Danish surgeons allow the most athletic activities after total hip and knee replacement

  • Mia K. Laursen
  • Jakob B. Andersen
  • Mikkel M. Andersen
  • Ole H. Simonsen
  • Mogens B. Laursen
Original Article

Abstract

Background and purpose

Counselling patients for or against athletic activities after well performed total hip arthroplasty (THA) and total knee arthroplasty (TKA). Level of evidence is low, and the current international guidelines are based on North American expert opinions in 2001 and 2008. Could technical and operative development and social or cultural differences apply for different counselling?

Methods

All Danish experts in head of departments performing more than 100 THAs or TKAs per year, were invited to fill in a questionnaire regarding the most popular sport activities in the Danish 60–69 years old population

Results

Response rate was 74 and 89 % for the TKA and THA departments, respectively. A pronounced variation between the departments was observed and compared to the latest published US recommendations in 2007, the present Danish recommendations are significantly more liberal. Athletic activities are now allowed by 87 % of the Danish arthroplasty departments. Of these 55 % allow for high-impact activities after THA compared to 21 % in US in 2007 (p < 0.0001). Recommendations for TKA patients are less liberal. Only 38 % of the departments allow for high-impact activities after TKA compared to the 55 % after THA (p < 0.0001).

Interpretation

Based on the pronounced variation between departments and the fact that a highly significant trend was observed over 5 years on an undocumented basis it was concluded that there is an imminent need for a higher scientific level on this issue—which hopefully can develop in a few years using PROMs in large scale follow-up studies.

Keywords

Total hip arthroplasty Total knee arthroplasty Athletics after joint replacement Physical activities 

Introduction

Physical activity has been proven to prevent several chronic diseases, improve fitness, and decrease mortality [1, 2]. Regular exercise producing cardiovascular fitness, more over has been shown to stimulate weight loss, reduce anxiety as well as depression, and improve bone density and muscle coordination [3, 4, 5, 6].

For older adults, staying physically active is of utmost importance, which is also true for the increasing number of patients having total knee or hip replacement.

Because of the beneficial effects of physical activity, international guidelines have been developed for levels of health-enhancing physical activity. These guidelines recommend 30 min or more of moderate-intensity aerobic (endurance) physical activity at least 5 days/week or vigorous-intensity aerobic physical activity for a minimum of 20 min at least 3 days/week [7, 8]. However, the current question of most interest always will be: How much loading will an artificial knee or hip tolerate? What kind of physical activity should be recommended to those patients? As the design and quality of the prostheses are currently improved, the optimal answer will have to be altered, which was illustrated by surveys among American hip and knee surgeons in 2001, 2007 and 2008 [9, 10, 11]. From these surveys, the then current specialist’s recommendations were derived. Aside from those; no recommendations have been published to our knowledge, and national or international guidelines have not been developed. Hence, updated specialist recommendations are currently warranted. In the present study, we have investigated the current Danish specialist’s recommendations.

Methods

From the Danish National Hip Register (DHR) and the Danish National Knee Register (DKR) 2010 reports, we selected all departments, both public and private, performing at least 100 THAs or TKAs. The leading surgeon in each department was asked to fill in a questionnaire about which athletic activities patients in his/her department were allowed to take part in after uneventful recovery from surgery. In Denmark, most arthroplasties are performed in specialised elective units manned with 2–6 surgeons who perform between 80 and 300 arthroplasties each per year. Furthermore, all Danish hospitals (private and public) have been accredited according to The Danish Healthcare Quality Programme [12], a public accreditation programme working by the same principles as The Joint Commission and ISQua. Accreditation is achieved only if the control panel detects full consistency between treatment descriptions on the hospital’s website, in the written instructions given to the patients, and in daily practice at the clinic. Regardless of whether the latter is provided by the department head or the youngest specialist.

