Following surgery, patients should be encouraged to reestablish and maintain a physically active lifestyle. Remaining physically active allows patients to maintain their general health46,47
after TJA and to enhance the quality of the interface between the bone and prosthesis.54
There is evidence that increased bone quality may improve prosthesis fixation and decrease the incidence of early loosening.27,54
Surgeon concerns about participation in sporting activities following TJA are generally based on the increased joint load caused by athletic activity. Jogging has been shown to increase hip joint loads to more than 500% of a patient’s body weight.4
Higher joint load results in increased implant wear and joint debris.48
Increased use is associated with increased joint wear48
and leads to periprosthetic osteolysis and eventual prosthetic failure.53
Thus, the questions remain regarding what is considered a “safe” athletic activity and what constitutes “excessive” and therefore “dangerous” athletic activity that may threaten the integrity of the implant. These parameters of function continue to be widely debated since there is minimal prospective evidence or randomized controlled trials to definitively support either side.
Many studies have reported decreased athletic activity after TKA or THA.6,8,21
In a study by Huch et al,21
the majority of patients cited “precaution” as the reason for their decreased postoperative athletic activity, which is most likely influenced by surgeons counseling patients to protect the life span of their prostheses. In contrast, there have been studies in the literature reporting that patients may actually increase their sports involvement after surgery22,56
and that there may be little to no adverse effects of high activity on TKA or THA.41
In light of these contradictory findings and increasing patient desires to engage in a highly active lifestyle, many surgeons now promote a more liberal level of athletic activity after TJA.
Survey data from the Hip Society and Knee Society regarding recommended athletic activities after joint replacement found that the number of “not recommended” sports decreased from 1999 to 2005 while activities that were “allowed with experience” or “allowed” increased.16,18
However, individual surgeon opinions are not necessarily well reflected by these collective opinions; when asked if they had changed their recommendations over the same time span, most surgeons did not report changes in opinion regarding “not recommended,” “allowed,” and “allowed with experience” activities.18
Thus, the controversy regarding sports participation after total joint replacement seems to lack a clear consensus opinion. With a lack of definitive evidence on safe activity loads and the shift from paternalistic medicine to a culture of health care consumers who often have increased expectations and functional demands, sporting activities after total joint replacement remain a frequently debated topic among orthopaedic surgeons. Surgeons must remain diligent to give patients the best postoperative instructions on returning to sports based on the existing evidence, not based on anecdotes or patient desires.
states that to recommend a certain activity after TKA or THA, factors such as wear, joint load, intensity, and type of prosthesis must be taken into account for each patient and sport in question. Though he agrees with the popular opinion that reduction of wear is one of the main factors in improving long-term results after total joint replacement, he argues that one of the most important questions to answer when dealing with a patient who wants to engage in an athletic activity is whether it is performed for exercise for physical fitness, recreation, or the patient’s profession. These variables affect the risk-benefit balance for patients who want to engage in athletic activity after TJA.
Bauman et al3
argue that activity recommendations should be assessed for each patient on an individual basis. Factors to consider include the patient’s general health, prosthesis type and joint replaced, preoperative involvement in physical activity or sports and the level of intensity, and the activity that a patient wants to pursue after surgery. To maintain physical fitness, an endurance activity can be performed several times per week with high-intensity effort. Since joint load influences the amount of wear on the joint prosthesis in an exponential fashion,28
many surgeons believe that only activities with low joint loads (eg, swimming, cycling, or possibly power walking) should be recommended for routine participation.27
Participation in high-impact activities with high joint load greatly increases the risk of premature wear, thus leading to an otherwise avoidable premature prosthesis failure and revision surgery (as well as the associated inherent risks of undergoing another operation).
Kilgus et al25
found higher rates of THA revision in patients with high activity versus those with low activity. A Swedish THA registry reported 20% revision in younger patients versus 5% in older patients.32
While this finding is probably related to higher activity levels in younger patients, studies have shown similar activity rates for patients of all ages who have undergone joint replacement surgery.49,52,59
Thus, age is not necessarily an appropriate proxy for activity level when studying TJA.
