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Endurance sports after total knee replacement: A biomechanical investigation
Abstract
No biomechanical evaluation of total knee designs exists for loads occurring during sports activities. It was the purpose of the present study to evaluate the contact stress distribution and contact area of different knee joint designs for loads that occur during four common recreational endurance activities.
Three different total knee designs were evaluated for loads occurring during cycling (1.2 body weight (BW) at 80 degrees of knee flexion), power walking (4 BW at 20 degrees), hiking (8 BW at 40 degrees), and jogging (9 BW at 50 degrees) using Fuji pressure-sensitive film. The designs consisted of a flat tibial inlay, a curved inlay, and an inlay with mobile bearings. Five measurements were conducted for each load. The pressure sensitive films were scanned and analyzed using an image analysis program.
During cycling, the area with stress levels above the yield point of polyethylene (overloaded area) was below 15 mm2 for each design. During power walking, the mobile bearing design showed no overloaded area, whereas it was below 50 mm2 for the flat and curved design. During downhill walking and jogging, more than 140 mm2 were overloaded for each design.
It was concluded that patients after total knee replacement should alternate activities such as power walking and cycling. For mountain hiking, patients are advised to avoid descents or at least use ski poles. Jogging or sports involving running should be discouraged after total knee replacement.
... Several authors have noted their concerns over patients returning to physical activity following a joint replacement, and that it must be balanced out by the potential overall health benefits of exercise on cardiovascular, metabolic, and musculoskeletal systems [12,16,[43][44][45]. Many studies examining physical activity and sports after joint replacement have reported on TKA only, [43][44][45] and some highlights are reported here. ...
... Several authors have noted their concerns over patients returning to physical activity following a joint replacement, and that it must be balanced out by the potential overall health benefits of exercise on cardiovascular, metabolic, and musculoskeletal systems [12,16,[43][44][45]. Many studies examining physical activity and sports after joint replacement have reported on TKA only, [43][44][45] and some highlights are reported here. Due to the biomechanical differences between the TKA and UKA, we can not simply transfer TKA recommendations to the UKA patient. ...
... In a review of current literature and exercise recommendations after total joint replacement, it is generally advised to avoid jogging, tennis, and running sports due to concerns that these activities cause excessive stress in the polyethylene joint bearings risking delamination and polyethylene wear, prosthetic loosening, and increased revision rates [43][44][45]. Loads during these high impact activities can reach up to 8-10 times body weight (BW), with running at 16km/hr reaching 14 BW [44,45]. ...
... In theory, the manner in which these movements occur with greater frequency have more detrimental effects on the knee prosthesis, in particular greater risk of loosening of the tibial component. 7,37,38 Thus, patients with a total knee prosthesis should avoid, in addition to the sports already mentioned for weight-bearing joints, high-impact knee flexion activities, such as high-speed running, mountaineering, and slope walking, among others. 5,7,37 The popularity of unicompartmental knee arthroplasty (Figure 1-C) has increased in recent years, emerging as an effective alternative to classic total arthroplasty (bi or tricompartmental) in patients with isolated osteoarthritis of medial or lateral femoral-tibial compartments. ...
... 7,37,38 Thus, patients with a total knee prosthesis should avoid, in addition to the sports already mentioned for weight-bearing joints, high-impact knee flexion activities, such as high-speed running, mountaineering, and slope walking, among others. 5,7,37 The popularity of unicompartmental knee arthroplasty (Figure 1-C) has increased in recent years, emerging as an effective alternative to classic total arthroplasty (bi or tricompartmental) in patients with isolated osteoarthritis of medial or lateral femoral-tibial compartments. 39,40 Its indications have led to increasing use at a very early age, resulting in higher functional levels and expectations in comparison with total knee arthroplasty. ...
... 1,4 However, these theories remain to be proven and most orthopedists also apply the sports recommendations for total knee arthroplasty to unicompartmental arthroplasty. 5,7,37,41 Walker et al. 42 retrospectively studied 101 patients who underwent medial unicompartmental arthroplasty, with a mean follow-up of 4.4 ± 1.6 years, and found a rate of return to sports practice of 93%, mostly for low-impact sports activities. Specifically, 27% of the patients returned to physical activity in 1 month, 56% returned in 3 months, 77% returned in 6 months, and the remaining 23% needed longer than 6 months or remained inactive. ...
The success of joint replacement surgery has been responsible for raising patients' expectations regarding the procedure. Many of these procedures are currently designed not only to relive the pain caused by arthrosis, but also to enable patients to achieve functional recovery and to engage in some degree of physical activity and sports. However, as physical exercise causes an increase in forces exercised through the articular prosthesis, it can be an important risk factor for its early failure. Scientific literature on sports after arthroplasty is limited to small-scale retrospective studies with short-term follow-up, which are mostly insufficient to evaluate articular prosthesis durability. This article presents a review of the literature on sports in the context of hip, knee, shoulder and intervertebral disc arthroplasty, and puts forward general recommendations based on the current scientific evidence.
Systematic Review, Level of Evidence III.
... A return-to-sports questionnaire was derived by the authors based on prior studies on arthroplasty patients. 5,9,20,27,29 The survey consisted of questions regarding pre-and postoperative activity levels, type of sports, and patient-reported outcomes. Surveys regarding preoperative sporting activities asked patients to recall sports levels within 5 years before their procedures rather than immediately preoperatively. ...
... Surveys regarding preoperative sporting activities asked patients to recall sports levels within 5 years before their procedures rather than immediately preoperatively. Based on the categorizations described by Vail et al 26 and Kuster et al, 9 individual sports were divided into 3 categories by impact on the knee: low (ie, swimming, walking, bicycling), medium (ie, downhill skiing, doubles tennis, hiking), and high (ie, soccer, basketball, baseball). Patients who did not indicate that they participated in sports preoperatively were not included in the final analysis. ...
Background: Return to sports is an important outcome in ensuring patient satisfaction after knee-replacement surgery. However, few studies have directly compared unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), and patellofemoral arthroplasty (PFA).
Hypothesis: TKA will result in lower rates of return to sports than either UKA and PFA due to increased complexity and
invasiveness.
Methods: Patients who underwent UKA, TKA, or PFA with 1 to 2 years of follow-up were sent a questionnaire regarding return to sports, satisfaction with return to sports, pain, the University of California, Los Angeles activity scale, and the High Activity
Arthroplasty Score (HAAS). The patients who underwent either TKA or UKA were matched 2:1 with regard to age and sex to patients who underwent PFA. Differences were compared using analysis of variance, t tests, and chi-square tests.
Results: A total of 202 patients were eligible. After matching, the final cohort consisted of 23 PFA patients, 46 UKA patients, and 46 TKA patients. The majority of patients were female (87%), and the mean ± SD age was 56 ± 9.1 years. The UKA group had higher
HAAS values than the TKA group pre- and postoperatively (9.9 vs 7.1 [P < .001] and 12.4 vs 9.5 [P < .001], respectively). Patients with UKA had higher rates of return to sports after surgery than those with TKA or PFA (UKA, 80.5%; TKA, 71.7%; PFA, 69.5%; P <0.08). In addition, the UKA group had the highest satisfaction with this outcome. Improvement between pre- and postoperative scores was similar in all 3 groups.
Conclusion: Patients who underwent UKA reported better activity scores and return-to-sports rates than patients who had TKA and PFA. No differences were found in improvement after surgery, suggesting that preoperative differences were reflected postoperatively. These findings inform shared decision making and can help to manage patient expectations after surgery.
... Clinical charts were reviewed for demographic data, preoperative diagnosis, and medical comorbidities. The authors derived a return to sport questionnaire (Appendix I) that was based on the work of several other prior return to sport studies for arthroplasty patients [26,27,[31][32][33]. The questionnaire assessed the pre-and postoperative sporting activities (43 sports, walking was not considered a sport), focusing on what type of sports patients engage in and the time to return to each sport. ...
... The questionnaire assessed the pre-and postoperative sporting activities (43 sports, walking was not considered a sport), focusing on what type of sports patients engage in and the time to return to each sport. Sports were categorized, according to the level of impact on the knee, into low, intermediate and high impact sports based on the studies by Vail [34] and Kuster [33]. Postoperative satisfaction with return to sports was recorded using a five-level Likert scale and the subjective level of return was graded as lower, similar or higher level compared to preoperative level. ...
