Three-dimensional knee joint kinematics during golf swing and stationary cycling after total knee arthroplasty

Native knee kinematics are reproduced during the golf swing after total knee arthroplasty apart from rotation: A case control study of hip and knee kinematics of patients returning to golf compared to match controls

OBJECTIVES

Golf is a popular sport in older adults and this same population has an increasing prevalence of osteoarthritis affecting major joints such as the knee. To the authors' knowledge, the effect of Total Knee Arthroplasty (TKA) on the movements in the golf swing has not been extensively investigated despite the large prevalence of golfers who have undergone TKA. We aimed to determine lower limb joint kinematics during the golf swing and whether these are influenced following TKA.

METHODS

A case- control study was undertaken with ten right-handed golfers who had undergone TKA (cruciate-retaining single radius implant) and five matched golfers with native knees. Each golfer performed five swings with a driver whilst being recorded at 200 ​Hz by a ten-camera motion capture system. Knee and hip three-dimensional joint angles (JA) and joint angular velocities (JAV) were calculated and statistically compared between the groups at six swing events.

RESULTS

The left knee demonstrated large effect sizes for lower external rotation during take away, mid (p ​= ​0.01) and top of backswing in the TKA group. In contrast, the right knee demonstrated large effect sizes for lower external rotation in the TKA group during the downswing, contact and follow-through phases. There were no differences in knee flexion/extension, ab/adduction, or JAV between the groups. Both hips demonstrated statistically significantly (p ​= ​0.02 for left and p ​= ​0.04 for right) lower flexion in the TKA group during the takeaway swing event, and lower internal rotation in the backswing and greater external rotation in the downswing of the right hip.

CONCLUSION

Normal knee kinematics were observed during the golf swing following TKA, with the exception of reduced external rotation in the left knee during the backswing and the right during the down swing. The differences demonstrated in the hip motion indicate that they may make compensatory movements to adjust to the reduced external rotation demonstrated in the knee.

LEVEL OF EVIDENCE

IV.

Lower Limb Biomechanics during the Golf Downswing in Individuals with and without a History of Knee Joint Injury

Although prevention is better than treatment, after a knee injury occurs, the adjustment of the movement technique back to the posture before the injury and the restoration of accuracy is very important for professional and amateur players. This study aimed to compare the differences in lower limb mechanics during the golf downswing between those with and without a history of knee joint injury. A total of 20 professional golfers with single-digit handicaps were recruited for this study, 10 of whom had a knee injury history (KIH+), while another 10 players were without a knee injury history (KIH-). From the 3D analysis, selected kinematic and kinetic parameters during the downswing were analyzed using an independent samples t-test with a significance level of α = 0.05. During the downswing, individuals with KIH+ exhibited a smaller hip flexion angle, smaller ankle abduction angle, and larger ankle adduction/abduction range of motion (ROM). Moreover, there was no significant difference found in the knee joint moment. Athletes with a history of knee injury can adjust the motion angles of their hip and ankle joints (e.g., by avoiding excessive forward leaning of the trunk and maintaining stable foot posture without inward or outward rotation) to minimize the impact of changes in their movement patterns resulting from the injury.

Cycle Sprint Test for the Evaluation of Lower Limb Muscle Power After Total Knee Arthroplasty: A Proof-of-Concept Study

Background

Lower limb muscle power is emerging as an important determinant of patient function after knee injury or surgery. This study tested proof of concept of a cycle sprint test for the evaluation of lower limb muscle power, as an outcome measure for patients having total knee arthroplasty (TKA).

Methods

Thirty-two patients were enrolled, of which 16 completed all follow-ups (3, 6, and 12 months). All patients completed the Oxford Knee Score and Knee Injury and Osteoarthritis Outcome Score questionnaires, a 10-m walk test, and 30-second sit-stand test. A trainer-mounted road cycle fitted with an instrumented crank was used for the cycle sprint test. Maximum muscle power was measured from 3, 10-second maximal efforts.

Results

Significant improvements in Oxford Knee Score and Knee Injury and Osteoarthritis Outcome scores relative to baseline were achieved at each follow-up (P < .001), and functional test performance improved significantly at 6 and 12 months (P < .001). Compared with the baseline of 268W, muscle power was significantly lower at 3 months (239W, −13%, P < .05) and significantly higher at 12 months (308W, +12%, P < .05).

