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Sports Medicine

, Volume 48, Issue 7, pp 1695–1726 | Cite as

The Effect of Total Hip Arthroplasty on Sports and Work Participation: A Systematic Review and Meta-Analysis

  • Alexander HoorntjeEmail author
  • Kim Y. Janssen
  • Stefan B. T. Bolder
  • Koen L. M. Koenraadt
  • Joost G. Daams
  • Leendert Blankevoort
  • Gino M. M. J. Kerkhoffs
  • P. Paul F. M. Kuijer
Open Access
Systematic Review

Abstract

Background

Total hip arthroplasty (THA) is a successful procedure to treat end-stage hip osteoarthritis. The procedure is increasingly performed in adults of working age, who often wish to return to sports (RTS) and return to work (RTW). However, a systematic overview of the evidence on RTS and RTW after THA is lacking.

Objectives

Our aim was to systematically review (1) the extent to which patients RTS and RTW after THA, including (2) the time to RTS and RTW.

Methods

We searched MEDLINE and Embase from inception until October 2017. Two authors screened and extracted the data, including study information, patient demographics, rehabilitation protocols and pre- and postoperative sports and work participation. Methodological quality was assessed using the Newcastle–Ottawa scale. Data on pre- and postoperative sports and work participation were pooled using descriptive statistics.

Results

A total of 37 studies were included, of which seven were prospective studies and 30 were retrospective studies. Methodological quality was high in 11 studies, moderate in 16 studies, and low in ten studies. RTS was reported in 14 studies. Mean RTS was 104% to the pre-surgery level and 82% to the pre-symptomatic sports level. Time to RTS varied from 16 to 28 weeks. RTW was reported in 23 studies; the mean was 69%. Time to RTW varied from 1 to 17 weeks.

Conclusion

A great majority of patients RTS and RTW after THA within a timeframe of 28 and 17 weeks, respectively. For the increasingly younger THA population, this is valuable information that can be used in the preoperative shared decision-making process.

Key Points

Eight out of ten patients return to a sports level equal to their pre-symptomatic level after total hip arthroplasty. A return to high-impact sports activities is less likely but is definitely possible in experienced patients.

Overall, seven out of ten patients return to work after total hip arthroplasty. However, modern-day studies showed a mean return to work of 86%. This might be attributed to the increase in total hip arthroplasty in patients aged < 65 years as well as more liberal work recommendations.

Preoperative sports participation and lower age are predictive of a successful return to sports. Preoperative sick leave and a high workload are predictive of no return to work.

1 Introduction

Total hip arthroplasty (THA) to treat severe osteoarthritis (OA) of the hip joint is one of the most successful orthopedic procedures performed nowadays [1]. The use of THA has skyrocketed in recent decades. In the USA, utilization rates of THA doubled from 102 to 210 per 100,000 between 2000 and 2011 [2, 3]. Likewise, THA utilization rates have been steadily increasing in other developed countries, including the UK, Australia, and most European countries [2]. Numerous reasons for the increasing incidence of THA exist, including the ageing society and the growing prevalence of obesity [4]. Another important factor is patients’ participation in an active lifestyle and in highly demanding work and sports activities, both at younger and at older ages [5]. The largest increase in absolute numbers of THA is observed in patients aged < 65 years [2, 6], with the greatest percentage increase in the group aged 45–54 years [3].

There is patient demand for improved recovery after hip arthroplasty. Alterations of the technique with tissue-sparing approaches may improve early recovery [7]. Improved bearing materials have shown better outcomes with less wear problems, allowing a return to daily activities with full impact [8]. In a younger and more active patient population, a return to daily activities includes return to sports (RTS) and return to work (RTW) [9, 10]. Although of major importance to the patient, scientific data on RTS and RTW issues after THA have been scarce. A systematic review concerning RTW identified seven studies and found that RTW ranged from 25 to 95% at 1–12 months postoperatively [11]. Timing of RTW ranged from 1.1 to 13.9 weeks. However, the authors did not pool their data for RTW because of the heterogeneity of included studies and found that the overall methodological quality of the included studies was moderate to low [11]. Since the search for the abovementioned review in 2013, newer studies have also focused on RTW after THA [12, 13].

No previous study has systematically summarized the available evidence on RTS after THA. Klein et al. [14] evaluated the allowable or recommended sporting activities after THA based on recommendations from 549 orthopedic surgeons. In general, low-impact activities such as swimming, walking, and dancing were allowed, and intermediate-impact sports such as Pilates, ice-skating, and downhill skiing were allowed in individuals experienced in these activities. There was consensus between the surgeons that high-impact sports were not allowed. However, those recommendations were based on expert opinion and not supported by results from clinical studies. Although some research has been performed on RTS after THA, the actual extent of and time to RTS remain largely unknown [15, 16]. Furthermore, there appears to be a discrepancy between previous RTS recommendations and the actual sports participation that is achieved by modern-day THA patients [17]. Lastly, prognostic factors for RTS after THA have never been systematically reviewed.

A comprehensive evidenced-based review of the literature on the possibility of returning to both sports and work after THA is lacking. Therefore, the purpose of the present analysis was to systematically review the available evidence on the extent to which THA patients RTS and RTW and the timing of this return. In addition, reported prognostic factors for RTS and RTW were reviewed. The results of this study may aid the orthopedic surgeon in providing adequate guidance to future patients about the likelihood of RTS and RTW after THA.

2 Methods

2.1 Search Strategy

The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were used for this systematic review [18]. A research protocol was developed before the literature search was commenced. This protocol was published online at the PROSPERO International prospective register of systematic reviews (http://www.crd.york.ac.uk/PROSPERO/; registration number CRD42016052471). A clinical librarian (JD) developed the search strategy in close cooperation with the first author. A systematic search in the MEDLINE and Embase databases was performed from inception until 24 October 2017. A scoping search consisting of citation analysis identified a set of relevant references. From this reference set, search concepts and, subsequently, search terms were derived. Main concepts were (sport OR work-related activities) AND {[(recovery of function OR surgery) AND longitudinal study design] OR (return to sports & work)} AND total hip arthroplasty. Details of the search strategy can be found in the Electronic Supplementary Material (ESM), Appendix S1. The reference lists of selected studies were screened to identify additional studies for inclusion. We also performed a cited reference search in Web of Science to identify more recent studies.

2.2 Eligibility Criteria and Study Selection

The results of our MEDLINE and Embase searches were cross-checked and duplicate papers were excluded. The titles and abstracts of the remaining papers were screened by two independent reviewers (AH, KJ) for suitability for inclusion. The Rayyan screening tool for systematic reviews was used to screen titles and abstracts [19]. Discrepancies were resolved by discussion; where there was doubt, the article was included in the full-text screening process. One author (KJ) then selected suitable studies based on the eligibility criteria established in the research protocol. This selection was then reviewed by a second author (AH), and discrepancies were resolved by discussion or by consulting a third reviewer (PK). Inclusion criteria were as follows: observation or intervention studies, describing patients with hip OA who underwent THA, who were participating in sports or working before surgery and intended to RTS and/or RTW after surgery. No restrictions were placed on language or publication year. Review articles were excluded for data extraction, but their references were checked for additional studies that were not identified in our primary search. Exclusion criteria were no primary diagnosis of hip OA, hip resurfacing arthroplasty, and no specific data about RTS or RTW.

2.3 Outcome Measures

The primary outcome was the percentage of patients RTS and/or RTW, and the timing of RTS/RTW. The secondary outcomes were specific activity outcome measures, including the University of California Los Angeles (UCLA) activity score (1–10, where 1 = no physical activity and 10 = extremely active) [20] and the Grimby scale (1–6, where 1 = hardly any physical activity and 6 = regular hard exercise) [21]. The Reichsausschuss für Arbeitszeitermittlung (REFA; German workload classification) classification system was used (0 = work with no physical demand and 4 = work with most heavy physical demand) as a work-related outcome measure.

2.4 Data Extraction

Data were systematically extracted from the included studies by one author, and this was independently repeated by a second author. Disagreements were resolved by discussion and, if necessary, by consulting a third reviewer. The authors used a standardized data extraction form that included the following data: (1) study information: author, year, country; (2) study design and follow-up; (3) information about study population: cohort, population size, sex, age, body mass index (BMI), comorbidities; (4) description of rehabilitation protocols used; (5) definition of outcome measures; (6) preoperative activity and definition, e.g., pre-symptomatic or at time of surgery; (7) postoperative activity; (8) RTS and RTW percentages and time to RTS and RTW; (9) confounding factors taken into account in the study, such as sex, age, BMI, motivation, surgeon’s advice, preoperative sports participation, workload or sick leave. When information was missing or unclear, we approached the authors for additional information.

