Ask the Experts: Advising patients on sports activity following joint arthroplasty

Total joint arthroplasty (TJA) is one of the most successful medical innovations developed during the 20th century. Joint replacement operations have been documented to relieve pain, improve function, correct deformity, increase social mobility, preserve an independent lifestyle, and contribute to psychological well being. As the clinical success of total joint replacement has been documented and publicized, patient expectations regarding the procedure have increased. Many patients undergoing TJA expect to participate in athletic activity. However, there is considerable variability in the athletic experience of patients prior to TJA and their expectations regarding athletic activity after TJA. There is also little consensus among joint replacement surgeons regarding appropriate activity after TJA, and the orthopedic literature includes limited evidence-based information for orthopedic surgeons to use to advise patients on appropriate athletic activity after TJA.

Following joint replacement, patients who participate in athletic activity experience increased force crossing the reconstructed joint, increasing joint-bearing surface wear, increased stress at the bone-implant fixation surface, and a higher prevalence of traumatic injury to the joint when compared with patients who have a low-level of activity and avoid athletics. More importantly, implant wear has been demonstrated to be related to the use of the joint implant. Patients with joint replacements who participate in athletics will wear the implant more than patients who do not participate in athletics. It is not clear how much athletic activity should be reasonably allowed or recommended following TJA in order to promote durability and survival of the joint reconstruction.

In this Round Table discussion, Drs. Bigliani, Iorio, Stuart and Trousdale will offer their expert opinions regarding athletic activity following TJA.

William L. Healy, MD
Moderator

Round Table Participants Moderator William L. Healy, MD Chair, Department of Orthopaedic Surgery Lahey Clinic, Burlington, Mass. Professor of Orthopedic Surgery Boston University Boston, Mass. Louis U. Bigliani, MD Frank E. Stinchfield Professor and Chairman of Orthopedic Surgery Columbia University New York, N.Y. Michael J. Stuart, MD Professor and Vice-Chairman Department of Orthopedic Surgery Co-Director, Sports Medicine Center Mayo Clinic Rochester, Minn. Richard Iorio, MD Director of Adult Reconstruction Lahey Clinic, Burlington, Mass. Professor of Orthopaedic Surgery Boston University Boston, Mass. Robert T. Trousdale, MD Professor of Orthopedics Consultant Department of Orthopedic Surgery Mayo Clinic Rochester, Minn.

Limiting activity

William L. Healy, MD: Do you “limit” athletic activity for your joint replacement patients?

Robert T. Trousdale, MD: The amount of quality data discussing exact activities that should be allowed after a total hip or total knee replacement is relatively scant. There is a fair amount of survey data that is really just based on professional opinion. In light of that, the majority of our patients who undergo total joint replacement (TJR) want to resume some of their recreational activities and I allow them to do so. I take what I consider a common-sense approach. I don’t think it is reasonable to do ultra-high impact activities with a mechanical implant in place, I tell patients there are much better exercises — as far as load on an implant — than running. I allow and encourage cross-country skiing, downhill skiing, social squash or tennis, golf or anything low-impact exercise, including exercise machines, swimming, and lifting weights, etc.

Richard Iorio, MD: I generally advise patients to avoid high-impact activities after lower extremity TJA. However, as younger, more athletic patients undergo lower extremity TJA, the discussion about how much activity is recommended frequently occurs. There are patients who will participate in high-impact activities despite my counseling against such activity. These patients are highly informed about the risks of these activities and the possible adverse consequences high-impact activity could have on the durability of their arthroplasty. I have had patients play competitive basketball, participate in 100-mile competitive bicycle races, and downhill ski race. These patients have not had mechanical failure due to their athletic activity. It remains to be seen if their athletic activity will impact the survivorship of their implant.

Encouraging activity

Healy: Do you “encourage” athletic activity for your joint replacement patients?

Michael J. Stuart, MD: I think it is important to differentiate between “exercise” and low-demand and high-demand “sports” participation. Pain relief, increased activity level and enhanced quality of life are the goals of knee replacement surgery. However, current implant designs and bearing surfaces have a finite lifespan, in part affected by patient characteristics and activity level.

