The Effect of Total Hip Arthroplasty on Sports and Work Participation: A Systematic Review and Meta-Analysis

Pickleball Primer: An Overview of Common Injuries, Treatment, and Optimization Strategies in Pickleball Athlete

Pickleball is one of the fastest growing sports in the United States with millions of players nationwide. It is a relatively appealing sport because of its ease of access, low impact, and highly social atmosphere, allowing players of all ages to participate. As the number of players continues its dramatic increase, player injuries are certain to increase in turn. There is little to no orthopaedic research on pickleball-related injuries and a paucity of data regarding treatment and prevention strategies. This summary was designed to familiarize orthopaedic surgeons with the basics of the sport and highlight potential pickleball-related injuries they may encounter in practice.

Intensive physical activity following total hip arthroplasty increased the revision risk after 15 years: a cohort study of 973 patients from the Geneva Arthroplasty Register

BACKGROUND AND PURPOSE

Younger recipients of total hip arthroplasty (THA) highly prioritize returning to preoperative levels of physical activity (PA). Surgeons have tended to give cautious advice concerning high-impact sports participation, but there have been few long-term studies. The purpose of our study was to investigate the risk of revision arthroplasty in relation to postoperative PA levels.

METHODS

Patients registered in the Geneva Arthroplasty Register (GAR) who had elective THA when they were aged < 65 years were studied. Postoperative PA was collected prospectively 5-yearly using the UCLA activity scale. Cox proportional hazards models were used to estimate associations between PA and risk of revision THA.

RESULTS

Amongst 1,370 eligible subjects, median age at THA 58 years (interquartile range 51-61), UCLA scores were available for 973 (71%). During follow-up over 15 years, there were 79 revisions, giving a cumulative risk of 7.4% (95% confidence interval [CI] 5.8-9.4). After adjusting for covariates, we found an increased risk of revision for each unit increase in postoperative PA (HR 1.2, CI 1.1-1.4), and among people performing the most intensive PA (HR 2.7, CI 1.3-5.6) compared with those who were inactive.

CONCLUSION

The overall risk of revision was small but intensive and moderate PA may be associated with an increased risk of revision.

Early functional recovery outcomes and return to work after primary total hip arthroplasty: a novel patient reported outcomes questionnaire

PURPOSE

Clinical and patient reported outcomes are often collected before and after the procedure to benchmark and study outcomes for patients. These outcomes and scores are useful for tracking patient outcomes after surgery, however, the fact that these commonly used measures typically provide information about a patient's level of pain and function at a single point in time is a limitation.

METHODS

We present early functional recovery and return to work outcomes after primary THA from a novel questionnaire administered in a global, multi-center, prospective clinical study.

RESULTS

By 6 and 12 weeks post-op, a large proportion of study subjects were able to perform functional recovery outcomes after their THA: walk without an aid (74%; 94%); drive (76%; 97%); basic activities of daily living (94%; 99%); perform light household duties (91%; 96%); perform moderate-to-heavy household duties (54%; 86%); go up and down a flight of stairs (92%; 99%); put on socks/stockings (77%; 93%); bend down to pick up an object from the floor (87%; 97%); stand up from a chair (96%; 99%); perform leisure recreational activities (54%; 84%); perform primary goal identified pre-THA (69%; 86%). 60% were able to return to work by 12 weeks post-op. These questions showed strong association with the Forgotten Joint Score.

CONCLUSION

Excellent patient reported early functional recovery outcomes and satisfaction were observed at 6- and 12-weeks post-op in this cohort and is the first reported data using a novel PRO.

CLINICAL TRIAL REGISTRATION

NCT03189303, registered June 14, 2017.

Total Hip Arthroplasty in Teenagers: A Systematic Literature Review

BACKGROUND

Total hip arthroplasty (THA) in teenagers is generally avoided. Nevertheless, recent THA procedures in a very young patient show improved functional outcomes and implant survival, resulting in lower revision rates. This review aims to present an overview of the available literature on THA in teenagers and to provide evidence to inform caregivers.

METHODS

In this systematic review, studies required a primary THA method and a teenage patient population. Studies must report at least one of the following outcome measures: functional outcomes, implant survival, and complications. In addition, demographic and surgical data were collected.

RESULTS

Sixteen studies were analyzed, including 2040 patients and 2379 hips, with an average 7.7-year follow-up. The mean patient age was 18 years, with an average revision rate of 11.7%. The overall average relative improvement of the 2 most frequently used patient-reported (functional) outcome measures were 84.3 and 92.3% at the latest follow-up. Prosthesis, or liner loosening, was the cause of revision in 50.2% of the cases. Loosening was the most frequent complication (14.8%), together with prosthesis/liner wear (14.8%). Cementless fixation (70.7%), ceramic-on-ceramic articulation (34.7%), and the posterior surgical approach (82.3%) were the most applied techniques.

CONCLUSIONS

The functional outcomes after THA in teenagers improved at follow-up. The average revision rate is relatively high, especially in the pre-1995 studies, with post-1995 studies reporting similar revision rates to the adult patient group. Research to further improve implant survival as well as the ease of revisions in teenagers is needed.

LEVEL OF EVIDENCE

Level III-systematic review.

Three out of four working-age patients have fulfilled expectations towards paid employment six months after total hip or knee arthroplasty: a multicentre cohort study

To investigate factors associated with fulfilment of expectations towards paid employment after total hip/knee arthroplasty (THA/TKA). Cohort study including preoperatively employed patients aged 18-64 scheduled for THA/TKA. Expectations were collected preoperatively, and 6 and 12 months postoperatively with the paid employment item of the Hospital-for-Special-Surgery Expectations Surveys (back-to-normal = 1; large improvement = 2; moderate improvement = 3; slight improvement = 4; not applicable = 5). Patients scoring not applicable were excluded. Fulfilment was calculated by subtracting preoperative from postoperative scores (< 0: unfulfilled; ≥ 0: fulfilled). Multivariable logistic regression analyses were conducted separately for THA/TKA at 6 and 12 months postoperatively. Six months postoperatively, 75% of THA patients (n = 237/n = 316) and 72% of TKA patients (n = 211/n = 294) had fulfilled expectations. Older age (TKA:OR 1.08, 95% CI 1.01-1.15) and better postoperative physical functioning (THA:OR 1.10, 95% CI 1.06-1.14; TKA:OR 1.03, 95% CI 1.01-1.06) increased the likelihood of fulfilment. Physical work tasks (THA:OR 0.12, 95% CI 0.03-0.44), preoperative sick leave (TKA:OR 0.33, 95% CI 0.17-0.65), and difficulties at work (THA:OR 0.10, 95% CI 0.03-0.35; TKA:OR 0.41, 95% CI 0.17-0.98) decreased the likelihood of fulfilment. Twelve months postoperatively similar risk factors were found. Three out of four working-age THA/TKA patients had fulfilled expectations towards paid employment at 6 months postoperatively. Preoperative factors associated with fulfilment were older age, mental work tasks, no sick leave, postoperative factors were better physical functioning, and no perceived difficulties at work.

Activity Following Total Hip Arthroplasty: Which Patients Are Active, and Is Being Active Safe?

BACKGROUND

Younger and physically active patients demand a return to sport after total hip arthroplasty (THA). However, because of the risk of implant wear and loosening, high-impact activities are often not recommended. The current study evaluates predictive factors and revision rates in patients with higher activity levels.

METHODS

This retrospective study included 4152 hips in 3828 patients aged 45-75 that underwent primary THA for primary osteoarthritis between 2009 and 2019 with a minimum follow-up of 2 years. Pain and Lower Extremity Activity Scale (LEAS) were assessed before and 2 years after surgery. Activity was classified as low (LEAS 1-6), moderate (LEAS 7-13), or high (LEAS 14-18).

RESULTS

Pain and LEAS improved from preoperative to 2-years postoperative (p < 0.001). The activity level was low in 6.2%, moderate in 52.9%, and high in 40.9% of the patients. Younger age, lower BMI, ASA, and CCI, male sex, and higher preoperative LEAS correlated with higher activity at 2 years (p < 0.001). The predicted revision-free survival rates between the activity groups were better for more highly active patients (p < 0.001).

CONCLUSIONS

High physical activity 2 years following THA, with participating in sports like jogging several times a week, did not increase the risk of revision surgery. THA patients should not be prevented from a highly active lifestyle.

Return to Daily Activities, Work, and Sports at 3 Months After Total Hip Arthroplasty

Background

It is largely unknown if and when patients return to daily activities after undergoing total hip arthroplasty (THA) and which factors might influence this return. This study aimed to assess the percentages of patients who had been able to return to daily activities, work, and sports at 3 months after THA. Furthermore, the time to return and factors influencing the return (patient characteristics, surgical characteristics, and preoperative patient-reported outcomes) were assessed.

Methods

A retrospective cohort study of patients who underwent THA was performed with use of prospectively collected data. At 3 months postoperatively, patients completed a questionnaire regarding their return to 16 different activities across the categories of daily activities, work, and sports. The percentage of patients who returned to an activity, the time to return, and factors influencing the return were analyzed with use of logistic regression models utilizing backward selection.