2.5 Quality Assessment

We used the Newcastle–Ottawa Scale (NOS) to assess the methodological quality of the studies [22] (ESM Appendix S2). One author (KJ) reviewed the quality of all included studies. This was independently repeated by two authors (AH and PK), who each reviewed half of the included studies. Discrepancies were resolved by discussion. With the NOS, every study is assessed on eight items, which are subdivided into three groups: the selection of the study groups (four items), the comparability of the groups (one item), and ascertainment of the outcomes of interest for cohort studies (three items). A maximum of one star can be allotted to every item in the selection of the study groups and ascertainment of the outcome groups of interest for cohort studies. A maximum of two stars can be assigned to the comparability of the groups. Thus, a study can receive a maximum of nine stars. In a previous systematic review, Takahashi and Hashizume [23] defined a study as of high quality if it scored seven or more stars. To further improve the distinction between high- and low-quality studies, we defined high-quality studies as those obtaining eight or nine stars for the present systematic review. A study was rated as moderate quality if it obtained six or seven stars. Studies with five stars or fewer were rated as low quality.

2.6 Pooling Data

Patient demographics were analyzed using descriptive statistics. For pooling of RTS and RTW data, we used the methodology previously described by Witjes et al. [24] and Hoorntje et al. [25] for their studies on RTS and RTW after knee arthroplasty and knee osteotomy. Concerning RTS, studies were included if detailed numbers of patients who participated in specific sports pre- and postoperatively were presented. Sports were categorized as low, intermediate, or high impact based on the classification by Vail et al. [26] (ESM Appendix 3). We calculated pooled RTS percentages using descriptive statistics by comparing pooled pre- and postoperative sports participation data. Finally, these results were described as the average number of sports per patient. RTS percentages were analyzed for all included studies and separately for the high-quality studies. RTW data were pooled using descriptive statistics for studies that provided pre- and postoperative numbers of working patients. RTW percentages were analyzed for all included studies and separately for the high-quality studies. RTW was also analyzed separately for studies published before and after 2000 because of the large increase in THA utilization in patients of working age in the last 2 decades [27]. All statistical analyses were performed using SPSS (version 24.0.; IBM Corp, Armonk, NY, USA).

3 Results

3.1 Literature Search

Figure 1 presents the PRISMA flowchart of our screening process. Our primary search in the MEDLINE and Embase databases yielded 1514 articles. After removing 498 duplicates, 1016 articles remained. After screening of titles and abstracts, we excluded 924 articles. Thus, 92 full-text articles were screened for eligibility. After full-text screening, 37 studies were included. Reasons for exclusion of full-texts were wrong outcome measure (n = 19), wrong study design (n = 15), no full text available (n = 11), wrong population (n = 5), same cohort (n = 4), and insufficient data (n = 1). Searching the references of the included studies provided one additional study [28].
Fig. 1

PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram. RTS return to sports, RTW return to work

3.2 Study Characteristics

Table 1 presents the data extracted for each of the included studies. The studies were published between 1965 and 2016. Eight of the 37 studies included were published before 2000. Three case–control studies, one cross-sectional study, six prospective cohort studies, 24 retrospective cohort studies, two non-randomized controlled studies, and one randomized prospective study were included. Most studies were written in English (n = 34), one was written in French, and two were written in German. One study was performed in each of Australia, Denmark, Finland, Greece, Italy, and Switzerland; two were performed in each of Canada, France, Japan, Poland, Spain, Sweden, and the Netherlands; five each were performed in Germany and the UK; and seven were performed in the USA. Of these 37 studies, 13 reported RTS [29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41], 22 reported RTW [12, 13, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61], and two reported both RTS and RTW [28, 42].
Table 1

Return to sports and work after total hip arthroplasty: data extracted from studies included in the review (n = 37)

Study

Study design

Study populationa

Operation type (+ fixation implant)

Rehabilitation protocol

Abe et al. [29] 2014; Japan; level of evidence: III

Case–control; follow-up: 4.8 y (range 2.3–7.8)

608 pts with OA (85 M [14%], 523 F [86%])

Age: 62 y (range 26–98)

BMI: 23.2 (range 14.7–34.2)

Co: NR

Primary THA: Cemented 107; uncemented 420

Full weight bearing as tolerated from first postop day

Sports participation allowed at 6 mo postop (except contact sports)

Arbuthnot et al. [30] 2007; UK; level of evidence: III

Retrospective; follow-up: 7.6 y (range 2.0–20.0)

66 pts with OA who played golf pre-op (sex NR)

Age: 70.4

BMI NR

Co NR

Primary THA (not otherwise specified)

NR

Atkinson et al. [42] 2010; UK; level of evidence: I

Non-randomized controlled; follow-up: 2.8 y (range 1.0–5.0)

39 pts with bilateral hip OA

Group 1: Single-episode bilateral THR (n = 18) (11 M [61%], 7 F [39%]

Age: 61.9

BMI and Co NR

Group 2: Staged bilateral THR (interval 44 wks [16–88]); n = 21 (13 M [62%], 8 F [38%])

Age: 63.7

BMI and Co NR

Uncemented THA (anterolateral approach)

NR

Berger et al. [43]; 2004; USA; level of evidence: II

Prospective; follow-up: 0.3 y

100 pts aged 40–75 y of age without previous hip surgery, BMI < 35 (74 M [74%], 26 F [26%])

Age: 56 (range 41–75)

BMI: M 26.8 (range 22.5–33.0); F 24.1 (range 20.6–29.1)

Co NR

Uncemented THA (minimally invasive two-incision approach) with rapid rehabilitation protocol

Preop pt education meeting

Weight bearing as tolerated postop

Start activities as soon as tolerated

Outpatient physical therapy

Bohm [44] 2010; Canada; level of evidence: II

Prospective; follow-up: 1.0 y

46 pts who had undergone THA and were working preop

RTW: n = 40 (21 M [53%], 19 F [47%])

Age: 49.9

BMI and Co NR

No RTW: n = 6 (1 M [17%], 5 F [83%])

Age: 60.3

BMI and Co NR

Primary THA (not otherwise specified)

NR

Chatterji et al. [31] 2004; Australia; level of evidence: III

Retrospective; follow-up: 1.0–2.0 y

216 pts who had undergone THA 1–2 y before the study

Age: 67.8 ± 10.2

Sex, BMI, and Co NR

Primary THA (cemented, uncemented, and hybrid)

Postop physiotherapy until hospital discharge

No outpatient physiotherapy treatment

Clyde et al. [45] 2013; USA; level of evidence: III

Retrospective cohort; follow-up: 5.2 y (range 1.4–10.4)

43 pts aged ≥ 18 y receiving workers’ compensation at time of THA

Primary THA: n = 43 (31 M [72%], 12 F [39%])

Age: 55.0 (range 53.5–56.4)

BMI: 31.7 (range 30.6–32.8)

Co NR

Primary THA (not otherwise specified)

NR

Danielsson [46] 1965; Sweden; level of evidence: II

Prospective; follow-up: 3.5 y (range 1.0–7.0)

30 pts who underwent THA (10 M [33%], 20 F [67%])

Age: 59 (range 32–76)

BMI and Co NR

Primary THA (not otherwise specified)

Physiotherapy for 2.5 wks after operation

Start increasing weight bearing after 4 wks

Del Piccolo et al. [40] 2016; Italy; level of evidence: III

Retrospective; follow-up: Conventional stem: 4.4 y (range 1.3–6.0); short stem: 4.5 y (range 1.3–5.7)

78 pts aged 18–50 y with OA

Conventional stem: n = 58c

Age: 38.7 (range 18.0–49.0)

Sex, BMI and Co NR

Short stem: n = 20

Age: 39.9 (range 22.0–49.0)

Sex, BMI and Co NR

Primary uncemented THA: standard stem 58; short femoral stem 20

Mobilize on day 2 postop

Full weight bearing with crutches from wk 4

Crutches for 6–8 wks

Low-impact activities from wk 6 postop

Dubs et al. [28] 1983; Switzerland; level of evidence: III

Retrospective cohort; follow-up: 5.8 y (1.0–14.0)

110 M pts (mostly aged ≤ 60) with hip OA

Age: 55.4 (range 29.0–68.0)

BMI and Co NR

Cemented THA

NR

Hara et al. [32] 2017; Japan; level of evidence: III

Retrospective; follow-up: 5.7 y (range 1.0–16.6)

524 pts with primary OA or secondary OA due to acetabular dysplasia (84 M [16%], 440 F [84%])

Age: 62.9 (range 22.0–86.0)

BMI: 22.9 (± 3.3)

Co NR

Uncemented THA (posterolateral approach)

Full weight bearing as tolerated with crutches or walker for 3–4 wks

Progress to walking without ambulatory aids when pain free

Huch et al. [33] 2005; Germany; level of evidence: II

Prospective cohort; follow-up: 5.0 y

420 pts aged < 76 y with advanced OA (199 M [48%], 221 F [52%])

Age: 60.5 ± 9.7

BM: < 25: 126 (30%); 25 to < 30: 200 (48%); ≥ 30: 94 (22%)

Co: diabetes, 31 (7%); hypertension, 190 (45%); gout, 44 (11%)

Primary THA (not otherwise specified)

NR

Innmann et al. [34] 2016; Germany; level of evidence: III

Retrospective cohort; follow-up: 11.0 y (range 10.0–12.0)

86 pts aged < 61 y, who had undergone primary uncemented THA (53 M [62%], 33 F [38%]

Age: 63 (range 40–72)

BMI: 27 (range 18–39)

