Activity and Sports After Total Knee and Hip Arthroplasty Scott T. Ball, MD
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1 Activity and Sports After Total Knee and Hip Arthroplasty Scott T. Ball, MD Chief, Adult Joint Reconstruction Department of Orthopaedic Surgery University of California, San Diego
2 Disclosures DePuy Orthopaedics Biocomposites, Inc. Conformis
3 Who does this affect? Approximately 500,000 Total Knee Replacements / year Approximately 200,000 Total Hip Replacements / year Approximate Age Distribution At least 100,000 patients under age 55 per year < 55 >
4 What are patients being sold? Pictures from Manufacturers and Surgeons Websites
5 What are the concerns? Wear, Osteolysis, Loosening
6 What are the concerns? Broken Implants
7 What are the concerns? Periprosthetic Fractures
8 What are the opinions? 1999 Recommendations by the Hip Society Healy WL, et al. Am J Sports Med, May-Jun 2001 No jogging No singles tennis No skiing No basketball No baseball / softball No soccer No volleyball
9 What are the opinions? 2005 Recommendations by the Hip Society and AAHKS Klein GR, et al. J Arthroplasty, Feb 2007 Activity % Allowed Singles Tennis 15% Doubles Tennis 63% Jogging 5% Skiing 25% Baseball / Softball 15%
10 What are the opinions? 2008 Recommendations by the Hip Society and AAHKS Swanson EA,et al. J Arthroplasty Activity % Allowed Singles Tennis 20% Doubles Tennis 70% Jogging 20% Skiing 35% Baseball / Softball Not Included Sprinting 3%
11 What are the opinions? 2008 Recommendations by the Hip Society and AAHKS Swanson EA,et al. J Arthroplasty Higher volume surgeons are more liberal Surgeons that do more revisions are more liberal Activity restrictions are becoming more liberal Opinions are not based on evidence
12 What are the facts? Activity levels after joint replacement are grossly under-reported UCLA activity score is most commonly used Used in < 10% of major joint outcomes studies We know surprisingly little about patient activity after joint replacement Let s talk about what we do know
13 What are the Facts? Health Benefits of Exercise Cardiovascular Anxiety / Depression Bone Health / Bone Density Muscularity / Coordination Barry HC, Eathorne SW. Med Clin North Am Paffenbarger RS Jr, et al. N Engl J Med
14 What are the Facts? May be beneficial for: Diabetes Hypertension Coronary Artery Disease Obesity Low Back pain Pollock ML, Wilmore JH. Exercise in health and disease: evaluation and prescription for prevention and rehabilitation. 2nd ed. Philadelphia: WB Saunders; 1990.
15 What are the Facts? Current recommendations for baseline activity 30 minutes of moderate aerobic activities for 5 or more days per week OR, 20 minutes of vigorous aerobic activity at least 3 days per week A minimum of 10,000 steps/day as a target for obtaining health benefits Florian D. Naal, MD and Franco M. Impellizzeri, PhD. How Active are Patients Undergoing Total Joint Arthroplasty?: A Systematic Review. Clin Orthop Relat Res. 2010
16 What are the facts? Steps per day in joint replacement patients No studies showing step counts above 10,000 Activity level / step counts decline with age
17 What are the facts? Validation of activity reporting after hip arthroplasty Ball ST, Severns D. 20 self-proclaimed active patients Average age = 52 (41-73) UCLA activity score 8 or higher (max 10) Minimum 1 year follow-up Average steps/day = 8,800 25% of patients > 10,000 steps/day UCLA activity score correlates poorly with objective activity monitors / pedometers / accelerometers
18 What are the facts? Return to Sports after joint replacement Pre-Surgery Sports Post-Surgery Sports TKA (5 years) Sports participation declines by 30% 42% 34% 49% 32% THA (5 years) Sports participation remains equal 36% 56% 78% 55% Hip Resurfacing (2 years) Participation remains high 96% 98% Huch K, et al. Ann Rheum Dis Bradbury N, et al. Am J Sports Med Dahm DL, et al. J Arthroplasty Naal FD, et al. Am J Sports Med
19 What are the facts? Tennis After Total Hip Replacement 58 competitive tennis players 8 year follow-up All patients returned to competitive tennis 16% complained of residual pain with tennis post-op Mont MA, et al. Am J Sports Med.2002.
20 What are the facts? Tennis After Knee Replacement 33 competitive tennis players 7 year follow-up All patients returned to competitive tennis 12% complained of residual pain/stiffness post-op Mont MA, et al. Am J Sports Med.1999.
21 What are the facts? Golf after Total Hip Replacement 115 patients 6 year follow-up All patients returned to golf 86% pain free Improved average drive distance Improved average handicap Mallon WJ, Callaghan JJ. J Arthroplasty.1992.
22 What are the facts? Golf after total knee replacement 83 patients 5 year follow-up 84% reported no knee pain while playing Improved average drive distance Improved average handicap Right handed golfers have more pain in left knee replacement Mallon WJ, Callaghan JJ. J Arthroplasty.1993.
23 What are the facts? The E-Knee Total knee with internal force strain gauges Provides real-time force measurements from inside the knee Cycling (1.3 x body weight) Treadmill (2.05 x body weight) Walking (2.6 x body weight) Tennis (3.6 x body weight) Jogging (4.3 x body weight) Golf (4.5 x body weight) D Lima D, et al. Clin Orthop Rel Res; 466: 2008.
24 Ouch!
25 What is the effect of activity on the implants? Polyethylene Wear
26 Wear of today s implants / materials Prior to Y2K, conventional polyethylene was used C 2000, cross-linked polyethylene introduced 75% reduction in wear vs. conventional poly Bitsch RG, Ball ST, Schmalzried TP. JBJS 90-A; c 2010, 2 nd generation cross-linked poly introduced 50% reduction in wear vs. 1 st generation 2 nd Gen X-linked poly 85%-90% decreased wear compared to implants from just 17 years ago
27 Monitoring Wear after Joint Replacement X-rays every few years Look for evidence of wear and bone loss If identified, follow-up more often Consider prophylactic revision to halt the process and place better quality materials (before the whole implant fails!)
28 Monitoring Wear after Joint Replacement 56 y active F. Primary THA approximately 14 years ago. Osteolysis
29 What do I tell my patients? Your artificial joint may restrict you, but I won t. Regular activity is more important for your health than inactivity is for your joint replacement. You are only young once; enjoy activity now while you are able to. Hip Resurfacing: No precautions. Total Hip / Total Knee: If you have to jog for exercise, run on a treadmill or just on flats or uphill, not downhill. You have to come back at least every 5 years for xrays. If you are out doing something really cool, you have to send me a picture!
30
31 Thank You!
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