Knee arthroplasties have similar results in high- and low-activity patients

Patients Regularly Return to Medium- and Low-Impact Types of Sporting Activities Following Distal Femoral or Proximal Tibial Replacement After Resection of a Primary Bone Sarcoma

BACKGROUND

Little is known about the resumption of sporting activities following megaprosthetic reconstruction of the distal femur and proximal tibia after resection of a bone sarcoma. Thus, the aims of our study were: (1) to assess the functional outcome; (2) to evaluate pre- and post-operatively performed sporting activities; and (3) to identify potential beneficial and limiting factors.

METHODS

Between 1993 and 2015, a total of 230 patients underwent distal femoral replacement (DFR), and 96 patients underwent proximal tibial replacement (PTR). The exclusion criteria were death, amputation, living overseas, and a congenital disability. Functional outcome and sporting activities were assessed using the Musculoskeletal Tumor Society Score (MSTS), Toronto Extremity Salvage Score (TESS), Forgotten Joint Score (FJS), subjective knee value (SKV), the Tegner activity score (TS), and the modified weighted activity score (WAS).

RESULTS

There were 93 patients who had a median follow-up of 182 months (interquartile range (IQR) 130 to 260) after DFR with the following median scores: MSTS 18 (IQR 12 to 23), TESS 75% (IQR 60 to 84), FJS 25 (IQR 8 to 40), SKV 53% (IQR 40 to 70), TS 3 (IQR 3 to 4), and WAS 4 (IQR 0 to 8). There were 42 patients who had a median follow-up of 193 months (IQR 137 to 244) after PTR had the following median scores: MSTS 17 (IQR 15 to 22), TESS 78% (IQR 68 to 88), FJS 32 (IQR 20 to 46), SKV 60% (IQR 40 to 70), TS 3 (IQR 3 to 4), and WAS 4 (IQR 1 to 10). Postoperatively, 61% of DFR and 76% of PTR patients participated in at least one sporting activity.

CONCLUSIONS

The functional outcome is overall good with a regular resumption of sporting activities. Patients' age at surgery and higher preoperative sporting levels were associated with better functional outcomes and higher postoperative sporting activity.

Understanding the impact of physical activity level and sports participation on implant integrity and failure in patients following unicompartmental and total knee arthroplasty: A scoping review

Objective

Recommendations discouraging high levels of physical activity and sports following unicompartmental (UKA) and total knee arthroplasty (TKA) have been questioned in recent years. This scoping review aimed to summarize the literature examining the impact of physical activity level and sports participation on implant integrity and failure in patients following UKA and TKA.

Methods

Five databases (Medline, Embase, SCOPUS, CINAHL, ProQuest) were searched up to April 17, 2024. Retrospective, prospective and cross-sectional studies were included if they assessed the impact of physical activity level and/or sports participation (exposure variables) on implant integrity and/or failure (outcome variables) at ≥1 year following UKA or TKA. Two authors independently conducted abstract/full text reviews and data charting. Extracted data were summarized using descriptive analysis.

Results

Of 2014 potential records, 20 studies (UKA: n ​= ​6 studies, 2387 patients/TKA: n ​= ​14 studies, 7114 patients) met inclusion criteria. Following both UKA & TKA, most patients regularly participated in light to moderate physical activities and lower impact sports (e.g. walking, cycling, golf). No studies reported a deleterious effect of physical activity level or sports participation on implant integrity or failure post UKA (mean follow-up: 3.3-10.3 years). Three studies reported an association between greater levels of physical activity with increased risk of implant failure post TKA (mean follow-up: 1-11.4 years).

Conclusions

No studies demonstrated an association between greater levels of physical activity and sports participation with increased implant wear or failure post UKA, whereas results were mixed following TKA. There is a need for large, prospective cohort studies with long-term follow-up.

Return to athletics after total knee arthroplasty: a survey study of 784 recreational athletes across 12 sports

BACKGROUND

Postoperative return to recreational activity is a common concern among the increasingly active total knee arthroplasty (TKA) patient population, though there is a paucity of research characterizing sport-specific return and function. This study aimed to assess participation level, postoperative return to activity, sport function, and limitations for recreational athletes undergoing TKA.

METHODS

A survey of recreational sports participation among primary, elective TKA patients from a single academic center between June 2011 and January 2022 was conducted. Of the 10,777 surveys administered, responses were received from 1,063 (9.9%) patients, among whom 784 indicated being active in cycling (273 [34.8%]), running (33 [4.2%]), jogging (68 [8.7%]), swimming (228 [29.1%]), tennis (63 [8.0%]), skiing (55 [7.0%]), or high-impact team sports (64 [8.2%]) between two years preoperatively and time of survey administration, and were included for analyses.

RESULTS

Cycling (62.3% at two years preoperatively vs. 59.0% at latest follow-up) and swimming (62.7% at two years preoperatively vs. 63.6% at latest follow-up) demonstrated the most favorable participation rate changes, while running (84.0% at two years preoperatively vs. 48.5% at latest follow-up) and skiing (72.7% at two years preoperatively vs. 45.5% at latest follow-up) demonstrated the least favorable participation rate changes. The majority of respondents were "satisfied" or "very satisfied" with their return across all sports, though dissatisfaction was highest among runners and joggers. For cycling, running, jogging, and swimming, respondents most commonly reported no change in speed or distance capacity, though among these cyclists reported the highest rates of improved speed and distance. The majority of returning skiers reported improved balance, form, and ability to put on skis.