Purpose:
The present study provides insight into patient satisfaction with return to sports after unicompartmental knee arthroplasty (UKA) and to what type of activities patients return. This is important because indications for UKA have expanded and younger and more active patients undergo surgery currently.
Methods:
Patients who received a UKA were contacted between 12 and 24 months' post-surgery, receiving a questionnaire to evaluate postoperative satisfaction with return to sports, level of return, type of activities performed pre- and postoperatively, and (activity) outcome scores (NRS, UCLA, HAAS). Descriptive statistical analysis focused on the influence of patients' sex and age, and a regression model was fitted to assess the predictors for high satisfaction postoperatively.
Results:
One hundred and sixty-four patients (179 UKAs) with a mean age of 62.3 years responded at an average follow-up of 20.2 months. Preoperatively, 132 patients (81%) participated in sports, which increased to 147 patients (90%) after UKA. Analyzing outcomes for each knee individually, satisfaction with return to sports was recorded in 83% (149/179). Return to a higher or similar level was reported in 85.4% of the cases (117/137). Most common sports after UKA were cycling (45%), swimming (38%), and stationary cycling (27%). Overall, 93.9% of patients were able to return to low impact sports, 63.9% to intermediate and 32.7% to high impact sports. Regarding activity scores, preoperative NRS score improved from 6.40 ± 2.10 to 1.33 ± 1.73 postoperatively (p < .001). The mean preoperative UCLA score improved from 5.93 ± 2.19 to 6.78 ± 1.92 (p < .001) and HAAS score from 9.13 ± 3.55 to 11.08 ± 2.83 postoperatively (p < .001). Regression analyses showed that male sex, preoperative UCLA score and sports participation predicted high activity scores postoperatively.
Conclusion:
The vast majority of patients undergoing medial UKA returned to sports postoperatively, of which over 80% was satisfied with their restoration of sports ability. Male patients, patients aged ≥70, and patients who participated in low-impact sports preoperatively achieved the highest satisfaction rates. Regarding type of sports, male patients and patients aged ≤55 were most likely to return to high and intermediate impact sports. This study may offer valuable information to help manage patients' expectations regarding their ability to return to sports based on demographics and type of preoperative sporting activities.
... TKA group had a lower extension and lower range of axial rotation and an increased tibial posterior displacement [27]. Also, many TKA exhibit a mismatch between the femoral and tibial radius with high peak pressures on the polyethylene inlay [28]. ...
... Differently, cycling and power walking seem to be suitable activities while mountain hiking; patients are advised to avoid descents or at least use ski poles and walk slowly downhill to reduce the load on the knee joint. So, it is very important to consider both the load and the knee flexion regarding recommendation suitable for physical activities [28,29]. ...
People wish to stay more and more active, and as a consequence physical activity can ameliorate affluence-related chronic disease such as cardiovascular disease, diabetes mellitus, and cancer [1].
... Несмотря на то, что первичной задачей любого вида эндопротезирования коленного сустава является устранение болевого синдрома и улучшение функции сустава, нельзя забывать и об ожиданиях пациентов, желающих вернуться к привычной физической активности. Большинство авторов отмечают, что пациентам после эндопротезирования она необходима, так как это полезно не только для опорно-двигательной, но и для сердечно-сосудистой системы [8,14,27,28,38]. Кроме этого, упражнения, повышающие мышечную силу и координацию, уменьшают риск получения перипротезного перелома при падении больного [17]. ...
... Традиционно после эндопротезирования коленного сустава рекомендуется отказаться от бега, поднятия тяжестей, а также нагрузок, связанных с ротацией коленного сустава, так как это может привести к раннему износу компонентов эндопротеза и повысить риск ревизии [14]. По данным M.S. Kuster, E. Spalinger [28], нагрузка на сустав при занятии подобными видами спорта может превышать нормальную в 8-10 раз, например, при беге 16 км/час нагрузка превышает обычную в 14 раз. Пиковая нагрузка при активном занятии спортом приходится на диапазон от 40 до 60° сгибания в коленном суставе, и большинство современных тотальных эндопротезов коленного сустава в этом диапазоне не имеют высокой конгруэнтности [8]. ...
In the article recent publications dedicated to unicompartmental knee arthroplasty are analyzed. Evolution of indications and contraindications, mid- and late term results, difference in functional outcomes in comparison with total knee arthroplasty are discussed. Taking into consideration all relevant information unicompartmental knee arthroplasty may be considered as effective and reliable method of treatment of patients with knee osteoarthrosis and osteonecrosis.
... 28 Researchers who studied biomechanical forces through a total knee replacement (TKR) during different activities agreed with the consensus on avoiding jogging or running postreplacement. 29 Given high tibiofemoral loads through the knee with downhill walking/hiking, athletes with a TKR should use caution, trekking poles, and limit their pack weight to decrease the risk of early wear of the loadbearing surface. 24,25,29 Mountaineering should be practiced with caution, especially lead climbing, to decrease the risk of high-impact falls. ...
... 29 Given high tibiofemoral loads through the knee with downhill walking/hiking, athletes with a TKR should use caution, trekking poles, and limit their pack weight to decrease the risk of early wear of the loadbearing surface. 24,25,29 Mountaineering should be practiced with caution, especially lead climbing, to decrease the risk of high-impact falls. 30 Athletes in suitable physical condition, with prior experience, good rehabilitation from their injury or surgery, with normal proprioception, balance, and strength should be able to participate in most activities. ...
Participation in wilderness and adventure sports is on the rise, and as such, practitioners will see more athletes seeking clearance to participate in these events. The purpose of this article is to describe specific medical conditions that may worsen or present challenges to the athlete in a wilderness environment.
... From the studies that described pre-and/or postoperative participation in specific types of sports and/or times to RTS, data were pooled and categorised into low-, intermediate-or high-impact sports, according to the levels of impact on the knee joint (see electronic supplementary material, Appendix S3). This classification is in compliance with Vail and Mallon [36] and supported by a biomechanical study from Kuster et al. [37], in which both peak loads and flexion angles of the knee were considered. We calculated pooled RTS percentages by comparing pooled pre-and postoperative sports participation data. ...
... In the meantime, the 'intelligent participation' recommendations of Kuster et al. [37] should be considered. They do not only look at the impact of the sport on the joints, but also take into account prior experiences and the way a patient will perform his or her sport. ...
Background
People today are living longer and want to remain active. While obesity is becoming an epidemic, the number of patients suffering from osteoarthritis (OA) is expected to grow exponentially in the coming decades. Patients with OA of the knee are progressively being restricted in their activities. Since a knee arthroplasty (KA) is a well accepted, cost-effective intervention to relieve pain, restore function and improve health-related quality of life, indications are expanding to younger and more active patients. However, evidence concerning return to sports (RTS) and physical activity (PA) after KA is sparse.
Objectives
Our aim was to systematically summarise the available literature concerning the extent to which patients can RTS and be physically active after total (TKA) and unicondylar knee arthroplasty (UKA), as well as the time it takes.
Methods
PRISMA guidelines were followed and our study protocol was published online at PROSPERO under registration number CRD42014009370. Based on the keywords (and synonyms of) ‘arthroplasty’, ‘sports’ and ‘recovery of function’, the databases MEDLINE, Embase and SPORTDiscus up to January 5, 2015 were searched. Articles concerning TKA or UKA patients who recovered their sporting capacity, or intended to, were included and were rated by outcomes of our interest. Methodological quality was assessed using Quality in Prognosis Studies (QUIPS) and data extraction was performed using a standardised extraction form, both conducted by two independent investigators.
Results
Out of 1115 hits, 18 original studies were included. According to QUIPS, three studies had a low risk of bias. Overall RTS varied from 36 to 89 % after TKA and from 75 to >100 % after UKA. The meta-analysis revealed that participation in sports seems more likely after UKA than after TKA, with mean numbers of sports per patient postoperatively of 1.1–4.6 after UKA and 0.2–1.0 after TKA. PA level was higher after UKA than after TKA, but a trend towards lower-impact sports was shown after both TKA and UKA. Mean time to RTS after TKA and UKA was 13 and 12 weeks, respectively, concerning low-impact types of sports in more than 90 % of cases.
