Encouraging sports participation after total hip ­arthroplasty: a desirable objective!

Schmidt Ina¹, Cadosch Diether², Loeffler Tim³, Leumann André^1
1 Ortholeu Basel, Basel, Switzerland
² Department of Orthopaedics and Traumatology, University of Oxford, Oxford, England
³ Physioactivecare Basel, Basel, Switzerland

Introduction

Total hip arthroplasty is one of the most effective orthopaedic procedures, significantly improving quality of life in patients with end stage osteoarthritis or other debilitating hip conditions.
Last year more than 21,000 patients underwent total hip arthroplasties (THA) in Switzerland, the age average was 67. Swiss people are known for their athletic/active lifestyle, so there might be a high rate of patients, who are seeking to return to high levels of physical activities after surgery. Traditionally reserved for older, less active individuals, the ­demographic of THA recipients has shifted towards younger and more active patients (Figure 1).
This shift has challenged the traditional postoperative activity recommendations and necessitated a reevaluation of guidelines regarding sport and physical exertion after THA. The orthopaedic surgeon, who is, beside the patient, in a way responsible for the survival of the THA, wants to base his recommendations on good evidence.

The data

Multiple studies showed that patients can safely return to a wide range of sport following THA. A meta-analysis 2023 [1] reported that over 90% of patient resumed sports activities within one year postoperatively. Another umbrella review [2]showed that most of the patients reached their preoperative activity level after 7-12 month for low and moderate impact sports.
However, not only did the level of sport activity increase for older people during the last decades, also the sport types did change. Originally, hiking, cycling and swimming were allowed. In a latter period, Tennis, golfing, skiing and running became popular among THA patients. Nowadays, ­patients aim at regaining all type of sports including trail running, climbing, ski mountaineering, combat sports and kite surfing or soccer.
While performing sports is beneficial for general health (e.g. cardiovascular) and should be encouraged by all medical professionals, it was also evidenced that sports active THA patients show improved function and higher patient satis­faction than non-active THA patients. But one has to be aware that performing sports after hip arthroplasty may be associated with several specific risk factors: Of them, often discussed are: a) trauma involving the THA (e.g. periprosthetic fracture), b) THA dislocation, c) aseptic loosening, d) increased wear and therefore shortened implant survival.
The recommendations of international societies are ­vague. The American Association of Hip and Knee Surgeons (AAHKS) recommends low impact activities and individualized decisions regarding higher impact sports. The Hip ­Society suggests that patients may engage in more vigorous sports depending on experience, coordination and implant type. They recommend to include patient specific factors such as age, BMI, bone quality, surgical approach, implant fixation and surgeon expertise in order to guide decisions regarding return to sports.
Clinical experience shows that patients do not care too much about recommendations. As long as they are pain free, they do whatever they wish.
With that in mind, it is evident, that returning to high impact sport has a higher risk for traumatic injuries, but also for aseptic loosening. Here, a more closely monitoring of these patients is recommended.

External Factors

Baseline patient characteristics like body weight, muscular strength and coordination skills significantly influence the postoperative results and therefore the return to sports.
The mechanical load on the joint might be an important factor influencing the performance and longevity of hip prothesis. Adequate muscular strength and coordination can reduce pathological joint loading and contribute to improved biomechanical stability. [3]
Approximately two decades ago, biomechanical studies were conducted to quantify the load on the hip joint by implanting THA with load-sensors in order to measure in-vivo loads directly during everyday activities such as standing, walking, and stair climbing, utilizing sensor-based measurement systems. These methodologies were subsequently refined in gait laboratory environments. Findings indicated that specific activities can subject the hip joint to substantially increased loads – for example, stumbling may generate forces up to ten times body weight, alpine skiing up to five times body weight, and stair climbing approximately two and a half times body weight. [4,5]
In several databases one can find the subdivision into low/moderate/high impact activities. Recommendations and point of care are summarized in Table 1. Obviously, low-impact activities are safest and more beneficial. Moderate impact activities aim at maintaining musculoskeletal health while placing minimal stress on the prosthetic joint. High-impact sports are generally discouraged due to risk of injury, dislocation or implant wear. However, in criteria based analysis it can be considered to be allowed.

Engaging in the right type of sport can help to improve joint stability by strengthening the periarticular muscles and improve proprioceptive and balance functions and therefore it reduces the risk of prosthesis-related complications. Thus, patients with THA regaining sports activity show higher ­patient satisfaction, improved joint function and longer implant survival. Therefore, sports activity after THA has to be encouraged.
However, the choice of sports type is important. While low impact and moderate impact sports types are allowed and beneficial, high impact sports are possible for experienced athletes, but should not be recommended for beginners. Very high impact sports types should not be recommended at all.
Low impact and moderate impact sports types can be used in the rehab process (see below). High impact sports should only be re-started, when complete muscular recovery is achieved. In these high demanding patients, return to sport testing is a good option to check for muscular function. Return to sport testing may include a) isometric and isokinetic strength testing (Figure 2); b) jump testing; c) functional testing (e.g. hop test); d) proprioceptive and postural testing;
e) psychological assessments.