The physical and psychological benefits of fitness are attainable without undue risk to the prosthetic knee. I encourage my patients to “enjoy,” but not “abuse” their knee arthroplasty. I advise them to participate in nonimpact and low-impact activities, but avoid repetitive impact loading such as running or jumping. Despite these recommendations, some patients choose to participate in heavy labor and sports.

Iorio: Patients participate in athletic activity for a variety of reasons other than competition. Physical and mental health improvements are byproducts of athletic activity. I encourage my patients to return to nonimpact athletic activity for which they have been properly trained. The functional improvement seen after TJA is a bonus for patients. Pain relief is the primary goal. As long as their participation in athletic activity does not jeopardize the survivorship of their implant, I encourage patients to participate in athletic activity.

Trousdale: Yes, I absolutely do. The benefits of athletic activity from a mental and physical standpoint I feel outweigh any negatives to the joint replacement itself as long as the athletic activity is “reasonable.” That involves the relatively low-impact activities I mentioned earlier.

Louis U. Bigliani, MD: In general for traditional total shoulder arthroplasty for primary osteoarthritis and secondary arthritis, I encourage patients to be as active and athletic as possible. This includes sports such as racquet sports, golf, skiing, biking, running, swimming and weight training utilizing light weights with multiple repetitions. I tend to discourage water skiing, contact sports, heavy weightlifting, shooting with a shotgun and advanced rock climbing. Generally if the soft tissues are good, total shoulder arthroplasty is a fairly durable implant with excellent longevity and a low revision rate even in athletes. I tend to restrict stressful activity and sports in patients with reverse prosthesis and soft tissue problems.

Evidence-based recommendations

Healy: What evidence do you use to make recommendations to patients regarding athletic activity following arthroplasty?

Iorio: There is little evidence available to help orthopedic surgeons counsel their patients concerning athletic activity after TJA. Expert opinion remains the best available guideline. As the quality of the bearing surfaces improves and survivorship of TJA implants improves, the extent of perceived allowable athletic activity continues to be expanded. Just as the recommendations of the Hip and Knee Societies expanded between 1999 and 2005, I expect they will continue to become more adventurous as the technology of joint replacement improves.

Stuart: The orthopedic literature does not provide high-level evidence on athletic activity after knee arthroplasty. I rely on common sense and the Knee Society survey recommendations when counseling patients on specific activities following knee replacement surgery. They are encouraged to participate in walking, biking and swimming; allowed to play golf and doubles tennis; and are advised to avoid long-distance running, basketball, soccer, volleyball and singles tennis.

Trousdale: Again, the evidence for that is really survey data — opinion based. There are really no well done prospective, randomized activity data that justify the use of certain activities. Hence, I think we are left with using a common-sense approach.

Bigliani: I have used the experience of more than 35 years of our shoulder service as a basis for my recommendations that I previously mentioned. I have seen several of Dr. Neer’s patients, at long-term follow-up of greater than 20 years who have been very active and still have an intact total shoulder arthroplasty.

Hip and Knee Society recommendations

Healy: Are you familiar with the survey recommendations for athletic activity following hip and knee replacement developed by The Knee Society and The Hip Society?

Iorio: Yes, I am one of the authors of those reports from 1999 and 2005. I expect the recommendations would be more permissive toward expanded athletic activity if the study was repeated in 2011.

Trousdale: Yes, I am and I use that in part, realizing that the quality of that data is relatively poor.

Healy: The Knee Society and The Hip Society surveys on athletic activity following hip and knee replacement surgery is level 5 expert opinion. However, it is from a large group of acknowledged experts and it is currently the best information we have to recommend athletic activity following TJA.

Patient’s desire to play

Healy: Does a patient’s desire to participate in athletic activity affect your recommendation regarding unicompartmental knee replacement or total knee replacement?