Conclusions
Low- and higher-impact sports after both TKA and UKA are possible, but it is clear that more patients RTS (including higher-impact types of sports) after UKA than after TKA. However, the overall quality of included studies was limited, mainly because confounding factors were inadequately taken into account in most studies.
... During downhill walking and jogging the polyethylene insert was frequently overloaded. 79 The golf swing produced significantly larger magnitudes of rotational motions in comparison to stationary cycling. 80 Radiolucencies were common in active golfers at only 4.7 years after TKA (53.7% in all TKA, 79.1% in cemented TKA). ...
... However, wear is related to use, not simply time after implantation 14 and experimental studies have demonstrated that some activities overload the TKA. 79 Therefore despite the Roller skating 54 59, 60 Bold references indicate the broadest consensus. a Walking on even/uneven surfaces and stair climbing; b Hiking with the use of ski poles and avoiding descents; c Road cycling on even surfaces/on an incline; d Cross-country skiing on flat ground, no skating, groomed snow, broader ski; e Downhill skiing not on mogul slopes, avoiding crowded slopes. ...
A relevant number of patients expect participation in sports activities after total knee arthroplasty (TKA). Fulfilment of these expectations has been correlated to patient satisfaction after TKA. The ability to attend sporting activities therefore seems to play a role in enhancing patient satisfaction, especially for younger patients. Younger and more active patients have a significantly higher revision rate. Therefore, besides its well-documented positive effects on general health, participation in sports activities after knee arthroplasty might be associated with an increased risk of premature loosening. Advantages and risks of sports activities should therefore be balanced when counselling patients regarding activity after knee arthroplasty. This systematic review was performed to survey the evidence on sports activities after unicondylar and TKA and summarize available recommendations. Overall, the level of evidence regarding sports activities after knee arthroplasty is only moderate. Low to moderate impact sports have been recommended while high impact activities should not be performed after TKA.
... 28 Researchers who studied biomechanical forces through a total knee replacement (TKR) during different activities agreed with the consensus on avoiding jogging or running postreplacement. 29 Given high tibiofemoral loads through the knee with downhill walking/hiking, athletes with a TKR should use caution, trekking poles, and limit their pack weight to decrease the risk of early wear of the loadbearing surface. 24,25,29 Mountaineering should be practiced with caution, especially lead climbing, to decrease the risk of high-impact falls. ...
... 29 Given high tibiofemoral loads through the knee with downhill walking/hiking, athletes with a TKR should use caution, trekking poles, and limit their pack weight to decrease the risk of early wear of the loadbearing surface. 24,25,29 Mountaineering should be practiced with caution, especially lead climbing, to decrease the risk of high-impact falls. 30 Athletes in suitable physical condition, with prior experience, good rehabilitation from their injury or surgery, with normal proprioception, balance, and strength should be able to participate in most activities. ...
Risk of injury in cold environments is related to a combination of athlete preparedness, preexisting medical conditions, and the body's physiologic response to environmental factors, including ambient temperature, windchill, and wetness. The goal of this section is to decrease the risk of hypothermia, frostbite, and nonfreezing cold injuries as well as to prevent worsening of preexisting conditions in cold environments using a preparticipation screening history, examination, and counseling. Cold weather exercise can be done safely with education, proper preparation, and appropriate response to changing weather conditions.
... 28 Researchers who studied biomechanical forces through a total knee replacement (TKR) during different activities agreed with the consensus on avoiding jogging or running postreplacement. 29 Given high tibiofemoral loads through the knee with downhill walking/hiking, athletes with a TKR should use caution, trekking poles, and limit their pack weight to decrease the risk of early wear of the loadbearing surface. 24,25,29 Mountaineering should be practiced with caution, especially lead climbing, to decrease the risk of high-impact falls. ...
... 29 Given high tibiofemoral loads through the knee with downhill walking/hiking, athletes with a TKR should use caution, trekking poles, and limit their pack weight to decrease the risk of early wear of the loadbearing surface. 24,25,29 Mountaineering should be practiced with caution, especially lead climbing, to decrease the risk of high-impact falls. 30 Athletes in suitable physical condition, with prior experience, good rehabilitation from their injury or surgery, with normal proprioception, balance, and strength should be able to participate in most activities. ...
As the participation in wilderness events becomes more popular, the likelihood of participation by those with existing medical conditions will also increase. It is important for safety and for the enjoyment of the participant that medical conditions, especially those that could worsen in remote or extreme environments, be addressed and optimized before travel. Finally, the preparticipation consult allows an excellent time for education on medication and equipment use, warning signs of worsening disease and general safety tips to ensure safe participation in most wilderness pursuits.
... Ainsi, les forces supportées par la hanche et le genou sont différentes pour la même activité sportive. En effet, le pic de force augmente au niveau du genou dès que le mouvement nécessite de la flexion [5,16,17]. Selon cet aspect mécanique, la pratique de la randonnée sera encouragée avec bâtons de ski et le port d'un sac à dos lourd sera à éviter. La pratique du ski alpin correspond aussi à d'importantes contraintes au niveau du genou de plus de dix fois le PdC selon le niveau de pratique. ...
... Ensuite, les capacités sportives qui dépendent de l'expérience et de la condition physique du sujet doivent avoir fait l'objet d'une évaluation (test d'effort, mise en situation) et d'un réentraînement à l'effort progressif. L'avis du chirurgien orthopédique doit être pris afin d'obtenir des informations sur le type de prothèse et la qualité de sa pose en plus des éventuelles complications postopératoires rencontrées : anémie, thrombophlébite, raideur résiduelle, luxation, infection… À partir de cet état des lieux, nous déconseillons l'apprentissage d'un sport à risque (contact ou à fort impact) ou en compétition en raison du risque de survenue d'un accident aiguë (fracture sur prothèse, luxation) [17,26]. Nous conseillons un sport antérieurement pratiqué avec d'éventuelles adaptations, notamment en cas de PTG, pour la pratique du golf avec voiturette pour les déplacements, pour la pratique du tennis à privilégier en double et pour la pratique de la randonnée sous couvert de bâtons de ski… Les risques pris devront être mentionnés au patient en terme d'usure et d'un remplacement plus précoce de la prothèse en raison de l'absence de preuves suffisantes pour affirmer le contraire. ...
ObjectiveTo recommand sports activities after joint arthroplasty from the literature analysis, the French surgeon's opinion and wish patients.MethodFrom the Medline data base interrogation according to keywords: Sports, Arthroplasty, Athletics, Physical training, two different readers, an orthopedic surgeon and a Physical Medicine and Rehabilitation physician selected articles in French or English language according to the level of proofs of the french classification of the Accreditation and Health Evaluation National Agency (Anaes). Professional practices were estimated by the interrogation of 30 orthopedic surgeons members of the french West Orthopaedics Society (SOO). The demand of sports practice was studied with patients recently operated for a primary total knee arthroplasty (TKA) after gonarthrosis.ResultTwenty-two articles were selected from 305 articles obtained by the search according to keywords. Ten literature reviews are limited by the absence of prospective randomized study. A level II study and eleven level IV articles are reported.DiscussionAccording to the subjective orthropedic surgeon's opinion, the objective results based on the joint load studied and the percentage of arthroplasty revision, sport is beneficial for the individual health but perhaps not for the arthroplasty survey. However, aerobic and leisure activities are recommended (walking, swimming, cycling) in agreement with the demand of the patients recently operated with a TKA. TKA differs from Total Hip Arthroplasty for jogging because of knee joint constraints during the knee flexion. A single study reports sports possibilities after shoulder arthroplasty and ankle arthroplasty and no study reports results after elbow arthroplasty.
... These findings are comparable with Hepperger et al. [19], who showed a significant increase of the Tegner Activity Level at 24 months after knee replacement compared with preoperative Tegner Activity Level. Patient expectations often associate activity level with wear and deformation of the polyethylene insert [11,12]. However, golf is a low-impact sport and our results demonstrating the successful return to golf corroborate the recommendations established by international societies of knee surgery (Knee Society, SFHG/SOF-COT) [21] and confirm the advice of the 97.2% of surgeons involved in this study who authorized their patients to return to golf after surgery. ...