CONCLUSION

Return to sport is feasible following TKA with high satisfaction. Swimming and cycling represent manageable postoperative activities with high return-rates, while runners and joggers face increased difficulty returning to equal or better activity levels. Patients should receive individualized, sports-specific counseling regarding their expected postoperative course based on their goals of treatment.

Comprehensive evaluation of risk factors for aseptic loosening in cemented total knee arthroplasty: A systematic review and meta-analysis

Purpose

Aseptic loosening is the most common cause for revisions after total knee arthroplasty (TKA). Despite many studies exploring various risk factors associated with aseptic loosening, findings often present inconsistencies. To address this, we conducted a thorough review of the literature to identify and analyse these risk factors in cemented TKA. Additionally, we performed a meta-analysis to reconcile the divergent conclusions observed across studies.

Methods

We searched PubMed, Web of Science and Embase from 1996 up to 2024 and evaluated the quality of the included literature. Seventy-four studies were included to assess the association of BMI, diabetes, high physical activity (HPA), osteoporosis, rheumatoid arthritis (RA), cement material and implant design. Twenty-nine studies were used to calculate relative risk and CIs (using the random effects theory) and study heterogeneity for six different risk factors (BMI, diabetes, HPA level, cement material, polyethylene and implant design).

Results

Patients with diabetes are eight times more likely to experience aseptic loosening compared to those without diabetes (RR = 9.18, 95% CI: 1.80-46.77, p < 0.01). The use of tibial stem extension or highly crosslinked polyethylene can help reduce the incidence of aseptic loosening. However, we did not identify BMI, HPA, osteoporosis, RA, the use of high-viscosity cement and the utilization of mobile-bearing designs as risk factors for aseptic loosening post-cemented TKA.

Conclusions

Patients with diabetes undergoing TKA should be counselled regarding their potential increased risk of aseptic loosening. The use of tibial stem extensions and HXLPE can mitigate the incidence of aseptic loosening in cemented TKA. However, given a limited number of studies were included in the meta-analysis, we believe that higher-level studies are necessary to clearly identify other risk factors.

Level of Evidence

Level III.

Distal Humeral Replacement in Patients with Primary Bone Sarcoma: The Functional Outcome and Return to Sports

Distal humeral replacement (DHR) is a limb-salvage option for the endoprosthetic reconstruction of bone defects following the resection of a primary bone sarcoma. As primary bone sarcomas are only occasionally located around the distal humerus, there is a paucity of information regarding postoperative function, and patients' resumption of sporting activities. With advances in diagnostics and in surgical and oncological treatment leading to an increased patient life expectancy and higher quality of life, patients' functional outcome and return to sports activities are of increasing interest. Between 1997 and 2021, a total of 24 patients underwent DHR with a single-design modular implant at a tertiary sarcoma center. A total of 14 patients who died of their disease were excluded, leaving a study cohort of 10 patients, with a median age of 30 years on the day of surgery (IQR 20-37). At the last follow-up, after a median of 230 months (IQR 165-262), the median MSTS was 19 (IQR 13-24), the median TESS was 79 (IQR 66-87), the median SEV was 38% (IQR 24-53), the median TS was 6 (IQR 4-7), and the median WAS was 3 (IQR 1-8). Among the variables of gender, surgery on the dominant extremity, intraoperative nerve resection, extra-articular tumor resection, chemotherapy, radiotherapy, and revision surgeries, none were associated with a better/lower functional outcome score or return to sports activities. However, a higher level of sports performance prior to diagnosis (WAS > 10) was associated with a higher level of sports performance postoperatively (p = 0.044).

Total knee arthroplasty improves sports activity and the patient-reported functional outcome at mid-term follow-up

PURPOSE

The purpose of this study was to assess (1) sports participation and preference for the type of sports activity after TKA, (2) mid-term functional outcome and activity level, (3) correlation of different age groups with activity level and functional outcomes, and (4) mid-term survivorship of the prosthesis.

METHODS

A retrospective review of prospectively collected data was performed. 182 patients were included who underwent primary TKA between January 2010 and December 2016. Inclusion criteria were symptomatic knee osteoarthritis, age 50-90 years, and with a minimum of 5-year follow-up after TKA. Patients with rheumatoid arthritis and revision TKA were excluded. Sports participation and sports preference, Oxford Knee Score (OKS), Tegner Activity Level, and Visual Analogue Scale (VAS) for pain were recorded pre- and postoperatively at 6 months, 1 year, 2 years, and 5 years. The patient cohort was subdivided according to age groups; activity levels, patient-reported outcomes, and improvement in knee pain were correlated with these age groups. Kaplan-Meier curves were used to investigate survivorship at a minimum of 5 years.

RESULTS

The mean age of the cohort was 75.6 ± 7.2 years (range 52-89). Significant improvement was noted in sports participation (p < 0.003). After TKA, there was no change in the preference for sports and none of the patients had to discontinue their sporting activity. OKS improved significantly at all follow-up time points compared to the preoperative score (p < .0001). Patients' sports and physical activity improved significantly at 1 year compared to the preoperative activity level (p < 0.001). Although the Tegner activity level improved over time, this improvement was not significant (NS), while it was significantly higher in males than in females (p < 0.004). Significant improvement was found in the VAS for pain at all follow-up time points compared to the preoperative score (p < .0001). Survivorship was found to be 100% at a 5-year follow-up.

