes on the health system. The aim of this study is to update the literature by producing Medicare projections for revision total joint arthroplasty procedures from 2040 through 2060.

Methods

The study uses 2000-2019 data from the CMS Medicare Part-B National Summary and combines procedure counts using CPT codes for revision total joint arthroplasty procedures. In 2019, revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA) procedures totaled 53,217 and 30,541, respectively, forming a baseline from which we generated point forecasts between 2020 and 2060 and 95% forecast intervals (FI).

Results

On average, the model projects an annual growth rate of 1.77% for rTHAs and 4.67% for rTKAs. By 2040, rTHAs were projected to be 43,514 (95% FI = 37,429-50,589) and rTKAs were projected to be 115,147 (95% FI = 105,640-125,510). By 2060, rTHAs was projected to be 61,764 (95% FI = 49,927-76,408) and rTKAs were projected to be 286,740 (95% FI = 253,882-323,852).

Conclusions

Based on 2019 total volume counts, the log-linear exponential model forecasts an increase in rTHA procedures of 42% by 2040 and 101% by 2060. Similarly, the estimated increase for rTKA is projected to be 149% by 2040 and 520% by 2060. An accurate projection of future revision procedure demands is important to understand future healthcare utilization and surgeon demand. This finding is only applicable to the Medicare population and demands further analysis for other population groups.

Late summer is a risk factor for periprosthetic joint infection after total joint arthroplasty: A retrospective cohort study

To explore whether season is a risk factor of periprosthetic joint infection (PJI) after total joint arthroplasty (TJA) and explain it with the theory of traditional Chinese medicine. This was a retrospective cohort study. Only patients who suffered from PJI within 1 month after TJA were included in the study. Occurrence of PJI was the outcome of this study. Chi-squared test and t test was used to assess differences for baseline characteristics. Chi-square test was used to analyze whether season was related to the occurrence of PJI. Logistic regression was used to evaluate the association between season and occurrence of PJI. The incidence of PJI in summer is significantly higher than that in winter, whether after total knee arthroplasty (Chi-square value = 6.455, P = .011) or total hip arthroplasty (Chi-square value = 6.141, P = .013). Summer was an independent risk factor for PJI (OR = 4.373, 95% confidence interval = 1.899-10.673, P = .004). To be more exact, compared to nonlate summer (19.51%), and PJI is mainly concentrated in late summer (80.49%). Late summer was an independent risk factor of PJI after TJA. The infection rate of PJI after TJA in late summer is higher than other seasons. A more thorough preoperative disinfection procedure is needed in late summer.

Return to Sport After Total Shoulder Arthroplasty and Hemiarthroplasty: A Systematic Review

PURPOSE

One of the most frequent concerns of the increasing number of patients undergoing shoulder arthroplasty is the possibility to resume sport after surgery. This systematic review determined the rate of return to sport after total shoulder arthroplasty (TSA) and hemiarthroplasty (HA).

MATERIALS AND METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to perform this systematic review. A systematic electronic search was performed using the PubMed (MEDLINE), EMBASE, and Cochrane Library databases. All the studies analyzing the rates of reverse shoulder arthroplasties were pooled; data were extracted and statistically analyzed. Only studies with at least 10 adult patients recruited were considered. All studies had to relate return to sport after TSA or HA.

RESULTS

A total of 76 studies were included for a total of 694 patients. The mean age and average follow-up were, respectively, 64.5 years (range: 24 to 92 y) and 4.5 years (range: 0.5 to 12 y). The mean rate of return to sport ranged from 49.3% to 96.4%. The mean time to resume sports was 8.1 months. The overall rate of return to sport after the procedures, according to a random effect model, was 83%. The mean level of sports at the time of the survey was worsened in 9.4% (±2.82%), improved or reported from good to excellent in 55.6% (±13.6%), and did not change in 40% (±1.4) of patients.

CONCLUSIONS

On the basis of current available data, return to sports after TSA and HA is possible and is highly frequent. The subjective level of practice does not change or improve in most patients. More studies and better designed trials are needed to enrich the evidence on specific sport recovery after the procedure.

Return to Sports After Total Hip Arthroplasty: An Umbrella Review for Consensus Guidelines

BACKGROUND

Current recommendations on safe return to sports (RTS) after total hip arthroplasty (THA) are subjective and based on studies of varying quality.

PURPOSE

The aim of this study was to synthesize systematic reviews and meta-analyses on post-THA RTS to propose practice guidelines identifying which sports can be resumed, when they can be resumed, and what risks are present.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

This umbrella review followed the Joanna Briggs Institute (JBI) protocol and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The Embase, Medline, and Cochrane databases were searched. Included studies were either systematic reviews or meta-analyses addressing primary or secondary outcomes. Outcomes of interest included safe sports after THA, time to RTS, prognostic indicators of RTS, reasons patients do not RTS, percentage of patients who RTS, implant complications, and objective classification of sports by impact level. Included reviews had data extracted and were assessed for methodological quality using the JBI protocol. The authors defined RTS as "returning to a sport the patient participated in at any point preoperatively."

RESULTS

Patients demonstrated a trend toward lower-impact sports postoperatively. Sports were classified as low (eg, walking), moderate (eg, downhill skiing), or high impact (eg, soccer). A total of 82% (range, 55%-104%) of patients were able to RTS at a mean time of 6 months (range, 4-7 months). The best prognostic indicator for RTS was previous experience in that sport. The main reason patients did not RTS was surgeon recommendation. Aseptic loosening was the most cited complication after RTS.

CONCLUSION

Most patients are able to return to preoperative levels of low- (eg, walking) and moderate-impact (eg, hiking) sports between 7 and 12 months after THA. Patients planning a return to high-impact (eg, singles tennis) sports should be counseled on the possible risks of traumatic injuries and aseptic loosening and monitored closely.

A high physical activity level after total knee arthroplasty does not increase the risk of revision surgery during the first twelve years: A systematic review with meta-analysis and GRADE

BACKGROUND

High physical activity (HPA) levels after total knee arthroplasty (TKA) might be related to increased wear and subsequent aseptic loosening, negatively affecting TKA survival. This systematic review studied the association between activity levels and risk of revision surgery at medium (3-10 years) and long term (>10 years) follow up in patients with TKA.

METHODS

Databases (PubMed, Embase) were searched up to 12 October 2021. Studies comparing low physical activity (LPA) and HPA levels in TKA patients and related risk of revision surgery were eligible for inclusion. After data extraction and evaluation of methodological quality, a meta-analysis was performed. Quality of evidence was assessed using the GRADE framework. PROSPERO registration: CRD42020194284.

RESULTS

Five cohort studies and one case-control study met the inclusion criteria, involving 4811 TKA procedures in 4263 patients (mean follow up 4-12 years). Five studies were of moderate methodological quality and one of low quality. Meta-analysis demonstrated no association between HPA level and an increased risk of all-cause revision surgery (risk ratio (RR) 0.62, 95 % confidence interval (CI) 0.24-1.63, level of certainty: very low) or revision surgery due to aseptic loosening (RR 1.33, 95 % CI 0.34-5.24, level of certainty: moderate). Only one study reported on survivorship, with an improved survivorship for the HPA group (odds ratio of 2.4, 95 % CI 1.2-4.7, level of certainty: low).