Results

A total of 2,006 patients were studied. Most of the studied activities had been returned to by the majority of patients at 3 months after THA, with the percentage of patients who returned to an activity ranging from 28.8% to 97.9%. The mean or median time to return to an activity ranged from 1 to 56 days after THA. For 13 out of 16 activities, 1 or more of the studied factors influenced the return to the activity. R2 values ranged from 0.057 to 0.273.

Conclusions

At 3 months after THA, 8 out of 10 patients had returned to daily activities, 7 out of 10 had returned to work, and 5 out of 10 had returned to sports. Factors that clearly influenced the return to daily activities, work, and sports could not be established. These findings might be useful in setting realistic expectations when counselling patients on their return to daily activities, work, and sports after THA.

Level of Evidence

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Time to return to work by occupational class after total hip or knee arthroplasty

Aims

For the increasing number of working-age patients undergoing total hip or total knee arthroplasty (THA/TKA), return to work (RTW) after surgery is crucial. We investigated the association between occupational class and time to RTW after THA or TKA.

Methods

Data from the prospective multicentre Longitudinal Leiden Orthopaedics Outcomes of Osteoarthritis Study were used. Questionnaires were completed preoperatively and six and 12 months postoperatively. Time to RTW was defined as days from surgery until RTW (full or partial). Occupational class was preoperatively assessed and categorized into four categories according to the International Standard Classification of Occupations 2008 (blue-/white-collar, high-/low-skilled). Cox regression analyses were conducted separately for THA and TKA patients. Low-skilled blue-collar work was used as the reference category.

Results

A total of 360 THA and 276 TKA patients, preoperatively employed, were included. Patients were mainly high-skilled (THA 57%; TKA 41%) or low-skilled (THA 24%; TKA 38%) white-collar workers. Six months post-THA, RTW rates were 78% of low-skilled blue-collar workers compared to 83% to 86% within other occupational classes, increasing after 12 months to 87% to 90% in all occupational classes. Six months post-TKA, RTW rates were 58% of low-skilled and 64% of high-skilled blue-collar workers compared to 80% to 89% of white-collar workers, and after 12 months 79% of low-skilled blue-collar workers compared to 87% to 92% within other occupational classes. High-skilled white-collar workers (THA: hazard ratio (HR) 2.12 (95% confidence interval (CI) 1.32 to 3.40); TKA: HR 2.31 (95% CI 1.34 to 4.00)) and low-skilled white-collar workers (TKA: HR 1.82 (95% CI 1.04 to 3.18)) had a higher hazard to RTW within six months postoperatively.

Conclusion

Clear differences existed in time to RTW among both THA and TKA patients in each of the groups studied. These findings may help guide tailored patient-specific information during preoperative consultation and advice postoperatively, as well as to create awareness among workers and their employers.

Return to Sports and Return to Work After Total Hip Arthroplasty: A Systematic Review and Meta-analysis

BACKGROUND

Return to work (RTW) and sports (RTS) are critical gauges to improvement among patients after total hip arthroplasty (THA). This study aimed to determine rates, timelines, and prognostic factors associated with RTW and RTS outcomes after primary THA.

METHODS

A systematic review was conducted on MEDLINE, EMBASE, and CENTRAL databases with 57 studies meeting inclusion/exclusion criteria. The risk of bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions and risk of bias in randomized trials (RoB2) tools. Meta-analysis and pooled analysis were conducted, with forest plots to summarize odds ratios and 95% confidence interval (CI).

RESULTS

The pooled RTW rate across all studies was 70% (95% CI, 68%-80%), with rates varying significantly from 11% to 100%. The mean time to RTW was 11.2 weeks (range 1-27). A time point analysis showed increasing RTW rates with a maximum rate at 2 years of 90%. Increased age (p < 0.001) and preoperative heavy labor (p = 0.005) were associated with lower RTW rates. The RTS rate ranged from 42% to 100%, with a pooled rate of 85% (95% CI, 74%-92%). The mean time to RTS was 16.1 weeks (range 8-26). The RTS ranged from 20% to 80% with a pooled proportion of 56% (95% CI, 42%-70%, I2 = 90%) for high-intensity sports and from 75% to 100% for low-intensity sports with a pooled proportion of 97% (95% CI, 83-99, I2 = 93%).

CONCLUSION

Most patients RTW and RTS after THA in an increasing manner as time passes with rates more than 85% after 1 year. These rates may be greatly affected by various factors, most notably age, the intensity of the sport, and the type of work performed. In general, young patients, low-demand work or sports can be resumed as soon as 4 to 6 weeks after surgery, but with increased restrictions as the intensity increases. This information should be used by practitioners to manage postoperative expectations and provide appropriate recommendations to patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Return to work following primary total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND

Total hip arthroplasty (THA) is increasingly common in younger patients, who are more likely to be working preoperatively. There is a need for an updated review of the literature regarding the rate and time to return to work (RTW), which is important when counseling patients, and also from an economic standpoint.

METHODS

A systematic review and meta-analysis of the literature was performed on January 20, 2022, and studies reporting the rate and/or time to RTW after THA were included. Two authors independently selected relevant papers. RTW was extracted and analyzed using fixed-effects or random-effects models where appropriate.

RESULTS

A total of 48 studies were included in the final analysis. We found that 70.7% of patients were working after primary THA. Among patients who were working before surgery, this rate increases to 87.9%, while 28.1% of patients who were not working preoperatively started working after surgery. Younger patients were more likely to RTW, while patients with a physically demanding job were less likely to RTW. Minimally invasive techniques were reported to yield a higher rate of RTW and an earlier time to RTW.

CONCLUSION

We found that the majority of patients return to work after THA, and some patients are able to start working after surgery. Compared to previous reviews, patients seem to have a higher rate and earlier RTW. The overall trend of the literature suggests that patients are returning to work earlier and at a higher rate compared to previous reviews.

Function and employment after total hip replacement in older adults: A narrative review

The burden of osteoarthritis (OA) has increased steadily due to an aging population, increasing life expectancy, obesity and lifestyle factors. Total hip replacement has become one of the most prevalent and successful operations globally and it is projected that demand will continue to grow as the incidence of OA continues to increase. Patients undergoing the operation expect much-improved function and pain relief but also increasingly need to return to work postoperatively, especially given the growing demand for the procedure and the encouragement of older people to continue working by most governments in the developed world. This review provides an overview of function and employment outcomes after hip arthroplasty. Despite the generally good success rate, some patients do not attain good functional outcomes and it is important that we develop ways to identify these patients preoperatively. We describe the effect of demographic, clinical and other factors on functional outcomes, as well as trajectories of physical function and pain recovery beyond the first few weeks after total hip replacement. Regarding employment outcomes, many people in work preoperatively are likely to resume to work after recovery; however, patients feel that they lack guidance from clinicians about returning to work postoperatively. Our review encompasses factors associated with return to work, timing of return to work, and potential temporary or permanent limitations that people might experience at work depending on type of employment.

Return to Sports After Total Hip Arthroplasty: An Umbrella Review for Consensus Guidelines

BACKGROUND

Current recommendations on safe return to sports (RTS) after total hip arthroplasty (THA) are subjective and based on studies of varying quality.

PURPOSE

The aim of this study was to synthesize systematic reviews and meta-analyses on post-THA RTS to propose practice guidelines identifying which sports can be resumed, when they can be resumed, and what risks are present.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

This umbrella review followed the Joanna Briggs Institute (JBI) protocol and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The Embase, Medline, and Cochrane databases were searched. Included studies were either systematic reviews or meta-analyses addressing primary or secondary outcomes. Outcomes of interest included safe sports after THA, time to RTS, prognostic indicators of RTS, reasons patients do not RTS, percentage of patients who RTS, implant complications, and objective classification of sports by impact level. Included reviews had data extracted and were assessed for methodological quality using the JBI protocol. The authors defined RTS as "returning to a sport the patient participated in at any point preoperatively."

RESULTS

Patients demonstrated a trend toward lower-impact sports postoperatively. Sports were classified as low (eg, walking), moderate (eg, downhill skiing), or high impact (eg, soccer). A total of 82% (range, 55%-104%) of patients were able to RTS at a mean time of 6 months (range, 4-7 months). The best prognostic indicator for RTS was previous experience in that sport. The main reason patients did not RTS was surgeon recommendation. Aseptic loosening was the most cited complication after RTS.

CONCLUSION

Most patients are able to return to preoperative levels of low- (eg, walking) and moderate-impact (eg, hiking) sports between 7 and 12 months after THA. Patients planning a return to high-impact (eg, singles tennis) sports should be counseled on the possible risks of traumatic injuries and aseptic loosening and monitored closely.

Sports activity participation and subjective health status of patients after total hip arthroplasty via the anterolateral-supine approach: a case series study

Background

No reports have been published about participation in sports activity and subjective health status after total hip arthroplasty via the anterolateral approach in the supine position (ALS-THA) in Japanese patients. This study assessed sports activity participation and subjective health status, as well as factors potential associated with these variables, in patients who underwent ALS-THA.