Co NR

Primary uncemented THA

NR

Johnsson and Persson [47] 1986; Sweden; level of evidence: III

Retrospective; follow-up: 2.0 y

118 pts aged < 60 y with OA (76 M [64%], 42 F [36%])

Age: 54 (range 36–59)

BMI and Co NR

Primary cemented THA

NR

Karampinas et al. [35] 2017; Greece; level of evidence: IV

Retrospective; follow-up: 2 y

Pts aged < 65 y with OA

BFH group: n = 16 (11 M [69%], 5 F [31%])

Age: range 52–70

BMI and Co NR

SMF group: n = 18 (11 M [61%], 7 F [39%])

Age: range 52–70

BMI and Co NR

Uncemented THA (posterior approach): BFH, SMF

Partial weight bearing allowed on postop day 2

Progress to full weight bearing as tolerated

Use of crutches for 4 wks

Kleim et al. [12] 2015; UK; level of evidence: IV

Cross-sectional; follow-up: 1.8 ± 0.9 y

52 pts aged < 60 y with OA (23 M [44%], 29 F [56%])

Age: 52 ± 7.9

BMI and Co NR

Primary THA (not otherwise specified)

NR

Krischak et al. [48] 2013; Germany; level of evidence: III

Retrospective cohort; follow-up: 2.0 y

736 pts aged 18–60 y with OA (483 M [66%], 253 F [34%])

Age: 50.4 ± 6.2 (range 24.0–60.0)

BMI and Co NR

Primary THA (not otherwise specified)

NR

Lefevre et al. [36] 2013; France; level of evidence: IV

Retrospective; follow-up: 8.8 ± 7.1 y

27 Judokas aged > 60 y with at least a black belt

Age: 63 ± 7.2

Sex, BMI and Co NR

Primary THA (not otherwise specified)

NR

Leichtenberg et al. [13] 2016; the Netherlands; level of evidence: II

Prospective observational; follow-up: 1.0 y

67 pts aged < 65 y with OA + working preop (34 M [51%], 33 F [49%])

Age: 56 ± 6.6

BMI: 28 ± 6.0

Co NR

Primary THA (not otherwise specified)

NR

Mikkelsen et al. [49] 2014; Denmark; level of evidence: I

Non-randomized controlled; follow-up: 0.1 y

365 pts with OA undergoing THA (191 M [52%], 174 F [48%])

Age: 68.7 ± 10.0

BMI: 26.8 ± 4.5

Co NR

Primary THA (posterior approach)

Physiotherapy 1–2 times daily

Home-based training program for 3 wks

RG: traditional rehabilitation including movement restrictions

UG: no movement restrictions

Mobasheri et al. [50] 2006; UK; level of evidence: III

Retrospective; follow-up: 3.0 y (range 0.5–10.0)

86 pts aged < 60 y

with OA (56 M [65%], 30 F [35%])

Age: 51.4 (range 29.0–60.0)

BMI and Co NR

Primary THA (not otherwise specified)

NR

Mont et al. [39] 1999; USA; level of evidence: III

Retrospective; follow-up: 8.0 y (range 2.0–22.0)

58 pts who were playing tennis and had undergone THA (50 M [86%], 8 F [14%])

Age: 62 (range 47–77)

BMI and Co NR

Primary THA

Fixation (n): Cemented 22 (29%), uncemented 48 (64%), hybrid 5 (7%)

NR

Nevitt et al. [62] 1984; USA; level of evidence: III

Retrospective; follow-up: 4.0 y

178 pts aged ≤ 60 y with degenerative, congenital or post-traumatic hip disorder (78 M [44%], 100 F [56%])

Age: 50 (range 21–60)

BMI and Co NR

Primary THA (not otherwise specified)

NR

Pagnano et al. [51] 2006; USA; level of evidence: II

Retrospective; follow-up: minimum 0.5 y after second THA

26 pts with bilateral OA (10 M [38%], 16 F [62%])

Age: 69 (range 42–80)

BMI and Co NR

Staged bilateral uncemented THA

Full weight-bearing as tolerated

Peak et al. [52] 2005; USA; level of evidence: I

Randomized prospective; follow-up: 0.5 y

265 pts undergoing primary THA (139 M [52%], 126 F [48%])

Age: 58.3 (range 14.0–88.0)

BMI: RG, 29.3 (range 15.9–50.2); UG, 28.7 (range 17.6–45.7)

Co NR

Uncemented THA (anterolateral approach)

Limited ROM (< 90° flexion)

Full weight bearing as tolerated

RG: traditional rehabilitation including full hip precautions 6 wks postop

UG: no hip precautions

Poehling-Monaghan et al. [53] 2015; USA; level of evidence: III

Retrospective cohort; follow-up: 0.7 y

Pts with OA who had not undergone previous surgery

DA THA: n = 126 (59 M [46%], 67 F [53%])

Age: 64.8 ± 12.4

BMI: 30.0 ± 5.5

Co NR

MP THA: n = 96 (52 M [54%], 44 F [45%])

Age: 63.9 ± 12.5

BMI: 30.5 ± 6.0

Co NR

Primary THA: DA, MP

Rapid rehabilitation protocol

Seen by a physical therapist twice daily

Weight bearing allowed as tolerated with gait aids

Pons [54] 2010; Spain; level of evidence: III

Retrospective cohort; follow-up: 3.2 y (range 0.1–8.2)

128 pts with OA (90 M [70%], 38 F [30%])

Age: 57 (range 22–76)

BMI and Co NR

Primary uncemented collum femoris preserving THA (posterolateral approach)

Immediate partial weight bearing

Full weight bearing 3 wks postop

Pop et al. [61] 2016; Poland; level of evidence: IV

Retrospective; follow-up: 10.0 y

32 pts aged < 65 y at follow-up who underwent THA between

2003 and 2005 and did not experience postop complications (18 M [56%], 14 F [44%])

Age: 58 (range 39–65)

BMI NR (38% overweight, 28% obese)

Co NR

Uncemented THA (84%)

Postop rehabilitation: yes, 22; no, 10

Raguet et al. [41] 2015; France; level of evidence: III

Retrospective; follow-up: 8.0 y (range 1.0–19.0)

7 pts who underwent THA and practice ultrarunning (6 M [86%], 1 F [14%])

Age: 69.9 (range 61.0–86.0)

BMI: 22.4 (range 19.0–25.0)

Co NR

Uncemented THA (postero-lateral approach)

NR

Sankar et al. [55] 2013; Canada; level of evidence: II

Prospective cohort; follow-up: 1.0 y

190 pts aged 18–85 y with OA, who were working at baseline (100 M [53%], 90 F [47%])

Age: 56.1 ± 9.9

BMI: < 30: 120 (63%); ≥ 30: 69 (36%)

Co NR

Primary THA (not otherwise specified)

NR

Schmidutz et al. [37] 2012; Germany; level of evidence: IV

Retrospective case study; follow-up: 2.7 y (range 2.0–4.2)

68 pts aged < 65 y, undergoing THA, head-neck-shaft angle > 120° (41 M [60%], 27 F [40%]

Age: 55 (range 20–73)

BMI: 26 (range 18–39)

Co NR

Short stem hip arthroplasty (ceramic head)

Restrictions concerning weight bearing and ROM for the first 6 wks

RTS recommendations based on consensus guidelines

Suarez et al. [56] 1996; Spain; level of evidence: IV

Retrospective case study; follow-up: unknown

747 pts aged 18–64 y who were working preop (598 M [80%], 149 F [20%])

Age: 46.9 (range 18.0–64.0)

BMI and Co NR

Primary THA (not otherwise specified)

Rehabilitation was adapted to pt and could include: Kinesiotherapy postop day 1–10: hydrotherapy, ergo therapy, physical therapy for 4–5 wks

Suckel and Best [38] 2006; Germany; level of evidence: III

Retrospective; follow-up: 4.9 y (range 1.0–18.8)

16 pts (22 THAs) with OA who were playing golf preop

Age: 65.7 (range 58.0–78.0)

Sex, BMI, and Co NR

Primary THA (18 uncemented, 3 hybrid, 1 cemented)

NR

Tilbury et al. [57] 2015; the Netherlands; level of evidence: II

Prospective cohort; follow-up: 1.0 y

71 pts aged < 65 y with OA who had undergone THA + were working at baseline (37 M [52%], 34 F [48%])

Age: 56.0 ± 6.6

BMI: 27.8 ± 6.0

Co NR

Primary THA (not otherwise specified)

NR

Truszcynska et al. [58] 2013; Poland; level of evidence: III

Retrospective cohort; follow-up: 2.0 ± 1.5 y

54 pts aged < 65 y with OA who were working preop (29 M [54%], 25 F [46%])

Age: 55.9 ± 7.4

BMI and Co NR

Primary THA (not otherwise specified)

NR

Visuri et al. [59] 1987; Finland; level of evidence: III

Retrospective; follow-up: 4.2 y

539 pts who had undergone THA (166 M [31%], 373 F [69%])

Age range 25–84

BMI and Co NR

Primary THA (not otherwise specified)

NR

White [60] 1987; England; level of evidence: III

Retrospective; follow-up: 7.5 y (range 5.0–10.0)

33 pts aged < 45 y (12 M [36%], 21 F [64%])