Conclusion

The concept of muscle power measurement using a cycle sprint test before and after TKA has been demonstrated in this study. Identification of individuals with lower limb muscle power deficits after TKA may inform rehabilitation programs and enhance long-term outcomes.

Return to Play and Performance in Golfers After Total Knee Arthroplasty: Does Component Type Matter?

BACKGROUND

Golf is a popular sport among patients undergoing total knee arthroplasty (TKA). The golf swing requires significant knee rotation, which may lead to changes in golfing ability postoperatively. The type of implant used may alter the swing mechanics or place different stresses on the knee. The purpose of this study was to evaluate golf performance and subjective stability after TKA and compare outcomes between cruciate-retaining (CR) and posterior-stabilized (PS) implants.

HYPOTHESIS

Patients with CR implants will experience better stability during the golf swing compared to patients with PS implants.

STUDY DESIGN

Retrospective cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Patients who underwent primary TKA were identified from the medical record and sent an electronic questionnaire focusing on return to play (RTP), performance, pain, and stability during the golf swing. Knee injury and Osteoarthritis Outcome Scores (KOOS) were collected before and at multiple time points after surgery. Patients were surveyed postoperatively and asked to evaluate overall performance, pain, and stability before and after surgery. Outcomes were compared based on implant type.

RESULTS

Most patients (81.5%) were able to return to golf at an average of 5.3 ± 3.1 months from surgery. The average postoperative KOOS was 74.6 ± 12.5 in patients able to RTP compared with 64.4 ± 9.5 in those who were not (P < 0.05). Knee pain during golf significantly improved from 6.4 ± 2.1 to 1.8 ± 2.2 (P < 0.01). There were no significant differences in pain, performance, or stability between the CR and PS patients.

CONCLUSION

Most patients can successfully return to golfing after TKA. Knee replacement offers patients reliable pain relief during the golf swing and fewer physical limitations during golf, with no detriment to performance. There is no difference in performance or subjective knee stability based on component type.

CLINICAL RELEVANCE

Understanding associated outcomes of different TKA knee systems allows for unbiased and confident recommendations of either component to golfers receiving total knee replacement.

[Premature wear of total knee arthroplasty in sports shown in a golfer]

Sport with an endoprosthesis is controversially discussed, whereas golf with a knee endoprosthesis is usually allowed. This case shows that playing golf can lead to severe wear of the prosthesis. The wear pattern of the components of the prosthesis suggests increased rotational loads. A change to a constrained prosthesis was made because of metal-to-metal contact. It is important to inform the patient before surgery about sports with endoprosthesis. Athletic loads are not part of prosthesis testing according to ISO.

In vivo kinematic analysis of replaced hip during stationary cycling and computer simulation of optimal cup positioning against prosthetic impingement

BACKGROUND

Dynamic hip kinematics during stationary cycling after total hip arthroplasty (THA) have been unclear. Furthermore, no computer simulation of optimal cup position based on in vivo kinematics has yet been assessed.

METHODS

This study consisted of 7 patients who underwent unilateral primary THA for symptomatic osteoarthritis. Using a flat-panel X-ray detector, continuous radiographs were obtained during stationary cycling. We analyzed the three-dimensional replaced hip kinematics from the top to the bottom position of the crank using image-matching techniques and quantified minimum liner-to-stem neck distance. Simulation analyses with in vivo kinematics were performed to examine patient-specific optimal cup placement against prosthetic impingement.

FINDINGS

During stationary cycling, pelvis showed 27.1° of posterior tilt on average without significant change. Hip flexed by 59.4° and 19.3° on average at the top and bottom positions, respectively. Minimum liner-to-neck distance was 8.8 mm on average at the bottom position. Liner-to-neck, bone-to-bone, or bone-to-component impingement was not observed at any positions in any hips. Simulation analysis of cup placement showed that larger cup anteversion, inclination, and use of elevated liner significantly decreased the minimum distance between posterior liner and stem neck. Cup anteversion of more than 30° with elevated liner could cause posterior liner-to-neck impingement at bottom position.

INTERPRETATION

Stationary cycling after THA provides no excessive hip range of motion or liner-to-neck contact. Cup placement and use of elevated liner significantly influence the minimum liner-to-neck distance, in some cases simulating posterior prosthetic impingement.