Methods

Of 698 patients who underwent total hip arthroplasty at our institution between 2013 and 2018, questionnaires were sent to 355 patients under 80 years old who had undergone ALS-THA and 242 responded. Patients were asked about their subjective health status, participation in sports activity, the EuroQol 5-dimensions 5-level (EQ-5D-5L), the University of California Los Angeles (UCLA) activity scale score and the Forgotten Joint Score (FJS). Patient characteristics and hospitalization information were also collected. Patients’ subjective health status was categorized as “healthy” or “unhealthy”. Univariate and multivariate logistic regression analyses were performed to determine factors associated with participation in sports activity after ALS-THA and a “healthy” status.

Results

The pre- and postoperative sports activity participation rates were 54.0% and 57.8%, respectively. Most patients (76.8%, n = 182) were considered “healthy”. Age (P = .019) and UCLA activity score (P < .001) were significantly associated with sports activity after ALS-THA. FJS (P = .002) and EQ-5D-5L (P = .004) were significantly associated with a “healthy” status.

Conclusion

Patients participating in sports activity after ALS-THA are older and have higher UCLA activity scores and patients considered “healthy” have higher FJS and EQ-5D-5L scores.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05886-6.

Activities and participation after primary total hip arthroplasty; posterolateral versus direct anterior approach in 860 patients

BACKGROUND AND PURPOSE

In the past decade, a shift occurred in surgical total hip arthroplasty (THA) approaches to the posterolateral (PLA) and direct anterior approach (DAA). Comparisons of postoperative activities and participation between surgical approaches for THA are sparse. We therefore investigated the association between PLA and DAA for THA regarding the construct "activity and participation" (ICF model) during the first postoperative year.

PATIENTS AND METHODS

This was an observational cohort study on osteoarthritis patients scheduled for primary THA in 2 hospitals. Questionnaires to assess the ICF domain "activity and participation" were completed preoperatively, and 3, 6, and 12 months postoperatively (HOOS Activities of daily living (ADL) and Sport and Recreation Function (SR), Hospital for Special Surgery Hip Replacement Expectations Survey, and questions regarding return to work). Each hospital exclusively performed one approach (PLA [Alloclassic-Zweymüller stem] or DAA [Taperloc Complete stem]) for uncemented THA. Hospital was included as instrumental variable, thereby addressing bias by (un)measured confounders. Adjusted mixed-effect models were used, stratified by employment.

RESULTS

Total population: 238 PLA (24% employed) and 622 DAA (26% employed) patients. At 12 months, the PLA group had a lower ADL score (-7, 95% CI -12 to -2 points). At 6 months, significantly fewer PLA patients had fulfillment of the expectation sports-performance (OR = 0.3, CI 0.2-0.7]. Other outcomes were comparable. Employed population: At 6 and 12 months, PLA patients scored clinically lower on ADL (respectively -10, CI -19 to 0 and -9, CI -19 to 0 points) and SR (respectively -13, CI -21 to -4 and -9, CI -18 to -1 points). At 6 months, fewer PLA patients fulfilled the expectation joining recreational activities (OR = 0.2, CI 0.1-0.7]. Fulfillment of other expectations was comparable between groups. PLA patients less often returned to work within 3 months (31% vs. 45%), but rates were comparable at 12 months (86% vs. 87%).

INTERPRETATION

Overall, functional recovery regarding "activity and participation" was comparable for PLA and DAA. Among employed patients, DAA resulted in better functional recovery and more fulfillment of expectations compared with PLA patients. DAA might also facilitate faster return to work.

Feasibility and sustainability of working in different types of jobs after total hip arthroplasty: analysis of longitudinal data from two cohorts

OBJECTIVES

To investigate the rates of return to work and workability among working-age people following total hip arthroplasty (THA).

METHODS

Participants from the Geneva Arthroplasty Registry and the Clinical Outcomes for Arthroplasty Study aged 18-64 years when they had primary THA and with at least 5 years' follow-up were mailed a questionnaire 2017-2019. Information was collected about preoperative and post-THA employment along with exposure to physically demanding activities at work or in leisure. Patterns of change of job were explored. Survival analyses using Cox proportional hazard models were created to explore risk factors for having to stop work because of difficulties with the replaced hip.

RESULTS

In total, 825 returned a questionnaire (response 58%), 392 (48%) men, mean age 58 years, median follow-up 7.5 years post-THA. The majority (93%) of those who worked preoperatively returned to work, mostly in the same sector but higher rates of non-return (36%-41%) were seen among process, plant and machine operatives and workers in elementary occupations. 7% reported subsequently leaving work because of their replaced hip and the risk of this was strongly associated with: standing >4 hours/day (HR 3.81, 95% CI 1.62 to 8.96); kneeling/squatting (HR 3.32, 95% CI 1.46 to 7.55) and/or carrying/lifting ≥10 kg (HR 5.43, 95% CI 2.29 to 12.88).

CONCLUSIONS

It may be more difficult to return to some (particularly physically demanding) jobs post-THA than others. Rehabilitation may need to be targeted to these types of workers or it may be that redeployment or job change counselling are required.

Influence of social support on return to work after total hip or total knee arthroplasty: a prospective multicentre cohort study

OBJECTIVES

There is strong evidence that social support is an important determinant of return to work (RTW). Little is known about the role of social support in RTW after total hip or knee arthroplasty (THA/TKA). Objective was to examine the influence of preoperative and postoperative perceived social support on RTW status 6 months postoperatively.

DESIGN

A prospective multicentre cohort study was conducted.

SETTING

Orthopaedic departments of four Dutch medical centres; a tertiary university hospital, two large teaching hospitals and a general hospital.

PARTICIPANTS

Patients planned to undergo THA/TKA, aged 18-63 and employed preoperatively were included.

MAIN OUTCOME MEASURES

Questionnaires were filled out preoperatively and 3 and 6 months postoperatively and included questions to assess patients' perceived social support targeting three sources of social support: from home (friends, family), from work (coworkers, supervisors) and from healthcare (occupational physician, general practitioner, other caregivers). Control variables included age, gender, education, type of arthroplasty and comorbidities. RTW was defined as having fully returned to work 6 months postoperatively. Univariate and multivariate logistic regression analyses were conducted.

RESULTS

Enrolled were 190 patients (n=77 THA, n=113 TKA, median age was 56 years, 56% women). The majority returned to work (64%). Preoperatively, social support from the occupational physician was associated with RTW (OR 2.53, 95% CI 1.15 to 5.54). Postoperatively, social support from the occupational physician (OR 3.04, 95% CI 1.43 to 6.47) and the supervisor (OR 2.56, 95% CI 1.08 to 6.06) was associated with RTW.

CONCLUSIONS

This study underscores the importance of work-related social support originating from the occupational physician and supervisor in facilitating RTW after primary THA/TKA, both preoperatively and postoperatively. Further research is needed to confirm our results and to understand the facilitating role of social support in RTW, as arthroplasty is being performed on a younger population for whom work participation is critical.

Short-Term Functional Outcomes of Short Femoral Neck Stems Are the Same as Those of Conventional Stems in Primary Total Hip Arthroplasty

(1) Background: In this study, two types of implants were compared-a conventional hip stem and a femoral neck prosthesis. (2) Methods: The femoral neck prosthesis study group included 21 patients, while the conventional hip stem control group was 40 patients. The first examination was the pre-op check, while the next ones were performed 6 weeks, 1 year, and 3 years after surgery. The Harris Hip Score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Hip Score (OHS), University of California at Los Angeles Activity Score (UCLA), and Visual Analog Scale EQ (VAS EQ) forms were completed at each clinical study visit. (3) Results: The HHS in the femoral neck prosthesis group and the conventional hip stem group 6 weeks after surgery was 68.8 ± 16.47 and 67.6 ± 8.92, respectively, and 1 year after surgery, this was 93 ± 5.58 vs. 90.6 ± 5.17, respectively. The OHS of the femoral neck prosthesis group was 34.8 points after 6 weeks, 45.5 points after 1 year, and 43.9 points after 3 years. The respective values in the conventional hip stem group were 35.5, 41.55, and 42.13 points. The WOMAC values for the femoral neck prosthesis group were 70.6, 92.7, and 86 points, respectively, while for the conventional hip stem group, they were 74, 88.1, and 86.1 points. The UCLA scores recorded in the conventional hip stem group ranged from 3.15 to 5.05 points, but a higher mean value of 5.33 points was obtained in the femoral neck prosthesis group. VAS EQ was equal to 84 points three years after the operation. (4) Conclusions: The study showed no significant differences in the functional scores of both groups, and the new type of cervical femoral stem could be the first choice in younger patients.

Development of a clinical prediction rule to identify physical activity after total hip arthroplasty

OBJECTIVE

To develop clinical prediction rule (CPR) of physical activity at 1-year after total hip arthroplasty (THA).

DESIGN

Retrospective cohort study.