Background:
Regular and competitive golfers are concerned by the ability to recover their previous activity golfing after total knee arthroplasty (TKA). The purpose of this study was to conduct targeted analysis of the effect of unilateral total knee replacement on the playtime and golf level in a population of experienced golfers, with a minimum follow-up of two years.
Methods:
Questionnaires were distributed to the French Golf Federation's golfing members. Those who were older than 50 years and had undergone a unilateral primary TKA provided information on the timing of return to play, mode of movement on the course, pain during golfing, physical activity via University of California Los Angeles scale, level of golf and weekly playing time, before and after surgery. In addition, surgeons' recommendations and level of arthroplasty satisfaction were collected.
Results:
Questionnaires were completed by 290 competitive golfers, of which 143 were eligible for inclusion. The average time to return to the 18-hole course was 3.7 months. Participants surveyed at a minimum 2 years after TKA played at a higher level than before surgery with a handicap improvement of 0.85 and increased their average weekly playtime from 8.9 to 10.2 hours. Knee pain while playing golf decreased after surgery (6.13 to 1.27 on the visual analog scale) and the University of California Los Angeles score improved (7.02 to 7.85).
Conclusion:
This study demonstrated the ability of regular golfers to return to golf within six months after unilateral total knee replacement, with increasing level of golf and weekly playtime and better golfing comfort.
... 2, 3 Power walking has been recommended as endurance sport after total knee joint replacement, since biomechanical stress at the knee joint is lower than during jogging. 4 During power walking, active upper body movements are added to the usual walking exercise (Figure 1). Arm swing is emphasized deliberately. ...
Background: Arm swing is deliberately emphasized during power walking, a popular aerobic fitness exercise. Electromyographic (EMG) activation curves of arm and shoulder muscles during power walking have not yet been examined. Aim: To describe the amount and pattern of EMG activity of upper limb muscles during power walking. Data are compared to normal walking and jogging. Method:Â Twenty volunteers were examined on a treadmill at 6 km/h during (a) normal walking, (b) power walking, (c) jogging. EMG data were collected for the trapezius (TRAP), anterior (AD) and posterior deltoid (PD), biceps (BIC), triceps (TRI), latissimus dorsi (LD) and erector spinae (ES) muscles. Results:Â Activity of four muscles (AD, BIC, PD, TRAP) was three- to fivefold stronger during power walking than normal walking. Smaller significant increases involved the TRI, LD and ES. Two muscles (AD, TRAP) were more active during power walking than running. Normal walking and power walking involved similar EMG patterns of PD, LD, ES, while EMG patterns of running and walking differed. Interpretation: Emphasizing arm swing during power walking triples the EMG activity of upper limb muscles, compared to normal walking. Similar basic temporal muscle activation patterns in both modes of walking indicate a common underlying motor program.Â
... Data were pooled from the studies that described preand/or postoperative participation in specific types of sports and categorised into low-, intermediate-, or highimpact sports according to the levels of impact on the knee joint (ESM Appendix S3). This classification complies with Vail et al. [31] and is supported by a biomechanical study from Kuster et al. [32], which considered both peak loads and flexion angles of the knee. We calculated pooled RTS percentages by comparing pooled pre-and postoperative sports participation data. ...
Background:
Knee osteotomies are proven treatment options, especially in younger patients with unicompartmental knee osteoarthritis, for certain cases of chronic knee instability, or as concomitant treatment for meniscal repair or transplantation surgery. Presumably, these patients wish to stay active. Data on whether these patients return to sport (RTS) activities and return to work (RTW) are scarce.
Objectives:
Our aim was to systematically review (1) the extent to which patients can RTS and RTW after knee osteotomy and (2) the time to RTS and RTW.
Methods:
We systematically searched the MEDLINE and Embase databases. Two authors screened and extracted data, including patient demographics, surgical technique, pre- and postoperative sports and work activities, and confounding factors. Two authors assessed methodological quality. Data on pre- and postoperative participation in sports and work were pooled.
Results:
We included 26 studies, involving 1321 patients (69% male). Mean age varied between 27 and 62 years, and mean follow-up was 4.8 years. The overall risk of bias was low in seven studies, moderate in ten studies, and high in nine studies. RTS was reported in 18 studies and mean RTS was 85%. Reported RTS in studies with a low risk of bias was 82%. No studies reported time to RTS. RTW was reported in 14 studies; mean RTW was 85%. Reported RTW in studies with a low risk of bias was 80%. Time to RTW varied from 10 to 22 weeks. Lastly, only 15 studies adjusted for confounders.
Conclusion:
Eight out of ten patients returned to sport and work after knee osteotomy. No data were available on time to RTS. A trend toward performing lower-impact sports was observed. Time to RTW varied from 10 to 22 weeks, and almost all patients returned to the same or a higher workload.
... 2, 3 Power walking has been recommended as endurance sport after total knee joint replacement, since biomechanical stress at the knee joint is lower than during jogging. 4 During power walking, active upper body movements are added to the usual walking exercise (Figure 1). Arm swing is emphasized deliberately. ...
Arm swing is deliberately emphasized during power walking, a popular aerobic fitness exercise. Electromyographic (EMG) activation curves of arm and shoulder muscles during power walking have not yet been examined. Aim: To describe the amount and pattern of EMG activity of upper limb muscles during power walking. Data are compared to normal walking and jogging. Method: Twenty volunteers were examined on a treadmill at 6 km/h during (a) normal walking, (b) power walking, (c) jogging. EMG data were collected for the trapezius (TRAP), anterior (AD) and posterior deltoid (PD), biceps (BIC), triceps (TRI), latissimus dorsi (LD) and erector spinae (ES) muscles. Results: Activity of four muscles (AD, BIC, PD, TRAP) was three- to fivefold stronger during power walking than normal walking. Smaller significant increases involved the TRI, LD and ES. Two muscles (AD, TRAP) were more active during power walking than running. Normal walking and power walking involved similar EMG patterns of PD, LD, ES, while EMG patterns of running and walking differed. Interpretation: Emphasizing arm swing during power walking triples the EMG activity of upper limb muscles, compared to normal walking. Similar basic temporal muscle activation patterns in both modes of walking indicate a common underlying motor program.
... With regard to tibiofemoral contact forces and ligament strains, cycling is typically classified as a low-demand activity and therefore recommended in rehabilitation protocols. 10,14,17,18,20 However, cycling for more than 30 minutes per day has been found to be a risk factor for OA. 5 Valid data regarding tibiofemoral joint loading during cycling are lacking. Recommendations are based mainly on calculations using gait analyses and analytical models. ...
Within-subject, repeated-measures design.
To measure tibiofemoral contact forces during cycling in vivo and to quantify the influences of power, pedaling cadence, and seat height on tibiofemoral contact forces.
Cycling is usually classified as a low-demand activity for the knee joint and is therefore recommended for persons with osteoarthritis and rehabilitation programs following knee surgery. However, there are limited data regarding actual joint loading.
Instrumented knee implants with telemetric data transmission were used to measure the tibiofemoral contact forces. Data were obtained in 9 subjects, during ergometer cycling and walking, 15 ± 7 months after total knee arthroplasty. Tibiofemoral forces during cycling at power levels between 25 and 120 W, cadences of 40 and 60 rpm, and 2 seat heights were investigated.
Within the examined power range, tibiofemoral forces during cycling were smaller than those during walking. At the moderate condition of 60 W and 40 rpm, peak resultant forces of 119% of body weight were measured during the pedal downstroke. Shear forces ranged from 5% to 7% of body weight. Forces increased linearly with cycling power. Higher cadences led to smaller forces. A lower seat height did not increase the resultant force but caused higher posterior shear forces.
Due to the relatively small tibiofemoral forces, cycling with moderate power levels is suited for individuals with osteoarthritis and rehabilitation programs following knee surgery, such as cartilage repair or total knee replacement. The lowest forces can be expected while cycling at a low power level, a high cadence, and a high seat height.
... Many studies have been conducted on comparison of the fixedbearing and mobile bearing total knee arthroplasty. [7][8][9][10] However, there is a paucity of information in the literature regarding comparison of rotating platform and high flexion rotating platform total knee arthroplasty. So, we compared the results of PFC Sigma RP-F total knee arthroplasty with those of total knee arthroplasty using LCS mobile bearing knee system in order to assess the clinical results including the maximal flexion angle after a followup of at least 2 years. ...