CONCLUSION

After TKA, patients can be able to return to sporting activity or even perform better than before surgery. Maximum improvement was noted in the first post-operative year. The male and younger groups perform better than the female and older groups. Sports and physical activity do not negatively impact survivorship of the knee prosthesis at mid-term follow-up and all patients are encouraged to take up sports participation after their TKA.

LEVEL OF EVIDENCE

Level 3.

A high physical activity level after total knee arthroplasty does not increase the risk of revision surgery during the first twelve years: A systematic review with meta-analysis and GRADE

BACKGROUND

High physical activity (HPA) levels after total knee arthroplasty (TKA) might be related to increased wear and subsequent aseptic loosening, negatively affecting TKA survival. This systematic review studied the association between activity levels and risk of revision surgery at medium (3-10 years) and long term (>10 years) follow up in patients with TKA.

METHODS

Databases (PubMed, Embase) were searched up to 12 October 2021. Studies comparing low physical activity (LPA) and HPA levels in TKA patients and related risk of revision surgery were eligible for inclusion. After data extraction and evaluation of methodological quality, a meta-analysis was performed. Quality of evidence was assessed using the GRADE framework. PROSPERO registration: CRD42020194284.

RESULTS

Five cohort studies and one case-control study met the inclusion criteria, involving 4811 TKA procedures in 4263 patients (mean follow up 4-12 years). Five studies were of moderate methodological quality and one of low quality. Meta-analysis demonstrated no association between HPA level and an increased risk of all-cause revision surgery (risk ratio (RR) 0.62, 95 % confidence interval (CI) 0.24-1.63, level of certainty: very low) or revision surgery due to aseptic loosening (RR 1.33, 95 % CI 0.34-5.24, level of certainty: moderate). Only one study reported on survivorship, with an improved survivorship for the HPA group (odds ratio of 2.4, 95 % CI 1.2-4.7, level of certainty: low).

CONCLUSION

During the first 12 postoperative years after TKA, there seems to be no increased risk for revision surgery for patients with a HPA level compared with patients with an LPA level.

Sport after Knee Replacement Surgery - a Review of Sport Habits and Key Surgical Aspects

As an increasing number of younger patients are undergoing total knee replacement (TKR) surgery, many wish to participate in sport, but still expect that the implant will survive for a extended period. Most of the current literature shows that patients predominantly participate in low impact activities, both before and after surgery. A few studies show that with appropriate previous experience, high-impact sports are possible and might not result in increased implant failure rates. These include a decrease in point loads on the polyethylene by using more conform bearing surfaces, avoidance of varus component alignment to minimise stresses at the implant bone interface and avoiding patella resurfacing to facilitate activities in deep knee flexion.A TKR is no longer an absolute contraindication for higher impact activities such as golf, tennis and ski. What is more important than implant specific factors seem to be patient specific factors, including preoperative activity level, and preoperative sport skills.The current review paper reports on the current sport habits of TKR patients, analyses biomechanical loads on the knee during different sport activities and reports on implant selection and technical considerations for the active patient undergoing TKR.

What sports activity levels are achieved in long-term survivors with modular endoprosthetic humerus reconstruction following primary bone sarcoma resection?

Background

The aim of the study was to assess (1) sports activity, (2) sports involving the upper extremities, (3) functional outcome and (4) sports-related complications of long-term survivors of primary malignant bone tumors of the proximal humerus.

Methods

A total of 18 patients with an endoprosthetic reconstruction for primary malignant bone sarcoma of the proximal humerus (8 male, 10 female, mean age 19.9 ± 8.4 years, range 7.8–37.4 years) with an average follow-up of 18.1 ± 7.4 years (range 6.7–29.8 years) were included. The type of sport, frequency, duration of each sport session and the University of California, Los Angeles (UCLA) activity score were assessed before surgery, at 1 year, 3 years and at the latest follow-up. Functional outcome was assessed by the Toronto extremity salvage score (TESS).

Results

The mean UCLA activity score decreased from 8.0 (±1.3, range 5–9) preoperative to 4.2 (±1.7, range 3–8) at 1‑year follow-up (p < 0.05). After 3 years it increased to 5.1 (±1.75, range 3–8) and further to 7 (±1.8, range 4–9) at the last follow-up. The mean postoperative TESS was 80.8 (±6.4, range 75.7–91.4) at the latest follow-up. Patients who were initially more active without reconstruction including a synthetic mesh were more likely to develop soft tissue complications accompanied by proximal endoprothesis migration.

Conclusion

Patients with a modular endoprosthetic reconstruction of the humerus following primary bone sarcoma resume participation in sports. Regarding the low incidence of periprosthetic infections, utilization of a synthetic mesh for reconstruction to prevent soft tissue complications in active patients should be considered.

Does hip or knee joint replacement decrease chances to complete an ultra-trail race? Study in participants at the Ultra-Trail du Mont Blanc®

INTRODUCTION

The number of patients with hip or knee joint replacements is increasing. Some of these patients want to practice sport, including in high-impact sports such as ultra-trails. Is the proportion of drop-out higher among runners after a hip or knee replacement? What are the symptoms of these patients?

HYPOTHESIS

Hip or knee joint replacements are associated with a higher drop-out rate during an ultra-trail.

