ARTHROPLASTY

Athletic activity after lower limb arthroplasty A SYSTEMATIC REVIEW OF CURRENT EVIDENCE

S. S. Jassim, S. L. Douglas, F. S. Haddad From University College London Hospital, London, United Kingdom

In this systematic review, our aim was to explore whether or not patients are able to return to athletic activity following lower limb joint replacement. We also investigated any evidence as to whether participation in athletic activity post-joint replacement increases complications and reduces implant survival. A PubMed, Embase and Sports Discus search was performed using the MeSH terms ‘Sport’, ‘Athletic’, ‘Athlete’, ‘Physical’, ‘Activity’, ‘Arthroplasty’, ‘Total Hip Replacement’, ‘Hip Resurfacing’, ‘Total Knee Replacement’, ‘Unicompartmental Knee Replacement’ and ‘Unicondylar Knee Replacement’. From this search, duplications were excluded, the remaining abstracts were reviewed and any unrelated to the search terms were excluded. The remaining abstracts had their full papers reviewed. Following joint replacement, participation in sporting activity is common principally determined by pre-operative patient activity levels, BMI and patient age. The type of joint replaced is of less significance. Total time spent performing activity does not change but tends to be at a lower intensity. There is little evidence in the literature of an association between high activity levels and early implant failure. Cite this article: Bone Joint J 2014;96-B:923–7.

 S. S. Jassim, MRCS, MBBS, Specialist Registrar  S. L. Douglas, MRCS, MBBS, Specialist Registrar  F. S. Haddad, MD (Res), MCh (Orth), FRCS (Orth), Consultant Orthopaedic Surgeon University College London Hospital, 235 Euston Road, London, NW1 2BU, UK. Correspondence should be sent to Mr S. S. Jassim; e-mail: [email protected] ©2014 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.96B7. 31585 $2.00 Bone Joint J 2014;96-B:923–7. Received 11 January 2013; Accepted after revision 27 February 2014

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Lower limb joint replacement (JR) is a common and successful operation for patients with intractable hip and knee pain with associated functional disability.1,2 Degenerative joint disease is increasing and has been mirrored in a rise in demand for surgery.3,4 Historically, surgical outcomes following JR were assessed through rates of mortality, operative complications and implant survival. However, more sophisticated measures have been developed to accurately reflect health gains with improved pain and functional scores.5-7 Scoring systems have evolved to assess more advanced postoperative function including, to some degree, athletic activity.8 Few studies have explicitly investigated outcomes in patients aged under 50 years or the prevalence of joint disease and JR outcomes in populations involved in regular athletic activity. The prevalence of degenerative joint disease increases with age, obesity9 and occupational physical loading.10 The association between athletic activity and osteoarthritis has been established by epidemiological studies.11-14 Athletes requiring JR will have high expectations of maintaining activity following surgery. Patient satisfaction following joint surgery correlates highly with patient expectations rather than a measure of absolute function15 and

therefore surgeons must be aware of relevant evidence to be adequately able to counsel patients wishing to return to sport after JR. Studies have investigated the ability of patients to participate in athletic activity after JR and some have described an increase in participation16 while others have described a reduction.17 However, criticism has been levelled at these reports for being poorly designed, under-powered and having short follow-ups. Also evidence of complications and implant survival in athletic populations has not been explicitly described.18 The purpose of this systematic review is to explore whether or not patients are able to return to athletic activity post-JR and whether that return increases complications and reduces implant survival.

Materials and Methods We included all studies relevant to participation in athletic activity following lower limb JR involving the hip or knee, including total joint replacement (TJR), unicompartmental knee replacement (UKR), patellofemoral joint replacement (PFJR) and hip resurfacing (HR). We decided not to include ankle joint replacement because of a relatively little long-term follow-up data in comparison with hip and knee 923