Risk Factors for Knee Injury in Golf: A Systematic Review

Background

Golf is commonly considered a low-impact sport that carries little risk of injury to the knee and is generally allowed following total knee arthroplasty (TKA). Kinematic and kinetic studies of the golf swing have reported results relevant to the knee, but consensus as to the loads experienced during a swing and how the biomechanics of an individual’s technique may expose the knee to risk of injury is lacking.

Objectives

Our objective was to establish (1) the prevalence of knee injury resulting from participation in golf and (2) the risk factors for knee injury from a biomechanical perspective, based on an improved understanding of the internal loading conditions and kinematics that occur in the knee from the time of addressing the ball to the end of the follow-through.

Methods

A systematic literature search was conducted to determine the injury rate, kinematic patterns, loading, and muscle activity of the knee during golf.

Results

A knee injury prevalence of 3–18% was established among both professional and amateur players, with no clear dependence on skill level or sex; however, older players appear at greater risk of injury. Studies reporting kinematics indicate that the lead knee is exposed to a complex series of motions involving rapid extension and large magnitudes of tibial internal rotation, conditions that may pose risks to the structures of a natural knee or TKA. To date, the loads experienced by the lead knee during a golf swing have been reported inconsistently in the literature. Compressive loads ranging from 100 to 440% bodyweight have been calculated and measured using methods including inverse dynamics analysis and instrumented knee implants. Additionally, the magnitude of loading appears to be independent of the club used.

Conclusions

This review is the first to highlight the lack of consensus regarding knee loading during the golf swing and the associated risks of injury. Results from the literature suggest the lead knee is subject to a higher magnitude of stress and more demanding motions than the trail knee. Therefore, recommendations regarding return to golf following knee injury or surgical intervention should carefully consider the laterality of the injury.

Electronic supplementary material

The online version of this article (doi:10.1007/s40279-017-0780-5) contains supplementary material, which is available to authorized users.

The effects of a 3-month controlled hiking programme on the functional abilities of patients following total knee arthroplasty: a prospective, randomized trial

PURPOSE AND HYPOTHESIS

Improvements in pain, function and sports activity are the main goals of patients following total knee arthroplasty (TKA). Participation in sports has become an increasingly important contributor to patients' quality of life (QoL). Hiking is one of the most popular summer activities among elderly people in alpine regions. Consequently, this randomized controlled trial investigates the impact of a 3-month guided hiking programme on patients' functional abilities and QoL following TKA. It was hypothesized that patients who participate in this programme would demonstrate improvements in functional and QoL parameters compared with a control group.

METHODS

Forty-eight TKA patients were included and randomized into either the intervention group (IG; n = 25) or the control group (CG; n = 23). The IG participated in a 3-month hiking programme (2-3 times a week), whereas the CG performed activities of daily living. The stair climb test (SCT), QoL questionnaires and isokinetic force measurements were completed at three time points (i.e. pre-test, post-test, retention-test). ANOVAs for repeated measurements were conducted for the SCT results. The Friedman test and the Mann-Whitney U test were performed for the QoL parameters.

RESULTS

After the 3-month hiking programme, the IG achieved faster overall walking times on the SCT. The time decreased from 4.3 ± 0.6 s (pre-test) to 3.6 ± 0.4 s (post-test) for the stair ascent (p = 0.060) and from 3.6 ± 0.6 s (pre-test) to 3.2 ± 0.5 s (post-test) for the stair descent (p = 0.036). The IG showed significant improvement on some of the subscales of the Knee Injury and Osteoarthritis Outcome Score from pre-test to retention-test (p < 0.01). In the CG, no significant changes were observed (n.s.).

CONCLUSIONS

The results indicate moderate improvement in the functional abilities and QoL of TKA patients who participated in a 3-month guided hiking programme compared with the patients in the CG. Hiking did not have any acute detrimental effects on the TKA patients during this study period.

LEVEL OF EVIDENCE

II.

Kinematic analysis of stair climbing in rotating platform cruciate-retaining and posterior-stabilized mobile-bearing total knee arthroplasties

INTRODUCTION

The aim of our study was to compare and contrast the effects of two types of mobile-bearing total knee arthroplasties (TKA), namely, the cruciate-retaining (CR) and posterior-stabilized (PS) TKAs, on clinical outcomes and in vivo kinematics during stair climbing.