MATERIAL AND METHODS

We conducted a monocentric retrospective epidemiological study. A questionnaire translated into French, English and Spanish were sent to all runners registered for one or more of the 5 races of the 2015 to 2017 Ultra-Trail du Mont-Blanc® (UTMB®) editions. There were no exclusion criteria. The drop-out rate of patients who responded to the questionnaire was calculated among patients with and without hip or knee joint replacement. Specific symptoms related to these joint replacements were identified before, during and after the race.

RESULTS

Out of the 24,855 participants having run at least one of the 3 editions, 2,469 responded. Some of them ran several races: these 2469 runners were on 3171 start lines and 2548 finish lines (drop-out rate of 19.6%). Among these 2469 runners, 18 had hip and/or knee replacement and were on 27 start lines and 17 finish lines (drop-out rate of 37%). The race was finished by 3 of the 6 runners with a total hip arthroplasty (THA), all of the 8 runners with a hip resurfacing arthroplasty (HRA) and 3 of the 4 runners with a total knee arthroplasty (TKA). Among runners with THA, pubalgia or groin pain was described by one of them before the race, 3 during the race and 2 after the race. Among runners with HRA, pygalgia or groin pain was described by 2 of them during the race. As for the TKA, there was no specific symptom. No answering runner had a unicompartmental knee prosthesis.

DISCUSSION

Running ultra-trail is possible after a hip or knee joint replacement. All of the 8 runners with HRA finished the race. We may remain cautious about the long-term survival of prostheses.

LEVEL OF PROOF

IV; monocentric retrospective epidemiological study.

Sports activity is maintained or increased following total knee arthroplasty

PURPOSE

The purpose of this study was to investigate sports activities and functional abilities in patients following total knee arthroplasty (TKA). It was hypothesized that patients who had undergone TKA would return to a higher activity level as that experienced preoperatively.

METHODS

Two hundred patients were included in this prospective single-cohort study. All the patients completed subjective questionnaires (Tegner Activity Level, Oxford Knee Score, Visual Analog Scale for pain) prior to surgery as well as at 6, 12, and 24 months postoperatively. Additionally, sports behaviour was evaluated. Sports frequency was divided into four categories: more than 5 times a week, 2-3 times a week, occasionally, and no sports activities. Additionally, the patients were asked to state their three favourite summer and winter sports.

RESULTS

All patient-reported outcome scores improved significantly over time (p ≤ 0.005). The Tegner Activity Level increased significantly from the preoperative state to 24 months postsurgery (p = 0.005). Six months after surgery, 43% of the patients returned to the same and 35% to a higher Tegner Activity Level than prior to surgery. Gender-related differences were observed for the Tegner Activity Level showing a higher activity level for the male than for the female patients. Overall, 24 months postsurgery 83% of the patients practiced sports in comparison with 79% prior to surgery.

CONCLUSIONS

Following TKA, the patients were able to increase sports performance, while pain was reduced. Therefore, patients who want to continue their desired sports may safely consider TKA.

LEVEL OF EVIDENCE

II.

Total knee arthroplasty in young patients: Factors predictive of aseptic failure in the 2nd-4th decade

Objective

In a recently published article we reviewed our long term outcomes of TKA in young patients (<55) with end stage OA. The purpose of this study was to identify what additional factors may predict aseptic failure in these young patients.

Methods

A retrospective review of all patients in our young TKA database was performed, and included failure only for mechanical wear and loosening.

Results

The IB-II prosthesis, a thin polyethylene (<9 mm), and higher Knee Society functional class at midterm follow-up was associated with higher failure rate.

Conclusion

This study helps better identify the etiology of failed young patient TKA.

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.

What Sport Activity Levels Are Achieved in Patients After Resection and Endoprosthetic Reconstruction for a Proximal Femur Bone Sarcoma?

BACKGROUND

Limited information is available about sports activities of survivors after resection and reconstruction of primary malignant bone tumors with megaprostheses. Because patients often ask what activities are possible after treatment, objective knowledge about sports activities is needed to help assess the risks of sports participation and to help guide patients' expectations.

QUESTIONS/PURPOSES

The aims of this study were to evaluate (1) what proportion of patients with proximal-femoral megaprostheses placed as part of tumor reconstructions can perform sports; (2) what activity levels they achieved; and (3) whether sports activity levels are associated with an increased likelihood of revision.

METHODS

This retrospective study considered all 27 living patients in our institutional tumor registry with enduring proximal-femoral reconstructions performed more than 5 years ago who were between the ages of 11 and 49 years at the time of the reconstruction; seven were lost to followup and one was excluded because of paraplegia as a result of a car accident and another because of senile dementia; another two were excluded from statistics because of growing prostheses and skeletal immaturity at the time of followup, leaving 16 (11 male, five female) for analysis. Their mean age was 26 ± 12 years (range, 11-49 years) at surgery, and the mean followup was 18 ± 7 years (range, 5-27 years). Types of sports, frequency per week, duration of each sports session as well as the UCLA and modified Weighted Activity Score were assessed retrospectively by an independent assessor a median of 18 years (range, 5.3-27 years) after surgery.

RESULTS

Patients recalled that preoperatively 14 were practicing sports 5 (± 4) hours/week. At followup, 11 of the patients were practicing one or more sports activities 2 (± 3) hours/week on a regular basis. The preoperative UCLA and modified Weighted Activity Score levels of 9 and 6 fell to levels of 6 (p = 0.005) and 3 (p = 0.025), respectively, at followup. With the numbers of patients available for study, we could not determine that prosthetic failures were associated with sport activity levels.