SETTING

University hospital with orthopedic surgery.

PARTICIPANTS

The study group included 321 patients (56 men) who underwent primary THA.

INTERVENTION

Not applicable.

MAIN OUTCOMES MEASURES

The data collected included age, body mass index, clinical score from the questionnaires, hip pain, range of motion, muscle strength, and Physical functions (10-Meter Walk Test, Timed Up and Go test and Sit-to-stand). Patients were classified into sufficient and insufficient activity groups based on their University of California, Los Angeles (UCLA) activity score 1 year after THA. Variables measured preoperatively and at 3 weeks postoperatively were analyzed using univariate and multivariate methods to derive CPR for physical activity.

RESULTS

A CPR was developed using the following five factors and cut-offs: age, ≤70.5 years; preoperative UCLA activity score, ≥3.5; preoperative hip abduction strength, ≥0.54 Nm/kg; preoperative knee extension strength, ≥1.04 Nm/kg; and 10-Meter Walk Test, ≤8.49 s at 3 weeks after surgery. The presence of four of the five factors predicted a sufficient physical activity level at 1-year, with a positive likelihood ratio of 5.94 and probability of 85.4%. The presence of five predictor variables increased the probability of sufficient physical activity after THA to 94.7%.

CONCLUSION

This study developed a CPR for physical activity at 1-year after THA. Having four or more of the five measurements were useful indicators for predicting of physical activity at 1 year postoperatively.

Effectiveness of self-efficacy-enhancing interventions on rehabilitation following total hip replacement: a randomized controlled trial with six-month follow-up

Background

As the world’s population ages, hip replacement, a routine treatment for arthritis, has become more common. However, after surgery, rehabilitation has some limited effectiveness with postoperative complications and persistent impairments. This study aimed to explore the effect of a self-efficacy-enhancing intervention program following hip replacement on patients’ rehabilitation outcomes (self-efficacy, functional exercise compliance, hip function, activity and social participation, anxiety and depression, and quality of life).

Methods

A prospective randomized controlled trial with a repeated-measures, two-group design was conducted in a grade A general hospital in Guangdong Province, China. A total of 150 participants with a unilateral total hip replacement were recruited via convenience sampling. Participants were randomly assigned to either the self-efficacy enhancing intervention group (n = 76) or the control group (n = 74). The intervention encompassed a face-to-face education before discharge and four telephone-based follow-ups in six months after surgery. Researchers collected baseline data on one to three days after surgery, and outcomes data were collected one, three, and six months after surgery.

Results

Average age (deviation) in intervention and control group were 58 (10.32) and 59 (10.82), respectively. After six months, intervention group scored 86.83 ± 5.89 in rehabilitation self-efficacy, significantly higher than control group (72.16 ± 6.52, t = -10.820, p < 0.001) and their hip function has turned to “excellent” (90.52 ± 4.03), while that of the latter was limited to a “middle” level (78.47 ± 7.57). Statistically significant differences were found in secondary outcomes (p < 0.001). The advantage of intervention in improving quality of life was seen in the long term rather than in the early postoperative period.

Conclusions

The self-efficacy-enhancing intervention performed by nurses induced better exercise compliance and physical, psychological, and social functions after hip replacement compared with routine care. We recommend such interventions to be combined with routine care soon after hip replacement. Further research should focus on the social participation of patients with hip replacement.

Trial registration Retrospectively registered at Chinese Clinical Trial Registry (31/01/2020, No. ChiCTR2000029422, http://www.chictr.org.cn/index.aspx).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03116-2.

Is Training With Gym Machines Safe After Hip Arthroplasty?—An In Vivo Load Investigation

Background: Training with gym machines is one of the most popular physical activities after total hip arthroplasty (THA). However, to date, there are no evidence-based recommendations for physical activity after THA, worldwide. The aim of the study is to evaluate the in vivo hip joint loads during exercises on four widely used gym machines in order to provide a source for an evidence-based patient counselling for arthroplasty surgeons.

Methods: The in vivo hip joint loads in seven patients (59.6 ± 6.4 years, 28.6 ± 2.1 kg/m²) with instrumented hip implants were assessed. The resulting force (F_res), bending moment (M_bend), and torsional moment (M_tors) were evaluated during the training on leg curl/leg extension machines (loads: 20, 30, and 40 kg), leg press machine [backrest: 10°, 30°, and 60°; load: 50, 75, and 100%BW (bodyweight)], and a rope pull machine (abduction/adduction/flexion/extension; each ipsi- and contralateral; load 10 kg). These loads were compared with the loads during walking on treadmill at 4 km/h (median peak values: F_res 303%BW, M_bend 4.25%BWm, and M_tors 2.70%BWm).

Results: In each of the four performed exercises with a total of 23 different load conditions or exercise modes analyzed, a significantly lower or not different load was detected with respect to F_res, M_bend, and M_tors measured while walking with 4 km/h. Nevertheless, F_res and M_bend demonstrated a trend to increased loading during the ipsilateral monopod standing rope pull exercises hip flexion, extension, and abduction.

Conclusion: Based on our investigation, we assume that the investigated gym machines and external loads can be considered mainly as low-impact sports (with some exceptions) and thus as safe physical activity after THA. Due to the fact that the examinations were conducted in the mean 17.4 months after THA, the applicability of the results to the immediate postoperative period is limited.

Risk of revision arthroplasty surgery after exposure to physically demanding occupational or leisure activities: A systematic review

INTRODUCTION

Lower limb arthroplasty is successful at relieving symptoms associated with joint failure. However, physically-demanding activities can cause primary osteoarthritis and accordingly such exposure post-operatively might increase the risk of prosthetic failure. Therefore, we systematically reviewed the literature to investigate whether there was any evidence of increased risk of revision arthroplasty after exposure to intensive, physically-demanding activities at work or during leisure-time.

METHODS

We searched Medline, Embase and Scopus databases (1985-July 2021) for original studies including primary lower limb arthroplasty recipients that gathered information on physically-demanding occupational and/or leisure activities and rates of revision arthroplasty. Methodological assessment was performed independently by two assessors using SIGN, AQUILA and STROBE. The protocol was registered in PROSPERO [CRD42017067728].

RESULTS

Thirteen eligible studies were identified: 9 (4,432 participants) after hip arthroplasty and 4 (7,137participants) after knee arthroplasty. Narrative synthesis was performed due to considerable heterogeneity in quantifying exposures. We found limited evidence that post-operative activities (work or leisure) did not increase the risk of knee revision and could even be protective. We found insufficient high-quality evidence to indicate that exposure to physically-demanding occupations increased the risk of hip revision although "heavy work", agricultural work and, in women, health services work, may be implicated. We found conflicting evidence about risk of revision hip arthroplasty associated with either leisure-time or total physical activities (occupational or leisure-time).

CONCLUSION

There is currently a limited evidence base to address this important question. There is weak evidence that the risk of revision hip arthroplasty may be increased by exposure to physically-demanding occupational activities but insufficient evidence about the impact on knee revision and about exposure to leisure-time activities after both procedures. More evidence is urgently needed to advise lower limb arthroplasty recipients, particularly people expecting to return to jobs in some sectors (e.g., construction, agriculture, military).

Overstretching Expectations May Endanger the Success of the “Millennium Surgery”

Total hip arthroplasty (THA) is an extremely successful treatment strategy. Patient expectations, however, have increased; if not properly guided by surgeons, at present, patients expect next to pain-free restoration of the joint and a fast return to work and sports. While the revision rates after THA also increased in younger patients, knowledge on musculoskeletal loads still remains sparse, and the current recommendations on postoperative rehabilitation are based on expert opinions only. The aim of this study was to unravel biomechanical contact conditions in “working age” (&lt;60 years, 53.5 ± 3.0 years) and “retirement age” (&gt;60 years, 67.7 ± 8.6 years) patients during activities recommended post-THA. We hypothesized that working age patients would show substantially increased hip contact loads compared to older patients. The in vivo joint contact force (Fres) and torsion torque (Mtors), reflecting the main contact load situation, experienced during activities of daily living and sports activities were measured in a unique group of 16 patients with instrumented THA. We summarized patient activities and sports recommendations after THA mentioned within the literature using PubMed (without claim of completeness). The measurements showed that younger working age patients experienced significant (p = 0.050) increased Mtors (21.52 ± 9.11 Nm) than older retirement age patients (13.99 ± 7.89 Nm) by walking. Bowling, as a recommended low-impact sport, was associated with Fres of up to 5436 N and Mtors of up to 108 Nm in the working age group, which were higher than the Fres (5276 N) and Mtors (71 Nm) during high-impact soccer. Based on our results, age was proven to be a discriminator in joint loading, with working age patients presenting with increased loads compared to retirement age patients, already during daily activities. The current patient recommendations have led to further increased joint loadings. If THA cannot be delayed in a patient, we propose counselling patients on a carefully considered return to sports, focusing on low-impact activities, as indicated hereby. The findings from this work illustrate the need to provide critical feedback to patient expectations when returning to work and sports activities. Patients returning to more intensive sports activities should be carefully monitored and advised to avoid as much overloading as possible.