In contrast, there have been reports of a negative correlation between physical activity and lower extremity TJA revision rates. Widhalm et al57
found lower rates of prosthesis loosening among active patients. Dubs et al12
reported lower rates of revision surgery after THA in active patients (1.6%) than in inactive patients (14.3%). Interestingly, one study reported that 5 of 60 inactive patients showed signs of prosthesis loosening at 5 years, while no patients in the active group had signs of loosening at that time point. At 10-year follow-up, 2 patients from the active group showed signs of loosening, and there was no new loosening in the inactive group.14
This suggests that some degree of activity promotes bone density and decreases early prosthesis loosening but that too much activity leads to excessive wear and increased late prosthesis loosening. Clearly, long-term follow-up is needed for the full effects of activity on TJA. It is also worth noting that significant surgical innovation has occurred since many of the studies on revision rates; their conclusions may not be valid for current clinical practice. In general, limiting activities to low joint loads (eg, swimming or walking) decreases excessive wear, which may then allow for a more predictable, successful functional outcome and avoidance of revision surgery.
The belief that high-impact activities and overuse lead to component failure is not universally supported.41
In one study, only 4% of active competitive tennis players (2 of 33) needed revision surgery, thus demonstrating that sports activity may not predispose highly active individuals to premature component failure or the need for revision surgery any more than it does sedentary individuals after similar procedures. Furthermore, both of those who required revision surgery had cemented TKAs, which suggests that parameters regarding the procedure itself may be a stronger correlate with a successful surgery than patient activity after the procedure. Another example involves the observation that deep knee flexion with standard TKAs has been associated with increased load and, potentially, increased failure rates2,43
; in contrast, newer, high-flexion TKAs with posterior stabilization are designed to more accurately replicate normal knee kinematics and allow for greater knee flexion. Argenson et al2
found that patients who received a high-flexion TKA and were able to achieve postoperative knee flexion greater than 125° reported higher subjective outcomes than those with flexion less than 125°. This again suggests that details of the procedure (ie, prosthesis choice) have a high degree of interplay with other factors, such as patient activity, in determining overall patient outcomes. Further evaluation of athletic activity and newer prosthesis designs, such as high-flexion TKAs or metal-on-metal bearings, should be performed to determine if they allow a safe increase in athletic activity compared to traditional prostheses.
Some authors suggest that it is “safer” for clinicians to recommend low levels of activity after total joint replacement operations than to advocate high-risk or high-demand athletic activity.18
It is prudent to advise patients to avoid recreational and athletic activities until their quadriceps and hamstrings are sufficiently rehabilitated, to decrease early postoperative injury; ultimately, though, patients should be allowed to choose which activities they wish to participate in after TJA. Contact sports and high-impact loading sports, such as soccer, baseball, hockey, football, and basketball, have a higher risk of directly damaging the replaced joint, and patients should be appropriately counseled regarding the risks of engaging in those sports.
Many of the principles described above for lower extremity TJA also apply to upper extremity TJA, such as TSA. Schumann et al51
found that 89% of patients who participated in sports preoperatively were able to participate in sports at a similar level after TSA ( and ), although a significant number (36.7%) reported persistent restrictions on their sports activities after surgery. Motivation and training are important determinants in how much athletic activity patients achieve postoperatively. Patients in that study did not stop all sports activities after TSA. In comparison, other studies report that 16% to 19% of patients do not resume sports activities after TSA. It is not known if postoperative limitations were due to shoulder problems or comorbid medical conditions.36,50
Forty-seven-year-old right-hand dominant man 2 years following a right total shoulder replacement. He has returned to all activities including throwing a football, mountain-biking, and swimming.
Seventy-three-year-old right-hand dominant man 2 years following a right total shoulder replacement. He has returned to playing golf without difficulty. He has no pain and no limitations.
In summary, joint replacements relieve pain, improve function, correct physical deformity, increase social mobility, preserve an independent lifestyle, and contribute to psychological well-being.22
Arthroplasty patients often believe that their level of physical activity will increase after their surgery as their pain decreases,22
but this does not always occur.6,8,21
Although joint replacements are cost-effective medical treatments that provide substantial improvements in quality of life, the true relationship between athletic activity and the rate of revision surgery remains unclear.12,17,25
The existing literature does not allow one to definitively draw conclusions on sports in general or high-risk activity after TJA in particular. The prevailing belief is that overuse is related to prosthesis loosening or excessive wear of component surfaces. Patients who participate in high-impact activities may be more likely to need revision surgery at long-term follow up.41