CONCLUSIONS

Patients who survive primary malignant bone tumors in the proximal femur reconstructed by megaprostheses are able to perform some sports activities. The estimates of activity levels made in this study probably are best-case estimates, given that some patients were lost to followup; patients unaccounted for might not be doing as well as those represented here. Also, the degree to which sports participation influences implant durability remains, for the most part, unanswered; studies with more patients and longer followup will be needed to determine to what degree prosthesis survivorship relates to sporting activity levels. Most patients perform low-impact sports and at a lower level than they had preoperatively. Because this is a preliminary study of a select group of patients, further information is necessary to weight the benefits of higher sports activity levels against potential risks. If this can be confirmed in a larger number of patients, the information may guide surgeons in their discussion with patients preoperatively and give them some objective assessment of what to expect regarding sports activities.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Aerobic Physical Fitness and Recreational Sports Participation After Total Knee Arthroplasty

Context:

Total knee arthroplasty (TKA) is routinely performed in younger patients who desire to be active in fitness and recreational sports. The activities patients can participate in without symptoms and the level of aerobic fitness routinely maintained are important to investigate.

Objective:

To determine physical activity (PA) and recreational sports resumed after primary TKA, symptoms or limitations with these activities, and the effect of postoperative rehabilitation on achieving fitness and sports goals.

Data Sources:

A systematic review of the literature from 2005 through 2015 was conducted using the PubMed database.

Study Selection:

Original investigations that were conducted at least 1 year after primary TKA and reported the percentage of patients who returned to recreational activities or routinely participated in aerobic PA recommended by the American Heart Association (AHA) were included in this study.

Study Design:

Systematic review.

Level of Evidence:

Level 4.

Data Extraction:

Data were extracted as available from 19 eligible studies. Assessment of study quality was rated using the MINORS (Methodological Index for Non-Randomized Studies) instrument.

Results:

There were 5179 knees (mean age, 67.5 years) followed for a mean 4.8 years postoperatively. Marked variability was present between studies regarding the percentage of patients who resumed recreational activities (34%-100%), most of which were low impact. Only 2 studies used accelerometers to measure PA; these reported a low range (0%-16.5%) of patients who met AHA guidelines. Few studies determined whether symptoms or limitations were experienced during PA. None described rehabilitation exercises or factors that would influence patients’ ability to return to recreational or fitness activities.

Conclusion:

Little evidence is available regarding the effect of TKA on return to recreational and (objectively measured) aerobic fitness. The extent of symptoms or limitations during PA and the long-term effects of such problems remain unclear. Valid predictions cannot be made on factors that may affect return to recreational sports or other aerobic PA after TKA.

Primary modular total knee replacement in severe and unstable osteoarthritis. Predictive factors for failure

PURPOSE

Severe cases of osteoarthritis with ligamentous instability require the use of a modular knee arthoplasty. To assess the survival, the complications, the clinical, radiological and functional outcomes, and the quality of life of those patients in whom a Optetrak Condylar Constrained Knee (CCK) had been implanted as a primary implant. To study how the pre-operative conditions (deformity, age, sex …) and the characteristics of the arthroplasty (stems, supplements, constrained component …) could change the survival or the clinical outcomes of the implants.

METHODS

We performed an observational retrospective study of 105 CCKs implanted between 1999 and 2005. The mean follow-up was nine years (7, 13). Mean age was 70.5 years. The mortality was 6.9 %. There were 9.3 % of the patients lost during the follow-up. We studied all the medical files of the patients in order to assess the pre-operative, surgical and postoperative conditions. We used the Knee Society Score (KSS), both clinical and functional, to study the functional and clinical situation. We analysed the X-ray using the Knee Society roentgenographic evaluation. The quality of life was studied using the Oxford Knee Score (OKS). Then in order to find predictor conditions, we made statistical multivariable predictive studies attending to the preoperative factors and to the arthroplasty conditions to compare both outcomes and survival (Kaplan-Meier groups curves and Cox Multivariable Models [hazard ratio]). Processing and data analysis was performed using SPSS 15.0.

RESULTS

The outcomes did not show differences between all the groups. While the mean result of the clinical KSS was 75.8, the mean functional KSS was 73.1. We did not find a condition associated with worst results of the knees (p > 0.05). The KSS obtained was excellent or good in 74.9 %. The global survival at 24 months was 93.8 % and at 96 months was 90.1 %. There were some conditions associated with poorest survival of the arthroplasties: patients younger than 70 years old, tibial tuberosity osteotomy, use of long stems and new surgery two months after arthoplasty (p < 0.05). The 11.1 % of the arthroplasties required more surgeries (3.3 % were soft tissue surgeries and 7.8 % were revisions). The mean OKS obtained was 34.78. Satisfaction was obtained by 86.2 % of the patients.

CONCLUSIONS

All severe and unstable knees obtained similar and overall excellent-good outcomes and survival using the Optetrak CCK. Although we found that there are some factors that could change the survival of the total knee replacement, these did not change the outcomes.

What sports activity levels are achieved in patients with modular tumor endoprostheses of osteosarcoma about the knee?

BACKGROUND

Advances in multimodal treatment have improved survival of patients with nonmetastatic osteosarcoma. At the same time, implant design has improved the outcomes of limb salvage with modular endoprostheses. However, little is known about sports activity in long-term survivors with osteosarcoma.