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replacements. We considered all case series and cohort studies that reported results with validated scoring systems, complication rates and implant survival data. Any studies that were found without validated scoring systems were scrutinised for their study design and some were included after discussion (see below). We excluded any review articles. We did not exclude any study on the basis of length of follow-up or number of participants. We used a Medline search for all articles published in any language, but any studies that did not have an English translation were subsequently excluded. We used the following Medical Subject Headings (MeSH) terms for our literature search in combination with Boolean operators (in upper cases): 1) ‘Sport’ OR ‘Athletic’ OR ‘Athlete’ OR ‘Physical’ OR ‘Activity’ AND 2) (i)‘Arthroplasty’, (ii)‘Total Hip Replacement’, (iii)‘Hip Resurfacing’, (iv)‘Total Knee Replacement’, (v)‘Unicompartmental Knee Replacement’, (vi)‘Unicondylar Knee Replacement’ and (vii)‘Patellofemoral Joint Replacement’. The results of the Medline search were cross-checked with the Embase and Sports Discus databases and any duplicate papers were excluded. The remaining papers were independently assessed by two authors (SJ, SD) for suitability for inclusion. The titles and abstracts of search results were reviewed and if there was doubt regarding the suitability of the study, the full article was retrieved for further scrutiny. All final decisions, in the case of uncertainty were made by the senior author (FSH). The citations within any article were also scrutinised for any missing papers following the initial search. All papers were examined for details concerning the size of the study, the joints involved, outcome scores used and length of follow-up. Each study then had their design evaluated, with respect to level of evidence, and description of their findings based on preferably validated outcome scores, ability to participate in sports, the types of activity studied and the identification of any complications and implant survival relating to sporting activity. We aimed to only include studies that described specific sporting activities and used validated scores. However, they were included if collectively we felt the data constructively contributed to overall conclusions.

Results A total of 42 suitable papers were identified as relevant for analysis. The flow diagram in Figure 119 demonstrates the process of identifying the relevant papers. The total number of patients in all the included studies was 10758, with a mean of 256 patients per study (22 to 2085). The mean age of all participants was 61.7 years (42 to 71.5). The mean follow-up length of the studies was 4.7 years (1 to 10.5). Of the studies, 17 investigated knees alone (12 TKR,17,20-30 three UKR,31-33 two both,34,35) 20 studies investigated hips alone (12 THR,16,36-46 seven HR,47-53 one both54) and four studies investigated both hip and knee joints.55-58

The most popular joint outcome scoring systems were the Knee Society Score (KSS)59 (used by ten studies) and the Oxford Knee Score (OKS)60 (six studies) for the knee. The most popular hip outcome scoring systems were the Harris Hip Score (HHS)61 (eight studies) and Oxford Hip Score (OHS)62 (six studies). The most popular athletic activity-rating scores were the University of California Los Angeles (UCLA)63 (15 studies) and the 4-level Saltin-Grimby Physical Activity Level Scale (SGPALS)36 (six studies). The SGPALS, although not commonly reported has been shown to possess good validity and reliability in epidemiological studies when compared with the UCLA score.64 The most popular general health indices were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score65 (five studies) and the Short Form 12(SF-12) (four studies).66 The rest used generalised or sports-specific outcome questionnaires to evaluate particular skills within sports, such as golf swing or tennis serve. Overall, 31 of the studies used validated outcome questionnaires 17,21,22,25-35,37,41-48,50-54,56-58 and 13 of these compared pre-operative with post-operative scores17,21,29,31,32,35,43,48,50,51,53,56,58; all of these demonstrated statistically significant improvement in post-operative scores. In total, eight studies gave descriptions of joint replacement outcomes for specific sports (four for golf20,28,38,43 two for tennis,23,39 one for running,51 one for skiing,40) 22 studies discussed a number of general activities 16,17,21,25,26,29,30,32-37,41,46,49,50,53,54,55,57 ; these were a mixture of high-impact, such as tennis and jogging, or lowimpact, such as walking, swimming and cycling. A further 12 alluded to activity in general but made no mention of specific sports.22,24,31,42,44,45,47,48,52,56,58,67 The rate of return to sport varied widely and was described as between 54% and 98% across the papers. Lower rates were seen in less recent studies without validated activity outcome questionnaires.16,36,37 Higher levels of activity were associated with lower ages,26,29,51,53,55,57,58 male gender,25,26,41,44,55,57,58 lower BMI,22,26,58 participation in sport pre-operatively,55,58 and absence of other joint pain.26,55,58 For example, Williams et al58 demonstrated that male gender gave an odds ratio (OR) of 4.84 and a higher pre-operative UCLA score gave an OR of 1.61 for a UCLA score of 7 or more after surgery. Dahm et al26 reported that patients over the age of 70 years had lower mean UCLA scores compared with patients under the age of 70 years (6.8 vs 7.5, p < 0.001). In studies comparing performance and return to sport between different types of joint replacement, greater numbers of UKR patients performed better in comparison to TKR patients.34,35 There was no difference in performance between THR and HR patients,54 nor between knee and hip replacements in five studies54,56-58,67 although one study showed a more frequent return to sport in THR patients compared with TKR patients.55 Although few studies explicitly investigated implant survival in sporting populations, none of the studies reported THE BONE & JOINT JOURNAL

