Current post-arthroplasty activity recommendations based on few data

KOHALA COAST, Hawaii — A survey discussed at Orthopedics Today Hawaii 2009, here, revealed that although there are accepted activity recommendations for patients following joint arthroplasty, few surgeons believe there are data to support their advice.

“We have a desire to maximize the survivorship of the arthroplasty, but we also want the patients to have the quality of life that they desire,” Thomas P. Schmalzried, MD, said about post-arthroplasty activity restrictions at the meeting.

“We have improved fixation and improved materials, so it should be reasonable that we modify our recommendations for postoperative activity to be consistent with the advances we have made in arthroplasty,” he said.

Schmalzried cited data which indicate that patient activity can be very variable. “On a cohort basis, younger patients are more active than younger patients, but on an individual basis there can be tremendous variability.”

Earlier research has noted that activities such as golf, swimming and doubles tennis are the standard “allowed” activities, he said. Others that can be performed if the patient has experience are weightlifting, downhill skiing and cross-country skiing. Those usually not permitted include racquetball, squash, singles tennis, jogging, high-impact aerobics, baseball and softball.

“This is why I get patients every week who come in and tell me that is why they want a resurfacing, because ‘my doctor told me that I cannot play squash if I get a total hip,’” Schmalzried said. “I have to explain to them that it is not that you can’t do them. It is not an issue of capability; it is an issue of advisability. We are advising you not to do that because we would like the prolong the longevity of your arthroplasty.”

He reported results of a survey taken at this year’s American Association of Hip and Knee Surgeons meeting asking surgeons to stratify certain activities as to whether they would recommend them to patients after total joint replacement. Overall, the majority of respondents reported that there was not scientific evidence to support their recommendations.

“There were some slight differences between hips and knees, but in general, everyone agreed that there was no problem with walking on even surfaces, swimming, golf, cycling on flat roads and walking on stairs,” he said.

There was more variability when they addressed activities such as walking on uneven surfaces, cycling on an incline, doubles tennis and climbing uneven surfaces. “Most surgeons leaned away from sprinting, singles tennis, jogging and difficult skiing,” he said.

Schmalzried and colleagues found that surgeons tended to be more liberal with recommendations following total hip replacement than total knee replacement, and that high-volume surgeons tended to be more liberal than those with lower volumes.

“High-volume surgeons were more liberal in allowing walking up stairs and walking on uneven surfaces,” he said. “Surgeons doing high-volume knee revisions were more likely to allow singles tennis.”

Even though golf is usually recommended, recent data suggests that some of the highest stresses of these activities were in the forward knee in golf.

“There is a need for more quantitative data regarding stress levels and cycles,” Schmalzried said. “Even if we have that data, we are still faced with what I call a postoperative debate. What are we going to prioritize: the longevity of the arthroplasty or the quality of life for the patient?”

For more information:
Schmalzried TP. Activity following TJR. Presented at Orthopedics Today Hawaii 2009. Jan. 11-14, 2009. Kohala Coast, Hawaii.