QUESTIONS/PURPOSES

We wanted to evaluate (1) sports activity levels in long-term survivors of osteosarcoma about the knee who received a modular tumor endoprosthesis; (2) to determine if activity level changed over time from initial reconstruction or (3) was predicted from sports activity level before diagnosis; and (4) if complications that occurred affected sports or contributed to prosthetic failures.

METHODS

Between 1995 and 2005, we treated 120 patients for osteosarcoma about the knee with resection and modular endoprosthetic reconstruction; of those, 25 (21%) have died, six (5%) had an amputation, 39 (32%) did not speak German and so were ineligible, and 14 (12%) were either lost to followup or refused to participate, leaving 27 patients (14 females, 13 males; median age 19 years [range, 12-60 years); average followup 11 ± 4 years) (54% of the living, German-speaking cohort) for this analysis. Tumors were located in the distal femur (n = 16) and the proximal tibia (n = 11). Sports participation as well as the UCLA Activity Score and the modified Weighted Activity Score were assessed retrospectively. Moreover, postoperative complications were evaluated.

RESULTS

Before the diagnosis of osteosarcoma and 1, 3, and 5 years and at the latest followup, respectively, after their reconstructions, 24 (89%), nine (33%), 20 (74%), and 24 patients (89%) were able to perform sports activities. There was a reduction in high-impact activities. Those patients with followup longer than 5 years had no changes in sports activity at their latest followup. Patients who had higher levels of sports activity levels before surgery generally had higher levels of activity at last followup (UCLA Activity Score: r = 0.62, p < 0.0005; modified Weighted Activity Score r = 0.49, p < 0.01). Fourteen patients (51%) underwent revision surgery. With the numbers available, complications had no effect on sports activity. No sports activity-related complications were found.

CONCLUSIONS

Some long-term survivors of osteosarcoma can achieve high levels of sports activity. Preoperative activity levels seem to influence the postoperative activity levels. This information is important to give realistic expectations for long-term survivors of osteosarcoma of the knee.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Sports activity after total joint arthroplasty: recommendations for the counseling physician

Sports activity after total joint arthroplasty (TJA) has become an increasingly important topic, as many younger patients seeking TJA have higher postoperative expectations with regard to return to athletic activity. Our current knowledge of this area is largely based on retrospective clinical studies and surveys of surgeon recommendations. The decision to participate in sports after TJA depends on the patient's general health, prior athletic experience, type of TJA, and desired sporting activity. Ultimately, patients should discuss these factors with their physician in order to make an educated decision regarding sports activity after TJA. This article summarizes the best available evidence to help guide physicians in their conversation with patients regarding safe and appropriate sports activity after TJA.

Does impact sport activity influence total hip arthroplasty durability?

BACKGROUND

Return to sport is a key patient demand after hip arthroplasty and some patients are even involved in high-impact sports. Although polyethylene wear is related to the number of cycles and the importance of the load, it is unclear whether high-impact sport per se influences THA durability.

QUESTIONS/PURPOSES

Therefore, we compared (1) function between the patients involved in high-impact sports and the patients with lower activities as measured by the Harris hip score (HHS) and the Hip Osteoarthritis Outcome Score (HOOS); (2) linear wear rates; and (3) survivorships considering revision for mechanical failure with radiographic signs of aseptic loosening as the end point.

METHODS

We retrospectively identified 70 patients who engaged in high-impact sports and 140 with low activity levels from among 843 THAs from a prospectively collected database performed between September 1, 1995, and December 31, 2000. Patients were evaluated at a minimum followup of 10 years (mean, 11 years; range, 10-15 years) by two independent observers. We obtained a HHS and HOOS at each followup.

RESULTS

The mean HOOS was higher in the high-impact group for three of the five subscales of the HOOS. Mean linear wear was higher in the high-impact group than in the low-activities group. We also found a higher number of revisions in the high-activity group.

CONCLUSIONS

Our observations confirm concern about the risk of THA mechanical failures related to high-impact sport, and patient and surgeons alike should be aware of these risks of mechanical failures.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

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.

Introducing a knee endoprosthesis model increases risk of early revision surgery

BACKGROUND

New equipment and techniques often are used in clinical practice, occasionally without evidence of effectiveness and safety.

QUESTIONS/PURPOSES

We asked whether the stage of introduction of an endoprosthesis model for TKA affected the risk of early revision.

METHODS

We studied mandatory registry data from all centers in Finland (n = 69) that performed TKAs for primary osteoarthritis between 1998 and 2004. Of the total of 23,707 patients (28,760 TKAs), 22,551 patients (27,105 TKAs) had a followup of 5 years; we excluded longer followup from the analysis as subsequent revisions might result from wear rather than early technical failures. We used proportional hazards modeling for calculating the hazard ratios for the first 15 operations and subsequent increments of numbers of operations while adjusting for potentially confounding variables.

RESULTS

For the first 15 operations with a new endoprosthesis, the risk was elevated (hazard ratio, 1.48; 95% confidence interval, 1.14-1.91). Absolute risk increase of early revision for the first 15 patients was 1.7% (95% confidence interval, 0.7-2.7). The risk was not increased as the numbers of TKAs incrementally performed increased.

CONCLUSIONS

Our data show an increased risk of early revision surgery for the first patients obtaining a knee endoprosthesis model previously unused in the hospital. Patients should be informed if there is a plan to introduce a new model of endoprosthesis in the hospital and offered the possibility to choose a conventional endoprosthesis instead. Although introducing potentially better endoprostheses is important, there is a need for managed introduction of new technology.