We compared clinical outcomes after total knee arthroplasty with the Low Contact Stress (LCS) rotating platform mobile bearing knee system and the Press Fit Condylar Sigma rotating platform high flexion (PFC Sigma RP-F) mobile bearing knee system.
Fifty cases of total knee arthroplasty were performed with the PFC Sigma RP-F mobile bearing knee system and sixty-one cases were performed with the LCS mobile bearing total knee arthroplasty. The average duration of follow-up was 2.9 years.
The mean Hospital for Special Surgery (HSS) knee score was 62.1 (range, 52 to 75) in the LCS group and 61.9 (range, 50 to 74) in the Sigma RP-F group preoperatively, and 90.1 (range, 84 to 100) in the LCS group and 89.8 (range, 83 to 100) in the Sigma RP-F group at the final follow-up. The mean preoperative flexion contracture was 6.7° (range, 0° to 10°) in the LCS group and 9.3° (range, 0° to 15°) in the Sigma RP-F group preoperatively. The mean range of motion was 124.6° (range, 105° to 150°) in the LCS group and 126.1° (range, 104° to 145°) in the Sigma RP-F group at the final follow-up.
After a minimum duration of follow-up of two years, we found no significant differences between the two groups with regard to the range of knee motion or the clinical or radiographic results.
... The pressure sheet or foil (fuji foil) is made of two sheets separated by a layer containing microcapsules with a colouring agent. The obtained colour intensity can then be analysed (optical density) in relation to, e.g.,, endurance sports after total knee replacement (Kuster et al, 2000). However, the latter solution does not enable reliable dynamic measurements. ...
Some open questions arising in the dynamical formulation ofsystems of hinge-connected flexible bodies are discussed. The first one deals with the choice of the floating reference frame associated to abody undergoing large rigid body motions but small elastic deformations.The second one concerns the so-called geometric stiffening (orcentrifugal stiffening) effects. The last problem is concerned with theeventual appearance of higher-order terms in the kinetic energy of thesystem for large rates and large accelerations.
... The pressure sheet or foil (fuji foil) is made of two sheets separated by a layer containing microcapsules with a colouring agent. The obtained colour intensity can then be analysed (optical density) in relation to, e.g.,, endurance sports after total knee replacement (Kuster et al, 2000). However, the latter solution does not enable reliable dynamic measurements. ...
Background:
Downhill walking is a necessary part of daily life and an effective activity in post-operative rehabilitation following total knee arthroplasty. The purpose of this study was to determine differences in the behavior of total, medial, and lateral tibiofemoral compressive forces as well as knee extensor and flexor muscle forces between different limbs of patients with total knee arthroplasty (replaced, non-replaced) during downhill and level walking.
Methods:
Musculoskeletal modeling and simulation were implemented to determine muscle forces and tibiofemoral compressive forces in 25 patients with total knee arthroplasty. A 2 × 2 [Limb (replaced, non-replaced) × Slope (0°, 10°)] Statistical parametric mapping repeated measures analysis of variance was conducted on selected variables.
Findings:
Statistical parametric mapping did not identify any between-limb differences for compressive or muscle forces. Differences in joint compressive and muscle forces persisted throughout different intervals of stance-phase between level and downhill walking. Knee extensor muscle forces were distinctly greater during level walking for nearly all of stance phase. Knee flexor muscle force was greater during downhill walking for >60% of stance. Statistical parametric mapping did identify regions of significance between level and downhill walking that coincided temporally (near loading response and push off) with peak joint moment and joint compressive forces traditionally reported using discrete variable analyses.
Interpretation:
Downhill walking may be a safe and useful rehabilitation tool for post-knee arthroplasty rehabilitation that will not disproportionally load either the replaced or the non-replaced joint and where the quadriceps muscles can be strengthened during a gait-specific task.
Sports after knee arthroplasty play an increasingly important role for surgeons and patients. Therefore, physicians are frequently faced with the patient’s questions regarding their involvement in sports activities and what sports level will be possible after knee arthroplasty. However, the question of whether participating in sports after a knee arthroplasty is safe or if it has positive effects is highly debated. Several studies about sports after knee arthroplasty have been published, reporting controversial results. Sports activity is possible after UKA and TKA. Patients following UKA present higher return to sports rates and the time to return to sports is faster than in patients following TKA. The participation in sports seems to be more often possible in patients following UKA than TKA.
A formal unsupervised activity program should be recommended to all patients recovering from total knee arthroplasty (TKA) and total hip arthroplasty (THA).
In a subset of all patients undergoing TKA or THA, studies have found that an unsupervised activity program may be as efficacious as supervised physical therapy (PT) after surgery. Certain patients with inadequate independent function may continue to benefit from supervised PT.
For TKA, supervised telerehabilitation has also been proven to be an effective modality, with studies suggesting equivalent efficacy compared with supervised in-person PT.
Following TKA, there is no benefit to the use of continuous passive motion or cryotherapy devices, but there are promising benefits from the use of pedaling exercises, weight training, and balance and/or sensorimotor training as adjuncts to a multidisciplinary program after TKA.
No standardized postoperative limitations exist following TKA, and the return to preoperative activities should be dictated by an individual's competency and should consist of methods to minimize high impact stress on the joint.
Despite traditional postoperative protocols recommending range-of-motion restrictions after THA, it is reasonable to recommend that hip precautions may not be needed routinely following elective primary THA.
Stationary cycling is typically recommended following total knee arthroplasty (TKA) operations. However, knee joint biomechanics during cycling remains mostly unknown for TKA patients. Biomechanical differences between the replaced and non-replaced limb may inform applications of cycling in TKA rehabilitation. The purpose of this study was to examine the knee joint biomechanics of TKA patients during stationary cycling. Fifteen TKA participants cycled at 80 revolutions per minute and workrates of 80 Watts and 100 Watts while kinematics (240 Hz) and pedal reaction forces using a pair of instrumented pedals (1200 Hz) were collected. A 2x2 (limb x workrate) repeated measures ANOVA was run with an alpha of 0.05. Peak knee extension moment (KEM, p = 0.034) and vertical pedal reaction force (p = 0.038) were significantly reduced in the replaced limbs compared to non-replaced limbs by 21.3% and 5.3%, respectively. Peak KEM did not change for TKA patients with the increased workrate (p = 0.750). However, both peak hip extension moment (p = 0.009) and ankle plantarflexion moment (p = 0.017) increased due to increased workrate. Patients following TKA showed similar decreases in peak KEM and vertical pedal reaction force in their replaced compared to non-replaced limbs, as previously seen in gait. Patients of TKA may rely on their hip and ankle extensors to increases in workrate. Increasing intensity by 20 W did not exacerbate any inter-limb differences for peak KEM and vertical PRF.
Objective
Desires and expectations of patients in regard to resume participation in sport activities after knee arthroplasty strongly increased in recent years. Therefore, this review systematically reviewed the available scientific literature on the effect of knee arthroplasty on sports participation and activity levels.
Design
Systematic review and meta-analysis.
Data sources
PubMed, Embase, SPORTDiscus and reference lists were searched in February 2019.
Studies eligibility criteria
Inclusion of knee osteoarthritis patients who underwent total knee arthroplasty (TKA) and/or unicondylar knee arthroplasty. Studies had to include at least one preoperative and one postoperative measure (≥1 year post surgery) of an outcome variable of interest (ie, activity level: University of California, Los Angeles and/or Lower Extremity Activity Scale; sport participation: type of sport activity survey).
Results
Nineteen studies were included, consisting data from 4074 patients. Knee arthroplasty has in general a positive effect on activity level and sport participation. Most patients who have stopped participating in sport activities in the year prior to surgery, however, do not seem to reinitiate their sport activities after surgery, in particular after a TKA. In contrast, patients who continue to participate in sport activities until surgery appear to become even more active in low-impact and medium-impact sports than before the onset of restricting symptoms.
Conclusions
Knee arthroplasty is an effective treatment in resuming sports participation and physical activity levels. However, to achieve the full benefits from knee arthroplasty, strategies and guidelines aimed to keep patients capable and motivated to participate in (low-impact or medium-impact) sport activities until close before surgery are warranted.