CONCLUSION

During the first 12 postoperative years after TKA, there seems to be no increased risk for revision surgery for patients with a HPA level compared with patients with an LPA level.

Sports activity participation and subjective health status of patients after total hip arthroplasty via the anterolateral-supine approach: a case series study

Background

No reports have been published about participation in sports activity and subjective health status after total hip arthroplasty via the anterolateral approach in the supine position (ALS-THA) in Japanese patients. This study assessed sports activity participation and subjective health status, as well as factors potential associated with these variables, in patients who underwent ALS-THA.

Methods

Of 698 patients who underwent total hip arthroplasty at our institution between 2013 and 2018, questionnaires were sent to 355 patients under 80 years old who had undergone ALS-THA and 242 responded. Patients were asked about their subjective health status, participation in sports activity, the EuroQol 5-dimensions 5-level (EQ-5D-5L), the University of California Los Angeles (UCLA) activity scale score and the Forgotten Joint Score (FJS). Patient characteristics and hospitalization information were also collected. Patients’ subjective health status was categorized as “healthy” or “unhealthy”. Univariate and multivariate logistic regression analyses were performed to determine factors associated with participation in sports activity after ALS-THA and a “healthy” status.

Results

The pre- and postoperative sports activity participation rates were 54.0% and 57.8%, respectively. Most patients (76.8%, n = 182) were considered “healthy”. Age (P = .019) and UCLA activity score (P < .001) were significantly associated with sports activity after ALS-THA. FJS (P = .002) and EQ-5D-5L (P = .004) were significantly associated with a “healthy” status.

Conclusion

Patients participating in sports activity after ALS-THA are older and have higher UCLA activity scores and patients considered “healthy” have higher FJS and EQ-5D-5L scores.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05886-6.

Shift to low-impact sports and recreational activities following total knee replacement

Background:

A growing number of physically active patients undergoing total knee replacement (TKR) desires to resume their preoperative activity levels and to be able to engage in sports after surgery. The purpose of this study was to assess the sporting and physical activities of patients who had undergone TKR. It was hypothesized that the majority of patients treated by TKR would have been able to return to amateur sports and recreational activity .

Methods:

Ninety-seven patients who underwent TKR between 2014 and 2016, were retrospectively reviewed. Mean age was 70.1 years (range 64–83). Average follow-up time was 4.2 years (SD: 1.7). Assessment included Knee Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC), and Tegner activity level. Sporting and physical activities of all patients were reported. Wilcoxon’s signed ranks test was used for comparison between pre-operative and follow-up data. Significance was set at p < 0.05.

Results:

Both KOOS score and IKDC significantly improved after surgery (p < 0.001). No statistically significant differences were reported concerning Tegner activity level before and after surgery (p = n.s.). After surgery, a total number of 52 patients (53.6%) successfully returned to sporting and recreational activities, such as cycling, hiking, dancing and swimming. A return to activity rate of 81% of patients practicing sport before surgery was reported.

Conclusions:

TKR provides a high rate of return to sport postoperatively and confirms improved subjective results and reduced pain compared to preoperative status. However, most patients returned to low-impact activities, while a significant decrease was reported for mid- and high-impact sports.

Feasibility and sustainability of working in different types of jobs after total hip arthroplasty: analysis of longitudinal data from two cohorts

OBJECTIVES

To investigate the rates of return to work and workability among working-age people following total hip arthroplasty (THA).

METHODS

Participants from the Geneva Arthroplasty Registry and the Clinical Outcomes for Arthroplasty Study aged 18-64 years when they had primary THA and with at least 5 years' follow-up were mailed a questionnaire 2017-2019. Information was collected about preoperative and post-THA employment along with exposure to physically demanding activities at work or in leisure. Patterns of change of job were explored. Survival analyses using Cox proportional hazard models were created to explore risk factors for having to stop work because of difficulties with the replaced hip.

RESULTS

In total, 825 returned a questionnaire (response 58%), 392 (48%) men, mean age 58 years, median follow-up 7.5 years post-THA. The majority (93%) of those who worked preoperatively returned to work, mostly in the same sector but higher rates of non-return (36%-41%) were seen among process, plant and machine operatives and workers in elementary occupations. 7% reported subsequently leaving work because of their replaced hip and the risk of this was strongly associated with: standing >4 hours/day (HR 3.81, 95% CI 1.62 to 8.96); kneeling/squatting (HR 3.32, 95% CI 1.46 to 7.55) and/or carrying/lifting ≥10 kg (HR 5.43, 95% CI 2.29 to 12.88).

CONCLUSIONS

It may be more difficult to return to some (particularly physically demanding) jobs post-THA than others. Rehabilitation may need to be targeted to these types of workers or it may be that redeployment or job change counselling are required.

Femoral rollback at high-flexion during squatting is related to the improvement of sports activities after bicruciate-stabilized total knee arthroplasty: an observational study

BACKGROUND

In bicruciate-stabilized total knee arthroplasty (BCS-TKA), the relationship between the postoperative kinematics and sports subscales in patient-reported outcome measures (PROMs) remains unknown. The purpose of this study was to determine the relationship between kinematics and sports subscales using the PROMs after BCS-TKA.

METHODS

Sixty-one patients with severe knee osteoarthritis were examined at 13.5 ± 7.8 months after BCS-TKA. The patients performed squats under single fluoroscopic surveillance in the sagittal plane. Range of motion of the knee, axial rotation of the femur relative to the tibial component, and anteroposterior (AP) translation of the medial and lateral femorotibial contact points were measured using a 2D-to-3D registration technique. In addition, the relationship between the kinematics and improvement of the sports subscales in the Knee Injury and Osteoarthritis Outcome Score (KOOS) was evaluated.

RESULTS

In rotation angle, the femoral external rotation was observed from 0 to 50° of flexion. The amount of femoral external rotation did not correlate with PROMs-SP. In medial AP translation, posterior translation was observed from 0 to 20° and 80-110° of flexion. Mild anterior translation was observed from 20 to 80° of flexion. Beyond 80° of flexion, posterior translation was positively correlated with squatting. In lateral AP translation, posterior translation was observed from 0 to 20° and 80-110° of flexion. Beyond 80° of flexion, posterior translation was positively correlated with running, jumping, twisting/pivoting, and kneeling.

CONCLUSION

Femoral rollback at high flexion during squatting may be important to improve sports performance after BCS-TKA.

Return to sport post-knee arthroplasty : an umbrella review for consensus guidelines

AIMS

Return to sport following undergoing total (TKA) and unicompartmental knee arthroplasty (UKA) has been researched with meta-analyses and systematic reviews of varying quality. The aim of this study is to create an umbrella review to consolidate the data into consensus guidelines for returning to sports following TKA and UKA.

METHODS

Systematic reviews and meta-analyses written between 2010 and 2020 were systematically searched. Studies were independently screened by two reviewers and methodology quality was assessed. Variables for analysis included objective classification of which sports are safe to participate in postoperatively, time to return to sport, prognostic indicators of returning, and reasons patients do not.