Benefits of Combining Physical Therapy with Occupational Therapy in Hip Arthroplasty

(1) Background: Hip arthroplasty (HA) is a surgery that replaces the damaged hip joint with an artificial implant called a hip prosthesis. The increase in life expectancy correlated with the population aging level, to which the increase in the number of prosthetic interventions among the young population is added, translates to the imperative need to analyze the quality of life beyond the immediate postoperative period. Strict adherence to an individualized rehabilitation program (IRP), and adapted to each patient, is followed by an improved quality of life. The main goal is the recovery of the patient with HA. This study was aimed to demonstrate that an IRP, represented by physical therapy associated with occupational therapy, improves the quality of life of patients with HA; (2) Methods: In this study, conducted between 2019 and 2021, 50 patients with HA were divided into two groups: study group-group A (25 subjects compliant with the IRP) and control group-group B (25 subjects, non-compliance with the IRP). To evaluate the two study groups, we monitored the evolution of the modified Harris hip score (mHHS) in both hips (arthroplasty hip (AH), contra lateral hip (CH)), for four months, respectively 30 days before the surgery (T0) and at 90 days after the surgery (T1); (3) Results: We notice significant differences in mHHS values at 90 days-T1 after surgery, both on AH in favor of subjects from group A vs. group B (p = 0.030) and on CH, where mHHS values were statistically higher in group A compared to group B (p < 0.001). The results of our study outline at T1 moment, both on the AH (p = 0.030) and on the CH (p < 0.001), the fact that mHHS values were statistically higher in patients included in group A compared to group B. In terms of the results for mHHS, comparing AH with CH, it is noted that the number of subjects who had a good or excellent mHHS result in group A versus group B is statistically significant in the case of CH (group A: 23 (92%) vs. group B: 11 (44%), p = 0.039); (4) Conclusions: The study reveals clear advantages of HA in both hips, both in subjects who complied with the IRP and those who did not comply; the higher therapeutic benefits of IRP are outlined at the level of CH compared to AH; in patients who comply with the IRP, the mHHS parameters that have improved in both CH and AH are pain, leaning, and shoes and socks activities; in addition, limping was reduced in CH.

In vivo analysis of hip joint loading on Nordic walking novices

Objective

To evaluate the influence of Nordic walking (NW) on hip joint loads in order to determine whether it can be safely performed during postoperative physiotherapy in patients after orthopeadic surgery of the hip.

Methods

Internal hip joint loads were directly measured in vivo in 6 patients using instrumented hip prostheses during NW and ordinary walking (OW). All patients received training in two different NW techniques (double-poling and the diagonal technique) by a certified NW instructor. Measurements were conducted on a treadmill at a speed of 4 km/h on level ground, at 10% inclination and at 10% slope as well as on a level lawn at a self chosen comfortable speed. Resultant contact force (F_res), bending moment (M_bend) and torsional torque (M_tors) were compared between NW and OW as well as between both NW techniques.

Results

Joint loads showed a double peak pattern during all setups. Neither NW technique significantly influenced hip joint loads at the time of the first load peak during contralateral toe-off (CTO), which was also the absolute load peak, in comparison to OW. Compared to OW, double-poling significantly reduced F_res and M_bend at the time of the second load peak during the contralateral heel strike (CHS) on level ground both on the treadmill (− 6% and − 7%, respectively) and on the lawn (− 7% and − 9%). At 10% inclination, the diagonal technique increased F_res and M_bend at CHS (by + 6% and + 7%), but did not increase the absolute load peak at CTO.

Conclusion

Joint loads during NW are comparable to those of OW. Therefore, NW can be considered a low-impact activity and seems to be safe for patients that are allowed full weight bearing, e.g. during postoperative rehabilitation after THA.

Sports Activity and Patient-Related Outcomes after Cementless Total Hip Arthroplasty in Patients Younger than 40 Years

BACKGROUND

The management of degenerative hip diseases in young patients remains a challenge. Despite the improvement of hip-preserving procedures, total hip arthroplasty (THA) may be required in some instances. In addition, young patients undergoing THA have high expectations concerning their postoperative level of activity.

PURPOSE

(1) to define the sports activity level and the return to sports after THA, (2) to describe the modification or initiation of new sports disciplines, and (3) to report the clinically meaningful outcomes after THA in patients younger than 40 years.

METHODS

A total of 36 patients (40 hips) were prospectively analyzed at a midterm follow-up of 3.9 years. The modified Harris Hip Score (mHHS); the Visual Analog Scale (VAS) for pain; the University of California, Los Angeles (UCLA) activity scale; and sports and recreational activity levels were assessed via questionnaire. The minimal clinically important difference (MCID) was determined by calculating half of the standard deviation, and the substantial clinical benefit (SCB) as well as patient acceptable symptomatic state (PASS), were calculated by the anchor method for the mHHS.

RESULTS

At the final follow-up, there was a significant improvement in mHHS (34.1 to 92.6; p < 0.0001), UCLA (3.2 to 7.6; p < 0.0001), and VAS for pain (8 to 1; p < 0.0001). More patients were active in sports at follow-up than before surgery (44% to 92%, p < 0.0001). In addition, the duration and frequency of sports activities showed a significant increase (p < 0.0001). The MCID, SCB and PASS for mHHS were 89% and 58%, respectively. No revision surgery had to be performed.

CONCLUSION

This study showed that a large proportion of patients under 40 years of age who underwent THA increased their physical activity. Eighty-six percent of the patients were highly active, with a UCLA score ≥ 7. Furthermore, the reported MCID, SCB, and PASS for mHHS were achieved by more than 80% of patients.

In vivo loading on the hip joint in patients with total hip replacement performing gymnastics and aerobics exercises

A further increase in the number of total hip arthroplasty (THA) is predicted, in particular the number of young THA patients has raised and with it their demands. There is no standardized evidence-based rehabilitation program and no reliable guidelines for sports activities after THA. Stretching and strengthening gymnastics are routinely performed in rehabilitation and aerobics as a sport after THA. The aim of the investigation was to determine the in vivo force and moments acting on the hip prosthesis during gymnastics and aerobic exercises to provide a source for evidence-based recommendations. Hip joint loads were measured in six patients with instrumented hip implants. The resulting force F_Res, bending moment M_Bend at the neck and torsional moment M_Tors at the stem were examined during seven strengthening (with two different resistance bands) and four stretching gymnastic exercises and seven aerobic exercises with and without an aerobic step board compared to the loads during the reference activity walking. The stretching and strengthening gymnastics exercises and the aerobic exercises with and without a board demonstrated in their median peak force and moments mostly lower or similar values compared to walking. Significantly increased loads were recorded for the flexor stretching exercise in monopod stand (F_res and M_Bend), the strengthening abduction exercise on the chair (M_Tors) and the strengthening flexion exercise with the stronger resistance band (M_Tors). We also found a significant increase in median peak values in aerobic exercises with a board for the "Basic Step" (ipsilateral started F_res and M_Tors; contralateral started M_Tors), "Kickstep ipsilateral started" (F_res and M_Tors) and "Over the Top contralateral started" (F_res). The in vivo loads in THA patients during frequently performed stretching, strengthening and aerobic exercises were demonstrated for the first time. It was proved that stretching gymnastic exercises are safe in terms of resulting force, bending and torque moments for THA patients, although an external assistance for stabilization may be considered. Strengthening gymnastics exercises are reliable in terms of F_res, M_Bend and M_Tors, but, based on our data, we recommend to adhere to the communicated specific postoperative restrictions and select the resistance bands with lower tension. Aerobic exercises without an aerobic board can be considered as reliable activity in terms of force and moments for THA patients. Aerobic exercises with a board are not recommended for the early postoperative period and in our opinion need to be adapted to the individual muscular and coordinative resources.

Recommendations for Sport and Physical Activity after total Hip and Knee Arthroplasty: A Systematic Review

Due to the high success of arthroplasty, patients suffering from osteoarthritis have higher expectations regarding the relief of pain, functional recovery and capacity to perform physical and sports activity. The purpose of our article is to present a literature review based on papers published during the last decades, with emphasis on the current recommendations regarding sports after total joint replacement. We conducted a search using PubMed/Medline databases, selecting the scientific articles published between 2005-2020 which discuss the association between physical activity and total hip or knee arthroplasty. The benefits of physical activity in all kinds of joint prostheses outweigh the negative effects; therefore, the recommendation for low-impact sports (hiking, swimming, cycling or golf) at a moderate intensity is considered valid and patients with total hip or knee arthroplasty who preoperatively had a high level of physical activity can return to low-impact sports performed at moderate intensity after 3-6 months.

Direct anterior approach versus posterior approach in primary total hip replacement: comparison of minimum 2-year outcomes

INTRODUCTION

The direct anterior approach (DAA) has gained popularity in recent years for total hip arthroplasty (THA). Several authors reported significantly better early outcomes when compared to the posterior approach (PA). Nevertheless, controversy exists regarding longer-term benefits of the DAA.

