Musculoskeletal Care of the Mature Patient

 Sports, exercise and sex after a total joint replacement

To burn calories and improve your performance get a new joint  -hip or knee that is. Sex after a total joint replacement, the ultimate athletic activity

 Sexual relations are a legitimate but often embarrassing subject so patients shy away from the discussion. I have decided to address Sexual Relations through the following question and answer format. The illustrations are available by contacting the American Arthritis Foundation

 Will I be able to resume sexual relations after joint replacement?

 The vast majority of patients resume safe and enjoyable post-operative physical intimacy.

Many patients experience impaired sexual function with the progression of arthritis because of preoperative pain and loss of joint motion. With the elimination of pain and restoration of motion following joint replacement, one may return to the thrilling days of yesteryear. 

When can I resume sexual intercourse?

 While we discourage postoperative, inpatient coitus, intimacy may be resumed (or initiated) when comfort and motion allow. Just as individual recovery times vary; desire, emotion and functional restoration is a special process in everyone.

 What positions are safe during intimacy?

 Total joint replacement precautions as introduced at preoperative joint camp, and re-enforced at the time of hospital discharge, need to be observed at all times. In general, follow the dos and don’ts and positions illustrated in the graphics available form the aforementioned resources. Patient on Top, Partner on bottom; Patient on the bottom, Partner on the Top; Patient on side, Partner on side; Standing position for both patient and partner.

Most postoperative patients, male and female, prefer “passive” intercourse in the bottom position. 

What should I tell my partner?

 Good communication is essential so be frank and openly discuss your desires or lack thereof. Sex after joint replacement is a very individualized matter since the postoperative medications or symptoms following removal of the urinary catheter may delay restoration of normal physiologic functions

What should I avoid?

 Basically anything that hurts or places your new joint in excessive flexion (knee toward chest), adduction  (leg toward center of body) and internal rotation (toes turned inward).

When your surgeon indicates that it is safe to return to work or to the workout, it is safe to fully enjoy the entire range of physical intimacy

Our final goal is patient satisfaction and we try

Musculoskeletal Care of the Mature Patient

Sports and exercise after a total joint replacement

Disclaimer-Despite improvements in implant materials, design and prosthetic technology; implant fixation remains a critical factor limiting athletic activity after total joint arthroplasty in patients over age 65. For those under age 65, increased activity may result in cycling of the articular bearing surfaces and a risk of loosening from articular wear and particle production. Sports may increase the risk of dislocation; implant failure, and peri-prosthetic/prosthetic fracture.

Total Hip Replacement

Hip Resurfacing

Total Knee Replacement

Unicompartmental Knee Arthroplasty

The issue is not whether you can return to sports but whether you may participate in sports without affecting the outcome and survivorship of the prosthesis. As I review all relevant science on the subject of sports participation for patients who have undergone a hip or knee replacement, it becomes apparent that the largest group of artificial joint recipients who return to high level athletics are recipients of hip resurfacing or unicompartmental knee prostheses. It also becomes apparent that sports participation after joint replacement is very much impacted by your level of preoperative sports participation as well as your body mass index. In general, 95% of joint replacement surgeons impose no permanent restrictions on swimming, golf, walking on level surfaces, cycling on level surfaces and stair climbing. Five to six years of follow-up after a total joint replacement is too short to allow me to evaluate implant survivorship. What is scientifically documented is that you will have less pain and better motion and function after a new hip or a new knee. What is clinically observed is that the majority of patients can return to return to most sports after a new hip or knee. The remaining unproven scientific question is not whether you can or will be able to but whether you should? In 1973, I helped pioneer knee replacement surgery in the United States. Earlier during my residency training, I partook in the introduction of hip replacement surgery here in the Midwest. In 1979, I was a member of the team of three who introduced cementless joint replacement in the U.S. Until, the early 2000s, our preoperative informed consent emphasized prosthetic survivorship and minimizing those activities that might or could result in premature failure of the prosthesis. It seems that sports after total joints is the demand of the maturing athlete but also the result of medical advertising to promote market share. It’s not the length of you hospital stay or size of your scar but the survivorship of the prosthesis that must influence your ultimate choices.

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

Musculoskeletal Care of the Mature Patient

 Sports and exercise after a total joint replacement

So you lost the battle and had a joint replacement, you can still win the war. In the 1960s through the 1980s, a total joint replacement was offered by an orthopedic surgeon to relieve pain, improve social mobility, provide functional independence, and to enhance psychological well-being. By next year, 2011, it is forecast that greater than 50% of total hip and total knee replacement recipients will be patients less than 65 years of age. This is a population being bombarded with information pertaining to the health benefits of exercise. The current population of joint replacement candidates is interested in a Return to Sports owing to the scientific evidence associated with increased physical activity, improved functional capacity, improved quality of life, and longer life expectancy.

Not to dampen sports after total joint enthusiasm, but first some words of caution. Just as your natural hip and knee were subject to wear and tear, breakdown and fracture leading to a joint replacement, so too despite improvements in implant materials, design operating technique and prosthetic technology do not eliminate the risk for a revision of that artificial implant. With excessive loading and high intensity activities such as high-impact sports (e.g. alpine skiing, running), there is a greater likelihood of revision surgery in 10 to 15 years after the index implant. Lower intensity, lower impact sports (e.g., golf and walking) should not contribute to early failure. Our problem is that there is very little scientific information on athletics after a total joint replacement. Because of my personal interest in this subject, in 2005, I co-authored an article presented at an international meeting, SICOT, and again in 2007 at the Scientific Podium of the Orthopedic Research Society during the American Academy of Orthopedic Surgery Annual meeting as well as a poster exhibit:

KNEE JOINT BIOMECHANICS DURING CYCLING IN PATIENTS WITH TOTAL KNEE ARTHROPLASTY

*Martin, A; ***Caglar, O; ****Mueller, M; *****Andriacchi, TP; **Sheinkop, MB; +**Wimmer, MA with the assitance of Langhenry,M

*Academic Teaching Hospital, Feldkirch, Austria +**Rush University Medical Center, Chicago, Illinois, USA.

So there you have it, a scientific basis for exercise after a total hip and total knee replacement. While our studies focused on forces around the knee, at the same measurement of forces at the hip were required.

Next week, the Blog focus on athletic activity after a total joint replacement will be sports specific:

Tennis, Golf, Walking, Hiking, Jogging, Cycling, and Skiing so be sure to return to www.sheinkopmd.com