RESULTS

A total of 410 articles were found, including 58 duplicates. Seven articles meeting inclusion criteria reported that 34% to 100% of patients who underwent TKA or UKA were able to return to sports at 13 weeks and 12 weeks respectively, with UKA patients more likely to do so. Prior experience with the sport was the most significant prognostic indicator for return. These patients were likely to participate in low-impact sports, particularly walking, cycling, golf, and swimming. Moderate-impact sport participation, such as doubles tennis and skiing, may be considered on a case-by-case basis considering the patient's prior experience. There is insufficient long-term data on the risks to return to high-impact sport, such as decreased implant survivorship.

CONCLUSION

There is a consensus that patients can return to low-impact sports following TKA or UKA. Return to moderate-impact sport was dependent on a case-by-case basis, with emphasis on the patient's prior experience in the sport. Return to high-impact sports was not supported. Patients undergoing UKA return to sport one week sooner and with more success than TKA. Future studies are needed to assess long-term outcomes following return to high-impact sports to establish evidence-based recommendations. This review summarizes all available data for the most up-to-date and evidence-based guidelines for returning to sport following TKA and UKA to replace guidelines based on subjective physician survey data. Cite this article: Bone Jt Open 2022;3(3):245-251.

Risk of revision arthroplasty surgery after exposure to physically demanding occupational or leisure activities: A systematic review

INTRODUCTION

Lower limb arthroplasty is successful at relieving symptoms associated with joint failure. However, physically-demanding activities can cause primary osteoarthritis and accordingly such exposure post-operatively might increase the risk of prosthetic failure. Therefore, we systematically reviewed the literature to investigate whether there was any evidence of increased risk of revision arthroplasty after exposure to intensive, physically-demanding activities at work or during leisure-time.

METHODS

We searched Medline, Embase and Scopus databases (1985-July 2021) for original studies including primary lower limb arthroplasty recipients that gathered information on physically-demanding occupational and/or leisure activities and rates of revision arthroplasty. Methodological assessment was performed independently by two assessors using SIGN, AQUILA and STROBE. The protocol was registered in PROSPERO [CRD42017067728].

RESULTS

Thirteen eligible studies were identified: 9 (4,432 participants) after hip arthroplasty and 4 (7,137participants) after knee arthroplasty. Narrative synthesis was performed due to considerable heterogeneity in quantifying exposures. We found limited evidence that post-operative activities (work or leisure) did not increase the risk of knee revision and could even be protective. We found insufficient high-quality evidence to indicate that exposure to physically-demanding occupations increased the risk of hip revision although "heavy work", agricultural work and, in women, health services work, may be implicated. We found conflicting evidence about risk of revision hip arthroplasty associated with either leisure-time or total physical activities (occupational or leisure-time).

CONCLUSION

There is currently a limited evidence base to address this important question. There is weak evidence that the risk of revision hip arthroplasty may be increased by exposure to physically-demanding occupational activities but insufficient evidence about the impact on knee revision and about exposure to leisure-time activities after both procedures. More evidence is urgently needed to advise lower limb arthroplasty recipients, particularly people expecting to return to jobs in some sectors (e.g., construction, agriculture, military).

Overstretching Expectations May Endanger the Success of the “Millennium Surgery”

Total hip arthroplasty (THA) is an extremely successful treatment strategy. Patient expectations, however, have increased; if not properly guided by surgeons, at present, patients expect next to pain-free restoration of the joint and a fast return to work and sports. While the revision rates after THA also increased in younger patients, knowledge on musculoskeletal loads still remains sparse, and the current recommendations on postoperative rehabilitation are based on expert opinions only. The aim of this study was to unravel biomechanical contact conditions in “working age” (&lt;60 years, 53.5 ± 3.0 years) and “retirement age” (&gt;60 years, 67.7 ± 8.6 years) patients during activities recommended post-THA. We hypothesized that working age patients would show substantially increased hip contact loads compared to older patients. The in vivo joint contact force (Fres) and torsion torque (Mtors), reflecting the main contact load situation, experienced during activities of daily living and sports activities were measured in a unique group of 16 patients with instrumented THA. We summarized patient activities and sports recommendations after THA mentioned within the literature using PubMed (without claim of completeness). The measurements showed that younger working age patients experienced significant (p = 0.050) increased Mtors (21.52 ± 9.11 Nm) than older retirement age patients (13.99 ± 7.89 Nm) by walking. Bowling, as a recommended low-impact sport, was associated with Fres of up to 5436 N and Mtors of up to 108 Nm in the working age group, which were higher than the Fres (5276 N) and Mtors (71 Nm) during high-impact soccer. Based on our results, age was proven to be a discriminator in joint loading, with working age patients presenting with increased loads compared to retirement age patients, already during daily activities. The current patient recommendations have led to further increased joint loadings. If THA cannot be delayed in a patient, we propose counselling patients on a carefully considered return to sports, focusing on low-impact activities, as indicated hereby. The findings from this work illustrate the need to provide critical feedback to patient expectations when returning to work and sports activities. Patients returning to more intensive sports activities should be carefully monitored and advised to avoid as much overloading as possible.

Return to sport after reverse total shoulder arthroplasty is highly frequent: a systematic review

IMPORTANCE

One of the most frequent concerns of the increasing number of patients undergoing shoulder arthroplasty is the possibility to resume sport after surgery.

OBJECTIVE

The aim of this systematic review was to determine the rate of return to sport after reverse total shoulder arthroplasty (RSA) and the subjective level of performance.

EVIDENCE REVIEW

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to perform this systematic review. A systematic electronic search was performed using the PubMed (MEDLINE), Embase and Cochrane Library databases. All the studies analysing the rates were pooled; data were extracted and statistically analysed. The eligibility criteria were studies with at least 20 adult patients recruited. All studies had to relate return to sports after RSA.

FINDINGS

A total of six studies were included for a total of 457 patients. Mean age and average follow-up were, respectively, 74.7 years (range 33-88 years) and 3.6 years (range 1-9.4 years). The mean rate of return to sport ranged from 60% to 93%. The mean time for resuming sports was 5.3 months. The overall rate of return to sport after reverse shoulder arthroplasty was 79%. The mean level of sports at the time of the survey was worsened in 7.9%, improved in 39.6% and had no change in 55.2% of the cases.

CONCLUSIONS AND RELEVANCE

Based on the current available data, return to sports after reverse shoulder arthroplasty is possible and highly frequent. The subjective level of practice undergoes no change or improves in most of the cases. More studies and better-designed trials are needed in order to enrich the evidence on specific sports recovery after the procedure.

LEVEL OF EVIDENCE

IV.

Wear analysis of the first-generation cross-linked polyethylene at minimum 10 years follow-up after THA: no significant effect of sports participation

The impact of sports on long-term wear of highly cross-linked polyethylene (XLPE) after total hip arthroplasty (THA) is not fully understood. We investigated (1) the wear performance of the first-generation XLPE, and (2) whether sports participation influences the steady wear rate of XLPE. The femoral head penetration into the cup was measured digitally on radiographs of hips undergoing THA with XLPE. We retrospectively reviewed data that included age, gender, body mass index, follow-up period, preoperative diagnosis, types of XLPE, ball diameter, head material, inclination of the cup, physical function score, and sports participation. Statistical analyses were applied to determine whether sports affect the wear of XLPE and which factors were associated with the steady wear rate. Creep and steady wear rate were found to be 0.18 mm and 0.005 mm/year, respectively. Sports participation, regardless of impact, provided no significant difference in the steady wear rate. Multiple regression analysis demonstrated that sports did not increase the steady wear rate. Our findings showed excellent wear performance of the first-generation XLPE at a minimum of ten years after THA, without significant effect of sports participation on the liner wear.