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Records idenfied through database search: n = 1907

Records aer duplicates removed: n = 1497

Studies excluded by tle: n = 1430

Studies retrieved for further evaluaon: n = 67

Studies excluded by abstract: n = 13 Studies excluded aer full-text evaluaon: n=6 Studies excluded for no English translaon: n=6

Studies included in final analysis: n = 42 Fig. 1 Flow chart depicting the search process in identifying suitable papers for analysis (Adapted from PRISMA guidelines for systematic reviews).19

an increase in rates of complication associated with sporting activity with respect to less-active controls. A total of three studies did note an increase in polyethylene wear with increased activity, but no increase in revision rate.22,40,45 In those explicitly investigating revision rates, none found an increase in rates in sporting populations24,33,37 and none found an increase in revision risk associated with increased UCLA activity score.44,52

Discussion With operations apparently being performed on progressively younger patients, functional demands on implants are increasing, with many people wanting to maintain high VOL. 96-B, No. 6, JULY 2014

levels of activity. We have shown that the majority of patients, in particular those who are young and active preoperatively without multiple joint pathologies, are able to return to sporting activity after JR, with some qualification. A variety of sports of different intensities and impact on replaced joints have been found in the reports we have analysed. Although the majority have shown that patients are more inclined to return to low- rather than high-impact activities, there has been no clear consensus on whether this is a rational position for patients or their surgeons. Some of the suggestions made to explain this tendency include pain in the replaced joint, a personal feeling of apprehension or instructions from the operating surgeon. Klein et al68

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sought consensus amongst surgeons on acceptable sporting activities post-THR. From orthopaedic consultants belonging to the Hip Society and the American Association of Hip and Knee Surgeons who were surveyed, it was agreed that swimming, golf and cycling were permissible, while contact sports and jogging were not. They found that 91% of the 614 respondents would allow their patients to return to sporting activity six months post-surgery, with one third allowing activity at three months, supporting an earlier survey conducted by McGrory et al.69 The surgical opinions expressed in these studies were based on experience rather than on evidence, and therefore the reason for a patients’ inability to return to high-impact activities is still not clear. Papalia et al70 investigated published reports involving sport after TKR and found high rates of return-to-sport, with no significant differences between TKR and UKR cohorts. They felt that because of study heterogeneity and a lack of consistent outcome scoring systems, definitive comparisons on physical outcome post-surgery could not be made. The authors called for more randomised controlled studies into the subject. Vogel et al71 also concluded that sport was possible after JR, but noted that patients tended to be restricted to low-impact activities. Our study has built on the findings of these by providing more recent papers and more explicitly describing implant survival in sporting populations after TJR. The limitations of this study are common to other systematic reviews; in particular that some papers may not have been found with our search criteria. This may have been due to the initial search terms or exclusion of those papers with no English translation available. However, from examining the bibliographies of other studies, we do not appear to have missed any studies that would have significantly altered our conclusions. With the studies we have reviewed, there is significant heterogeneity with respect to the outcome scores used. Many have used sports questionnaires, designed by the authors, which have not been validated.16,20,23,24,36,38,39,40,49,55,67 Such instruments are prone to recall bias as many rely on a patient’s ability to describe sporting activity several years before the study was carried out. Early studies in this review have not used validated outcome scoring systems, which has made rigorous comparison with other studies impossible. Many of the studies have used more generic scoring systems, such as WOMAC and SF-12 which are not joint-specific, and do not allow comparison between joints or the different implants. Finally, the majority of the studies do not exceed ten-years of followup. While we have shown that implant-survival is not reduced in active patients, the length of follow-up is not yet adequate to make definitive conclusions on this matter. In conclusion, we have identified from the literature that following JR, patients are able to return to sporting activity. The intensity of activity to which patients return tends to be less than before surgery. We have not seen, at mid-term at least, an increase in implant failure in active patients,

although some studies have found higher radiological wear in active populations. We recommend more long-term prospective studies to see if these findings are maintained or change significantly in order to allow patients considering JR to be better informed regarding their post-operative prognosis for athletic participation. Supplementary material A table giving full details of the studies analysed with demographics and results is available with the electronic version of this article at http://www.bjj.boneandjoint.org.uk. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primary edited by D. Rowley and first proof edited by G. Scott.

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