Total hip and knee arthroplasties are two of the most successful procedures. Both have been found to be cost-effective and beneficial to a patient’s quality of life [1–4]. Historically, joint arthroplasty was reserved for those above the age of 65 who were debilitated from the pain of end-stage osteoarthritis. However, as the success of the operation has become widely known, patients are often inquiring about joint replacement earlier to help maintain and/or restore activity including athletic participation. The young active patient with end-stage osteoarthritis is in a therapeutic dilemma. The mechanism of failure for the majority of lower extremity joint replacements at long-term follow-up is aseptic loosening [5]. There is obvious concern that joint arthroplasty in young patients would therefore succumb to wear earlier due to increased use, potentially condemning the patient to numerous revisions and potentially catastrophic failure in their lifetime [6–10]. Despite such concern, arthroplasty is used to treat end-stage osteoarthritis in younger patients that seek to restore function and even return to athletic activity [11, 12]. Fortunately, the concern for increased wear and early failure has not been fully realized, and survival rates as high as 94% can be found at nearly 20 years in young active patients [12]. In this chapter we will explore the literature and current recommendations concerning hip and knee arthroplasties in patients that wish to remain physically active in sports.
Routine patella resurfacing in total knee arthroplasty (TKA) has been the standard management in TKA and is considered the gold standard in most centers worldwide. However, studies have reported comparable long-term results in TKA without resurfacing the patella. When resurfaced, the patella component consists of either full polyethylene (PE) with a button or a more anatomical shape, or is metal backed with or without mobile PE bearings. Despite hypothetical advantages, mobile bearing metal-backed components have yet to prove acceptable outcomes, since considerable problems have been reported, such as increased PE wear, metallosis, fracture, or dissociation (spinout) requiring revision surgery.
Der prothetische Kniegelenkersatz spielt in der heutigen Orthopädie eine wichtige Rolle. So wurden 1996 weltweit mehr als 400.000 Knieprothesen implantiert. Auch sind die Langzeitresultate von Knieprothesen sehr gut und mit denjenigen von Hüftprothesen vergleichbar. Eine gut zementierte und korrekt eingesetzte moderne Knieprothese hat eine über 90%ige Chance, 15 Jahre zu überleben. Viele verschiedene Prothesenmodelle sind heute auf dem Markt, das Angebot ist für den Orthopäden kaum mehr überblickbar. Nebst dem bi-/trikompartimentellen Oberflächenersatz ist auch die unikompartimentelle Knieprothese zu erwähnen, auf die wir im folgenden Kapitel nicht eingehen werden. Die bi-/trikompartimentalen Designs können entsprechend dem Führungsgrad der Prothese in verschiedene Kategorien eingeteilt werden (Abb. 16.1).
A knee arthroplasty is commonly indicated to cure worn knees of the elderly. Its purpose is to obtain pain relief and better range of motion and, by doing so, regain an adequate mobility for the daily living. Nowadays, orthopedic surgeons are often confronted by sports activity demands of their patients. Walking, swimming, and biking are the most common sports which patients are allowed to perform after a total knee arthroplasty. But practicing golf, tennis, and skiing are also demanded and are among the expectations of the patients. The preservation and restoration of the extensor mechanism composed of patella and its lever arm, and the quadriceps muscle, is of upmost importance to respond to this type of high demand. Muscle atrophy and strength loss of quadriceps muscle are always present in an elderly arthritic knee which affects the functional capacity. In order to obtain results suiting the expectations of these high-demanding patients, special care should be given while operating the extensor mechanism and its rehabilitation needs a close follow-up.
There has been a resurgence of interest in unicompartmental knee arthroplasty (UKA) for treatment of medial unicompartmental knee osteoarthritis (OA). Improved prosthetic design, minimally invasive surgical techniques, and strict patient selection criteria have resulted in improved survivorship and functional outcomes. A review of orthopedic literature was conducted regarding the advantages of UKA versus total knee arthroplasty (TKA), UKA indications, survivorship, conversion of UKA to TKA, rehabilitation, and outcomes. The UKA appears to be a viable option for patients with knee medial compartment OA, including younger and active patients. Survivorship rates of 94% to 97% at 10 years have been reported.
Joint replacement surgery by improving function and relieving pain was proved to be an effective and reliable intervention, especially in the treatment of arthritic hip and knee joints. The advances in surgical techniques and implant properties have led to an increase in patients’ expectations; therefore, returning to sports after joint replacement is desired by many, particularly those who participate in sports activities preoperatively. Sporting activities cause concentrated stresses on smaller areas in knee prosthesis when compared with normal knees. High-impact sports may cause fatigue and implant failure. Despite the advances in knee arthroplasty, it is rational to avoid high-impact sports. Recommending low-impact sports after total knee replacement is advisable, as benefits have been shown by previous studies.
Rehabilitation programs are as important in the overall success of total knee arthroplasty (TKA) as surgical technique and implant design. However, most rehabilitation protocols are based on empirical guidelines rather than on scientific facts and are seldom supervised by the surgeon. As a result, the variety of recommended programs is large and confusing in content, ranging from unsupervised walking to complete instruction in functional activities and specific exercises. Popular programs include active and passive range of motion (ROM) exercises, continuous passive motion (CPM) and isometric quadriceps strengthening.
Total knee arthroplasty is an effective procedure for relieving symptoms and restoring patients' activities of daily living. Strenuous and vigorous activities after surgery are usually limited and depend on patient preoperative levels and expectations and on implant factors. Modern implant designs are conceived to ensure higher flexion and more physiological kinematics through range of motion. Mobile-bearing knees should meet these expectations. Sports activities after joint replacement are possible and are best indicated for patients who were previously active. High-impact sports should be discouraged, as concern exists about premature polyethylene failure.
The last two decades the development of the Total Knee Arthroplasty is plenty active. This leads to the implantation of a Total Knee Arthroplasty in patients younger than 55 year and attended with a shifting in the expectation of the patient and the lifetime of the prosthesis. (Sport)physical therapists and orthopaedic surgeons frequently confronted with the question for sport resumption after Total Knee Arthroplasty. In the literature there is a lack of information about sport activities with a Total Knee Arthroplasty. Nevertheless the patient expects an advice about sport resumption from the orthopaedic surgeon and physical therapist. The treatment result is an important factor in this advice. Therefore, the clinician could ground on the six P's explained in this article.
The increasing life expectancy and the rising number of total joint replacements together with an increasing desire for activity of the elderly leads to the question of the load capacity of implants. Former studies demonstrated, that patients with total hip replacements increased their sports activities after the operation, whereas patients with total knee replacements reduced their activities. There are only limited data about the load capacity of total joint replacements. Different studies reveal inconsistent results concerning the loosening rates by sports activities, but the authors agree on the increase in abrasion. Biomechanical considerations suggest, that some loads are especially suitable for patients with endoprosthesis (bicycling, swimming) whereas others are not (jogging, downhill skiing). We believe that patients with endoprothesis have to be advised individually. The experience of the patient with a special sport discipline is important since optimal movements and reasonable intensity help to reduce the load of the joints. Risks and advantages as well as the quality of life of the individual patient should be taken into account for the doctor's advice.
Endurance events are increasing in popularity in wilderness and remote settings, and participants face a unique set of potential risks for participation. The purpose of this article is to outline these risks and allow the practitioner to better guide the wilderness adventurer who is anticipating traveling to a remote or desert environment.
Das von Patienten angestrebte postoperative Behandlungsziel nach endoprothetischem Ersatz des Hüft- und Kniegelenkes liegt nicht mehr nur allein in der Wiedererlangung einer schmerzfreien Belastbarkeit bei guter Bewegungsfähigkeit des jeweiligen Gelenkes, sondern zunehmend auch im Wunsch sportliche Aktivitäten wiederaufnehmen oder weiterführen zu können. Die Meinungen der behandelnden Ärzte als auch in der medizinischen Fachliteratur über das diesbezüglich empfohlene Ausmaß und die Art der Sportaktivitäten weichen zum Teil deutlich voneinander ab.