Sports Activity and Patient-Related Outcomes after Cementless Total Hip Arthroplasty in Patients Younger than 40 Years

BACKGROUND

The management of degenerative hip diseases in young patients remains a challenge. Despite the improvement of hip-preserving procedures, total hip arthroplasty (THA) may be required in some instances. In addition, young patients undergoing THA have high expectations concerning their postoperative level of activity.

PURPOSE

(1) to define the sports activity level and the return to sports after THA, (2) to describe the modification or initiation of new sports disciplines, and (3) to report the clinically meaningful outcomes after THA in patients younger than 40 years.

METHODS

A total of 36 patients (40 hips) were prospectively analyzed at a midterm follow-up of 3.9 years. The modified Harris Hip Score (mHHS); the Visual Analog Scale (VAS) for pain; the University of California, Los Angeles (UCLA) activity scale; and sports and recreational activity levels were assessed via questionnaire. The minimal clinically important difference (MCID) was determined by calculating half of the standard deviation, and the substantial clinical benefit (SCB) as well as patient acceptable symptomatic state (PASS), were calculated by the anchor method for the mHHS.

RESULTS

At the final follow-up, there was a significant improvement in mHHS (34.1 to 92.6; p < 0.0001), UCLA (3.2 to 7.6; p < 0.0001), and VAS for pain (8 to 1; p < 0.0001). More patients were active in sports at follow-up than before surgery (44% to 92%, p < 0.0001). In addition, the duration and frequency of sports activities showed a significant increase (p < 0.0001). The MCID, SCB and PASS for mHHS were 89% and 58%, respectively. No revision surgery had to be performed.

CONCLUSION

This study showed that a large proportion of patients under 40 years of age who underwent THA increased their physical activity. Eighty-six percent of the patients were highly active, with a UCLA score ≥ 7. Furthermore, the reported MCID, SCB, and PASS for mHHS were achieved by more than 80% of patients.

Highly Crosslinked Polyethylene Can Reduce Wear Rate in THA for High-Demand Patients: A Matched-Paired Controlled Study

BACKGROUND

The average age of patients benefiting from total hip arthroplasty (THA) has been declining. In addition to pain relief, patients seek to return to physical activity. However, the latter may increase polyethylene wear and therefore the potential risk of early aseptic loosening. The introduction of highly crosslinked polyethylene (HXLPE) has reduced wear rates in the general patient population. The objective of this study was to evaluate the influence of impact sports in patients operated with THA using ceramic-on-conventional polyethylene (cPE) versus ceramic-on-HXLPE, in terms of wear and function, with a minimum of five year follow-up.

METHODS

Sixty-eight patients practicing an impact sport (University of California Los Angeles score ≥8) who underwent a primary THA were included: 34 with a ceramic-on-cPE versus 34 with a ceramic-on-HXLPE using the same cementless acetabular and femoral component. Patients were matched-paired by age, sex, BMI, and University of California Los Angeles score. The wear analysis was performed using the IMAGIKA software. The Harris hip score and hip and osteoarthritis outcome score were collected.

RESULTS

The linear wear rate was statistically higher (P < .0001) in the cPE group (0.13503 ± 0.0630 mm/year) than in the HXLPE group (0.03059 ± 0.0084 mm/year). Postoperatively, the increase in Harris hip score was calculated at 37.64 for the entire cohort and was comparable in both groups (P = .3674). The hip and osteoarthritis outcome score for pain (P = .0009), daily life activities (P = .0016), and quality of life (P = .0179) were significantly higher in the HXLPE group, with, between groups, a difference inferior to the reported minimal clinical important difference. Three patients exhibited signs of periprosthetic osteolysis in the cPE group, one on the femoral side and two on the acetabular side. None were observed in the HXLPE group. No revision for aseptic loosening was reported in both cohorts.

CONCLUSION

Patients partaking in impact sports and receiving a ceramic-on-HXLPE THA demonstrated lower wear and osteolysis rates than those having a ceramic-on-cPE THA, with similar functional results.

The difficulty of continuing sports activities after open-wedge high tibial osteotomy in patient with medial knee osteoarthritis: a retrospective case series at 2-year-minimum follow-up

Purpose

This study aimed to investigate the rate at which patients returned to sports after open wedge high tibial osteotomy and identify the continuity of sports activity post-operatively.

Methods

Thirty-five patients (40 knees) who underwent open-wedge high tibial osteotomy (OW-HTO) in medial knee osteoarthritis were included in this study. The mean age of the patients who underwent surgery was 55.1 ± 10.7 years, and the mean follow-up period was 41.0 ± 24.7 months. Clinical results and radiographic parameters calculated in standing whole-leg radiographs preoperatively, post-operatively, and at the final follow-up were evaluated.

Results

Thirty-one patients (88.6%) were able to return to preoperative sports activity; however, only 14 patients (40.0%) completely returned to preoperative sports activity levels. Of the 31 patients who returned to sports activity, 10 patients (32.3%) maintained post-operative sporting activity levels at the final follow-up. In radiographic parameters, the weight-bearing line ratio was considered loss of correction in the post-operative period leading to the final follow-up. Patients who completely returned to sports and maintained sporting activity levels at the final follow-up had significantly higher the Knee Injury and Osteoarthritis Outcome Score pain subscale values and lower visual analogue scale of knee pain at pre-surgery and final follow-up than other patients, including those who partially returned to sports.

Conclusions

The proportion of patients who returned to sports after OW-HTO and were able to participate in competitions at the same activity level as before surgery was low and insufficient.

Level of evidence

Retrospective case series, IV

Surgical cup placement affects the heating up of total joint hip replacements

The long-term success of highly effective total hip arthroplasty (THA) is mainly restricted by aseptic loosening, which is widely associated with friction between the head and cup liner. However, knowledge of the in vivo joint friction and resulting temperature increase is limited. Employing a novel combination of in vivo and in silico technologies, we analyzed the hypothesis that the intraoperatively defined implant orientation defines the individual joint roofing, friction and its associated temperature increase. A total of 38,000 in vivo activity trials from a special group of 10 subjects with instrumented THA implants with an identical material combination were analyzed and showed a significant link between implant orientation, joint kinematics, joint roofing and friction-induced temperature increase but surprisingly not with acting joint contact force magnitude. This combined in vivo and in silico analysis revealed that cup placement in relation to the stem is key to the in vivo joint friction and heating-up of THA. Thus, intraoperative placement, and not only articulating materials, should be the focus of further improvements, especially for young and more active patients.

Return to Competitive Level of Play and Performance in Regular Golfers After Total Hip Arthroplasty: Analysis of 599 Patients at Minimum 2-Year Follow-Up

BACKGROUND

Total hip arthroplasty (THA) is performed in an increasingly younger and athletic population. Regular and competitive golfers are concerned with the likelihood of recovering their preoperative level of play. The purpose of this study was to assess the impact of primary THA on golfers' game, with a minimum follow-up of two years.

METHODS

Questionnaires were sent to the French Golf Federation's golfing members. Those who were older than 40 years and had undergone a unilateral primary THA provided information on the timing of return to play, pain during golfing, transportation mode, drive length, handicap and weekly playtime, before hip replacement, and postoperatively. In addition, data relating to the surgical procedure were collected.