MATERIALS AND METHODS

The Press-Fit Condylar Sigma rotating platform was used for both CR and PS TKAs. Patient-reported outcomes were assessed using the 2011 Knee Society Score. Quadriceps muscle strength was evaluated by isokinetic dynamometry. In vivo kinematics were evaluated using periodic sagittal plane radiographic images obtained during stair climbing to quantify anteroposterior (AP) tibiofemoral translation, implant flexion and axial rotation angles using image-matching techniques. Outcomes were evaluated in 20 TKAs, which had been undergone with clinical success, including ten knees with CR types and ten knees with PS types.

RESULTS

There were no significant differences between the CR and PS TKA groups (p > 0.05) in isometric extensor torque (1.0 ± 0.2 and 1.1 ± 0.6 N m/kg, respectively) or patient-reported score for stair climbing function (4.0 ± 0.5 and 3.8 ± 0.9, respectively). Both types of TKAs showed stable AP translation in the mid range of knee flexion and paradoxical translation in the low range of flexion, with limited rotation, during stair climbing. There were no significant differences between the CR and PS TKA groups (P > 0.05) in anterior translation from 80° to 40° of knee flexion (4.2 ± 1.2 and 3.5 ± 1.6 mm, respectively), posterior translation from 40° to 10° of knee flexion (2.3 ± 1.9 and 2.0 ± 1.5 mm, respectively), and total external rotation (2.8° ± 4.9° and 0.5° ± 5.0°, respectively).

CONCLUSIONS

Both CR and PS types of rotating platform mobile-bearing TKAs provided reproducible knee joint kinematics during stair climbing and equivalent clinical outcomes.

LEVEL OF EVIDENCE

IV.

Fatigue injury risk in anterior cruciate ligament of target side knee during golf swing

A golf-related ACL injury can be linked with excessive golf play or practice because such over-use by repetitive golf swing motions can increase damage accumulation to the ACL bundles. In this study, joint angular rotations, forces, and moments, as well as the forces and strains on the ACL of the target-side knee joint, were investigated for ten professional golfers using the multi-body lower extremity model. The fatigue life of the ACL was also predicted by assuming the estimated ACL force as a cyclic load. The ACL force and strain reached their maximum values within a short time just after ball-impact in the follow-through phase. The smaller knee flexion, higher internal tibial rotation, increase of the joint compressive force and knee abduction moment in the follow-through phase were shown as to lead an increased ACL loading. The number of cycles to fatigue failure (fatigue life) in the ACL might be several thousands. It is suggested that the excessive training or practice of swing motion without enough rest may be one of factors to lead to damage or injury in the ACL by the fatigue failure. The present technology can provide fundamental information to understand and prevent the ACL injury for golf players.

Return to Golfing Activity After Joint Arthroplasty

BACKGROUND

Many patients who are considering total joint arthroplasty, including hip, knee, and shoulder replacement, are concerned with their likelihood of returning to golf postoperatively as well as the effect that surgery will have on their game.

PURPOSE

To review the existing literature on patients who have undergone major joint arthroplasty (hip, knee, and shoulder), to examine the effects of surgery on performance in golf, and to provide surgeon recommendations as related to participation in golf after surgery. A brief review of the history and biomechanics of the golf swing is also provided.

STUDY DESIGN

Systematic review.

METHODS

We performed a systematic review of the literature in the online Medline database, evaluating articles that contained the terms "golf" and "arthroplasty." Additionally, a web-based search evaluating clinical practice recommendations after joint arthroplasty was performed. The research was reviewed, and objective and anecdotal guidelines were formulated.

RESULTS

Total joint arthroplasty provided an improvement in pain during golfing activity, and most patients were able to return to sport with variable improvements in sport-specific outcomes.

CONCLUSION

In counseling patients regarding the return to golf after joint arthroplasty, it is our opinion, on the basis of our experience and those reported from others in the literature, that golfers undergoing total hip, knee, and shoulder arthroplasty can safely return to sport.

Dynamic Hip Kinematics During the Golf Swing After Total Hip Arthroplasty

BACKGROUND

Although most surgeons allow their patients to play golf after total hip arthroplasty (THA), the effect on the implant during the golf swing is still unclear.