The selection of activities in the questionnaire is based on the 2005 survey from the Danish Institute of Governmental Research [13], from which we selected the 31 most popular sports activities in the age-group 60–69. For each activity, the surgeon should decide whether the fully recovered patient was advised to: 1—take part regardless of previous experience with the activity; 2—take part if the patient had experience with the activity before surgery; or 3—not take part in the activity. If the questionnaire was not returned within 2 months, we sent a reminder email, and if necessary a complimentary phone call was used to heighten the response rate.

Statistical method

We compared the percentage of surgeons allowing each activity based on our questionnaires to those of Klein (2007). Similarly, we compared the ‘allowed with experience’ and ‘not allowed’ categories.

In the following, assume that a certain allowance category (‘allowed’, ‘allowed with experience’, or ‘not allowed’) and an impact (‘high’, ‘intermediate’, and ‘low’) or a combination of these impacts (‘all’ and ‘high or intermediate’) are considered for statistical analysis.

Let m be the number of responding surgeons in Klein (2007) and n the number of responding surgeons in DK (2012). For activity number j (for example alphabetic order), let xj/m be the percentage of Klein (2007) surgeons recommending ‘Yes’ and yj/n the percentage of DK (2012) surgeons recommending ‘Yes’. As we assume that the surgeons are independent and also that the activity recommendations within a surgeon are independent, we can analyse the percentage using a logistic regression model with activity and source [Klein (2007) or DK (2012)] as explanatory variables. If we only had one activity, this would correspond to comparing two binomial proportions.

If the source variable is statistical significant (p < 0.05), this can be interpreted as an overall difference between Klein (2007) and DK (2012). This difference between sources can be converted into an odds ratio that can be interpreted as the increase in recommendation percentage (averaged over all activities) if surgeons from DK (2012) were to make a recommendation instead of surgeons from Klein (2007).

We only included the activities where both sources [Klein (2007) or DK (2012)] had a recommendation. Later, when comparing THA with TKA as sources, the same type of analysis was conducted.

Results

Twenty seven departments for TKA and 28 for THA met the inclusion criteria, and 20 respective 25 filled in the questionnaire. This gives us a response rate of 74 % for TKA and 89 % for THA. Calculated from the number of procedures performed at each department, the response rates are 78 % for TKA and 91 % for THA.

Over the years 1999–2007, there was a tendency for the US recommendations to be more liberal,and for instance, single tennis was not allowed before 2007 for THA (Table 1) and bicycling and canoeing was not allowed after TKA before 2005 (Table 2). Compared with the US recommendation in 2007, the Danish recommendations in 2012 are significantly more liberal. A total of 87 % allowed any athletic activity in 2012 compared to 77 % in 2007 (p < 0.0001, Table 3). Even high-impact activities were allowed by 48 % in 2012, compared to 21 % in 2007. Of these 48 %, 13 % allowed high-impact activities only to experienced patients. In 2012, still 13 % of surgeons did not allow athletic activity to THA patients, compared to 21 % in 2007.
Table 1

Expert opinions for THA

Activity

Allow (%)

Allow with experience (%)

Not allowed (%)

Healy (1999)

Healy (2005)

Klein (2007)

DK (2012)

Healy (1999)

Healy (2005)

Klein (2007)

DK 2012

Healy (1999)

Healy (2005)

Klein (2007)

DK (2012)

n

54

63

549

25

54

63

549

25

54

63

549

25

Soccer/contact sports

  

2

16

  

2

16

Yes

Yes

93

68

Handball

   

16

   

16

   

68

 Baseball/softball

  

13

   

27

 

Yes

 

57

 

Badminton

   

36

   

56

   

8

Singles tennis

  

16

56

  

28

40

Yes

 

52

4

Doubles tennis

Yes

 

64

  

Yes

29

   

6

 

Racquetball/squash

  

11

   

27

 

Yes

 

60

 

Golf

Yes

Yes

99

92

  

0

8

  

0

0

Bowling

 

Yes

90

80

Yes

 

8

20

  

1

0

Petanque

   

92

   

8

   

0

Billiard/shuffleboard

Yes

Yes

 

96

   

4

   

0

Horseback riding

   

60

Yes

Yes

 

32

   

8

Swimming

Yes

Yes

99

92

  

1

8

  