RESULTS

Surveys were completed by 883 competitive golfers of which 599 were eligible for inclusion. The mean time to return to a complete 18-hole course was 4.73 months (SD 4.15, range: 0.7-36). Participants surveyed at a minimum 2 years after THA played at a higher level than before surgery with a handicap improvement of 1.8 (P < .01) and increased their mean weekly playtime from 8.8 to 9.3 hours (P = .24, NS). Eighty-eight percent reported an increased or no change in drive distance. Hip pain while playing golf decreased after surgery (6.8 to 2.5 on the visual analog scale, P < .001).

CONCLUSION

This study highlighted that hip arthroplasty allowed regular and competitive golfers to return to the course with better golfing comfort than before surgery and with an objective improvement in driving distance and level of play.

Safer return to jazz dance instruction after simultaneous bilateral total hip arthroplasty

To describe the case of a 48-year-old Japanese female patient with more than two decades of experience in jazz dance instructor returning to work after simultaneous bilateral total hip arthroplasty (SBTHA). We provided her with a tailored postoperative physical therapy programme considering her preoperative activity level and skills using three-dimensional motion analysis for guidance. The patient returned to jazz dance instruction 8 months after undergoing SBTHA, and her disease-specific quality of life assessment score at 1-year postsurgery was almost perfect. Use of three-dimensional motion analysis helped facilitate our assessment of whether her hip angle was within the acceptable range for teaching the compound movements necessary in jazz dance, but her preoperative experience was crucial in determining her full-scale participation in jazz dance. At present, 7 years since the surgery, the patient is able to continue jazz dancing, the THA component remains stable.

Well-Placed Acetabular Component Oriented Outside the Safe Zone During Weight-Bearing Daily Activities

Background: A comprehensive and thorough understanding of functional acetabular component orientation is essential for optimizing the clinical outcome after total hip arthroplasty (THA). This study aimed to quantify the functional acetabular anteversion and inclination of unilateral THA patients during walking and static standing and to determine whether the functional acetabular orientation falls within the Lewinnek safe zone. Methods: Seventeen patients with unilateral THA received a CT scan and dual fluoroscopic imaging during level walking and static standing to evaluate in vivo hip kinematics. The pelvic functional coordinate system of the 3D CT-based computer model was defined by the line of gravity and anterior pelvic plane (APP) to measure functional acetabular anteversion and inclination in different postures. The Lewinnek safe zone was used to determine the acetabular malposition during functional activities. Results: The THA side demonstrated an average of 10.1° (± 9.6°, range -7.5° to 29.9°) larger functional anteversion and 16.0° (± 9.2°, range -7.2° to 29.9°) smaller inclination than native hips during level walking. Functional acetabular anteversion in the THA side during level walking and static standing was significantly larger than anatomical measurements (p < 0.05). Acetabular orientation of most well-placed THA components anatomically in the Lewinnek safe zone fell outside the safe zone during more than half of the gait cycle and static standing. Conclusion: The current study revealed that an anatomically well-placed acetabular cup does not guarantee a well-functional orientation during daily activities. The in vivo mechanical performance and loading conditions of the THA component during other weight-bearing activities should be investigated in further studies.

Return to Sports After High Tibial Osteotomy Using the Opening Wedge Technique

Objective  The present paper evaluates the resuming of physical activities by young, active patients who practiced some sport modality and underwent a high tibial osteotomy (HTO) using the opening wedge technique. Methods  A total of 12 patients submitted to HTO using the opening wedge technique were prospectively analyzed. All patients were not playing sports at that time. Pre- and postoperative Lysholm and International Knee Documentation Committee (IKDC) scores, visual analog scale for pain and performance level were compared. The average follow-up time was of 12 months. Results  One patient resumed sporting activities at a performance level significantly lower compared to the preoperative level, while eight patients returned at a slightly below level, two returned at the same level and one patient returned at a higher level in comparison with the preoperative period. Conclusion  For isolated medial osteoarthrosis treatment, HTO using the opening wedge technique has favorable clinical and functional results, allowing patients to resume their sporting activities.

Activity Recommendations After Total Hip and Total Knee Arthroplasty

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A formal unsupervised activity program should be recommended to all patients recovering from total knee arthroplasty (TKA) and total hip arthroplasty (THA).

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In a subset of all patients undergoing TKA or THA, studies have found that an unsupervised activity program may be as efficacious as supervised physical therapy (PT) after surgery. Certain patients with inadequate independent function may continue to benefit from supervised PT.

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For TKA, supervised telerehabilitation has also been proven to be an effective modality, with studies suggesting equivalent efficacy compared with supervised in-person PT.

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Following TKA, there is no benefit to the use of continuous passive motion or cryotherapy devices, but there are promising benefits from the use of pedaling exercises, weight training, and balance and/or sensorimotor training as adjuncts to a multidisciplinary program after TKA.

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No standardized postoperative limitations exist following TKA, and the return to preoperative activities should be dictated by an individual's competency and should consist of methods to minimize high impact stress on the joint.

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Despite traditional postoperative protocols recommending range-of-motion restrictions after THA, it is reasonable to recommend that hip precautions may not be needed routinely following elective primary THA.

Recommendations for Sport and Physical Activity after total Hip and Knee Arthroplasty: A Systematic Review

Due to the high success of arthroplasty, patients suffering from osteoarthritis have higher expectations regarding the relief of pain, functional recovery and capacity to perform physical and sports activity. The purpose of our article is to present a literature review based on papers published during the last decades, with emphasis on the current recommendations regarding sports after total joint replacement. We conducted a search using PubMed/Medline databases, selecting the scientific articles published between 2005-2020 which discuss the association between physical activity and total hip or knee arthroplasty. The benefits of physical activity in all kinds of joint prostheses outweigh the negative effects; therefore, the recommendation for low-impact sports (hiking, swimming, cycling or golf) at a moderate intensity is considered valid and patients with total hip or knee arthroplasty who preoperatively had a high level of physical activity can return to low-impact sports performed at moderate intensity after 3-6 months.

Twenty-one sports activities are recommended by the European Knee Associates (EKA) six months after total knee arthroplasty

PURPOSE

To elaborate recommendations for sports participation following TKA among the members of the European Knee Associates (EKA).

METHODS

A prospective online survey was conducted among the members of the European Knee Associates (EKA). The European Knee Associates (EKA) are a section of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA). The survey investigated recommendations for 47 sports disciplines. Possible answers were: allowed, allowed if experienced, not allowed, no opinion. The survey was conducted separately for 4 specific time frames: within 6 weeks after TKA; 6-12 weeks after TKA; 3-6 months after TKA; and more than 6 months after TKA. Consensus among the respondents was then analyzed.

RESULTS

EKA members (N = 120) participated in the survey. A high level of consensus was reached for a recommendation to allow 5 different sports in the first 6 weeks after TKA, 7 sports 6-12 weeks after surgery, 14 sports 3-6 months after TKA, and 21 out of 47 activities 6 months after surgery. In the first 6 weeks after TKA walking, stair climbing, swimming, aqua fitness, and static cycling were recommended. Six to twelve weeks after TKA, cycling on level ground and yoga were recommended in addition to the aforementioned activities. Further sports activities recommended beyond 12 weeks after TKA were: tennis doubles, golf, fitness/weight lifting, aerobics, hiking, Nordic walking and sailing. The sport for which the recommendation was "not allowed" following TKA was squash.