Age: 38 (range 24–44)

BMI and Co NR

Cemented THA (posterior approach)

NR

Study

Outcome measures

Preop (pre) activity + definition of preop

Postop activity

RTS + time to RTS

RTW + time to RTW

Confounding factors

Abe et al. [29] 2014; Japan; level of evidence: III

Sports participation (n)

  

48%

Time to RTS: unknown

Unknown

Adjusted for in analysis: age, sex, BMI, operation type, bearing type, femoral head size, preop jogging

Mentioned, not adjusted for: short term follow-up, motivation/reasons for not jogging

 Jogging

27

13

UCLA score

10

Definition: pre-surgery

 

Arbuthnot et al. [30] 2007; UK; level of evidence: III

Sports participation (n)

  

86%

Time to RTS: Return to practice: 4.1 mo (range 0–48)

Return to play: 5.4 mo (range 0–60)

Unknown

Adjusted for in analysis: none

Mentioned, not adjusted for: reasons for no return to golf, recall bias, surgeons’ advice

 Golf

66

57

Definition: pre-symptomatic and pre-surgery

 

Atkinson et al. [42] 2010; UK; level of evidence: I

Definition: pre-surgery

Unknown

Unknown

Adjusted for in analysis: age, ASA grade, bilateral THA (staged vs. single-episode)

Mentioned, not adjusted for: none

Time to RTS: Group 1: 24.8 wks; Group 2: 30.8 wks

Time to RTW: Part-time: Group 1: 13.8 wks; Group 2: 19.3 wks

 

Full-time: Group 1: 22.0 wks; Group 2: 35.8 wks

Berger et al. [43]; 2004; USA; level of evidence: II

Definition: pre-surgery

Unknown

100%

Time to RTW:

8 days (range 1–20)

Adjusted for in analysis: none

Mentioned, not adjusted for: selection bias, rapid recovery protocol, approach, surgeon’s advice

Bohm [44] 2010; Canada; level of evidence: II

Definition: pre-surgery

Unknown

86%

20% of pts who were not working pre-op resumed work

2% stopped working

Time to RTW: unknown

Adjusted for in analysis: sex, age, collecting disability insurance, preop job satisfaction, workload, Oxford Hip Score, functional limitations, education, personal income, self-employed, job motivation

Mentioned, not adjusted for: none

Chatterji et al. [31] 2004; Australia; level of evidence: III

Sports participation (n):

  

93%b

RTS [% (wks until RTS)]

Unknown

Adjusted for in analysis: age, sex, preop sports participation

Mentioned, not adjusted for: recall bias, physiotherapist’s advice, surgeon’s advice

 Overall

188

196

>100

 Ice skating

0

0

 Water skiing

0

0

 Volleyball

0

0

 Sailing

1

1

100 (?)

 Horse riding

1

1

100 (14)

 Croquet

2

0

0 (?)

 Rowing

2

0

0 (12)

 Snow skiing

4

1

25 (?)

 Hiking

6

5

83 (58)

 Jogging

7

1

14 (?)

 Gardening

9

4

44 (9)

 Aqua aerobics

17

32

>100 (9)

 Bush walking

20

20

100 (21)

 Tennis

14

1

7 (91)

 Fishing

23

17

74 (20)

 Cycling

28

18

64 (28)

 Exercise classes

28

21

75 (16)

 Bowling

36

28

78 (21)

 Golf

39

26

67 (22)

 Swimming

52

37

71 (8)

 Exercise walking

145

169

>100 (10)

Grimby scale

3.5 ± 1.2

Definition: pre-surgery

Unknown

 

Clyde et al. [45] 2013; USA; level of evidence: III

Occupational category (n):

  

Unknown

76%

Same job 91%; change of job 9%

Time to RTW primary THA: 17.3 wks (range 2.0–156.0)

Adjusted for in analysis: sex, age, BMI, follow-up period, workload

Mentioned, not adjusted for: recall bias, socioeconomic status, postop complications

 Unemployed

1

11

 Non-manual labor (little physical activity)

14

13

 Moderate labor (lifting < 20 lb)

17

14

 Strenuous labor (lifting 20–50 lb)

11

Definition of preop: pre-surgery

5

Danielsson [46] 1965; Sweden; level of evidence: II

Definition: pre-surgery

Unknown

57%

Previous work: 18%; light manual work: 39%

Time to RTW:

unknown

Adjusted for in analysis: workload

Mentioned, not adjusted for: none

Del Piccolo et al. [40] 2016; Italy; level of evidence: III

Intense sports activities (including skiing, free running, tennis and contact sports, n):

  

Similar RTS for light and medium level activities

RTS (%)

Unknown

Adjusted for in analysis: age, BMI, follow-up, THA design

Mentioned, not adjusted for: not randomized, general applicability, short follow-up

 Conventional stem

19

8

40%

 Short stem

9

4

44%

 

Definition: pre-symptomatic

 

Time to RTS: unknown

Dubs et al. [28] 1983; Switzerland; level of evidence: III

Sports participation (n):

  

RTS (%)

RTW (%)

93

29

80

> 100

Time to RTW: unknown

Adjusted for in analysis: implant loosening

Mentioned, not adjusted for: sex (only M), workload, surgeon’s advice

 Overall

86

61

71

 Hiking/climbing

44

41

93

 Skiing

43

4

9

 Swimming

28

35

> 100

 Running

17

17

100

 Ball sport

16

0

0

 Cycling

14

10

25

 Tennis

9

4

44

 Riding

9

1

11

 Light athletics

6

0

0

 Wrestling

2

0

0

 Rowing

2

0

0

 Sailing

1

3

> 100

 Boxing

1

0

0

 Canoeing

1

1

100

Workload (n)

  

Time to RTS: unknown

 Overall

108

100

 Strenuous

24

7

 Medium

41

33

 Light

43

60

 Retired

2

10

 

Definition: pre-surgery

 

Hara et al. [32] 2017; Japan; level of evidence: III

Sports participation (n):

  

> 100

RTS (%)

Unknown

Adjusted for in analysis: age, BMI, sex, preop sports participation, preop UCLA score

Mentioned, not adjusted for: none

 Overall

288

318

> 100

 Walking

48

84

> 100

 Swimming

50

61

> 100

 Gymnastics

23

50

 > 100

 Strength/muscle training

14

26

> 100

 Cycling

23

21

91

 Golf

23

13

57

 Dancing

12

6

50

 Bowling

10

4

40

 Racket games

17

6

35

 Aerobics

6

2

33

 Jogging

10

7

70

 Ball games

24

7

29

 Other

28

32

> 100

UCLA score

  

Time to RTS: unknown

 RTS, yes

4.3 ± 2.3

5.7 ± 1.8

 RTS, no

3.5 ± 2.0

4.1 ± 1.5 (p < 0.001)

Definition: pre-surgery

Huch et al. [33] 2005; Germany; level of evidence: II

Sports participation (n):

Lifetime/preop

 

> 100

Lifetime/preop

Unknown

Adjusted for in analysis: sex, age, smoking, workload, reasons for no-RTS

Mentioned, not adjusted for: BMI, surgeon’s advice, comorbidities, comparability responders and non-responders

 Overall

408/151

218

53/> 100

 Biking

248/42

181

73/> 100

 Hiking

227/4

161

71/> 100

 Swimming

193/38

151

78/> 100

 Downhill skiing

126/0

17

13/> 100

 Gymnastics

88/21

57

65/> 100

 Cross country skiing, jogging

71/0

20

28/> 100

 Tennis

46/4

10

22/> 100

 Dancing

25/0

20

80/> 100

Definition: lifetime and pre-surgery

Time to RTS: unknown

Innmann et al. [34] 2016; Germany; level of evidence: III

Sports participation (n):

  

RTS:

Unknown

Adjusted for in analysis: sex, age

Mentioned, not adjusted for: recall bias, selection bias, lack of preop data for SF-36 questionnaire

 Overall

86

77

89

 Cycling

25

36

> 100

 Hiking

17

12

71

 Exercise walking

14

16

> 100

 Tennis

15

5

33

 Soccer

10

0

 Fitness/weight lifting

8

14

> 100

 Jogging

7

4

57

 Downhill skiing

7

1

14

 Gymnastics

6

15

> 100

 Cross-country skiing

6

1

17

 Swimming

5

15

> 100

 Basketball/handball

5

0

 Table tennis

4

1

25

 Mountain climbing

4

1

25

 Nordic walking

2

6

> 100

 Aqua-aerobics

2

5

> 100

 Dancing

2

3

> 100

 No sports

20

18

90

UCLA (range)

3.8 ± 1.6 (1–9)

Definition: pre-symptomatic

6.2 ± 1.5 (3–10)

(p < 0.001)

Time to RTS: < 4 wks: 22%; 1–3 mo: 29%; 3–6 mo: 22%; > 6 mo: 6%

Johnsson and Persson [47] 1986; Sweden; level of evidence: III

Type of work (n):

  

Unknown

66%

Time to RTW: within 2 y

Adjusted for in analysis: sex, age, sick leave, workload, bilateral THA, reason for no RTW

Mentioned, not adjusted for: rehabilitation

 Household

2

3

 Light work

11

19

 Moderate work

25

32

 Heavy work

31

15

 