1

0

Jogging

  

6

68

  

5

4

Yes

Yes

87

28

Stairclimber

  

72

   

10

   

14

 

Walking

Yes

Yes

98

   

1

   

0

 

Speedwalking

 

Yes

81

   

8

   

9

 

Treadmill

  

87

   

8

   

4

 

Hiking

 

Yes

79

88

Yes

 

18

12

  

3

0

Ice or roller skating/skateboard

  

35

36

 

Yes

43

32

  

21

32

Bicycling (transport)

   

100

   

0

   

0

Road cycling

 

Yes

80

96

Yes

 

19

4

  

1

0

Mountain biking

   

60

   

24

   

16

Stationary bicycle

Yes

Yes

95

76

  

5

16

  

0

8

Low-impact aerobics

  

86

76

  

9

24

  

4

0

High-impact aerobics

  

6

   

7

   

84

 

Elliptical machine

  

92

   

5

   

1

 

Bodybuilding/weightlifting

  

46

64

 

Yes

33

24

  

19

12

 Weight machines

  

60

  

Yes

33

   

5

 

Athletics

   

32

   

36

   

28

Dancing

Yes

Yes

94

92

  

6

8

  

0

0

Yoga/pilates

  

58

68

  

24

28

  

10

4

Martial arts

  

9

20

  

38

20

  

49

60

Boxing

   

36

   

24

   

40

Shooting

   

96

   

4

   

0

Hunting

   

92

   

4

   

0

Fishing

   

96

   

4

   

0

Canoe/kayak

 

Yes

64

60

Yes

 

21

36

  

13

4

 Rowing

     

Yes

      

Sailing/windsurfing

   

36

   

48

   

16

Cross-country skiing

  

56

56

Yes

Yes

37

44

  

5

0

Downhill skiing

  

21

32

 

Yes

56

48

  

22

20

Stationary skiing

  

87

  

Yes

11

   

1

 

Snowboarding

  

11

   

28

   

55

 

In the “Healy”-columns “Yes” means that 73 % (or more) of the n experts agrees on the recommendation

Table 2

Expert opinions for TKA

Activity

Allow (%)

Allow with experience (%)

Not allowed (%)

DK

Healy (1999)

Healy (2005)

DK (2012)

Healy (1999)

Healy (2005)

DK (2012)

Healy (1999)

Healy (2005)

DK (2012)

n

58

70

21

58

70

21

58

70

21

Soccer/contact sports

  

5

  

10

Yes

Yes

86

Handball

  

5

  

10

Yes

 

86

Football

      

Yes

Yes

 

Lacrosse

      

Yes

  

Hockey

      

Yes

  

Basketball

      

Yes

Yes

 

Volleyball

      

Yes

  

Baseball/softball

         

Badminton

  

43

  

33

  

24

Singles tennis

  

43

  

43

Yes

 

14

Doubles tennis

   

Yes

Yes

    

Racquetball/squash

      

Yes

  

Shuffleboard

Yes

Yes

       

Golf

Yes

Yes

95

  

5

  

0

Bowling

Yes

Yes

90

  

5

  

5

Petanque/croquet

Yes

 

100

  

0

  

0

 Horseshoes

Yes

        

Billiard

  

100

  

0

  

0

Horseback riding

Yes

 

76

 

Yes

19

  

5

Swimming

Yes

Yes

100

  

0

  

0

Jogging

  

33

  

10

Yes

Yes

57

Stairclimber

         

Walking

Yes

Yes

       

Speedwalking

 

Yes

 

Yes

     

Treadmill

         

Hiking

 

Yes

81

Yes

 

14

  

5

Roller skating/skateboard

  

33

 

Yes

33

  

33

Ice skating

   

Yes

Yes

    

Fencing

         

Bicycling (transport)

  

100

  

0

  

0

Bicycling (sport)

 

Yes

86

Yes

 

14

  

0

Mountain biking

  

57

  

19

  

19

Rock climbing

      

Yes

  

Stationary bicycle

Yes

Yes

86

  

5

  

10

Low-impact aerobics

Yes

 

