Musculoskeletal Care of the Mature Patient
Sports and exercise after a total joint replacement
Athletics after total joints is controversial because of a paucity of scientific studies on the subject. Postoperative activity recommendation varies by geographical region, the comfort level of the surgeon, and the personal interests of the patient and physician. Furthermore, return to exercise does not necessarily imply a return to sports. The lesson here is the same I follow when trout fishing; pick a fly to match the hatch. If athletics and sports are important to you, pick a surgeon who understands your goals.
One reason behind the paucity of data might be explained by the change seen in the United States of the past ten years wherein prior to the year 2000, 85% of hip stems were cemented. Since the change of the millennium, 85% of all hip stems are done cementless. This biologic ingrowth methodology decreases loosening with better impact tolerance. In 2004, highly cross-linked polyethylene bearing surfaces were introduced for the hip and the knee so we have only five years of data to scrutinize. At the same time, ceramic bearing surfaces were changed from alumina to zirconium and most recent to delta ceramic, a combination of alumina and zirconium. In general because of constant improvement in technologies, the outcomes data is insufficient.
The known Science of Specific Sports
Cycling:
The studies in which I have participated indicate that the forces and impulses measured after a total joint are comparable to healthy subjects suggesting that after a knee replacement, the joint can be functionally restored.
Golf:
After a Total Hip Replacement, 87% of recipients have no pain while playing but 41% report mild pain or ache after the round. Average handicaps increase 1.1 strokes, the drive averages 30 feet further distance and plan to use a cart. After a Total Knee Replacement, 84% of respondents report no pain while playing, 35% had mild pain or ache after golf, the average increased handicap was 1.9 strokes, and the average drive increased about 30 feet. The targeted-side knee experiences significantly more discomfort. While the back-swing phase is slow and controlled, the downswing, impact and follow-through phases increase in speed but there is increased torque and shear on the targeted-side knee.
Walking, Hiking and Jogging:
In general, be aware analyzed forces across a hip joint indicate there is an increase of 2.5X body weight while walking and 5.2 X, while jogging. Instrumented implants indicate that the hierarchy of forces is stationery bicycle< walking<elliptical trainer<jogging. Peak shear stresses across knee prosthesis are measured at 40-60degrees flexion. The combinations of impact loading and shear stresses result in an increased subsurface polyethylene stress contributing to delaminating wear and destruction
Skiing:
The issue here is that skiers are a very physically active group in general. On the one hand, X-country classical skiing puts 4x body weight on the hip joint while skating places 4.6x body weight on the hip. In alpine skiing, long turns on a flat slope increase forces on the hip by 4.1x body weight while short turns on a steep slope concentrate forces to 7.8x.
Tennis:
The majority of joint replacement specialists allow the patient to return to tennis; but there is no agreement as to whether you should. Despite the popularity of tennis, there are no studies on the subject. About 16% of tennis players who have undergone a hip or knee replacement report some pain during or after a match. Anticipate increased court mobility but decreased speed.
Swimming:
There are no scientific studies on artificial hips and knees available for scrutiny. I have always counseled my patients to avoid breaststrokes and whip kicking, as those seem to result in the most complaints.
The take home message, your return to athleticism may shorten the life expectancy and alter the outcome of your prosthesis. Most recommendations are judgmental rather than scientifically based.
Hip Society: basketball, football, jogging and soccer are NOT RECOMMENDED
Knee Society: jogging, soccer, basketball, football, and volleyball are NOT RECOMMENDED
To be continued