Definition: 2 y preop

 

Karampinas et al. [35] 2017; Greece; level of evidence: IV

Sports participation (n):

  

RTS:

Unknown

Adjusted for in analysis: none

Mentioned, not adjusted for: type of prosthesis, pt fear of complications, surgeon’s advice

BFH group

   

 Low impact

8

8

100%

 Intermediate impact

6

8

> 100%

 High impact

2

0%

SMF group

   

 Low-impact

8

10

> 100%

 Intermediate impact

7

5

71%

 High impact

3

3

100%

UCLA score

  

Time to RTS: 16.5 wks (range 12.0–26.0)

 BFH group

3.5

6.7

 SMF group

3.8

7.9 (p = NR)

HHS score

  

 BFH group

56.5

93.7

 SMF group

48.5

94.4 (p = NS)

Definition: pre-surgery

Kleim et al. [12]

2015; UK; level of evidence: IV

Manual requirements (n):

  

Unknown

75%

Time to RTW: 12 ± 5 wks

Preop sick leave: 15 ± 4 wks

No preop sick leave: 10 ± 1 wks

Adjusted for in analysis: workload, preop sick leave, education

Mentioned, not adjusted for: time to RTW, selection bias, general applicability, motivation

 0 = no manual requirements

24

 1 = some manual requirement

17

 2 = heavy manual work

4

Definition: pre-surgery

Krischak et al. [48] 2013; Germany; level of evidence: III

Definition: pre-surgery

Unknown

85%

83% same job

17% different job

Time to RTW: unknown

Adjusted for in analysis: workload, age

Mentioned, not adjusted for: THA approach

Lefevre et al. [36] 2013; France; level of evidence: IV

Definition: unknown

82%

Time to RTS: 3.9 mo ± 2.7

All pts stopped participating at a competitive level

Unknown

Adjusted for in analysis: age

Mentioned, not adjusted for: selection bias, motivation, experience, surgeon’s advice

Leichtenberg et al. [13] 2016; the Netherlands; level of evidence: II

Type of work (n):

  

Unknown

Full RTW: 79%; partial RTW: 13%; no RTW: 7%d; time to RTW: unknown

Adjusted for in analysis: type of prosthesis, sex, age, education, self-employed, preop h worked, workload, preop work adaptions, preop workers compensation, preop sick leave

Mentioned, not adjusted for: recall bias, baseline HOOS

 Light

41

33

 Medium

14

10

 Heavy

4 Definition: presurgery

3 (p = 0.672)

Mikkelsen et al. [49] 2014; Denmark; level of evidence: I

Pts working (n)

  

Unknown

45%

Time to RTW: unknown

Adjusted for in analysis: rehabilitation protocol

Mentioned, not adjusted for: selection bias, short inclusion and follow-up period, lack of blinding, information bias, missing data

 RG

37

12

 UG

54

29 (p = 0.045)

 

Definition: pre-surgery

Mobasheri et al. [50] 2006; UK; level of evidence: III

Definition: pre-surgery

Unknown

RTW: employed preop: 96%; unemployed preop: 43%

Time to RTW: employed preop: 10.5 wks; unemployed preop: 35.0 wks

Adjusted for in analysis: reasons for no RTW, self-employment, sex, > 1 y unemployed preop

Mentioned, not adjusted for: preop sick-leave

Mont et al. [39] 1999; USA; level of evidence: III

Sports participation (n):

  

RTS (%)

Unknown

Adjusted for in analysis: level of play, singles vs doubles, return to competitive play, motivation

Mentioned, not adjusted for: fixation, recall bias, selection bias, surgeon’s advice

 Tennis

58

58

100%

 

Definition: pre-surgery

 

Time to RTS: 6.7 mo (range 1.0–12.0)

Nevitt et al. [62] 1984; USA; level of evidence: III

Work status (n):

Lifetime/pre-surgery

1 y postop/4 y postop

Unknown

RTW: 1 y postop: 68%; 4 y postop: 63%

35% limitations in physical activities; 41% limited in the kind or the amount of their work

Time to RTW: unknown

Adjusted for in analysis: sex, age, diagnosis, prior hip surgery, y of THA, joint pain, uni- or bilateral THA, preop work status

Mentioned, not adjusted for: timing of surgery, general unemployment rates, prosthesis type

 Working

139/81

95/87

 Disabled

NR/58

44/52

 

68% limitations in physical activities

44% limited in the kind or the amount of their work

Definition: lifetime and 1 mo pre-surgery

 

Pagnano et al. [51] 2006; USA; level of evidence: II

Definition: pre-surgery

Unknown

100%

Time to RTW: mini-posterior THA: 38 days (range 14–90)

Two-incision THA: 42 days (range 9–56)

Adjusted for in analysis: approach (mini-posterior vs. two-incision)

Mentioned, not adjusted for: influence of the first THA, complications

Peak et al. [52] 2005; USA; level of evidence: I

Working (n):

  

Unknown

RTW: RG 95%; UG 100% (p = NS)

Time to RTW (wks): RG 9.5; UG 6.5 (p < 0.001)

Adjusted for in analysis: rehabilitation protocol

Mentioned, not adjusted for: selection bias, approach

 RG

85

81

 UG

98

98

 

Definition: pre-surgery

 

Poehling-Monaghan et al. [53] 2015; USA; level of evidence: III

Definition: pre-surgery

Unknown

RTW at 8 weeks: DA 69%; MP: 97% (p < 0.01)

Time to RTW: unknown

Adjusted for in analysis: THA approach

Mentioned, not adjusted for: mismatch in experience

Pons [54] 2010; Spain; level of evidence: III

Definition: pre-surgery

Unknown

96%

Time to RTW: unknown

Adjusted for in analysis: none

Mentioned, not adjusted for: none

Pop et al. [61] 2016; Poland; level of evidence: IV

Employment status

 1 y preop

 1 y postop

 10 y postop

Unknown

Definition: 1 y preop, 1 y postop, 10 y postop

Unknown

Unknown

Employment status: 1 y preop: yes 28 (88%), no 0 (0%)

Disability/retirement: 4 (12%)

1 y postop: yes 15 (47%), no 4 (13%)

Disability/retirement: 13 (41%)

10 y postop: yes

13 (41%), no 1 (3%)

Disability/retirement: 18 (57%)

Time to RTW: unknown

Adjusted for in analysis: none

Mentioned, not adjusted for: functional capacity, BMI, sex, place of residence, level of physical capacity, comorbidities, supervised rehabilitation

Raguet et al. [41] 2015; France; level of evidence: III

Sports participation (n):

  

RTS (%)

Unknown

Adjusted for in analysis: none

Mentioned, not adjusted for: age, surgeon’s advice, bearing type, postop pain, fear of luxation

 Ultrarunning

7

7

100

UCLA score

10

Time to RTS: unknown

Definition: pre-symptomatic

Sankar et al. [55] 2013; Canada; level of evidence: II

Physical demands at work (n):

  

Unknown

87%

Time to RTW: ≤ 1 mo: 39%; ≤ 3 mo: 36%; 6–12 mo: 25%

Adjusted for in analysis: age, sex, education level, job sector, physical demands

Mentioned, not adjusted for: workplace accommodations

 Low demand

88

78

 High demand

74

67

 Unclassified

22

18

Definition: pre-surgery

Schmidutz et al. [37] 2012; Germany; level of evidence: IV

Sport participation (%):

Low impact

  

98%

RTS (%)

Unknown

Adjusted for in analysis: sex, age, level of impact

Mentioned, not adjusted for: recall bias, surgeons’ advice

 Cycling

69

69

100

 Hiking

54

57

> 100

 Nordic walking

12

18

> 100

 Gymnastics

22

26

> 100

 Fitness/weight training

22

38

> 100

 Dancing

22

22

100

 Swimming

57

56

98

 Golf

1

1

100

Intermediate impact

   

 Badminton

7

3

43

 Inline skating

4

1

25

 Tennis

15

3

20

 Downhill skiing

24

16

67

 Cross-country skiing

21

15

71

 Riding

7

3

43

 Martial arts

4

1

25

 Bowling

10

6

60

 Rock climbing

1

1

100

High impact

   

 Jogging

9

3

33

 Handball

1

0

 Volleyball

7

3

43

 Basketball

4

1

25

 Soccer

9

1

11

 Squash

7

0

-

UCLA score

Unknown

Definition: pre-surgery

7.6 ± 1.9 (range 3–10)

Time to RTS: 1–2 mo: 27%; 3–4 mo: 25%; 5 to ≥ 6 mo: 48%

Suarez et al. [56] 1996; Spain; level of evidence: IV

Type of work (n)

  

Unknown

25%

RTW (%)

Adjusted for in analysis: sex, age, workload, education, social security type, environment (rural/urban), family structure, underlying illness

Mentioned, not adjusted for: cultural background

 Heavy work

456

7

 

1.5

 Moderate work

134

84

 

63

 Light work

157

143

 

91

 

Definition: pre-surgery

  

Time to RTW: unknown

Suckel and Best [38] 2006; Germany; level of evidence: III

Sports participation (n):

  

RTS (%)