METHODS

Data was prospectively collected and retrospectively reviewed for primary THAs conducted between July 2008 and July 2016. Patients who underwent DAA and PA with minimum 2-year follow-up for Harris Hip Score (HHS), Forgotten Joint Score-12 (FJS-12), Veteran RAND 12 Mental (VR-12 Mental), Veteran RAND 12 Physical (VR-12 Physical), 12-Item Short Form Survey Mental (SF-12 Mental), 12-Item Short Form Survey Physical (SF-12 Physical), visual analogue scale, and patient satisfaction were included. Propensity score matching was performed on the DAA and PA cohorts (1:1) based on the following variables: age, sex, body mass index, and laterality.

RESULTS

205 DAA hips were satisfactorily matched to 205 PA hips. The DAA group had higher scores at final follow-up for VR-12 Mental (p = 0.0145), VR-12 Physical (p = 0.0236), SF-12 Mental (p = 0.0393), and SF-12 Physical (p = 0.0391). The DAA and PA groups had comparable HHS (p = 0.0737) and FJS-12 (p = 0.2900).

CONCLUSIONS

Although the DAA and PA groups had different follow-up periods, both the DAA and PA groups reported favourable outcomes at minimum 2-year follow-up. While both groups achieved comparable scores for the majority of PROs including VAS and patient satisfaction, the DAA group achieved superior quality of life outcomes when compared with a propensity score matched group of PA surgeries.

Recommendations for return to sports after total hip arthroplasty are becoming less restrictive as implants improve

INTRODUCTION

Total hip arthroplasty (THA) surgeries are expected to exponentially increase in the upcoming years, likely because of the overall broader indication of THAs. With these developments, an increasing number of younger (< 50 years) and active patients will receive surgical interventions, and expectations for an active lifestyle will accordingly increase. In addition, surgeons now have a growing array of techniques and implant materials to choose from. Despite these developments, evidence to provide the best standard-of-care to patients with high expectations for return to sports (RTS) is scarce and urgently needed. What recommendations do arthroplasty surgeons currently make to patients with high return to sports expectations, what factors may influence their recommendations and what surgical techniques and implant specifications are considered favorable in the treatment of patients with a more active lifestyle? This study was conducted to analyze the current recommendations, patient assessment, and patient counseling after THA to identify trends and relevant factors for surgical decision-making in patients with high-RTS expectations.

MATERIAL AND METHODS

We designed a questionnaire comprising five general items and 19 specific items that included 46 sub-items for hip arthroplasty and conducted a survey among 300 German surgeons specialized in arthroplasty at the German Arthroplasty Society (AE) to assess expert opinions, recommendations, surgical decision-making, and patient counseling for patients with high expectations for RTS after THA.

RESULTS

The majority of surgeons (81.9%) were in favor of RTS after THA. Risks associated with sports after THA were considered minimal (1%), with periprosthetic fractures ranking highest, followed by hip dislocation and polyethylene wear. Some surgical decision-making was influenced by high-RTS expectations in regard to implant fixation, stem type, femoral head diameter, and bearing-surface tribology. We observed an increasingly liberal counseling of patients for high-impact sports.

CONCLUSION

With the improvement of implants and surgical techniques, surgeons are more willing to encourage patients to adopt a more active lifestyle. However, the true long-term limitations need further investigation in future studies.

LEVEL OF EVIDENCE

5 Expert opinions.

Recommendations for Patients with High Return to Sports Expectations after TKA Remain Controversial

(1) Background: Improved surgical techniques and implants in total knee arthroplasty (TKA) have led to broader indications for surgical interventions of osteoarthritis of the knee. There is a growing young and active patient subgroup with high return to sports (RTS) expectations after TKA. The current lack of evidence regarding RTS capacity in this patient cohort, requires the consolidation of experts' opinions and experiences to address the special needs among these patients. The aim of this study was to assess current expert opinions in regard to preoperative patient assessment, surgical technique and decision-making and patient counseling for these patients. (2) Methods: We performed a survey among surgeons specialized in arthroplasty with a questionnaire designed to assess current recommendations, surgical techniques, and implant preferences as well as patient counseling in patients with high expectations for RTS after TKA. (3) Results: The majority of surgeons are in favor of return to low-impact sports after TKA within 3 to 6 months. Some even recommend return to high-impact sports. Despite improvement of surgical techniques and implants, we observed no clear preference for a single surgical technique or implant specification in active patients. (4) Conclusions: Current evidence for sports-associated complications after TKA is scarce. Despite a growing array of surgical techniques and implants, the available literature is still controversial with no single surgical technique or TKA design distinguishing itself clearly from others. Surgeons' recommendations are mostly based on their experience and training. Nonetheless, we observed growing faith in modern implants with some surgeons even recommending high-impact sports after TKA.

Return to work after hip resurfacing

INTRODUCTION

Hip arthroplasty is being performed in ever-younger patients, for whom return to work is a major issue. Type of job, type of implant and comorbidities all affect outcome. Heavy manual work is harder to resume after hip replacement, and reclassification or cessation of activity may ensue. This, however, is little dealt with in the literature, although its consequences are both psychologically and financially critical. The aim of the present study was to perform a retrospective analysis of return to work after hip resurfacing (HR).

MATERIAL

A retrospective study included patients undergoing Birmingham Hip Resurfacing with at least 6 months' follow-up. Occupational status was assessed, preoperatively and at follow up, as not working, in work or retired, type of work as sedentary, manual, or strenuous, and time to return to work was noted. Clinical assessment, preoperatively and at follow-up, used Postel Merle d'Aubigné, Harris, Devane, UCLA and Oxford scores.

RESULTS

One hundred and seventeen patients were included (114 male, 3 female) for 121 HRs. Mean age was 52.9 years (range, 29-66 years). Mean follow-up was 14.3 months (range, 6-20 months), with no loss to follow-up. Crutches were abandoned in week 3 on average (range, 1-7 weeks). Four patients had no occupation; analysis focused on the other 113. At follow-up, only one patient had not resumed work, and was reclassified. The other 112 (99.1% of those in work) returned to their previous job at a mean 9.4 weeks (range, 1-22 weeks). Nine patients required therapeutic part-time work for a mean 5.3 weeks (range, 3-8 weeks). Time to return to work was significantly shorter for "sedentary" workers than "physical" (manual/strenuous) workers: 6.4 weeks (range, 1-9 weeks) versus 13.5 weeks (range, 2-22 weeks).

DISCUSSION&CONCLUSION

Return to work was feasible for almost all these young patients after HR. Sedentary work was resumed very quickly (<7 weeks), while strenuous work required 3 months' sick leave.

LEVEL OF EVIDENCE

IV.

Sport after total hip arthroplasty: undoubted progress but still some unknowns

In this review, we discuss the evidence for patients returning to sport after hip arthroplasty. This includes the choices regarding level of sporting activity and revision or complications, the type of implant, fixation and techniques of implantation, and how these choices relate to health economics. It is apparent that despite its success over six decades, hip arthroplasty has now evolved to accommodate and support ever-increasing patient demands and may therefore face new challenges. Cite this article: Bone Joint J 2020;102-B(6):661-663.

Integrated care programmes for sport and work participation, performance of physical activities and quality of life among orthopaedic surgery patients: a systematic review with meta-analysis

Objectives

Orthopaedic surgery is primarily aimed at improving function and pain reduction. Additional integrated care may enhance patient’s participation in sports and work, possibly improving performance of physical activities and quality of life (QoL). We aimed to assess the effectiveness of integrated care among orthopaedic surgery patients.

Design

Systematic review with meta-analysis.

Data source

Medline, EMBASE and CINAHL (until 17 June 2019).

Eligibility for selecting studies

We searched for controlled studies on integrated care interventions consisting of active referral to case managers, rehabilitation with participation-based goals and/or e/mHealth, with outcomes of sports and work participation, performance of physical activities and/or QoL. Outcomes were normalised to 0–100 scales and statistically pooled.

Results

Seventeen articles (n=2494) of moderate quality were included reporting on patients receiving back, upper limb, knee or hip surgery. Only one study reported on return to sports and found no significant benefit. For return to work, one study did (90% vs 82%) and one did not (relative risk=1.18 (0.80 to 1.70)) observe significant benefits. Integrated care showed small effects for improving performance of physical activities (2.69 (–0.20 to 5.58); eight studies, n=1267) and QoL (2.62 (1.16 to 5.05); nine studies, n=1158) compared with usual care.

Summary/Conclusion

We found insufficient and inconsistent evidence for the effectiveness of integrated care for orthopaedic surgery patients regarding sport and work participation. Small effects were found for performance of physical activities and QoL. High quality research on integrated care focusing on sports and work participation is needed before integrated care can be implemented for orthopaedic surgery patients.

Return to work advice after total hip and knee replacement

BACKGROUND

Little is known about the information and advice on return to work received by patients undergoing total hip and knee replacement.

AIMS

To investigate patients' views and experiences of work-related advice provided by clinicians, and how this might be improved.