This article presents a literature review of the current recommendations regarding sports after total joint replacement and also suggests scientifically based guidelines. Patients should be encouraged to remain physically active for general health and also for the quality of their bone. There is evidence that increased bone quality will improve prosthesis fixation and decrease the incidence of early loosening. To recommend a certain activity after total knee or hip replacement, factors such as wear, joint load, intensity and the type of prosthesis must be taken into account for each patient and sport. It has been shown that the reduction of wear is one of the main factors in improving long-term results after total joint replacement. Wear is dependent on the load, the number of steps and the material properties of total joint replacements. The most important question is, whether a specific activity is performed for exercise to obtain and maintain physical fitness or whether an activity is recreational only. To maintain physical fitness an endurance activity will be performed several times per week with high intensity. Since load will influence the amount of wear exponentially, only activities with low joint loads such as swimming, cycling or possibly power walking should be recommended. If an activity is carried out on a low intensity and therefore recreational base, activities with higher joint loads such as skiing or hiking can also be performed. It is unwise to start technically demanding activities after total joint replacement, as the joint loads and the risk for injuries are generally higher for these activities in unskilled individuals. Finally, it is important to distinguish between suitable activities following total knee and total hip replacement. To recommend suitable physical activities after total knee replacement, it is important to consider both the load and the knee flexion angle of the peak load, while for total hip replacement, which involves a ball and socket joint, the flexion angle does not play an important role. During activities such as hiking or jogging, high joint loads occur between 40 and 60° of knee flexion where many knee designs are not conforming and high polyethylene inlay stress will occur. Regular jogging or hiking produces high inlay stress with the danger of delamination and polyethylene destruction for most current total knee prostheses. Based on these design differences between hip and knee replacements it is prudent to be more conservative after total knee arthroplasty than after total hip arthroplasty for activities that exhibit high joint loads in knee flexion.
Die Zahl der sportlich aktiven Menschen ist in den letzten Jahren stark angestiegen.
Wir untersuchten 101 Patienten nach Hüft-Totalprothese. Die Patienten wurden in Abhängigkeit von ihrer sportlichen Aktivität in drei Gruppen unterteilt. Die klinische und radiologische Evaluation erfolgte mittels Fragebögen und standardisierten Röntgenuntersuchung.
Der Harris-Hip- und Merle d’Aubigné Score zeigte keine statistischen Unterschiede. Der BMI war umgekehrt proportional zum Grad der Aktivität. Lysezeichen fanden sich bei 33% der aktiven, 30% mäßig aktiven und 53% nicht-aktiven Patienten (p > 0,05). Der lineare Polyethylen-Abrieb war in der nicht-aktiven Patientengruppe am höchsten.
Moderate sportliche Aktivität zeigte keinen negativen Einfluss auf das funktionelle Resultat nach Hüftprothese, kann aber zu einer besseren Osteointegration des Implantates im Femurschaft beitragen.
Patienten möchten sich nach einer Knieprothese häufig wieder sportlich betätigen. Die bisherigen Empfehlungen basieren jedoch auf dem Gefühl des Orthopäden und nicht auf wissenschaftlich fundierten Daten. Jede sportliche Aktivität bewirkt im Gelenk einen zusätzlichen Abrieb, was die Lebensdauer einer Prothese negativ beeinflussen kann. Um diesen Abrieb möglichst gering zu halten, sollten sportlichen Aktivitäten eine geringe Spannung auf dem Polyethylen Inlay hervorrufen.
Die folgende Arbeit versucht anhand der Literatur sowie biomechanischer Überlegungen sportliche Aktivitäten mit möglichst geringen Belastungen des Inlays zu finden. Beim Gehen auf der Ebene können Kniegelenkskräfte von 3- bis 4-mal Körpergewicht bei 20 ° Knieflexion auftreten. Beim abwärts Gehen steigen die Gelenkkräfte aufs 8 fache des Körpergewichts bei 40 ° Knieflexion.
Beim Fahrrad Fahren besteht eine Kniegelkenksbelastung von 1,2-mal Körpergewicht bei 80 ° und beim langsamen Joggen 8- bis 9-mal Körpergewicht bei 50 ° Knieflexion. Wegen der Geometrie der Femurkomponente spielt beim Kniegelenk, im Gegensatz zur Hüftprothese, auch der Flexionswinkel für die Kontaktfläche und die Inlay Spannung eine große Rolle. So kann eine Knieprothese extensionsnahe stärker belastet werden als in starker Flexion.
Aktivitäten wie Joggen produzieren sehr hohe Inlayspannungen und sollten nach einer Knieprothese gemieden werden. Auch abwärts Gehen produziert wegen der grossen Gelenkkraft und des Flexionswinkels hohe Inlay Spannungen. Beim Wandern sollten sich die Patienten auf das aufwärts Gehen beschränken und abwärts die Bahn benutzen. Falls die Patienten dennoch abwärts gehen müssen, sollten unbedingt Stöcke zur Entlastung gebraucht werden. Dies bringt eine Reduktion der Kniegelenksbelastung bis zu 20 %. Weiter empfiehlt sich ein Verzicht auf Abkürzungen sowie langsames Gehen. Fahrradfahren oder Power-Walking scheinen geeignete Sportaktivitäten nach einer Knieprothese zu sein.
This review deals with the pros and cons of using fixed or mobile bearing designs in the treatment of the young active patient. The risk of failure after total knee arthroplasty (TKA) in younger patients has not been fully defined but does not appear to be as high as that in total hip arthroplasty. Osteolysis is still a concern but is much lower in cemented TKA designs. Younger, more active patients may demand better function than is currently possible with fixed bearing designs. Mobile bearing TKA offers the advantages of increased conformity and greater mobility. This theoretically translates into improved function and range of motion and reduced stresses and wear. Although mobile bearing TKA designs have demonstrated survival rates comparable to successful fixed bearing designs, no conclusive evidence has been presented to support improved function and/or range of motion. Evidence of reduced wear has been reported, but the issue of undersurface wear has yet to be fully addressed. The potential that mobile bearing designs could be successfully used in younger more demanding patients has therefore not been realized. Currently, there is no overwhelming evidence available to favor either fixed or mobile bearing designs in this patient population.
Die Anforderungen an Gelenkendoprothesen nehmen stetig zu: Waren es früher Schmerzfreiheit und Mobilität, so sind es heutzutage
Langlebigkeit trotz starker Belastungen bis hin zur Möglichkeit der Sportausübung. Ein präoperativ sportlich aktiver Patient
möchte auch nach Endoprothesenversorgung seine bevorzugten Aktivitäten wie Wandern, Schwimmen und Radfahren, aber auch anspruchsvollere
Sportarten wie Schifahren, Tennis und Joggen ausüben. Dieser Artikel soll erläutern, welche Sportarten auf welchem Leistungsniveau
von Endoprothesenträgern ausgeübt werden. Gibt es Unterschiede im Vergleich prä- zu postoperativ? Mit welchen Risiken bzw.
negativen Einflüssen auf die Endoprothese ist bei intensiver Sportausübung zu rechnen? Welche Funktion hat der behandelnde
Arzt? Zusammenfassend werden Empfehlungen für Sportausübung nach Hüft- und Knietotalendoprothesen abgegeben.
The expectations of total joint replacement are constantly increasing: Freedom of pain and mobility used to be the primary
goal, while nowadays it is longevity despite heavy loading and intense sporting activity. A preoperative sportive patient
expects to be able to perform his favorite sporting activities like hiking, swimming and cycling, but also the more demanding
skiing, tennis and jogging, for example, after surgery. The aim of this article is to illustrate what level of sporting activities
can be performed by patients with total joint replacement. Are there differences between the pre- and postoperative levels?
What are the risks for, and negative influences on, the prosthesis during intense sporting activity? What is the role of the
physician? Finally, recommendations for sporting activities after total hip and knee replacement are given.
Estimates of knee joint loadings were calculated for 12 normal subjects from kinematic and kinetic measures obtained during both level and downhill walking. The maximum tibiofemoral compressive force reached an average load of 3.9 times body-weight (BW) for level walking and 8 times BW for downhill walking, in each instance during the early stance phase. Muscle forces contributed 80% of the maximum bone-on-bone force during downhill walking and 70% during level walking whereas the ground reaction forces contributed only 20% and 30% respectively.
Most total knee designs provide a tibiofemoral contact area of 100 to 300 mm ² . The yield point of these polyethylene inlays will therefore be exceeded with each step during downhill walking. Future evaluation of total knee designs should be based on a tibiofemoral joint load of 3.5 times BW at 20° knee flexion, 8 times BW at 40° and 6 times BW at 60°.