PURPOSE

To evaluate hip kinematics during the golf swing after THA.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Eleven hips in 9 patients who underwent primary THA were analyzed. All patients were right-handed recreational golfers, and these 11 hips included 6 right hips and 5 left hips. Periodic radiographic images of the golf swing were taken using a flat-panel x-ray detector. Movements of the hip joint and components were assessed using 3-dimensional-to-2-dimensional model-to-image registration techniques. Liner-to-neck contact and translation of the femoral head with respect to the acetabular cup (cup-head translation) were examined. Hip kinematics, orientation of components, and maximum cup-head translation were compared between patients with and without liner-to-neck contact.

RESULTS

On average, the golf swing produced approximately 50° of axial rotation in both lead and trail hips. Liner-to-neck contact was observed in 4 hips with elevated rim liners (2 lead hips and 2 trail hips) at maximum external rotation. Neither bone-to-bone nor bone-to-implant contact was observed at any phases of the golf swing in any of the hips. Four hips with liner-to-neck contact had significantly larger maximum external rotation (37.9° ± 7.0° vs 20.6° ± 9.9°, respectively; P = .01) and more cup anteversion (26.5° ± 6.1° vs 10.8° ± 8.9°, respectively; P = .01) than hips without liner-to-neck contact. No significant differences between hips with and without contact were found for cup inclination (42.0° ± 2.5° vs 38.1° ± 5.5°, respectively; P = .22), combined anteversion (45.3° ± 8.9° vs 51.4° ± 7.9°, respectively; P = .26), or maximum cup-head translation (1.3 ± 0.3 mm vs 1.5 ± 0.4 mm, respectively; P = .61).

CONCLUSION

In this analysis, the golf swing did not produce excessive hip rotation or cup-head translation in any hips. However, liner-to-neck contact during the golf swing was observed in 36% of the hips, with unknown effects on the long-term results.

CLINICAL RELEVANCE

Golf is an admissible sport after THA because dynamic hip stability was observed. However, the implant position, especially cup anteversion and the use of elevated rim liners, promoted liner-to-neck contact.

How Much Improvement in Patient Activity Can Be Expected After TKA?

Most patients expect an improvement of physical activity after total knee arthroplasty (TKA). The aim of this study was to evaluate improvement in physical activity after TKA. An accelerometer was used to measure activity in 221 patients before and 1 year after TKA. The measurements included the total number of steps and time spent lying, sitting/standing, or walking. Threshold for achievement of health-enhancing physical activity (HEPA) guidelines and step-defined lifestyle were applied to the data. Measured steps per day improved from 5371 to 6587. Only 50 patients (22.6%) met the HEPA guidelines, whereas 31% achieved an active lifestyle. Improvement in daily step number was influenced by age (P<.001), body mass index (P<.001) and preoperative activity (P<.001). After TKA, patients improved in physical activity and one-third achieved an active lifestyle. Patient-specific characteristics and preoperative levels of physical activity had a relevant influence on activity after TKA. [Orthopedics. 2016; 39(3):S18-S23.].

In vivo kinematics of healthy male knees during squat and golf swing using image-matching techniques

PURPOSE

Participation in specific activities requires complex ranges of knee movements and activity-dependent kinematics. The purpose of this study was to investigate dynamic knee kinematics during squat and golf swing using image-matching techniques.

METHODS

Five healthy males performed squats and golf swings under periodic X-ray images at 10 frames per second. We analyzed the in vivo three-dimensional kinematic parameters of subjects' knees, namely the tibiofemoral flexion angle, anteroposterior (AP) translation, and internal-external rotation, using serial X-ray images and computed tomography-derived, digitally reconstructed radiographs.

RESULTS

During squat from 0° to 140° of flexion, the femur moved about 25 mm posteriorly and rotated 19° externally relative to the tibia. Screw-home movement near extension, bicondylar rollback between 20° and 120° of flexion, and medial pivot motion at further flexion were observed. During golf swing, the leading and trailing knees (the left and right knees respectively in the right-handed golfer) showed approximately five millimeters and four millimeters of AP translation with 18° and 26° of axial rotation, respectively. A central pivot motion from set-up to top of the backswing, lateral pivot motion from top to ball impact, and medial pivot motion from impact to the end of follow-through were observed.