Internal Factors

Since the first modern type THA implantations in the sixties of the last century by Sir John Charnley, the THA implants and implantation techniques evolved in many ways. Also in the last two decades the total hip arthroplasty has reached important modernization steps.
Different surgical techniques evolved the so-called minimal-invasive THA surgery. The new surgical approaches are less invasive not only leading to smaller skin incision, but most beneficial to muscle preserving access to the hip joint. Here, especially the anterior approaches (direct anterior (DAA), anterolateral) have to be mentioned. The primary patient’s benefit is a faster recovery after surgery [6] and no restrictions of weight bearing and range of motion after surgery. The direct anterior approach uses the access between the rectus femoris and the tensor fascia lateral muscle, the anterolateral approach accesses the joint between tensor fascia lateral and the medial glute muscle. For these techniques, new instruments (e.g. hooks) had to be developed.
Important steps forward were found for the biomaterials and the design of the implants in order to obtain a higher survival rate and longer functionality of the implants.
In cementless implants, coating of the implant (stem or cup) is important to allow in-growth of bone into the trabecular surface of the implant to gain long-term stability. Improvements of this coating has significantly evolved. Now­adays cementless implants are coated with Titanium and Hydroxyapatite. Therefore, designing of short-stem implants with metaphyseal anchoring became possible favoring minimal-invasive anterior approaches (Figure 3).

While cohort studies showed survival rates of up to 94% after 15 years, one of the major factors for late-onset revisions is wear of the implants. Wear primarily appears as friction between head and cup. Thus, influenced by the tribological pairing of the two components.
Materials used for this purpose encompass metal, polyethylene, and bioceramics. Possible combinations include metal-on-polyethylene, metal-on-metal, ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoP) and ceramic heads and metallic inserts. In Switzerland, metal-on-metal pairing is not available because toxic metallic ion concentrations might appear in organs such as the kidney, although tribological friction rates would be very good. Ceramic-on-ceramic pairing shows also very low friction rates, but has the increased risk of ceramic fracture leading to thousands of small ceramic particles in the joint. Metal-on-polyethylene showed higher friction rates and is therefore used in patients with less than 10 years of life expectancy. Hence, the typically used combination is ceramic-on-Polyethylene (CoP).
With the introduction of the Highly cross linked Polyethylene (HXLPE) the risk of early wear decreased significantly [7]. It’s shown that the combination of CoP with HXLPE has an almost identical wear of debris than the combination CoC without the risk of fractured ceramic or squeeking hip like in CoC combination. [7,8,9]. In terms of wear, high impact sports do not increase wear rates in HXLPE pairings. Luckily, nowadays late-onset loosening of THA due to wear-induced granulomatous reactions is seen very rarely.
A Meta-Analysis of randomized trials by Shang et al. showed no significant differences of CoP pairing in comparison to CoC in view of revision, dislocation, implant infection, osteolysis or prosthetic loosening.
A study in 2001 [10] showed that due to higher friction artificial hip joints warm up more than natural joints during walking and other continuous activities. The in vivo measurements showed temperatures til 42 degrees °C in the synovia fluid, especially the combination CoCr head with PE Inlay. Higher temperature in the synovia could be a reason for long-term implant loosening, but no data could be found herefore.
Overall CoC and CoP (HXLPE) bearing surfaces shown comparable and excellent survivor rates and are superior to metal combinations due to revision [12,13].

Conclusion

Sport after hip arthroplasty is not only possible – it is beneficial. With advanced implants, less invasive approaches and a personalized rehabilitation plan the traditional recommendation for THA can be discarded [14]. The key is choosing the right activity, progressing carefully, and following professional advice. Therefore, decisions about sport resumptions should consider:
– Type of prosthesis
– Surgical techniques and post-operative healing
– Age, weight, muscle strength and postural control
– Patient experiences in sports

Scientifically, little is evidenced about sport types. Ongoing research is needed to refine return-to-sport guidelines and develop patient-specific recommendations based on the modern, high performance prostheses and less invasive surgical techniques. Decisions and recommendations are primarily based on personal experience and individualized rehabilitation protocols.
In our clinic we recommend a graduated step-wise return to physical activity based on individual patient factors such as age and baseline fitness. The steps should be criteria based on joint function and not on time since surgery. Functional testing of the rehab process is helpful in guiding patients to a safe return to activity path.
Low-impact sports are generally advisable and can be resumed as early as possible postoperatively, provided adequate muscular strength and joint stability. Moderate impact sports might be feasible after 3 months and high impact sports not before 6 months postoperative (Table 2).
We are convinced that postoperative criteria-based return to sport should be individualized and requires a balanced approach that protect the prosthetic joint while supporting the patient’s quality of life by being able to return to sport leading to a happy patient and a happy doctor.

Corresponding author

Dr. Ina Schmidt MD
Ortholeu Basel, Claragraben 78, 4058 Basel
info@ortholeu.ch
http://www.ortholeu.ch



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