METHODS

Semi-structured interviews with patients who had undergone total hip and knee replacement, were working prior to surgery and intended to return to work. Data were analysed thematically.

RESULTS

Forty-five patients from three UK regions were consented. Eight themes were identified including lack of information, lack of an individualized approach and accessibility and acceptability of information dissemination methods. Patients identified their information needs and who they felt was best placed to address them.

CONCLUSIONS

Patients receive little information and advice on return to work following total hip and knee replacement, although not all patients required this. However, more focus is needed on providing this, and patients should be screened to ensure resources are best targeted with interventions being tailored to the individual.

Therapeutic exercise and radiofrequency in the rehabilitation project for hip osteoarthritis pain

BACKGROUND

Severe hip osteoarthritis is responsible for disabling pain and functional impairment of the joint. Although total hip arthroplasty (THA) is a successful treatment, some patients have multiple comorbidities that represent contraindications for THA. Conventional drug therapies are often ineffective or responsible for numerous side effects. For these patients, it is difficult to draw up an acceptable rehabilitation path, as the main limitation is intense pain. New rehabilitation strategies that relieve pain and improve articular function need to be developed. The combination of traditional treatments such as education and therapeutic exercise with innovative, minimally-invasive therapies such as continuous radiofrequency (CRF) appears to reduce hip pain by determining the neurolysis of the joint.

AIM

The aim of our study was to describe the reduction in pain and improvements in joint function when CRF is combined with the therapeutic exercise in rehabilitation of patients with severe hip osteoarthritis.

DESIGN

Case series study.

SETTING

Rehabilitation service outpatients.

POPULATION

Twenty-five patients with severe hip osteoarthritis causing disabling pain and with contraindications to THA, and for whom conventional drug therapies were ineffective or responsible for numerous side effects.

METHODS

The study design included: initial clinical-functional assessment using the Harris Hip Score (HHS), the Numeric Rating Scale (NRS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); a pre-lesion anaesthetic block; hip neuroablation with CRF; a three-week kinesitherapy protocol (3 sessions per week); two further assessments using the same scales one month (T1) and six months (T2) after CRF.

RESULTS

Improvements at T1 and T2 follow-ups, after CRF (P=0.000) were recorded for articular pain and function. However, results at T2 were worse than those at T1 (P=0.000).

CONCLUSIONS

CRF combined with therapeutic exercise in rehabilitation of severe hip osteoarthritis is an attractive option for significant pain relief as it allows patients to carry out kinesitherapy more easily.

CLINICAL REHABILITATION IMPACT

CRF could represent a valid alternative in the rehabilitation of patients with severe hip osteoarthritis especially when other therapeutic approaches are unworkable.

Influence of Preoperative Tibiotalar Alignment in the Coronal Plane on the Survival of Total Ankle Replacement: A Systematic Review

BACKGROUND

It remains controversial whether significant preoperative tibiotalar varus and valgus deformity should be contraindications for total ankle replacement (TAR). The primary aim of this systematic review was to analyze the influence of preoperative tibiotalar varus and valgus alignment on the survival of TAR.

METHODS

The databases MEDLINE and Embase were searched from onset through September 2018. Two authors performed study selection and data extraction using a predefined data extraction tool. Implant survival in the alignment groups was reported as "revisions per 100 component years." Additional procedures, complications, and revisions were also reported. Assessment of the methodological quality was performed using the Newcastle-Ottawa Scale (NOS).

RESULTS

In total, 17 studies were considered eligible, in which a total of 1692 TARs were included from 1627 patients. The weighted mean follow-up was 52.4 (range, 1-147) months. The neutral alignment group included 711 TARs, the varus group included 545 TARs, and the valgus group included 332 TARs. Total revisions were 52, 37, and 36 in the preoperative tibiotalar neutral, varus, and valgus alignment groups, respectively. Revisions per 100 observed component years were 1.6, 1.7, and 2.5 in the preoperative tibiotalar neutral, varus, and valgus alignment groups, respectively. A total of 129 complications and 447 additional procedures were reported in 601 TARs.

CONCLUSION

There was a strong indication that preoperative varus alignment in the coronal plane had a comparable implant survival to neutral alignment. Preoperative valgus alignment demonstrated a more negative influence on implant survival.

LEVEL OF EVIDENCE

Level III, systematic review.

Genetic Predisposition to Developmental Dysplasia of the Hip

BACKGROUND

The etiopathogenesis of developmental dysplasia of the hip (DDH) has not been clarified. This systematic review evaluated current literature concerning all known chromosomes, loci, genes, and their polymorphisms that have been associated or not with the prevalence and severity of DDH.

METHODS

Following the established methodology of Meta-analysis of Observational Studies in Epidemiology guidelines, MEDLINE, EMBASE, and Cochrane Register of Controlled Trials were systematically searched from inception to January 2019.

RESULTS

Forty-five studies were finally included. The majority of genetic studies were candidate gene association studies assessing Chinese populations with moderate methodological quality. Among the most frequently studied are the first, third, 12th,17th, and 20th chromosomes. No gene was firmly associated with DDH phenotype. Studies from different populations often report conflicting results on the same single-nucleotide polymorphism (SNP). The SNP rs143384 of GDF5 gene on chromosome 20 demonstrated the most robust relationship with DDH phenotype in association studies. The highest odds of coinheritance in linkage studies have been reported for regions of chromosome 3 and 13. Five SNPs have been associated with the severity of DDH. Animal model studies validating previous human findings provided suggestive evidence of an inducing role of mutations of the GDF5, CX3CR1, and TENM3 genes in DDH etiopathogenesis.

CONCLUSION

DDH is a complex disorder with environmental and genetic causes. However, no firm correlation between genotype and DDH phenotype currently exists. Systematic genome evaluation in studies with larger sample size, better methodological quality, and assessment of DDH patients is necessary to clarify the DDH heredity. The role of next-generation sequencing techniques is promising.

Hip Arthroplasty with Increased Expectancy

The patient's demands and expectations after total hip arthroplasty have increased significantly. In particular, the athletic function is the focus of the patient's interest, whereby not the basic sports ability is inquired, but also the achievable sports level. The benefits of increased activity with a reduction in cardiovascular mortality and the minimization of osteoporosis risk are contrasted by amplified wear followed by prosthesis loosening. Activities are categorized in low-, intermediate- and high-impact kind of sport. Patient-based influencing factors such as physical condition and expertise in his sport, as well as the self-reference of the surgeon to the desired sport influence the recommendation and advice of the patient. Innovations in prosthesis design and materials technology allow meeting patient's expectations and aiming to improve the return to sport. After total hip arthroplasty, the majority of preoperatively active patients return to athletic activity, although there is a tendency to shift from "high-impact" to "low-impact" sports. The currently recommended sports include swimming, cycling, Nordic walking, sailing, golf, hiking, dancing and cross-country skiing. A limited recommendation exists for tennis (single), alpine skiing, mountain hiking and sportive running. Not recommended are marathon, football, handball, volleyball, basketball, martial arts, high jump, water skiing and rock climbing. The recommendations are based primarily on expert opinions and are in a progressive extension including "high-impact" sports.

Gait after Birmingham Hip Resurfacing: an age-matched controlled prospective study

Aims

The aim of this study was to assess the functional gain achieved following hip resurfacing arthroplasty (HRA).

Patients and Methods

A total of 28 patients (23 male, five female; mean age, 56 years (25 to 73)) awaiting Birmingham HRA volunteered for this prospective gait study, with an age-matched control group of 26 healthy adults (16 male, ten female; mean age, 56 years (33 to 84)). The Oxford Hip Score (OHS) and gait analysis using an instrumented treadmill were used preoperatively and more than two years postoperatively to measure the functional change attributable to the intervention.

Results

The mean OHS improved significantly from 27 to 46 points (p < 0.001) at a mean of 29 months (12 to 60) after HRA. The mean metal ion levels at a mean 32 months (13 to 60) postoperatively were 1.71 (0.77 to 4.83) µg/l (ppb) and 1.77 (0.68 to 4.16) µg/l (ppb) for cobalt and chromium, respectively. When compared with healthy controls, preoperative patients overloaded the contralateral good hip, limping significantly. After HRA, patients walked at high speeds, with symmetrical gait, statistically indistinguishable from healthy controls over almost all characteristics. The control group could only be distinguished by an increased push-off force at higher speeds, which may reflect the operative approach.

Conclusion

Patients undergoing HRA improved their preoperative gait pattern of a significant limp to a symmetrical gait at high speeds and on inclines, almost indistinguishable from normal controls. HRA with an approved device offers substantial functional gains, almost indistinguishable from healthy controls.

Cite this article: Bone Joint J 2019;101-B:1423–1430.

Total hip and knee replacement and return to work: clinicians' perspectives

PURPOSE

An ageing workforce means that our understanding of return to work following total hip and knee replacement is of increasing importance. The purpose of this qualitative study was to explore the views and experiences of clinicians in treating working patients undergoing total hip or knee replacement.

