Physician's Weekly Surgery Edition Article - Returning to Sports After Joint Replacements

       Many patients undergoing hip or knee replacement operations express a desire for resuming athletic activity after surgery. If patients wish to return to sports after their replacement, they should be instructed to train for their specific activity.

      According to the American Academy of Orthopaedic Surgeons, joint replacement is considered one of the most successful medical innovations of the 20th century. Hip and knee replacement operations are increasing in frequency and are continuing to achieve pain relief and improve function for patients with arthritic joints. William L. Healy, MD, says “the demand for knee replacement is expected to double by 2016; for hip replacement, it’s expected to double by 2026. Now more than ever, younger patients are considering joint replacement surgery earlier in life due to advances in surgery and devices. They’re expecting and choosing to participate in sports after surgery. They want to be able to coach and play sports with their children without pain.”



      New Review Data

      A review of data on athletic activity after joint replacement, published in the October 2008 Journal of Bone and Joint Surgery (JBJS), found that despite their wishes, in general, joint replacement patients reduced their athletic activity after the operation (Table 1). For those who returned to athletics after surgery, the intensity of participation was also reduced. “Younger patients tend to have a lower tolerance for discomfort and disability if they were involved in athletics,” says Dr. Healy. “They often want to be able to perform sporting activities at the same level they enjoyed them before having surgery. What patients need to understand is that joint replacements are great at relieving pain and restoring mobility, but that doesn’t necessarily translate to returning to sports.”

      Questions Remain

      There are still questions within the orthopedic community concerning the degree to which patients should return to athletic activities safely after hip or knee replacements. Research has shown that patients who participate in strenuous athletic activity after joint replacement have significant risks to consider, including increased stress on the reconstructed joint, increased wear to the artificial materials, and increased stress where the implant is attached (Table 2). “Although there is literature suggesting that joint replacement patients can be capable of engaging in high-level sports, we still don’t know if it’s in their best interest in terms of wear, loosening, and durability of the implant,” says Dr. Healy. For example, participation in running, skiing, or basketball can wear out new joints more quickly than other sports. More strenuous activities increase stress on the joint replacement. As joint prostheses undergo more wear, it can create debris that loosens in the joint; this can cause significant pain and fluid build-up. In severe cases, it can loosen the prosthesis, which necessitates a revision surgery.

      It is still unclear how much athletic activity should be reasonably allowed or recommended following joint replacement in order to promote durability and survival of the reconstructed joint. “The orthopedic literature on sports and joint replacement is limited,” says Dr. Healy. “The studies available are small, retrospective, and have short-term follow-up. There are recommendations in the form of expert opinion from the Hip Society and the Knee Society, as well as the American Society of Hip and Knee Surgeons, but these recommendations are not a substitute for evidence-based clinical research.”

      Educate Patients

      Surveys of the Hip Society and Knee Society featured in Dr. Healy’s JBJS study found that orthopedic surgeons allowed their patients to participate in more sports activities in 2005 than they did in 1999. These thought leaders also relaxed their restrictions on athletic activities after surgery. Considering the changing paradigm, Dr. Healy says that orthopedic surgeons need to educate patients on the risks associated with sports and higher levels of activity. “If our patients understand the associated risks and choose to return to their sport, they need to train properly and be motivated by enjoyment of the sport.”

      Dr. Healy recommends that orthopedic surgeons educate their patients on the potential risks they may be taking with their new joints. “Throughout the rehabilitation period, patients must be aware that playing sports is a risk. They should understand that training for their sport should involve rebuilding back, hip, and knee strength. As surgeons, we look at pain, function, implant survivorship, and need for revision surgery when assessing outcomes. Conversely, patients think mostly about their pain and activity. In the end, we want to prolong the life of the prosthesis.”

      William L. Healy, MD, has indicated to Physician’s Weekly that he has been a consultant for and has received grants/research aid from DePuy Orthopaedics.