LEVEL OF EVIDENCE

Level I, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

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.

The 2011 ABJS Nicolas Andry Award: 'Lab'-in-a-knee: in vivo knee forces, kinematics, and contact analysis

BACKGROUND

Tibiofemoral forces are important in the design and clinical outcomes of TKA. We developed a tibial tray with force transducers and a telemetry system to directly measure tibiofemoral compressive forces in vivo. Knee forces and kinematics traditionally have been measured under laboratory conditions. Although this approach is useful for quantitative measurements and experimental studies, the extrapolation of results to clinical conditions may not always be valid.

QUESTIONS/PURPOSES

We therefore developed wearable monitoring equipment and computer algorithms for classifying and identifying unsupervised activities outside the laboratory.

METHODS

Tibial forces were measured for activities of daily living, athletic and recreational activities, and with orthotics and braces, during 4 years postoperatively. Additional measurements included video motion analysis, EMG, fluoroscopic kinematic analysis, and ground reaction force measurement. In vivo measurements were used to evaluate computer models of the knee. Finite element models were used for contact analysis and for computing knee kinematics from measured knee forces. A third-generation system was developed for continuous monitoring of knee forces and kinematics outside the laboratory using a wearable data acquisition hardware.

RESULTS

By using measured knee forces and knee flexion angle, we were able to compute femorotibial AP translation (-12 to +4 mm), mediolateral translation (-1 to 1.5 mm), axial rotation (-3° to 12°), and adduction-abduction (-1° to +1°). The neural-network-based classification system was able to identify walking, stair-climbing, sit-to-stand, and stand-to-sit activities with 100% accuracy.

CONCLUSIONS

Our data may be used to improve existing in vitro models and wear simulators, and enhance prosthetic designs and biomaterials.

Knee arthroplasty: a cross-sectional study assessing energy expenditure and activity

BACKGROUND

What has been missing from current assessment tools post knee arthroplasty is a means by which a patient's mobility and activity levels can be objectively measured over time in a real world setting. The Intelligent Device for Energy Expenditure and Activity (Minisun, Fresno, USA) (IDEEA) is one such device that meets these criteria. It quantifies activity by measuring energy expenditure and records the type of activity performed. The purposes of this study were to (i) determine if there were differences in energy expenditure in different groups of patients at various time points pre- and post-surgery and (ii) determine the correlations between energy expenditure and each of the subjective International Knee Documentation Committee (IKDC), Oxford and Tegner scoring systems.

METHODS

Sixty-five total knee arthroplasty (TKA) patients were recruited into a cross-sectional study to collect energy expenditure and activity data using the IDEEA. Data were collected preoperatively and post-operatively at 6-week, 3-month, 6-month and 12-month time intervals.

RESULTS

Energy expenditure and type of activity did not significantly change over the five recording periods. The patients spent <5% of the recording time walking, stepping or in transitions between movements. Energy expenditure showed a low to moderate correlation with the subjective IKDC, Oxford and Tegner questionnaires.

CONCLUSIONS

Current evaluation questionnaires may not accurately record activity levels and TKA patients spend less time walking than the normal population. We believe the IDEEA is an effective tool for objectively measuring activity and energy expenditure following knee arthroplasty.

Predicting dissatisfaction following total knee replacement: a prospective study of 1217 patients

Up to 20% of patients are not satisfied with the outcome following total knee replacement (TKR). This study investigated the pre- and post-operative predictors of dissatisfaction in a large cohort of patients undergoing TKR. We assessed 1217 consecutive patients between 2006 and 2008 both before operation and six months after, using the Short-form (SF)-12 health questionnaire and the Oxford Knee Score. Detailed information concerning comorbidity was also gathered. Satisfaction was measured at one year when 18.6% (226 of 1217) of patients were unsure or dissatisfied with their replacement and 81.4% (911 of 1217) were satisfied or very satisfied. Multivariate regression analysis was performed to identify independent predictors of dissatisfaction. Significant (p < 0.001) predictors at one year included the pre-operative SF-12 mental component score, depression and pain in other joints, the six-month SF-12 score and poorer improvement in the pain element of the Oxford Knee Score. Patient expectations were highly correlated with satisfaction. Satisfaction following TKR is multifactorial. Managing the expectations and mental health of the patients may reduce dissatisfaction. However, the most significant predictor of dissatisfaction is a painful total knee replacement.

Management of osteoarthritis of the knee in the active patient

Total knee arthroplasty has been extremely successful in elderly patients with osteoarthritis. However, there is considerable controversy regarding how best to treat the younger, athletic patient with advanced arthritis. Treatment options range from nonsurgical management with exercise and nonsteroidal anti-inflammatory drugs, to joint arthroplasty with activity modification. When properly indicated, arthroscopic débridement, high tibial osteotomy, unicondylar knee arthroplasty, and total knee arthroplasty allow younger patients with arthritis to maintain an active, healthy lifestyle.

Does commitment to rehabilitation influence clinical outcome of total hip resurfacing arthroplasty?

Background

The purpose of this study was to evaluate whether compliance and rehabilitative efforts were predictors of early clinical outcome of total hip resurfacing arthroplasty.