76

  

14

  

10

High-impact aerobics

      

Yes

  

Elliptical machine

         

Bodybuilding/weightlifting

  

43

 

Yes

14

  

43

 Weight machines

   

Yes

Yes

    

Athletics

  

24

  

19

  

57

Dancing

Yes

Yes

95

  

5

  

0

Yoga/pilates

  

100

  

0

  

0

Martial arts

  

5

  

19

  

76

Boxing

  

29

  

19

  

52

Shooting

Yes

 

100

  

0

  

0

Hunting

  

95

  

0

  

0

Fishing

  

95

  

5

  

0

Canoe/kayak/rowing

 

Yes

86

Yes

 

10

  

5

Sailing/windsurfing

  

52

  

29

  

19

Cross-country skiing

  

67

Yes

Yes

29

  

5

Downhill skiing

  

33

 

Yes

48

  

19

Stationary skiing

   

Yes

Yes

    

In the “Healy”-columns “Yes” means that 73 % (or more) of the n experts agrees on the recommendation

Table 3

Statistics: results for comparison of Klein (2007) with DK (2012) (Table 1) and THA with TKA (Tables 12)

 

Number of activities

2007 (549 responses) versus 2012 (25 responses)

Number of activities

THA (25 responses) versus TKA (21 responses)

2007 mean

2012 mean

OR

p value

THA mean

TKA mean

OR

p value

Not allowed

 Any

−18

21.2

13.3

0.35

<0.0001

31

13.7

20.3

2.16

<0.0001

 H

3

76.3

52.0

0.25

<0.0001

7

44.0

61.9

2.41

0.0005

 I

7

18.0

9.7

0.44

0.0027

8

9.5

19.1

2.45

0.0063

 H + I

10

35.5

22.4

0.33

<0.0001

15

25.6

39.1

2.43

<0.0001

Allowed

 Any

−18

57.5

64.9

1.78

<0.0001

31

65.0

65.6

1.04

0.7821

 H

3

5.7

34.7

9.66

<0.0001

7

35.4

22.6

0.47

0.0060

 I

7

48.4

58.3

1.68

0.0035

8

55.5

52.4

0.87

0.5220

 H + I

10

35.6

51.2

2.69

<0.0001

15

46.1

38.5

0.67

0.0231

Allowed WE

 Any

−18

19.6

21.8

1.17

0.2136

31

21.0

13.9

0.56

0.0002

 H

3

15.0

13.3

0.84

0.6592

7

20.0

15.1

0.70

0.2325

 I

7

32.0

32.0

1.00

0.9954

8

35.0

28.5

0.73

0.1730

 H + I

10

26.9

26.4

0.97

0.8551

15

28.0

22.3

0.71

0.0705

Allowed + allowed WE

 Any

−18

77.1

86.7

3.57

<0.0001

31

86.1

79.5

0.47

<0.0001

 H

3

20.7

48.0

5.29

<0.0001

7

55.4

37.7

0.42

0.0005

 I

7

80.4

90.3

2.58

0.0006

8

90.5

80.9

0.41

0.0063

 H + I

10

62.5

77.6

3.74

<0.0001

15

74.1

60.7

0.41

<0.0001

The ‘number of activities’ column is the number of activities that both sources have a recommendation for and therefore are used in the comparison. The difference between ‘2012 mean’ and ‘THA mean’ is caused by the activities that are included in the comparisons (refer to Table 1 to see the activities that Klein (2007) do not have a recommendation for). The p value is for whether the OR (odds ratio) is equal to 1 or different from 1

Compared with THA (Table 1), the recommendations for TKA (Table 2) were significantly more restrictive (Table 3). Twenty per cent did not allow any athletic activity after TKA compared to 14 % after THA (p < 0.0001). Whereas 55 % allowed high-impact activities after THA only 38 % allowed this after TKA. Among these, only 22 % allowed high-impact activities if not experienced, compared to 35 % for THA. The recommendation by the departments did not depend on the number of procedures performed (Fig. 1). There was a significant difference between Klein (2007) and DK (2012).
Fig. 1