Unknown

Adjusted for in analysis: none

Mentioned, not adjusted for: side, surgeon’s advice, risk of wear, golf experience

 Golf

16

16

100

 

Definition: pre-surgery

 

Time to RTS: unknown

Tilbury et al. [57] 2015; the Netherlands; level of evidence: II

Definition: pre-surgery

Unknown

90%

Time to RTW: 12.5 ± 7.6 wks

Reason for no RTW: sick leave 2 (3%); retired 2 (3%); unknown 3 (4%)

Adjusted for in analysis: sex, age, BMI, education, radiographic severity, HOOS, EQ-5D score, Oxford Hip Score, SF-36 score

Mentioned, not adjusted for: recall bias, postop complications

Truszcynska et al. [58] 2013; Poland; level of evidence: III

Definition: pre-surgery

Unknown

59%

All of these pts returned to their preop employment level

Time to RTW: 94% within 6 mo

Adjusted for in analysis: sex, age, satisfaction with job, education level, compliance with exercise program, mental health

Mentioned, not adjusted for: none

Visuri et al. [59] 1987; Finland; level of evidence: III

Type of work (n):

  

Unknown

67%

Time to RTW: unknown

Adjusted for in analysis: age, sex, workload, social class, primary diagnosis, walking ability, pensioner groups

Mentioned, not adjusted for: type of prosthesis

 Laborers

303

27

 Service workers

69

22

 Mental workers

99

18

 Housewives

68

 

Definition: pre-surgery

 

White [60] 1987; England; level of evidence: III

Workload (n)

 Heavy manual work

8

Definition: Lifetime

6

Unknown

92%

3 pts took up employment for the first time following THA

Time to RTW: unknown

Adjusted for in analysis: diagnosis, workload

Mentioned, not adjusted for: previous surgery, weight gain, patient activity

Levels of evidence: I = randomized controlled study, II = prospective study, III = retrospective (comparative) study, IV = retrospective case series

ASA American Society of Anesthesiologists, BFH big femoral head arthroplasties, BMI body mass index, Co co-morbidities, DA direct posterior, EQ-5D EuroQol-5D, F female, HHS Harris Hip Score, HOOS Hip disability and Osteoarthritis Outcome Score, M male, mo months, MP mini-posterior, NR not reported, NS not significant, OA osteoarthritis, postop postoperative, preop preoperative, pts patients, RG restricted group, ROM range of motion, RTS return to sports, RTW return to work, SMF short modular femoral hip system, THA total hip arthroplasty, UCLA University of California, Los Angeles, UG unrestricted group, wk(s) week(s), y years

aAge is presented in years unless otherwise indicated and BMI is presented in kg/m2

bChatterji et al. reported return to sports of 175 of 188 patients (93%) performing sports preoperatively, plus 21 patients who took up at least one sport postoperatively

cDel Picolo et al. used different numbers in the abstract and in the methods section. We report number that was stated in the methods section

dTotal RTW percentage is 99% in original article

The total number of included patients was 6485, with 3066 males (47%) and 3016 females (47%). Five studies did not report the sex distribution in their cohort, thus sex was unknown for 6% of the included patients [30, 31, 36, 38, 40]. The mean duration of follow-up was 3.8 years (range 0.25–11), with one study not reporting time to follow-up [56]. The mean age across studies ranged from 38 to 71 years, with a total age range of 14–98 years. Patients’ BMI was specified in 14 studies, with mean BMI varying from 22 to 32 kg/m2. One study provided information on comorbidities [33]. The authors described that, of the included 420 patients, 7% had diabetes, 45% had hypertension, and 11% had gout. The approach was described in ten studies: one study used a direct anterior approach, two used an anterolateral approach, three used a posterolateral approach, three used a posterior approach, and one used a two-incision approach. The rehabilitation protocol was described in 13 studies. Immediate full weight bearing was allowed in seven studies [29, 32, 35, 43, 51, 52, 53] and partial weight bearing was recommended for 3–6 weeks in four studies [37, 40, 46, 54]. Two studies compared restricted and unrestricted movement protocols [49, 52]. The use of crutches was advised for 4–8 weeks in three studies [32, 35, 40].

3.3 Methodological Quality

Table 2 summarizes the results of the quality assessment. The methodological quality was rated as high in 11 studies, moderate in 16 studies, and low in ten studies. The lowest risk of bias was found for the item “selection of the cohort” (36 studies scored a star), the item “ascertainment of exposure” (34 studies scored a star), and the item “demonstration that the outcome of interest (RTS/RTW) was not present at the start of the study” (36 studies scored a star). The highest risk of bias was found for the item “assessment of outcome,” for which ten studies scored a star (Table 2).
Table 2

Methodological assessment according to the Newcastle–Ottawa scale

Study

Selection

Comparability

Outcome

Total scorea

Representativeness

Selection

Ascertainment

Outcome of interest

Assessment

FU

Adequacy of FU

Abe et al. [29]

*

*

*

*

**

*

7

Arbuthnot et al. [30]

*

*

*

*

*

*

*

7

Atkinson et al. [42]

*

*

*

*

*

*

*

7

Berger et al. [43]

*

*

*

*

*

*

6

Bohm [44]

*

*

*

*

**

*

*

8

Chatterji et al. [31]

*

*

*

*

**

*

7

Clyde et al. [45]

*

*

*

**

*

6

Danielsson [46]

*

*

*

*

*

*

*

7

Del Piccolo et al. [40]

*

*

*

*

*

*

*

7

Dubs et al. [28]

*

*

*

*

*

5

Hara et al. [32]

*

*

*

*

**

*

7

Huch et al. [33]

*

*

*

*

**

*

*

8

Innmann et al. [34]

*

*

*

*

*

*

*

7

Johnsson and Persson [47]

*

*

*

*

**

*

*

*

9

Karampinas et al. [35]

*

*

*

*

*

5

Kleim et al. [12]

*

*

*

*

**

6

Kirschak et al. [48]

*

*

*

*

**

*

*

*

9

Lefevre et al. [36]

*

*

*

*

4

Leichtenberg et al. [13]

*

*

*

*

**

*

*

8

Mikkelsen et al. [49]

*

*

*

*

*

5

Mobasheri et al. [50]

*

*

*

*

**

*

*

8

Mont et al. [39]

*

*

*

*

4

Nevitt et al. [62]

*

*

*

*

**

*

*

8

Pagnano et al. [51]

*

*

*

*

*

5

Peak et al. [52]

*

*

*

*

*

5

Poehling-Monaghan et al. [53]

*

*

2

Pons [54]

*

*

*

*

*

*

6

Pop et al. [61]

*

*

*

*

*

5

Raguet et al. [41]

*

*

*

*

*

*

6

Sankar et al. [55]

*

*

*

*

**

*

*

8

Schmidutz et al. [37]

*

*

*

*

**

*

*

8

Suarez et al. [56]

*

*

*

*

**

*

7

Suckel et al. [38]

*

*

*

3

Tilbury et al. [57]

*

*

*

*

**

*

*

8

Truszczynska et al. [58]

*

*

*

*

*

*

*

7

Visuri et al. [59]

*

*

*

*

**

*

*

*

9

White [60]

*

*

*

*

*

*

*

7

FU follow-up

– indicates no stars

aWe considered a study to be of high quality when the total score was eight or nine stars, moderate quality when the total score was six or seven stars, and low quality when the total score was five stars or fewer

3.4 Return to Sports

Of 15 studies that reported RTS and time to RTS, 14 reported the percentage of patients that RTS. Mean RTS percentages varied from 43 to > 144%, the latter indicating that more patients participated in sports activities postoperatively than preoperatively (Table 1). Ten studies describing the preoperative sports level as the moment before surgery (pre-surgery level) reported RTS percentages from 48 to > 100%. Four studies describing preoperative sports participation as the moment before the onset of restricting hip symptoms (pre-symptomatic level) reported that 43, 82, 86, and 100% could RTS [30, 34, 40, 41]. For the two high-quality studies, Huch et al. [33] and Schmidutz et al. [37], RTS was > 100% and 98%, respectively, relative to the pre-surgery level. In addition, Huch et al. [33] reported RTS with lifetime sports participation as a reference level and found an average RTS of 53%. Five studies reported time to RTS, with the average being 21.0 weeks (range 15.5–28.0) [30, 35, 36, 39, 42]. No studies with a low risk of bias reported time to RTS. In addition, Chatterji et al. [31], Innmann et al. [34], and Schmidutz et al. [37] reported the cumulative percentage of patients that had returned at different time points (Table 1).