CONCLUSIONS

The medial pivot motion was not always recognized during both activities, but a large range of axial rotation with bilateral condylar AP translations occurs during golf swing. This finding has important implications regarding the amount of acceptable AP translation and axial rotation at low flexion in replaced knees.

LEVEL OF EVIDENCE

IV.

Wear testing of moderate activities of daily living using in vivo measured knee joint loading

Resumption of daily living activities is a basic expectation for patients provided with total knee replacements. However, there is a lack of knowledge regarding the impact of different activities on the wear performance. In this study the wear performance under application of different daily activities has been analyzed. In vivo load data for walking, walking downstairs/upstairs, sitting down/standing up, and cycling (50 W & 120 W) has been standardized for wear testing. Wear testing of each activity was carried out on a knee wear simulator. Additionally, ISO walking was tested for reasons of comparison. Wear was assessed gravimetrically and wear particles were analyzed. In vivo walking produced the highest overall wear rates, which were determined to be three times higher than ISO walking. Moderate wear rates were determined for walking upstairs and downstairs. Low wear rates were determined for standing up/sitting down and cycling at power levels of 50 W and 120 W. The largest wear particles were observed for cycling. Walking based on in vivo data has been shown to be the most wear-relevant activity. Highly demanding activities (stair climbing) produced considerably less wear. Taking into account the expected number of loads, low-impact activities like cycling may have a greater impact on articular wear than highly demanding activities.

Kinematic analysis of healthy hips during weight-bearing activities by 3D-to-2D model-to-image registration technique

Dynamic hip kinematics during weight-bearing activities were analyzed for six healthy subjects. Continuous X-ray images of gait, chair-rising, squatting, and twisting were taken using a flat panel X-ray detector. Digitally reconstructed radiographic images were used for 3D-to-2D model-to-image registration technique. The root-mean-square errors associated with tracking the pelvis and femur were less than 0.3 mm and 0.3° for translations and rotations. For gait, chair-rising, and squatting, the maximum hip flexion angles averaged 29.6°, 81.3°, and 102.4°, respectively. The pelvis was tilted anteriorly around 4.4° on average during full gait cycle. For chair-rising and squatting, the maximum absolute value of anterior/posterior pelvic tilt averaged 12.4°/11.7° and 10.7°/10.8°, respectively. Hip flexion peaked on the way of movement due to further anterior pelvic tilt during both chair-rising and squatting. For twisting, the maximum absolute value of hip internal/external rotation averaged 29.2°/30.7°. This study revealed activity dependent kinematics of healthy hip joints with coordinated pelvic and femoral dynamic movements. Kinematics' data during activities of daily living may provide important insight as to the evaluating kinematics of pathological and reconstructed hips.

No influence of coronal laxity and alignment on lift-off after well-balanced and aligned total knee arthroplasty

PURPOSE

In vivo fluoroscopic analyses have revealed the kinematics after total knee arthroplasty (TKA), including femoral condylar lift-off. This study asked whether differences in static varus-valgus laxity or coronal limb alignment after TKA affect lift-off under weight-bearing conditions. It was hypothesised that there is a correlation between coronal laxity or alignment and lift-off during walking.

METHODS

The current study analysed nineteen subjects undergoing cruciate-retaining TKA performed by the measured resection technique. The varus-valgus laxity at knee extension was measured using a 150 N stress radiograph. The mechanical axis was measured using a full-standing radiograph. Continuous radiological images were taken while the subject walked on a treadmill, and the images during single-leg stance were analysed to determine the lift-off using a 3D-to-2D image-to-model registration technique.

RESULTS

The average angle in varus/valgus stress was 6.8 ± 1.8°/6.6 ± 2.1°. No statistically significant differences were observed between the varus and valgus laxity. The average amount of lift-off was 0.7 ± 0.4 mm. The static varus-valgus laxity (n. s.) or the differences in the laxities (n. s.) on the stress radiograph did not influence lift-off. The weight-bearing ratio was achieved within the middle third of the knee in 90 % of subjects. Two outliers with valgus alignment (68 ± 1 %) demonstrated no significant difference in lift-off in comparison with the majority of the subjects (46 ± 9 %).

