It is often surprising how seemingly basic questions are quite difficult to answer.
A number of months ago, a client of mine informed me that he was considering total hip replacement surgery. This gentleman quite enjoyed playing basketball, football, and softball. He asked if, after proper rehabilitation, he would be able to return to these activities. This seemingly straightforward question proved surprisingly difficulty to answer.
My initial answer to my client was “no, unfortunately not”. I had always been taught that exercises like walking, cycling, and swimming were acceptable and recommended following total hip replacement surgery, but that “high impact” activities were not appropriate. This was not only my opinion. Based on a review of available evidence in 2005, researchers concluded that “most total joint replacement patients should be strongly discouraged from participating in very high-impact athletics” (Golant, et al., 2010, p. 81). The rationale for this restriction was that high impact athletics would accelerate wear of the joint prosthesis and would necessitate early revision surgery (revision surgery is essentially a second joint replacement to address failed components from an earlier joint replacement) (Golant, et al., 2010, p. 78) . I was quite surprised when my patient told me that his surgeon assured him that he would be able to return to basketball, softball, and football following a total hip replacement.
Why was there such a disparity between my initial answer and what my patient heard from his surgeon? Part of the answer is that, to date, most of the recommendations against high impact athletics following total joint replacement are based largely on physician opinion rather than strong evidence (Jassim, Douglas, & Haddad, 2014, p. 926). Was there indeed evidence to support the notion that high impact athletics are safe for patients following total joint replacement? In an effort to assist my patient in getting a better answer to his question, I searched the PubMed data base for peer reviewed articles that addressed this issue.
It is important to note here that medical evidence is weighted, based on the type of information contained in a particular study. Case studies, presenting the findings of a single subject, are considered the weakest form of evidence. Randomized clinical trials, where one group of subjects receives a treatment and are measured against a control group that does not, are considered a stronger form of evidence. Systematic reviews are considered the strongest form of evidence. A systematic review is essentially a “study of studies”, where researchers gather a number of articles addressing a particular question, rate them for quality, and draw conclusions from the total amount of data available (Jewell, 2011, p. 18, 28).
I was able to find two systematic reviews that addressed the question of whether high impact activities were associated with early failure of hip replacement prostheses. Surprisingly, the authors of these reviews were not able to identify many studies that directly addressed this question. Based on the evidence that was available, one group of authors found no evidence of higher total joint replacement failure rates in subjects participating in “sporting activities” (Jassim, et al., 2014, p. 925). It is important to note, however, that this conclusion was based on only 2 studies, one of which involved a hip resurfacing procedure (a different procedure than total hip replacement) and the other including only younger subjects (Jassim, et al., 2014, p. 925, 927). These authors did note, however, that three other studies demonstrated an increased rate of prosthetic component wear (though not an increased rate of prosthetic failure) in subjects who participated in tennis (Jassim, et al., 2014, p. 925, 927).
A second review also acknowledged that there was little evidence regarding the safety of high impact activities on total joint replacement, but did cite one study that demonstrated increased failure rates in athletic individuals beginning at 10 years post-surgery. (Golant et al., 2010, p. 78). A third study (not a systematic review) also demonstrated increased failure rates 10 years post operatively in patients who participated in high impact activities. In this work, authors retrospectively reviewed 70 patients involved in high-impact activities after total joint replacement and compared their recovery with 140 patients who participated in lower intensity activities (Olliver et al., 2012, p. 3060). . The mean age of both groups was 59. Authors found that prosthetic wear rates (in terms of mm/ year) were nearly two times higher in the group that participated in high impact activities (p. 3064). Prosthetic survival rates were also much lower in the high impact group: approximately 20% of subjects in the high impact group needed a second surgery by 15 years post operatively, compared to only 6.5% of subjects in the lower impact group in the same time period (p. 3064) . The difference in prosthetic failure rates between the two groups became evident after approximately 10 years post operatively (p. 3064).
So, from all of this information, what can we conclude?
- There is not a great deal of data available on the question.
- Several studies demonstrate that high impact activities increase prosthetic wear rates in patients who have undergone total hip replacement.
- Two studies demonstrate higher prosthetic failure rates, starting at approximately 10 years post operatively in patients that participate in high impact activities.
While I acknowledge that the available evidence does not provide a definitive answer to my patient’s question, I concluded that the evidence available does indicate that there is an increased risk of early prosthetic failure in patients who participate in high impact activities following total hip replacement. While newer prosthetic technologies may minimize or eliminate this risk in certain populations, I was not able to identify any evidence demonstrating this.
Please feel free to direct questions and comments directly to me at firstname.lastname@example.org. If anyone is aware of other evidence addressing this question, please send it along- I will happily update this post as new information comes to light.
Golant, A., Christoforou, D.C., Slover, J.D., & Zuckerman, J.D. (2010). Athletic participation after hip and knee arthroplasty. Bulletin of the NYU Hospital for Joint Diseases, 68(2), 76-83.
Jassim, S.S., Douglas, S.L., & Haddad, F.S. (2014). Athletic activity after lower limb arthroplasty. The Bone & Joint Journal, 96-b(6), 923-927. doi: 10.1302/0301-620x.96b7
Jewell, D.V. (2011). Guide to evidence-based physical therapist practice. Jones & Bartlett Learning: Sudbury, MA.
Ollivier, M., Frey, S., Parratte, S., Flecher, X., & Argenson, J.N. (2012). Does Impact Sport Activity Influence Total Hip Arthroplasy Durability? Clinical Orthopedics and Related Research, 470: 3060-3066. doi: 10.1007/s11999-012-2362-z
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