Danish experts recommendations plotted against their production

Discussion

Our results could be biased by the chosen method; data collected are in fact the view of the heads of department in the larger arthroplasty units in Denmark, but we believe that all answers are given in the spirit of each departments fixed (and accredited) protocol for sporting activities, for all the activities covered and adhered to by all relevant specialists in the department. It is not possible for a senior member of a Danish orthopaedic department to maintain a very specialist practice run against differing views to his/her colleagues. In fact, all arthroplasty surgeons within a unit are forced to consensus on a fixed protocol for all treatment aspects. Otherwise, accreditation will be redrawn.

The orthopaedic literature on athletic activity after THA and TKA is mostly limited to small retrospective studies with short-term follow-up [14, 15]. One longitudinal four-centre study in 2005 found that most patients with hip (97 %) and knee (94 %) OA had performed sports activities during their life, only 36 % (hip patients) and 42 % (knee patients) had maintained sports activities at the time of surgery. Five years post-operatively, the proportion of patients performing sports activities increased to 52 % among patients with THA, but further declined to 34 % among those with TKA. Accordingly, the proportion of patients with THA performing sports activities for more than 2 h a week increased from 8 to 14 %, whereas this proportion decreased from 12 to 5 % among patients with TKA [16]. Differences in pain 5 years after joint replacement might explain some of the differences of sports activities as persistent post-operative pain were reported by 9 % of patients with THA and by >16 % with TKA. Also, the surgeons’ belief with regards to the mechanical strength of the artificial joint and its surroundings and the risks of overuse and traumatic injury, and consequently, recommendations are probably highly decisive for the patient. The present study is the first to demonstrate that the recommendations for THA patients are significantly more liberal compared with TKA, a total of 20 % of the departments did not allow any athletic activity after TKA, and this circumspection is probably only based on personal experience. To our knowledge, evidence to conclude increased soreness of TKA compared with THA has not been published. When patients who have undergone joint replacements choose to participate in athletic activity, orthopaedic surgeons should provide information with which to evaluate the risk of sports activity and recommend appropriate athletic activity. A trend among experts to allow more athletic activity and relax restrictions of sports activity after joint replacements may be based on outstanding patient outcomes, increasing surgeon confidence in surgical technique, and innovations in joint implants. This trend may also be a response to patients’ demands to participate in athletics after surgery. However, this trend in expert opinion is not evidence-based and may not be in the best interest of patients.

At this state, we still linger at the lowest possible level of evidence: “the expert opinion”. An increasing number of experts allow for increasing activity—but that will never alter the evidence level. Future research combining large patient cohorts with yearly Patient Reported Outcome Measures (PROM) regarding activities and level will give us the possibility to tell whether there are any differences in implant survival between patient groups in different sports and activity levels and possibly tell whether special implants should be preferred for patients with special demands for their future sports activities.

Discussion of statistical method

As several similar analyses have been conducted in Table 3, and some analyses of these have a subset of data in common, the reader should be cautious to interpret them jointly rather than as one single analysis at a time. Some multiple-testing correction could be invoked, but as it is not obvious how, as only a subset of data is in common, we chose not to perform such a correction.

It would be relevant to have the all the original responds from the surgeons in Klein (2007) in order to analyse if there were within-surgeon structure. We could have done this type of analysis for comparing THA with TKA as we have all the original observations, but to maintain the same interpretation of the results between the two analyses, we chose not to.

Notes

Acknowledgments

We thank the responding experts, without whom this review would have been impossible.

Conflict of interest

None.

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Copyright information

© Springer-Verlag France 2014

Authors and Affiliations

  • Mia K. Laursen
    • 1
  • Jakob B. Andersen
    • 1
  • Mikkel M. Andersen
    • 2
  • Ole H. Simonsen
    • 1
  • Mogens B. Laursen
    • 1
  1. 1.Orthopaedic DepartmentAalborg University HospitalAalborgDenmark
  2. 2.Department of Mathematical SciencesAalborg UniversityAalborgDenmark

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