CONCLUSION

The static coronal laxity and alignment did not influence the lift-off under dynamic weight-bearing conditions after well-balanced and aligned cruciate-retaining TKA. Measured resection technique can produce sufficient coronal stability and alignment without significant lift-off during walking.

Knee biomechanics during popular recreational and daily activities in older men

BACKGROUND

Physical activity is recommended for older adults, including those with knee pathology. However, demands on the knee during popular recreational activities are unclear. The study purpose was to determine knee biomechanics in healthy older men during golf and bowling and compare them to activities of daily living.

METHODS

Three-dimensional motion analysis was used to determine knee biomechanics in 19 healthy males (45-73 years): 11 golfers and eight bowlers. Subjects performed walking, stair ascent, stair descent, and either golf or bowling. Comparisons were made between the recreational activity and activities of daily living.

RESULTS

During bowling, flexion angle at peak extensor moment was as high as during stair descent, and peak extensor moment was as high as during stair ascent. For the golf lead knee, flexion angle at peak extensor moment and peak extensor moment were as high as during stair ascent, and peak abduction moment, internal and external rotation angles were larger than during all activities of daily living. Peak external rotation angle for the golf trail knee was larger than all activities of daily living.

CONCLUSION

The greatest challenge for the knee of healthy older males during bowling is eccentric control of knee flexion. Golf poses challenges in all three planes of motion for the lead knee and in the transverse plane for the trail knee.

CLINICAL RELEVANCE

Comparing mechanical demands on the knee during bowling and golf to those of stair negotiation provides a reference for clinicians when recommending recreational activities for older adults with knee pathology.

Hip joint torques during the golf swing of young and senior healthy males

STUDY DESIGN

Descriptive, laboratory study.

OBJECTIVES

To compare the 3-D hip torques during a golf swing between young and senior healthy male amateur golfers. The secondary purpose was to compare the 3-D hip joint torques between the trail leg and lead leg.

BACKGROUND

The generation of hip torques from the hip musculature is an important aspect of the golf swing. Golf is a very popular activity, and estimates of hip torques during the golf swing have not been reported.

METHODS

Twenty healthy male golfers were divided into a young group (mean ± SD age, 25.1 ± 3.1 years) and a senior group (age, 56.9 ± 4.7 years). All subjects completed 10 golf swings using their personal driver. A motion capture system and force plates were used to obtain kinematic and kinetic data. Inverse dynamic analyses were used to calculate 3-D hip joint torques of the trail and lead limbs. Two-way analyses of covariance (group by leg), with club-head velocity as a covariate, were used to compare peak hip torques between groups and limbs.

RESULTS

Trail-limb hip external rotator torque was significantly greater in the younger group compared to the senior group, and greater in the trail leg versus the lead leg.

CONCLUSION

When adjusting for club-head velocity, young and senior healthy male amateur golfers generated comparable hip torques during a golf swing, with the exception of the trail-limb hip external rotator torque. The largest hip torque found was the trail-limb hip extensor torque.

Physical activity after total joint arthroplasty

Context:

Total joint arthroplasty (TJA) is a common surgical option to treat painful degenerative joint disease. However, there is currently no consensus on the appropriate intensity of physical activity after TJA or how physical activity level affects the rate of revision surgery.

Materials and Methods:

A systematic review of the literature regarding physical or athletic activity after TJA was performed to determine current clinical opinion and recommendations regarding appropriate activity levels after TJA, as well as variables affecting successful surgery and improved outcomes.

Results:

Many studies in the literature regarding athletic activity after TJA focus on total hip arthroplasty and total knee arthroplasty. The literature reports contradictory results regarding rates of physical activity after TJA as well as the relationship between physical activity and rates of revision surgery. The current trend in expert opinion shows more liberal recommendations for patients to engage in athletic activity after TJA.

Conclusions:

Individual characteristics, lifestyle, and patient preferences must be taken into account when one considers appropriate recommendations for athletic activity after TJA. Current trends in clinical opinion favor a higher level of athletic activity after TJA, but clinicians should caution patients not to participate in contact sports or sports that create high joint loads in the replaced joint.

Sport activity following joint arthroplasty: a systematic review

INTRODUCTION

Although the clinical and functional outcomes of patients undergoing knee arthroplasty have widely been investigated, there is little information on the postoperative sport activity status.