CONCLUSION

The number of sports recommended by EKA surgeons increases stepwise over the postoperative time frames. The findings are regarded as clinically relevant as they may serve as a basis for answering patient questions on timing and giving recommendations for the resumption of sports activities following standard primary TKA and should be individualized by surgeons for their patients' expectations and goals.

LEVEL OF EVIDENCE

V.

[Recommendations for unicondylar knee replacement in the course of time : A current inventory]

BACKGROUND

A higher patient satisfaction stands in contrast to higher revision rates of unicondylar knee joint endoprosthetics (UKE) compared to total knee joint endoprosthetics (TKE). Furthermore, old "dogmas" regarding indications and contraindications persist, which is still reflected in the significantly different case numbers.

AIM

The aim of this article is to provide an overview of the current literature regarding 1. indication and contraindication (BMI, age, sport, arthrosis of other compartments, ligament status) and 2. the "eternal rival" fixed or mobile bearing for UKE.

RESULTS

The choice of the right patient remains essential, even if all the old "dogmas" of contraindications have been relativized or even outdated. Arthroses of the contralateral (in medial UKE correspondingly lateral) compartment and advanced arthroses of the lateral patella facet remain the only persistent contraindications. In contrast, a high BMI, age, chondrocalcinosis, medial patella facet and a defective (but particularly functionally stable) ACL are not contraindications; however, severe obesity is responsible for a significantly higher complication rate and probably a higher rate of loosening. Rather, the experience and thus the number of UKEs of the individual surgeon is decisive for the outcome, to which the discussion about mobile or fixed inlays must also be completely subordinated.

CONCLUSION

The indications for UKE can, therefore, be extended with a clear conscience on the basis of literature, and the current 1:10 UKE:TKE ratio in Germany can be shifted significantly.

Recommendations for return to sports after total hip arthroplasty are becoming less restrictive as implants improve

INTRODUCTION

Total hip arthroplasty (THA) surgeries are expected to exponentially increase in the upcoming years, likely because of the overall broader indication of THAs. With these developments, an increasing number of younger (< 50 years) and active patients will receive surgical interventions, and expectations for an active lifestyle will accordingly increase. In addition, surgeons now have a growing array of techniques and implant materials to choose from. Despite these developments, evidence to provide the best standard-of-care to patients with high expectations for return to sports (RTS) is scarce and urgently needed. What recommendations do arthroplasty surgeons currently make to patients with high return to sports expectations, what factors may influence their recommendations and what surgical techniques and implant specifications are considered favorable in the treatment of patients with a more active lifestyle? This study was conducted to analyze the current recommendations, patient assessment, and patient counseling after THA to identify trends and relevant factors for surgical decision-making in patients with high-RTS expectations.

MATERIAL AND METHODS

We designed a questionnaire comprising five general items and 19 specific items that included 46 sub-items for hip arthroplasty and conducted a survey among 300 German surgeons specialized in arthroplasty at the German Arthroplasty Society (AE) to assess expert opinions, recommendations, surgical decision-making, and patient counseling for patients with high expectations for RTS after THA.

RESULTS

The majority of surgeons (81.9%) were in favor of RTS after THA. Risks associated with sports after THA were considered minimal (1%), with periprosthetic fractures ranking highest, followed by hip dislocation and polyethylene wear. Some surgical decision-making was influenced by high-RTS expectations in regard to implant fixation, stem type, femoral head diameter, and bearing-surface tribology. We observed an increasingly liberal counseling of patients for high-impact sports.

CONCLUSION

With the improvement of implants and surgical techniques, surgeons are more willing to encourage patients to adopt a more active lifestyle. However, the true long-term limitations need further investigation in future studies.

LEVEL OF EVIDENCE

5 Expert opinions.

Reliable improvements in participation in low-impact sports following implantation of a patellofemoral inlay arthroplasty at mid-term follow-up

PURPOSE

The aim of this study was, to investigate the rate of return to sports (RTS) and physical activity after implantation of PFIA and to identify factors predictive of improved postoperative sporting ability.

METHODS

Sixty-two patients with a mean age of 46 ± 11 years, who underwent implantation of PFIA at the senior authors' institution, were enrolled. They were prospectively evaluated preoperatively and at a minimum of 2 years postoperatively with a mean follow-up of 60 ± 25 months. Clinical outcomes, return to sports and activity, type of sport or activity, subjective satisfaction, and frequency were evaluated by questionnaire.

RESULTS

The transformed overall Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score improved from 67 ± 16 to 77 ± 19 (p = 0.003), Tegner activity scale results improved from 3 ± 2 points to 4 ± 1 points (p < 0.001), and scores on the visual analog scale (VAS) pain scale decreased from 6 ± 2 points to 3 ± 2 points (p < 0.001). The sports frequency increased from 1 ± 2 sessions to 2 ± 1 sessions per week (p = 0.001). Ninety-four percent of the patients who did not fail could return to the same or higher level of sports, with 74% of the patients reporting an improved ability to perform sports. No preoperative factors could be detected to significantly influence RTS after surgery.

CONCLUSIONS

PFIA is a valid treatment option for the active patient with end-stage isolated patellofemoral OA. Reliable improvements in knee function, pain, and participation in low-impact sports were found.

LEVEL OF EVIDENCE

IV.

Recommendations for Patients with High Return to Sports Expectations after TKA Remain Controversial

(1) Background: Improved surgical techniques and implants in total knee arthroplasty (TKA) have led to broader indications for surgical interventions of osteoarthritis of the knee. There is a growing young and active patient subgroup with high return to sports (RTS) expectations after TKA. The current lack of evidence regarding RTS capacity in this patient cohort, requires the consolidation of experts' opinions and experiences to address the special needs among these patients. The aim of this study was to assess current expert opinions in regard to preoperative patient assessment, surgical technique and decision-making and patient counseling for these patients. (2) Methods: We performed a survey among surgeons specialized in arthroplasty with a questionnaire designed to assess current recommendations, surgical techniques, and implant preferences as well as patient counseling in patients with high expectations for RTS after TKA. (3) Results: The majority of surgeons are in favor of return to low-impact sports after TKA within 3 to 6 months. Some even recommend return to high-impact sports. Despite improvement of surgical techniques and implants, we observed no clear preference for a single surgical technique or implant specification in active patients. (4) Conclusions: Current evidence for sports-associated complications after TKA is scarce. Despite a growing array of surgical techniques and implants, the available literature is still controversial with no single surgical technique or TKA design distinguishing itself clearly from others. Surgeons' recommendations are mostly based on their experience and training. Nonetheless, we observed growing faith in modern implants with some surgeons even recommending high-impact sports after TKA.

No Differences in Midterm Sports Participation or Functional Scores After Total Hip Arthroplasty by Posterolateral Vs Anterolateral Approach

BACKGROUND

Patients undergoing total hip arthroplasty (THA) frequently question surgeons on return to sports. We compared midterm sports participation and functional scores after THA by posterolateral approach (PLA) vs anterolateral approach (ALA).