Data could be pooled for 14 studies that reported exact numbers of patients participating in sports pre- and postoperatively (Table 3), including 2318 patients (60% male, median age 62.9 years). Overall, RTS was 100%, but this percentage depended on the definition of the preoperative sports level. Average return to pre-surgery sports level was 104%, and average return to pre-symptomatic sports level was 82%. Both high-quality studies reported the return to pre-surgery sports level and found an average RTS of 131% (Table 3). In addition, one high-quality study also reported return to lifetime sports level, with an average RTS of 53% (Table 3).
Table 3

Pooled data for number of patients participating in any sport pre- and postoperatively

Preoperative reference for RTS

No. of pts participating in any sport

RTS (%)

Preoperatively

Postoperatively

Overall (14 studies)

1125

1130

100

Pre-surgery participation as reference for RTS (10 studies)

938

977

104

Pre-symptomatic participation as reference for RTS (4 studies)

187

153

82

High-quality studies; pre-surgery participation as reference for RTS (2 studies)

214

280

131

High-quality studies; lifetime participation as reference for RTSa (1 study)

408

218

53

No. number, pt(s) patient(s), RTS return to sports

aHuch et al. [33] reported both the pre-surgery and lifetime sports participation

In total, 11 studies described specific numbers of sports that were practiced pre- and postoperatively (Table 4), including 1605 patients (65% male, median age 63.0 years). Preoperatively, 1605 patients practiced an average of 1.1 sports, including 62% low-impact sports, 24% intermediate-impact sports, and 14% high-impact sports. Postoperatively, 1605 patients practiced an average of 1.0 sports, including 69% low-impact sports, 23% intermediate-impact sports, and 8% high-impact sports (Table 4). In the high-quality studies, 488 patients practiced an average of 1.3 sports preoperatively, including 52% low-impact sports, 37% intermediate-impact sports, and 11% high-impact sports. Postoperatively, 488 patients practiced an average of 1.1 sports, including 57% low-impact sports, 40% intermediate-impact sports, and 3% high-impact sports.
Table 4

Pooled data for pre- and postoperative sports participation for different types of sport impact levels

Impact level

Preoperative sports participation (11 studies)

Postoperative sports participation (11 studies)

Sports (n)

Pts (n)

Average sports/pt, n (%)

Sports (n)

Pts (n)

Average sports/pt, n (%)

Low (e.g., cycling, swimming, golfing)

1115

1605

0.69 (62)

1090

1605

0.68 (69)

Intermediate (e.g., hiking, downhill skiing)

427

1605

0.27 (24)

372

1605

0.23 (23)

High (e.g., tennis, running, ball sports)

250

1605

0.16 (14)

122

1605

0.08 (8)

Total

1792

1605

1.12

1584

1605

0.99

pt(s) patient(s)

3.5 Return to Work

Of 24 studies that reported RTW and time to RTW, 23 reported the mean percentage of RTW, which varied from 25 to > 122%, the latter indicating that more patients worked postoperatively than preoperatively (Table 1). For the high-quality studies, mean RTW percentages were 66, 67, 68, 85, 87, 87, 90, 93, and 122%, respectively [13, 44, 47, 48, 50, 55, 57, 59, 62]. Time to RTW was reported in eight studies, and the mean duration of inability to work varied from 1 to 17 weeks. Pooling of studies, including 3536 patients (53% male, median age 52.7 years), showed that 3097 patients worked preoperatively and overall RTW was 69% (Table 5). For the high-quality studies, a mean RTW of 83% was found. A large difference in RTW was found between studies published before or after 2000, with a mean RTW of 44% for studies published in or before 2000 and 86% for those published after 2000 (Table 5). Pooling of studies that reported time to RTW showed a mean inability to work of 8.9 weeks. For the high-quality studies (n = 2), a mean inability to work of 11.4 weeks was found [50, 57].
Table 5

Pooled data for return to work and average duration of inability to work

 

Number of working patients

 

Time to RTW

Preoperative (n)

Postoperative (n)

RTW (%)

Patients (n)

Inability to work (weeks)

Overall (23 studies)

3097

2138

69

Overall (8 studies)

746

8.9

High quality (9 studies)

1492

1242

83

High quality (2 studies)

157

11.4

Published in or before 2000 (16 studies)

1238

548

44

Published in or before 2000 (0 studies)

Published after 2000 (7 studies)

1859

1590

86

Published after 2000 (8 studies)

746

8.9

RTW return to work

3.6 Secondary Outcome Measures of Physical Activity

The UCLA activity score was reported in six studies. Abe et al. [29] compared postoperative joggers with non-joggers and found a significantly higher postoperative UCLA score (mean ± standard deviation [SD]) of 10 ± 0 for joggers (n = 23) compared with 6.6 ± 2.4 for non-joggers (n = 585). Hara et al. [32] found that both preoperative and postoperative UCLA scores were significantly higher in patients who participated in sports postoperatively than in those who did not: 4.3 ± 2.3 versus 3.5 ± 2.0 preoperatively and 5.7 ± 1.8 versus 4.1 ± 1.5 postoperatively. Innmann et al. [34] found a significant increase in UCLA score 11 years after THA, from 3.8 ± 1.6 preoperatively to 6.2 ± 1.5 postoperatively. Karampinas et al. [35] reported that UCLA scores significantly improved from 3.5 to 6.7 (SD unknown) in the big femoral head group and from 3.8 to 7.9 (SD unknown) in the short metaphyseal stem group. Raguet et al. [41] found a postoperative UCLA score of 10 for seven patients participating in ultrarunning. Lastly, Schmidutz et al. [37] found a postoperative UCLA score of 7.6 ± 1.9 after a mean follow-up of 2.7 years. The Grimby scale was reported in one study. Chatterji et al. [31] found a mean postoperative Grimby scale score of 3.5 ± 1.2, at 1–2 years after surgery.

3.7 Confounding Factors: Return to Sports

Of 15 studies reporting RTS, ten analyzed the effect of one or more confounding factors on RTS. Age was analyzed in eight studies, of which three found an age-dependent decline in RTS [29, 31, 33] and five found no association [32, 34, 37, 40, 42]. Sex was analyzed in five studies: two found a higher RTS in men than in women [29, 33], and three found no association [31, 34, 37]. BMI was analyzed in three studies, which found no association with RTS [29, 32, 40]. Four studies analyzed preoperative sports participation, and all found higher RTS in patients who had already participated in sports preoperatively [29, 31, 32, 33]. Additionally, Hara et al. [32] found that a higher preoperative UCLA score was associated with higher RTS. Lastly, one study analyzed the level of impact and found the chance of returning to intermediate- and high-impact sports activities was lower than that of returning to low-impact activities [37].

3.8 Confounding Factors: Return to Work

Of 24 studies reporting RTW, 22 analyzed the effect of one or more confounding factors on RTW. Age was analyzed in 13 studies, of which four found higher RTW in younger patients [13, 44, 48, 59] and nine found no association [36, 42, 45, 47, 55, 56, 57, 58, 62]. Sex was analyzed in 12 studies, of which two found that men returned to work faster than did women [50, 55] and ten found no association [13, 44, 45, 47, 56, 57, 58, 59, 61, 62]. The three studies that analyzed BMI found no association with RTW [45, 57, 61]. Workload was analyzed in 11 studies, of which six found that higher preoperative workload resulted in lower RTW [45, 47, 48, 56, 59, 60] and two found that higher workload resulted in longer postoperative inability to work [12, 55]. Three studies found no association between workload and RTW [13, 44, 46]. Additionally, three studies found that patients with higher education returned to work faster and more often [12, 13, 55], and one study found that patients with elementary school education returned to work considerably less often [56]. Three studies found no association between education level and RTW [44, 57, 58]. Five studies analyzed preoperative sick leave and found it to be associated with lower RTW [12, 13, 47, 50, 62]. Additionally, one study found that patients who collected a disability insurance preoperatively were less likely to RTW [44]. Self-employment was analyzed in three studies, of which one found that self-employment resulted in partial or no RTW [13] and two studies found no association [44, 50]. Job satisfaction was analyzed in two studies, one of which found that 97% of patients who returned to work were satisfied with their job [58]. In contrast, one study found lower job satisfaction in patients who did RTW [44]. THA approach was analyzed in three studies, one of which found that the mini-posterior approach resulted in higher RTW than did the direct anterior approach [53]. Two other studies found no association [44, 51]. Two studies investigating a restricted compared with an unrestricted rehabilitation protocol found that patients in the unrestricted rehabilitation protocol returned to work more often [49] and faster [52] than those with a restricted protocol.

4 Discussion

The aim of the present systematic review and meta-analysis was to investigate the extent of RTS and RTW after THA. Our most important finding was that a large percentage of patients returned to sports and work after THA. Concerning sports participation, the percentage of patients returning to any type of sports activity varied from 43 to > 100%, indicating that more patients participated in sports postoperatively than preoperatively. The average time to RTS was 21 weeks. We also found a decrease in participation in high-impact sports activities and a corresponding increase in participation in low-impact activities. Concerning work resumption, the percentage of patients who could RTW varied from 25 to > 100%, and the average time to RTW was 9 weeks.

4.1 Return to Sports

Our meta-analysis revealed an overall RTS percentage of 100%. However, this percentage varied considerably with the preoperative reference point that was used to define sports participation. For instance, 104% of patients returned to their pre-surgery sports level, whereas only 82% returned to their pre-symptomatic level. As stated, we believe that the pre-symptomatic level represents a more appropriate reference point for RTS, since many patients limit their sports participation before joint replacement because of pain and functional limitations [24, 25]. Still, our finding that more patients participated in sports postoperatively compared with their pre-surgery sports level, with an RTS of 104%, is encouraging. Both high-quality studies used the pre-surgery level and not the pre-symptomatic level as a reference and consequently found very high RTS percentages (98 and 144%) [33, 37]. Huch et al. [33] also compared lifetime sports participation with postoperative sports participation and found an overall RTS of 53%. However, this is likely an underestimation, since lifetime participation also includes sports that patients practiced in their youth and had stopped practicing for reasons unrelated to their hip. Overall, an RTS of 82% after THA seems the best estimate, which is in accordance with findings in patients undergoing knee arthroplasty and knee osteotomy [24, 25].