SOURCES OF DATA

We performed a comprehensive search of CINAHL, Embase, Medline and the Cochrane Central Registry of Controlled Trials, from inception of the database to 25 February 2011, using various combinations of the keyword terms 'Knee arthroplasty', 'Knee replacement', 'Total Knee replacement', 'Unicondylar Knee replacement', 'Knee Prosthesis', 'Sport Activity', 'Return To Sport Activity Level' and 'Recreational Sporting Level'. Twenty-two articles published in peer-reviewed journals were included in this review.

AREAS OF AGREEMENT

Patients report improved outcomes, in terms of pain, symptoms, activities of daily living, sport activity and quality of life, compared with preoperative status. Only low-impact physical activities are recommended. The Coleman Methodology Score showed great heterogeneity in the study design, patients' characteristics, management methods and outcome assessment, and generally low methodological quality.

AREAS OF CONTROVERSY

Data are too heterogeneous to allow for definitive conclusions on long-term outcomes of total knee arthroplasty. It is not possible to compare the post-operative sport activity status of the patients.

GROWING POINTS

Validated and standardized measures should be used to report outcomes of patients undergoing knee arthroplasty. Function surveys that better depict sport activities, and include actual physical function testing, should be used.

RESEARCH

There is a need to perform appropriately powered randomized clinical trials using standard diagnostic assessment, and a common and validated scoring system comparing reported outcomes and the duration of follow-up >2 years.

Golf after total knee arthroplasty: do patients return to walking the course?

BACKGROUND

Golf provides an opportunity for relatively low-impact exercise for nearly all age groups and is considered a recommended activity for patients after total knee arthroplasty.

HYPOTHESIS

We hypothesized that total knee arthroplasty would afford patients increased ability to participate in and enjoy golf, allowing a large percentage of these patients to walk the golf course.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Surveys were sent to 151 golfers who had undergone primary total knee arthroplasty from 1995 to 2000. The detailed survey included 33 questions specific to the patients' golf performance, enjoyment of golf, frequency of participation, timing of return to play, presence of pain, use of a cart, and related golf-specific issues.

RESULTS

We received and evaluated 93 responses (62%). Fifty-seven percent reported they had returned to golf within 6 months after total knee arthroplasty. Eighty-one percent of respondents reported golfing as frequently, or more frequently, than before knee replacement. Notably, golfers reported less pain while golfing after total knee arthroplasty than before (13% vs 83%; P < .0001), and 94% of respondents reported currently enjoying golf as much as or more than before surgery. Twenty-eight percent of respondents stated that they walked the course, rather than using a motorized golf cart, before surgery, while only 14% walked the course after surgery (P = .02).

CONCLUSION

In this population of golfers, total knee arthroplasty reliably relieved pain that had been previously experienced while golfing, and increased or maintained this group's enjoyment of playing golf. However, 86% of these patients reported using a cart while golfing. Further patient education is needed regarding the potential health benefits of walking during golf after total knee arthroplasty.

Ligament tension in the ACL-deficient knee: assessment of medial and lateral gaps

Obtaining symmetric and balanced gaps under equilateral loads is a common goal in posterior cruciate ligament (PCL)-retaining and -sacrificing TKAs. Owing to limitations in existing surgical tensors, however, tensing knee ligaments with standardized and symmetric loads has been possible only with the patella subluxated or everted. We therefore determined the influences of (1) patellar eversion versus complete reduction, (2) PCL resection, and (3) load magnitude on gap symmetry and balance in the anterior cruciate ligament (ACL)-deficient knee. We used a novel computer-controlled tensioner to measure gaps in 10 cadavers with an applied force of 50 N, 75 N, and 100 N per side. Gap data were acquired at 0 masculine, 30 masculine, 60 masculine, 90 masculine, and 120 masculine flexion with the patella reduced and everted and with the PCL intact and resected. Everting the patella tightened the medial and lateral flexion gaps between 90 masculine and 120 masculine by 0.7 mm to 2.7 mm. PCL resection increased gaps from 30 degrees to 120 degrees by 1 mm to 3 mm. Increasing the force from 50 N to 100 N increased the mean gap by 0.5 mm. Everting the patella and resecting the PCL influenced gap balance and symmetry. Surgeons should be aware of how these conditions affect gaps during assessment and balancing.