Stuart: Numerous factors affect the decision for unicompartmental arthroplasty, such as pain location and character, limb alignment, joint stability and knee range of motion to name a few. I discuss each patient’s expectations, including his or her anticipated activity level following surgery, but do not encourage high-demand sports after a partial or total knee replacement. There are certainly theoretical advantages of unicompartmental arthroplasty including retention of the cruciate ligament, articular cartilage and meniscus in the uninvolved compartment, but there are no long-term data to support repetitive impact loading. I continue to perform a valgus-producing proximal tibial osteotomy for selected, active patients with medial compartment arthritis and varus malalignment.

Iorio: No, the patient’s activity level does not effect whether I do a unicompartmental or tricompartmental knee arthroplasty. However, the higher the activity level, the more I would consider a high tibial osteotomy in a young, active man with varus medial compartment arthritis rather than an arthroplasty.

Healy: Does a desire to participate in athletics following knee replacement affect your decision making regarding fixed bearing knee replacement or mobile bearing knee replacement?

Stuart: No, I am unaware of evidence to support or refute that mobile bearing designs will reduce polyethylene wear, osteolysis and/or component loosening in patients who participate in athletic activities over an extended period of time.

Iorio: For TKA patients, I generally use a posterior cruciate substituting implant with an all polyethylene tibial component. My cohort of patients has a 98% survivorship at 18 years of follow-up and I continue to use this construct in almost all patients. If a patient demands a high-technology implant, I will implant a mobile bearing tibia, but this occurs infrequently. I don’t believe there is any functional advantage to high flexion or mobile bearing implants.

Trousdale: Again, as I mentioned earlier, for the patients who are doing high-impact rotational activities such as downhill skiing, cross-country skiing, relatively high-end tennis, squash or racquetball, I will consider a rotating platform knee replacement. We have completed a randomized prospective trial and at 5 years there is really no difference in any measurable activity between a well-done fixed bearing knee and a well-done rotating platform total knee.

Healy: Does the patient’s desire to participate in athletic activities affect your recommendation of hip replacement or hip resurfacing?

Trousdale: I continue to use hip resurfacing in a select group of middle-aged male patients where metal-on-metal bearing surface may be reasonable, and they have a strong preoperative bias towards resurfacing. I do share with those patients the blinded prospective randomized trial data (level I data that has been published) that really shows no major difference in activity between the patient with standard total hip replacement and the patient that undergoes resurfacing as long as the patients are blinded. Hence, I really don’t use activity as a driver for which implant I am going to use, rather I use the patient’s biases. If they are not biased, I am presently using standard total hip replacement in the majority of my patients. Furthermore, I give both groups the exact same recommendations regarding postoperative activity.

Healy: Does a patient’s desire to participate in athletic activity affect your recommendation regarding hemiarthoplasty of the shoulder or total shoulder replacement?

Bigliani: No, I prefer a total shoulder arthroplasty as they get much better motion and function. However in younger patients with a concentric glenoid and some glenoid cartilage on MRI, a surface replacement has been an excellent alternative. Patients with severe glenoid wear do not do well with hemiarthroplasty or a surface replacement.

Bearing surfaces

Healy: Do you consider alternative bearing surfaces from your usual bearing surface selections for patients who plan to participate in athletics following joint replacement — hip or knee?

Iorio: In young, heavy men I may consider an alternative bearing for hip replacement. With the concern about metal-on-metal hips, I have done several ceramic-on-highly crosslinked polyethylene THAs in these patients. There is very little evidence supporting decreased wear in these constructs, however in this high-demand cohort it may be beneficial. Metal-on-highly crosslinked polyethylene appears to be an enduring and forgiving bearing surface which may be best for all patients. Time will tell.

Stuart: The most common reason for knee replacement failure remains polyethylene wear and generation of particulate debris resulting in osteolysis and component loosening. Alternate bearing surfaces, such as highly crosslinked polyethylene, may offer improved wear characteristics, especially in young, athletically active patients. Although knee simulator test results have been promising, clinical data is lacking and validated, in-vivo polyethylene wear measurement techniques are not available.