MATERIALS AND METHODS

We conducted semi-structured interviews in primary and secondary National Health Service care using framework methodology. A total of 40 interviews were conducted. Participants included 12 hospital-based Allied Health Professionals and nurses, 12 orthopedic surgeons, and 16 General Practitioners. Data were analyzed thematically.

RESULTS

A key theme concerned participants' perceptions and experiences around the process and practice of listing working patients for total hip or knee replacement. Four sub-themes were identified; the perceived likelihood of listing employed patients for surgery, expectations and outcomes of surgery, the impact of work issues, and referral procedures and waiting lists.

CONCLUSIONS

Decisions around listing working patients for total hip and knee replacement are complex and difficult. Clinicians need to consistently consider patients' work issues, and to be supported in this by appropriate commissioning and service delivery decisions. Further research is indicated to better understand the work-related expectations and anticipated outcomes of both patients and clinicians, and the optimum timing of surgery to maintain and improve patients' work performance.Implications for rehabilitationClinicians need to consistently consider patients' work issues, and current evidence, in their consultations and decisions regarding total hip and knee replacement.Clinical practice should reflect the growing proportion of working patients undergoing total hip and knee replacement, and routinely measure work outcomes.Changes are required at commissioning and service levels to support clinicians in changing their practice with this patient population.

Low return-to-sports rate after elbow injury and treatment with radial head arthroplasty

BACKGROUND

The aim of this study was to analyze sports participation after radial head arthroplasty among recreational athletes.

METHODS

A total of 57 recreational athletes (mean age, 49 years; age range, 18-79 years) treated with radial head arthroplasty for non-reconstructible radial head fractures were included in this retrospective study. The return-to-sports rate and the time to return to sports were analyzed. The clinical and radiologic outcomes were compared between patients who returned to sports (group 1) and those who did not (group 2).

RESULTS

After a mean follow-up period of 8.4 years (range, 2.5-16.4 years), 30 of 57 patients (53%) had returned to sports. The mean sports frequency significantly decreased from 5.2 ± 5.0 h/week to 2.2 ± 2.9 h/week after surgery (P < .001). In group 1, 83% of patients returned to the same sports activity whereas 17% changed to a less demanding sports activity. The mean time to return to sports was 158 days (range, 21-588 days). Patients who returned to sports had a significantly better Mayo Elbow Performance Score (MEPS) (84 ± 19 points vs. 63 ± 20 points, P < .001); Disabilities of the Arm, Shoulder and Hand score (16 ± 17 vs. 46 ± 22, P < .001); and arc of flexion (114° ± 32° vs. 89° ± 36°, P = .007). A secondary radial head prosthesis (P = .046) and MEPS lower than 85 points (P = .001) were associated with a significantly lower return-to-sports rate. No differences regarding radiographic changes were found between the 2 groups (P ≥ .256).

CONCLUSION

The return-to-sports rate after radial head replacement is low. A secondary radial head prosthesis and a worse clinical outcome (MEPS < 85 points) significantly increase the risk of not returning to sports after radial head arthroplasty.

Managing Employees Undergoing Total Hip and Knee Replacement: Experiences of Workplace Representatives

Introduction There is little research on return to work (RTW) from a workplace perspective following hip and knee replacement (THR/TKR) despite employers and other workplace personnel having a key role. Our aim was to explore the experiences of individuals in the workplace in managing employees undergoing THR/TKR. Methods Employers and other workplace representatives from a cross-section of employment sectors and sizes, with experience of managing employees undergoing THR/TKR in the previous 12 months, were recruited. Interviewees included small business owners, line managers, colleagues, human resources managers and occupational health advisers. Semi-structured, qualitative interviews were conducted and data were analysed thematically. Results Twenty-five individuals were interviewed. The main themes identified were accommodating the employee, and barriers and facilitators to RTW. Accommodations included changes to the work environment, amended duties, altered hours, changed roles and colleague support. Perceived barriers and facilitators to RTW included the role of GPs and occupational health, surgical issues, characteristics of the work environment and of employees. Conclusions Employers are motivated to effect supported RTW for employees undergoing THR/TKR but have insufficient guidance. Strategies are required to signpost employers to existing RTW advice, and to develop recommendations specific to lower limb arthroplasty. Communication between medical practitioners and employers should be facilitated in order to enhance the RTW experience of individuals undergoing THR/TKR.

Return to work after primary total hip arthroplasty: a nationwide cohort study

Background and purpose - While the number of working-age patients undergoing total hip arthroplasty (THA) is increasing, the effect of the surgery on patients' return to work (RTW) is not thoroughly studied. We aimed to identify risk factors of RTW after THA among factors related to demographic variables, general health, health risk behaviors, and socioeconomic status. Patients and methods - We studied 408 employees from the Finnish Public Sector (FPS) cohort (mean age 54 years, 73% women) who underwent THA. Information on demographic and socioeconomic variables, preceding health, and health-risk behaviors was derived from linkage to national health registers and FPS surveys before the operation. The likelihood of return to work was examined using Cox proportional hazard modeling. Results - 94% of the patients returned to work after THA on average after 3 months (10 days to 1 year) of sickness absence. The observed risk factors of successful return to work were: having < 30 sick leave days during the last year (HR 1.8; 95% CI 1.4-2.3); higher occupational position (HR 2.2; CI 1.6-2.9); and BMI < 30 (HR 1.4; CI 1.1-1.7). Age, sex, preceding health status, and health-risk behaviors were not correlated with RTW after the surgery. Interpretation - Most employees return to work after total hip arthroplasty. Obese manual workers with prolonged sick leave before the total hip replacement were at increased risk of not returning to work after the surgery.

Clinical efficacy of orthopilot navigation system versus conventional manual of total hip arthroplasty: A systematic review and meta-analysis

BACKGROUND

To compare the clinical efficacy between Orthopilot navigation system and conventional manual surgery in total hip arthroplasty (THA).

METHODS

Electronic databases were searched to identify randomized controlled trials (RCTs) investigating Orthopilot navigation system versus conventional manual in patients undergoing THA. Outcome measurements include anteversion angle, inclination angle, preoperative leg length discrepancy, postoperative leg length discrepancy and femoral offset. Statistical software Stata 12.0 was used for data-analysis.

RESULTS

A total of 5 studies were finally included in this meta-analysis. The results showed that the conventional manual group have a less anteversion angle than that in Orthopilot navigation system group (weighted mean difference (WMD) = 4.67, 95% confidence interval (CI) = 3.53, 5.82, P = .000). And pooled analysis showed that the inclination angle in Orthopilot navigation group was less than that in conventional manual group (WMD = -4.19, 95% CI = -8.00, -0.37, P = .031). There was no significant difference between the preoperative leg length discrepancy and postoperative leg length discrepancy (P > .05). Orthopilot navigation system compared with conventional manual procedure was associated with decreased of femoral offset by 2.76 (WMD = -2.76, 95%CI = -3.90, -1.62, P = .000).

CONCLUSION

Both Orthopilot navigation system and conventional THA result in significant improvements in patient function with similar overall complication rates and have their own edges in cup position.

A pragmatic approach to prevent post-traumatic osteoarthritis after sport or exercise-related joint injury

Lower extremity musculoskeletal injuries are common in sport and exercise, and associated with increased risk of obesity and post-traumatic osteoarthritis (PTOA). Unlike other forms of osteoarthritis, PTOA is common at a younger age and associated with more rapid progression, which may impact career choices, long-term general health and reduce quality of life. Individuals who suffer an activity-related joint injury and present with abnormal joint morphology, elevated adiposity, weak musculature, or become physically inactive are at increased risk of PTOA. Insufficient exercise therapy or incomplete rehabilitation, premature return-to-sport and re-injury, unrealistic expectations, or poor nutrition may further elevate this risk. Delay in surgical interventions in lieu of exercise therapy to optimize muscle strength and neuromuscular control while addressing fear of movement to guarantee resumption of physical activity, completeness of rehabilitation before return-to-sport, education that promotes realistic expectations and self-management, and nutritional counseling are the best approaches for delaying or preventing PTOA.

Clinical efficacy of OrthoPilot navigation system versus conventional manual total hip arthroplasty: A systematic review and meta-analysis

Objective

This study was performed to compare the clinical efficacy between the OrthoPilot navigation system and conventional manual surgery in patients undergoing total hip arthroplasty.

Methods

The Embase, PubMed, CINAHL, and Cochrane databases were searched for clinical trials. The outcome measurements were the anteversion angle, inclination angle, and complications. Review Manager 5.3 statistical software was used for the data analysis.

Results

Significant differences were found in the femoral offset and overall complication rate between the conventional and navigation groups. Additionally, the conventional group had significantly less anteversion than the navigation group. However, the navigation group had significantly better inclination. The operation time was significantly shorter in the conventional than navigation group.

Conclusion

Both the OrthoPilot navigation system and conventional total hip arthroplasty result in significant improvements in patient function with similar overall complication rates and have their own advantages in achieving good cup position. The conventional procedure has a shorter operation time than does use of a navigation system.