METHODS

Of 1381 patients who underwent uncemented ceramic-on-ceramic THA for primary osteoarthritis, 503 were excluded because of preoperative or postoperative lower limb surgery, leaving 594 operated by PLA and 284 by ALA. Forgotten Joint Score (FJS), Oxford Hip Score (OHS), satisfaction, as well as motivation, participation, and discomfort regarding 22 sports were collected. A 1:1 matching was performed to obtain 2 groups of PLA and ALA patients with similar age, gender, body mass index, and sports motivation.

RESULTS

Matching yielded 2 equal groups of 259 patients. There were no significant differences in FJS (P = .057), OHS (P = .685), satisfaction (P = .369), or rates of participation in light (P = .999), moderate (P = .632), or strenuous sports (P = .284). Participation in strenuous sports was reported by 50 PLA (19%) and 61 ALA (24%) patients, with differences for downhill skiing (22 vs 39), running (10 vs 19), and cross-country skiing (18 vs 10). More than 50% of motivated patients practiced most of their sports. Severe discomfort was reported similarly in PLA and ALA patients, mainly during running (13 vs 11), team ball games (9 vs 7), and downhill skiing (7 vs 8).

CONCLUSION

There were no significant differences between PLA and ALA patients in terms of OHS, FJS, satisfaction, or sports participation rates. There is little or no evidence to promote an approach based on sports participation or functional improvement.

LEVEL OF EVIDENCE

Level III, comparative study.

What Opinions Do Tumor Reconstructive Surgeons Have about Sports Activity after Megaprosthetic Replacement in Hip and Knee? Results of the MoReSports Expert Opinion Online Survey

Sports activity has many benefits in cancer survivors. A key one is having sport activity contribute to the well-being of the individual. However, there are no guidelines about the intensity and kind of postoperative mobility workouts after hip or knee megaprosthetic treatment. Opinion research about sports after modular bone and joint replacement may provide an understanding of surgeons' attitudes on sports activity after megaprostheses of the hip and knee joint. A web survey with members of three international professional organizations of orthopedic tumor reconstructive surgeons was conducted between September 2016 and January 2018. Members were invited via personalized emails by the European Musculoskeletal Oncology Society (EMSOS), the International Society of Limb Salvage (ISOLS), and the Musculoskeletal Tumor Society (MSTS). The questionnaire included 26 questions. A total of 149 surgeons started the survey, and 76 finished the entire survey (American Association for Public Opinion Research (AAPOR) second response rate (RR2) EMSOS: 12.3%; ISOLS: 21.9%; MSTS: n/a). More than half of the respondents encourage sarcoma survivors after megaprosthetic treatment to reach an activity level that would allow them to regularly participate in active sporting events of University of California, Los Angeles (UCLA) activity level 7 and higher. Orthopedic tumor reconstructive surgeons do fear a number of complications (periprosthetic fracture, allograft failure/fracture, loosening, prosthetic or bearing failure, and early polyethylene wear) due to sports activity after modular bone-joint replacement, but they actually witness fewer complications than they conceptually anticipated. According to the surgeons' opinions, between four to seven types of sports after surgery could reasonably be recommended depending on the type of hip or knee procedures. This survey provides insights into opinions on what could be recommended, what could be allowed if surgeons and their patients agree on the potential negative outcome, and which sports should definitely not be allowed after hip and knee megaprostheses.

Allowed Activities After Primary Total Knee Arthroplasty and Total Hip Arthroplasty

It is essential for total knee arthroplasty patients to return to their previous level of activity to maintain a healthy lifestyle. This article reviews the current recommendations regarding return to physical activity after total knee arthroplasty and trying to find the balance between levels of activity and prosthetic joint preservation. In general, most total joint replacement patients are able to return to their previous level of activity and to a lesser extent to sports. This article discuss patients' actual levels of activity including their return to work and sport and the factors that influence meeting their expectations for surgery.

Effect of knee arthroplasty on sports participation and activity levels: a systematic review and meta-analysis

Objective

Desires and expectations of patients in regard to resume participation in sport activities after knee arthroplasty strongly increased in recent years. Therefore, this review systematically reviewed the available scientific literature on the effect of knee arthroplasty on sports participation and activity levels.

Design

Systematic review and meta-analysis.

Data sources

PubMed, Embase, SPORTDiscus and reference lists were searched in February 2019.

Studies eligibility criteria

Inclusion of knee osteoarthritis patients who underwent total knee arthroplasty (TKA) and/or unicondylar knee arthroplasty. Studies had to include at least one preoperative and one postoperative measure (≥1 year post surgery) of an outcome variable of interest (ie, activity level: University of California, Los Angeles and/or Lower Extremity Activity Scale; sport participation: type of sport activity survey).

Results

Nineteen studies were included, consisting data from 4074 patients. Knee arthroplasty has in general a positive effect on activity level and sport participation. Most patients who have stopped participating in sport activities in the year prior to surgery, however, do not seem to reinitiate their sport activities after surgery, in particular after a TKA. In contrast, patients who continue to participate in sport activities until surgery appear to become even more active in low-impact and medium-impact sports than before the onset of restricting symptoms.

Conclusions

Knee arthroplasty is an effective treatment in resuming sports participation and physical activity levels. However, to achieve the full benefits from knee arthroplasty, strategies and guidelines aimed to keep patients capable and motivated to participate in (low-impact or medium-impact) sport activities until close before surgery are warranted.

Hip Arthroplasty with Increased Expectancy

The patient's demands and expectations after total hip arthroplasty have increased significantly. In particular, the athletic function is the focus of the patient's interest, whereby not the basic sports ability is inquired, but also the achievable sports level. The benefits of increased activity with a reduction in cardiovascular mortality and the minimization of osteoporosis risk are contrasted by amplified wear followed by prosthesis loosening. Activities are categorized in low-, intermediate- and high-impact kind of sport. Patient-based influencing factors such as physical condition and expertise in his sport, as well as the self-reference of the surgeon to the desired sport influence the recommendation and advice of the patient. Innovations in prosthesis design and materials technology allow meeting patient's expectations and aiming to improve the return to sport. After total hip arthroplasty, the majority of preoperatively active patients return to athletic activity, although there is a tendency to shift from "high-impact" to "low-impact" sports. The currently recommended sports include swimming, cycling, Nordic walking, sailing, golf, hiking, dancing and cross-country skiing. A limited recommendation exists for tennis (single), alpine skiing, mountain hiking and sportive running. Not recommended are marathon, football, handball, volleyball, basketball, martial arts, high jump, water skiing and rock climbing. The recommendations are based primarily on expert opinions and are in a progressive extension including "high-impact" sports.

Does Prolonged Use of Walkers in Shoulder Arthroplasty Patients Lead to Accelerated Failure Rates?

Introduction: The effect of weight-bearing on a shoulder arthroplasty (SA) remains unclear, and recommendations regarding the use of a walker in SA patients have not been established. The purpose of this study was to determine outcomes and survivorship of SA in patients who routinely use a walker.

Methods: Fifty-three primary SA (10 hemiarthroplasties (HAs), 33 anatomic total shoulder arthroplasties (TSAs), 10 reverse shoulder arthroplasties (RSAs)) in 41 walker-dependent patients were followed for a minimum of three years (mean 64 months, range, 36-156). The average age at SA was 76 years. Shoulders were assessed for pain, range of motion (ROM), satisfaction, Neer ratings, American Shoulder and Elbow Surgeons (ASES) score, complications, survivorship, and radiographic outcomes.