We have enrolled more than 400 patients in a prospective, randomized clinical trial that compares conventional to highly crosslinked polyethylene in primary, posterior cruciate substituting total knee arthroplasty. Long-term follow-up of patients in this type of study is necessary to determine risk and prove efficacy.

Trousdale: I do not in the hip joint. I do use ceramic-on-ceramic bearing surfaces for my ultra-young patients —those patients who are less than 30 or so — as the benefits of that bearing couple potentially may be worth it in that patient group, realizing, of course, the downsides of the ceramic-on-ceramic bearing surface. In the knee, I use a rotating platform for a patient who is going to do high-impact rotational activities. For a patient who is an avid cross-country skier or downhill skier, golfer, or someone who does a lot of pivoting activities, I may consider a rotating platform total knee as that makes common sense. Again there is little hard data to support that but again using common sense as a driver for that implant design. I use highly crosslinked polyethylene in the hip in the vast majority of patients.

Special training

Healy: Do you have general medical or training advice for joint replacement patients who wish to participate in athletic activity?

Iorio: My patients with arthritic hip and knee joints choose to have joint replacement operations to relieve their pain, and improve their function. Many of our patients choose to have joint replacement operations in order to play sports. I allow my joint replacement patients to participate in athletic activities as they wish with in-depth counseling. I educate my patients regarding the risks associated with sports and higher levels of activity. This discussion includes the risk of instability, bearing surface wear, periprosthetic fracture, early implant loosening, and premature revision.

I advise my patients who choose to pursue sports after joint replacement to train for their specific athletic activity. I recommend extensive back, hip and knee rehabilitation with development of core strength. Stretching and strengthening programs can enhance athletic performance, prevent injury, and protect their joint reconstructions.

Obviously, previous experience with a specific athletic activity may enhance the safety of the patient when returning to sports after TJA. I always counsel my TJA patients to remember how they felt before their reconstruction, and to avoid activity that may recreate that pain.

Trousdale: No.

Healy: I advise my athletic patients who undergo joint replacement to train for their specific sport and participate in general strengthening programs and core strengthening exercises.

Bigliani: For the shoulder, we have a specific stretching and strengthening program for the first 3 to 4 months postoperative and restrict athletic activity. Only passive assistive exercises should be done for the first 3 to 4 weeks postoperatively. Then resistive and strengthening exercises are added over the next 3 months. After this period of time we evaluate the patient and determine if they can participate in a sport and will advise specific stretching and strengthening exercises.

Healy: Gentlemen, thank you for your time and your expertise.

References:

• Healy WL, Sharma S, Schwartz B, Iorio R. Athletic activity after total joint arthroplasty. J Bone Joint Surg (Am). 2008;90:2245-2252.
• Klein GR, Levine BR, Hozack WJ, et al. Return to athletic activity after total hip arthroplasty. Consensus guidelines based on a survey of the Hip Society and American Association of Hip and Knee Surgeons. J Arthroplasty. 2007;22:171-175.

• Louis U. Bigliani, MD, can be reached at 161 Ft. Washington Ave., Herbert Irving Pavilion, 2nd Floor, New York, NY 10032; 212-305-4565; e-mail: lub1@columbia.edu.
• William L. Healy, MD, can be reached at Department of Orthopaedic Surgery, Lahey Clinic Medical Center, 41 Mall Road, Burlington, MA 01805: e-mail: william.healy@lahey.org.
• Richard Iorio, MD, can be reached at the Lahey Clinic, 41 Mall Road, Burlington, MA 01805; 781-744-8227; e-mail: Richard.iorio@lahey.org.
• Michael J. Stuart, MD, can be reached at 200 1st St. SW, Rochester, MN 55905; -507-284-3462; e-mail: stuart.michael@mayo.edu.
• Robert T. Trousdale, MD, can be reached at Mayo Clinic, 200 First Street SW E14B, Rochester, MN 55905; 507-284-3663; e-mail: trousdale.robert@mayo.edu.
• Disclosures: Stuart receives research support from Stryker and USA Hockey Foundation and is a consultant for Arthrex and FIOS.