Methods

A cross-sectional survey was utilized to collect information from 147 resurfacing patients, who were operated on by a single surgeon, regarding their level of commitment to rehabilitation following surgery. Patients were followed for a mean of 52 months (range, 24 to 90 months). Clinical outcomes and functional capabilities were assessed utilizing the Harris hip objective rating system, the SF-12 Health Survey, and an eleven-point satisfaction score. A linear regression analysis was used to determine whether there was any correlation between the rehabilitation commitment scores and any of the outcome measures, and a multivariate regression model was used to control for potentially confounding factors.

Results

Overall, an increased level of commitment to rehabilitation was positively correlated with each of the following outcome measures: SF-12 Mental Component Score, SF-12 Physical Component Score, Harris Hip score, and satisfaction scores. These correlations remained statistically significant in the multivariate regression model.

Conclusions

Patients who were more committed to their therapy after hip resurfacing returned to higher levels of functionality and were more satisfied following their surgery.

Resurfacing is comparable to total hip arthroplasty at short-term follow-up

Metal-on-metal total hip resurfacing arthroplasty has had excellent reported results at early to midterm followup, and some studies suggest that outcomes are comparable to conventional THA. We compared the clinical and radiographic outcomes of two closely matched groups of 54 patients who underwent resurfacing and conventional THA, respectively. Each group consisted of 36 men and 18 women who had a mean age of 52 years and a mean body mass index of 29 kg/m(2). At a minimum followup of 24 months (mean, 40 months; range, 24-60 months), the mean Harris hip scores increased similarly in both groups (from 52 to 90 points and from 50 to 91 points for the resurfacing and conventional groups, respectively). Radiographic outcomes, revision rates, complications, pain scores, and satisfaction ratings of the two groups were similar. The patients who underwent resurfacing had higher postoperative weighted activity scores than the patients who underwent conventional THA, although they had higher preoperative weighted activity scores as well. The early outcomes of resurfacing are comparable to those of conventional THA.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Patient-reported outcome correlates with knee function after a single-design mobile-bearing TKA

With substantial interest devoted to improving knee flexion after TKA, it is important to document the relationship between high range of motion and patient-rated outcomes shown. We therefore asked whether single-design high-flexion mobile-bearing posterior-stabilized TKA resulted in: (1) improved knee function; (2) satisfying subjective results; (3) participation recreational and sporting activities; and (4) function correlated to the final range of motion. We prospectively followed 445 consecutive patients having 516 TKAs from September 2000 to January 2005. The same high-flexion posterior-stabilized mobile-bearing implant was used in all patients. Mean patient age was 71 +/- 8 years and mean body mass index was 28 +/- 4 kg/m(2). The minimum clinical followup was 2 years (mean, 3 years; range, 2-4 years). The postoperative range of knee flexion was 128 degrees +/- 4 degrees and the mean Knee Society function and knee scores were 91 +/- 6 and 96 +/- 3, respectively. Eighty-two percent of patients were involved in sporting activities and 86% returned to their previous level of activity. These data confirm that high postoperative range of knee flexion improve patient-rated outcomes.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

The Mark Coventry Award: in vivo knee forces during recreation and exercise after knee arthroplasty

Knee forces directly affect arthroplasty component survivorship, wear of articular bearing surfaces, and integrity of the bone-implant interface. It is not known which activities generate forces within a range that is physiologically desirable but not high enough to jeopardize the survivorship of the prosthetic components. We implanted three patients with an instrumented tibial prosthesis and measured knee forces and moments in vivo during exercise and recreational activities. As expected, stationary bicycling generated low tibial forces, whereas jogging and tennis generated high peak forces. On the other hand, the golf swing generated unexpectedly high forces, especially in the leading knee. Exercise on the elliptical trainer generated lower forces than jogging but not lower than treadmill walking. These novel data allow for a more scientific approach to recommending activities after TKA. In addition, these data can be used to develop clinically relevant structural and tribologic testing, which may result in activity-specific knee designs such as a knee design more tolerant of golfing by optimizing the conflicting needs of increased rotational laxity and conformity.

High-impact sports after total knee arthroplasty

Many patients will attempt high-impact loading activities after total knee arthroplasty. This study analyzed the clinical and radiographic results of these high-demand sports patients. A total of 31 patients (33 knees) were identified who participated in high-impact sports on average 4 times per week (range, 1-7 times per week) for a mean of 3.5 hours per week (range, 1 to 10 hours), including jogging, downhill skiing, singles tennis, racquetball, squash, and basketball. At 4 years mean follow-up (range, 2-9 years), 32 of 33 knees had successful clinical and radiographic outcomes. Overall satisfaction was a mean of 9.1 points on a scale of 0 to 10 points. These results indicate that some patients will participate in high-impact sports and enjoy excellent clinical outcomes at a minimum 4 years after surgery.

What patient and surgical factors contribute to implant wear and osteolysis in total joint arthroplasty?

Total joint arthroplasty has been a successful operation for decades. Our current patients are younger and more active than those in the past. They place higher demands on themselves and have expectations commensurate with their lifestyles. Time-limited longevity with the large number of anticipated total joint replacement procedures and their potential burden to health care is a growing concern. In the past two decades, implant wear and osteolysis have been identified as major causes for the failure of otherwise well-functioning implants. Osteolysis can be divided into several categories: patient-specific, implant-specific, and the result of surgical factors. Although these categories are interrelated and not mutually exclusive, they enable us to build a framework in which to further advance our understanding of osteolysis and apply this information in a clinically relevant manner.