4.2 Return to Work

Regarding return to work, our meta-analysis revealed an overall RTW of 69%. The previous systematic review by Tilbury et al. [11] did not pool RTW data, hampering the comparison with the present review. However, the authors described that RTW ranged from 25 to 95% in seven studies. For the present review, we found 23 studies reporting RTW percentages, which varied from 25 to > 100%. Thus, the newly published studies that we identified reported a range similar to that in the previous review [11]. Given the increasing number of THAs performed in working age patients in the last 2 decades [27], we compared RTW percentages for studies published before and after 2000. As expected, the pooled RTW percentage was considerably higher in studies published after 2000 (86 vs. 44%). Apart from the increased utilization of THA in patients of working age, this difference might also be attributed to the large increase in less physically demanding jobs in developed countries as well as more liberal recommendations concerning RTW after THA. This was illustrated by findings of two studies describing differences in RTW and time to RTW between a restricted and unrestricted rehabilitation protocol [49, 52]. Mikkelsen et al. [49] found higher RTW in an unrestricted group (no movement restrictions, RTW of 54%) than in a restricted group (restricted hip movement for 3 months; RTW of 32%). Peak et al. [52] found that patients in an unrestricted group (no movement restrictions) returned to work after 6 weeks compared with 9 weeks in a restricted group (movement restrictions for 6 weeks). Interestingly, none of the other included studies mentioned the effect of rehabilitation protocol or surgeons’ advice concerning RTW. Thus, the effect of different rehabilitation protocols and surgeons’ recommendations on RTW and time to RTW is an important topic for future studies. Lastly, one included study reported that 5 of 67 patients (7%) did not RTW, whereas nine patients (13%) could only partially RTW [13]. Since most patients expressed a preoperative desire to fully RTW, this subtotal loss of work capacity might be clinically relevant. Therefore, future studies should aim to distinguish between a full and partial RTW after hip arthroplasty.

4.3 Prognostic Factors

4.3.1 Prognostic Factors for Return to Sports

Regarding RTS, increasing age was associated with a decline in RTS in three studies, whereas five studies found no association. However, of those five studies, three limited their inclusion to patients aged < 60 years [34, 37, 40] and one study included a small number of patients [42], thus limiting statistical validity. In general, above the age of 65 years, a postoperative decline in sports participation might be expected for THA patients. An important prognostic factor for RTS is preoperative sports participation, which was analyzed by five studies, all of which found higher RTS in patients who had participated in sports preoperatively. This is in line with findings in patients undergoing knee arthroplasty and knee osteotomy [24, 25]. Only one study analyzed the impact level of a sport; the authors found that participation in intermediate- and high-impact sports was associated with lower RTS than participation in low-impact sports.

Remarkably, patients’ motivation to RTS, which is a proven prognostic factor for RTS in patients undergoing hip and knee arthroplasty [24, 63], was not mentioned in any of the included studies. Furthermore, surgeons’ advice is a main reason for patients to refrain from sports participation after THA [15, 63], but none of the included studies adjusted for this. Compared with the 1999 Hip Society recommendations for athletic activity after THA [64], subsequent expert opinion surveys found an increasing tolerance for and acceptance of granting patients permission to return to higher-impact activities, such as downhill skiing or ice skating [14, 65, 66]. Interestingly, Swanson et al. [65] found that high-volume hip surgeons were more liberal in their recommendations, indicating that, as experience with THA and RTS grows, orthopedic surgeons become less cautious. Thus, a trend of allowing more sports activities after THA can be observed over the past 2 decades. Although our data suggest that patients do engage in intermediate- and high-impact sports activities, we observed a shift from high-impact sports activities to low-impact sports activities. From a surgeon’s point of view, this may seem desirable, but it is important to discuss this with the patient before surgery. High-impact sports activities are known to negatively influence THA durability [67]. However, as some of the included studies have shown, a limited proportion of patients do participate in high-impact activities such as tennis, running, and judo. For many of these patients, the possibility of continuing their high-impact activities is the main reason for surgery. It appears that the experience level of patients, which was high in all patients returning to high-impact activities, influences the possibility of RTS. Thus, despite the increased risk of mechanical failure, a return to high-impact activities should not be completely ruled out, especially in experienced patients. The 15-year survival rate in highly active patients is reported to be approximately 80% for bearings that were used 20 years ago [68]. The risk of dislocation and fractures is low. To address the needs of active patients, surgeons can use bearings with low wear rates and femoral heads up to 36 mm in diameter [68]. Future studies are needed to identify the thresholds for physical activity in patients undergoing hip arthroplasty, above which the negative effects in terms of prosthesis wear exceed the positive effects in terms of general health improvement and patient satisfaction [15, 17].

4.3.2 Prognostic Factors for Return to Work

This systematic review is one of the first studies to systematically summarize the effects of confounding factors on RTW [11, 69] and the first to summarize the effects of confounding factors on RTS. These findings provide additional guidance for the orthopedic surgeon and the patient in preoperative counseling and discussing the probability of RTW and RTS. Regarding RTW, a previous literature review identified two studies of confounding factors influencing RTW after THA, both of which found that preoperative sick leave was associated with lower RTW [70]. Another review identified 15 studies describing beneficial or limiting factors for RTW after THA but did not summarize these findings [11]. Our systematic review identified 22 studies reporting on confounding factors for RTW. Preoperative sick leave appears to be a consistent prognostic factor for RTW. All studies that included preoperative sick leave in the analysis found lower RTW for patients who were absent from work preoperatively, which is in line with findings in patients undergoing knee arthroplasty [24, 71, 72]. Furthermore, a higher preoperative workload was associated with lower RTW in most studies. Similarly, a higher level of education, which results in more white-collar jobs and thus a lower physical workload, was associated with higher RTW. Factors such as collecting a preoperative disability pension or disability insurance, job satisfaction, employment versus self-employment, and THA approach, might be associated with RTW. However, only a limited number of studies investigated these factors, and more research is needed to verify this. To this end, future studies of RTW in THA patients should collect and discuss these factors.

4.4 Limitations

A limitation of the present analysis is the low availability of high-quality, prospective studies. Most studies had a retrospective design, thus increasing the risk of recall bias. Also, methodological quality was rated as moderate or low in most studies. Furthermore, no validated questionnaires for the assessment of RTS and RTW exist, which hampers comparisons between studies. The development of a core outcome set will allow for more reliable and valid collection of patient data on work and sports participation before and after THA [73].

5 Conclusion

Most patients were able to RTS and RTW after THA within a timeframe of 28 and 17 weeks, respectively. Participation in high-impact sports activities is less likely but not impossible. Furthermore, RTW with a high workload or after prolonged preoperative sick leave is less likely. For the increasingly younger THA population, this is valuable information that can be used by the orthopedic surgeon and the patient in the preoperative shared decision-making process.

Notes

Acknowledgements

The authors thank Dr. Abe and Dr. Sakai for kindly providing us with additional information regarding return to sports percentages in their study.

Compliance with Ethical Standards

Funding

No sources of funding were used to assist in the preparation of this article.

Conflict of interest

Alexander Hoorntje, Kim Janssen, Stefan Bolder, Koen Koenraadt, Joost Daams, Leendert Blankevoort, Gino Kerkhoffs and Paul Kuijer have no conflicts of interest relevant to the content of this review.

Supplementary material

40279_2018_924_MOESM1_ESM.xlsx (13 kb)
Supplementary material 1 (XLSX 13 kb)
40279_2018_924_MOESM2_ESM.doc (28 kb)
Supplementary material 2 (DOC 28 kb)
40279_2018_924_MOESM3_ESM.doc (28 kb)
Supplementary material 3 (DOC 28 kb)

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© The Author(s) 2018

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  • Alexander Hoorntje
    • 1
    • 2
    • 3
    Email author
  • Kim Y. Janssen
    • 1
  • Stefan B. T. Bolder
    • 2
  • Koen L. M. Koenraadt
    • 2
  • Joost G. Daams
    • 4
  • Leendert Blankevoort
    • 1
    • 3
  • Gino M. M. J. Kerkhoffs
    • 1
    • 3
  • P. Paul F. M. Kuijer
    • 5
  1. 1.Department of Orthopaedic Surgery, Academic Medical CenterAmsterdam Movement Sciences, University of AmsterdamAmsterdamThe Netherlands
  2. 2.Department of Orthopaedic SurgeryFoundation FORCE (Foundation for Orthopaedic Research Care and Education), Amphia HospitalBredaThe Netherlands
  3. 3.Academic Center for Evidence-Based Sports Medicine (ACES)AmsterdamThe Netherlands
  4. 4.Medical Library, Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
  5. 5.Coronel Institute of Occupational Health, Amsterdam Public Health Research Institute, Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands

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