Results: At most recent follow-up, 40 shoulders (75%) were pain free, elevation and external rotation improved significantly (P < .0001), and 87% of the patients were satisfied. Postoperative ASES scores averaged 74 (range, 38-92) points. There were 25 excellent, 16 satisfactory, and 12 unsatisfactory results based on modified Neer ratings. Four shoulders (7.5%) required reoperation at a mean of 40 months after the index arthroplasty. Radiographically, there were six cases of glenoid loosening in the anatomic SA group (25%), and two cases of severe glenoid erosion in the HA group (25%).

Conclusion: Routine use of a walker does not appear to lead to a markedly increased rate of SA failure at mid-term follow-up. Concerning radiographic findings were more common after HA and anatomic TSA than after RSA. Longer follow-up is required to determine the long-term impact of walker use on SA.

Return to Sports and Recreational Activity After Single-Stage Bilateral Short-Stem Total Hip Arthroplasty: 5-Year Results of a Prospective Observational Study

Background:

Single-stage bilateral total hip arthroplasty (THA) is an alternative to staged unilateral THA in patients suffering from bilateral hip arthritis; however, there is still broad concern regarding the safety and reliability of this procedure. Short-stem THA has emerged in recent years. To date, no data are available on sports and recreational activity levels after single-stage bilateral short-stem THA in the general patient population.

Hypothesis:

Patients who have undergone single-stage bilateral short-stem THA return to a satisfying level of sports and recreational activity at midterm follow-up.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 54 consecutive patients (108 hips) were prospectively included. Midterm follow-up was performed in 51 patients (94.4%). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and the Harris Hip Score (HHS) were assessed clinically after a mean of 5.2 years. After a mean of 4.9 years, activity levels were assessed using the University of California, Los Angeles (UCLA) activity scale via a questionnaire. Additionally, a detailed evaluation of sports behavior was conducted using an additional questionnaire. Pain and satisfaction with sporting ability were assessed using a visual analog scale (VAS). Complications and revisions were documented.

Results:

Patients had a mean WOMAC score of 98.0 (range, 60.0-100.0) and HHS score of 97.8 (range, 65.0-100.0) at final follow-up. The mean UCLA activity score was 4.7 (range, 2.0-10.0). An increasing number of patients were active in sports at follow-up compared with before surgery (76.5% vs 60.8%, respectively); 2 patients (3.9%) stopped participating in sports on a regular basis, and 10 (19.6%) commenced with sports after surgery. The most popular activities before surgery were cycling (31.4%), hiking (29.4%), swimming (21.6%), and fitness/weight training (15.7%). At follow-up, most patients were engaged in cycling (35.3%) and fitness/weight training (33.3%), followed by swimming (25.5%) and hiking (19.6%). The duration (hours per week) and frequency (times per week) of sporting activities remained stable. The mean VAS pain level during sports was 1.3 (range, 0.0-7.0). No revision surgery had to be performed.

Conclusion:

After single-stage bilateral short-stem THA, the study patients returned to satisfying levels of activity at midterm follow-up. Postoperatively, few patients were engaged in high-impact sports; however, more patients commenced with lower impact activities. Satisfaction with sporting abilities was high, and the complication rate in total was low.

In vivo kinematic analysis of replaced hip during stationary cycling and computer simulation of optimal cup positioning against prosthetic impingement

BACKGROUND

Dynamic hip kinematics during stationary cycling after total hip arthroplasty (THA) have been unclear. Furthermore, no computer simulation of optimal cup position based on in vivo kinematics has yet been assessed.

METHODS

This study consisted of 7 patients who underwent unilateral primary THA for symptomatic osteoarthritis. Using a flat-panel X-ray detector, continuous radiographs were obtained during stationary cycling. We analyzed the three-dimensional replaced hip kinematics from the top to the bottom position of the crank using image-matching techniques and quantified minimum liner-to-stem neck distance. Simulation analyses with in vivo kinematics were performed to examine patient-specific optimal cup placement against prosthetic impingement.

FINDINGS

During stationary cycling, pelvis showed 27.1° of posterior tilt on average without significant change. Hip flexed by 59.4° and 19.3° on average at the top and bottom positions, respectively. Minimum liner-to-neck distance was 8.8 mm on average at the bottom position. Liner-to-neck, bone-to-bone, or bone-to-component impingement was not observed at any positions in any hips. Simulation analysis of cup placement showed that larger cup anteversion, inclination, and use of elevated liner significantly decreased the minimum distance between posterior liner and stem neck. Cup anteversion of more than 30° with elevated liner could cause posterior liner-to-neck impingement at bottom position.

INTERPRETATION

Stationary cycling after THA provides no excessive hip range of motion or liner-to-neck contact. Cup placement and use of elevated liner significantly influence the minimum liner-to-neck distance, in some cases simulating posterior prosthetic impingement.

Analgesia effect of premixed nitrous oxide/oxygen during the rehabilitation after total knee arthroplasty: a study protocol for a randomized controlled trial

Background

The morbidity of knee arthritis is increasing among aged people and total knee arthroplasty has been its mainstream treatment to date. Postoperative rehabilitation is an important part of the procedure. However, the intense pain during the functional exercise involved has always been a challenge for both patients and health care professionals. The aim of this study is to test the analgesic effect of a mixture of nitrous oxide/oxygeb (1:1) inhalation for patients who are doing functional exercise 1 month after total knee arthroplasty.

Methods/design

This double-blind, randomized, placebo-controlled study will be implemented in the Rehabilitation Department in the General Hospital of Ningxia Medical University. Patients aged between 50 and 75 years who underwent a primary unilateral total knee arthroplasty are eligible for inclusion. The key exclusion criteria include: epilepsy, pulmonary embolism, intestinal obstruction, aerothorax. The treatment group (A) will receive a pre-prepared nitrous oxide/oxygen mixture plus conventional treatment (no analgesics), and the control group (B) will receive oxygen plus conventional treatment (no analgesics). Patients, physicians, therapists, and data collectors are all blind to the experiment. Assessments will be taken immediately after functional exercise begins (T0), 5 min (T1) after functional exercise begins, and 5 min after functional exercise has finished (T2). Patients will be randomly allocated between a treatment group (A) and a control group (B) in a ratio of 1:1. Primary outcome, including pain severity in the procedure, will be taken for each group. Secondary outcomes include blood pressure, heart rate, oxygen saturation, side effects, knee joint range of motion, Knee Society Score (KSS), rescue analgesia need, and satisfaction from both therapists and patients.

Discussion

This study will focus on exploring a fast and efficient analgesic for patients who are doing functional exercise after total knee arthroplasty. Our previous studies suggested that the prefixed nitrous oxide/oxygen mixture was an efficacious analgesic for the management of burn-dressing pain and breakthrough cancer pain. The results of this study should provide a more in-depth insight into the effects of this analgesic method. If this treatment proves successful, it could be implemented widely for patients doing functional exercise in the rehabilitation department.

Trial registration

ChiCTR-INR-17012891. Registered on 6 October 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3472-7) contains supplementary material, which is available to authorized users.