Estimates of knee joint loadings were calculated for 12 normal subjects from kinematic and kinetic measures obtained during both level and downhill walking. The maximum tibiofemoral compressive force reached an average load of 3.9 times body-weight (BW) for level walking and 8 times BW for downhill walking, in each instance during the early stance phase. Muscle forces contributed 80% of the maximum bone-on-bone force during downhill walking and 70% during level walking whereas the ground reaction forces contributed only 20% and 30% respectively. Most total knee designs provide a tibiofemoral contact area of 100 to 300 mm2. The yield point of these polyethylene inlays will therefore be exceeded with each step during downhill walking. Future evaluation of total knee designs should be based on a tibiofemoral joint load of 3.5 times BW at 20 degrees knee flexion, 8 times BW at 40 degrees and 6 times BW at 60 degrees.
The major load-bearing joints of the body are the hip, knee and ankle. Arthritic disability manifests itself principally at the hip and knee. Information will be presented on the forces transmitted at the hip and knee joints in respect of magnitude, direction and variation with time. The activities to be reviewed will include walking, ramp and stair ascent and descent, and the data will include the magnitudes of the relative movements between adjacent segments and the corresponding rates.
Total hip arthroplasty (THA) is commonly performed in an older population, for whom gold is often the only form of exercise. Members of the Hip Society do not feel that golfers have increased rates of complications after THA when compared to nongolfers and permit their patients to play gold with a THA. Most golfers will see their handicaps increase after total joint arthroplasty, although this does not appear to be a function of drive length. Most golfers with a successful primary total joint arthroplasty will not have pain while playing golf but will likely experience a mild ache in the hip region after playing. Hybrid and uncemented primary THAs appear to have lower rates of radiographic loosening in active golfers when compared to cemented THAs. However, symptoms of pain while playing or after playing do not differ among these groups, despite this radiographic difference.
Patients with either cemented surface replacements or cemented stemmed hip prostheses and who regularly participate in sporting activities or heavy labor after total joint arthroplasty are at twice the long-term risk of requiring revision surgery for loosening as patients who are less active. For patients with surface replacement total hip arthroplasty (THA), the adverse effects of activity are greatest in patients with preoperative diagnoses other than osteoarthritis, and were seen by the sixth year postsurgery. For patients with conventional stemmed prostheses, the effects of patient activity are not seen until about ten years postsurgery. For resurfacing THA for osteoarthritis, the long-term of loosening is primarily in patients who participate in high impact activities.
From a literature survey, it was evident that a wide variety of kinematic conditions occur at the femoral-tibial bearing surfaces, including various degrees of rolling and sliding. A test machine was constructed to reproduce these conditions, applied to spherical-ended metal 'femoral' components acting on a flat polyethylene 'tibial' plateau. The load was cyclic at 2.2 kN for 10 million cycles with distilled water lubricant. For cyclic load only, a shiny depression was formed. With oscillating and sliding superimposed, there was severe surface and subsurface cracking resulting in high wear. When rolling motion was applied, a shiny wear track was formed with minimal cracking and wear. Such surface phenomena were observed in retrieved knee specimens, probably reflecting the kinematics associated with the knee. Low-conformity components inserted with high ligamentous laxity are susceptible to anteroposterior sliding and hence high wear. More-conforming components are less susceptible to wear because they limit sliding as well as reduce contact stresses.
The extent of wear of retrieved, polyethylene tibial components appears to be related to design. To test this observation, 122 tibial inserts were graded for wear, and new components of several designs were tested for contact stress using Fuji film. Finite element analysis provided insight into subsurface stresses. Significant wear was seen in 61.5% of the tibial inserts examined. The presence of unconsolidated polymer powder was seen in 44% of the tibial inserts and was found to be statistically correlated with severe wear of the articulating surface. Contact stress in several noncongruent designs was found to exceed the yield strength of polyethylene. There was a positive correlation between the intensity of wear and the level of contact stress, with noncongruent designs having greater wear than fully congruent geometries. In the noncongruent designs, the thinner polyethylene components showed greater wear than thicker polyethylene inserts of the same design.
Significant wear-through and dissociation failures of metal-backed, point and line contact patellar replacements are associated with excessive contact stresses on the polyethylene-bearing surfaces. Analytical mathematical contact-stress analysis was used to evaluate various patellar component geometries under loading conditions consistent with walking, stair descent, and deep knee bends, respectively. Typical point- and line-contact patellar-surface geometries exceeded the manufacturer's recommended maximum permissible compressive stress level of 10 MPa by a factor greater than three, which also exceeds the yield stress of ultra-high, molecular-weight polyethylene. A metal-backed, rotating-bearing, area contact geometry patellar replacement maintained safe contact stress levels at less than half of the maximum permissible compressive stress level. These contact stress analyses predict early fatigue failure of all-polyethylene or metal-backed, point- and line-contact patellar replacements, while predicting long-term survival of area-contact, rotating-patellar replacements. Clinical evaluation of these various implants support the conclusions of these analyses. Contact stress analysis should precede any clinical use of patellar implants to avoid predictable failure mechanisms.
(C) Lippincott-Raven Publishers.
The metal backings of acetabular components can reduce the available polyethylene thickness, often to an alarming extent. This study indicated that the pitting and cracking of thin polyethylene surfaces have some similarities to tibial and patellar bearings and that creep-related deformation occurred more frequently in thin polyethylene components. Additionally, it appears that dimensional tolerances of the polyethylene inserts are difficult to maintain and may result in a nonuniform fit of both the femoral head into the component and the component into its own metal backing, which can lead to component separation. It is difficult to accurately measure the changes in material and mechanical properties of polyethylene over time. An additional ramification is that flaws, such as voids in the polyethylene, cannot be attributed to problems of bulk supply, fabrication, or postmanufacturing treatment. Orthopedic device manufacturers should keep samples of each lot of polyethylene used and provide components with serial numbers so that the source, composition, and properties of the original bulk material and material "as fabricated" can be documented. This would permit researchers studying revisions or postmortem samples to determine the changes in the polyethylene over time in vivo, thus improving the understanding of this crucial material. If manufacturers were to include dimensions and tolerances of the polyethylene inserts in their product literature, accurate measurements of wear of retrieved specimens may be possible.
Surfaces for condylar total knee replacement are designed using computergraphics techniques. An average anatomical femoral surface is represented mathematically. Mathematical equations are written to describe normal knee motion and normal laxity. Tibial surfaces are generated by placing the femur stepwise in multiple sequential positions, through a defined three-dimensional motion or laxity path. In addition, a flat tibial surface is defined, to represent the least amount of femoral-tibial conformity in currently-used knee replacements. Elasticity theory is used to calculate the maximum contact stresses at the femoral-tibial contact points. The least stresses are produced with a fixed axis cylindrical motion, while the highest are with a flat tibial surface. A surface based on laxity produces lower stresses than for normal knee motion, and is thought to be acceptable in terms of both freedom of motion and stability. Such a laxity surface is proposed as being suitable for total knee design.
Recent studies have linked regular physical activity with reduced likelihood of developing coronary heart disease. Even low- and moderate-intensity exercise such as walking, when carried out consistently, is associated with important cardiovascular health benefits. Walking has also been shown to reduce anxiety and tension and aid in weight loss. Regular walking may help improve cholesterol profile, help control hypertension, and slow the process of osteoporosis. Recent physiological studies have demonstrated that brisk walking provides strenuous enough exercise for cardiovascular training in most adults. A recently developed submaximal 1-mile walk test provides a simple and accurate means for estimating aerobic capacity and guiding exercise prescription. These new insights and tools will assist the clinician in the prescription of safe and effective walking programs.
We examined the physical activity and other life-style characteristics of 16,936 Harvard alumni, aged 35 to 74, for relations to rates of mortality from all causes and for influences on length of life. A total of 1413 alumni died during 12 to 16 years of follow-up (1962 to 1978). Exercise reported as walking, stair climbing, and sports play related inversely to total mortality, primarily to death due to cardiovascular or respiratory causes. Death rates declined steadily as energy expended on such activity increased from less than 500 to 3500 kcal per week, beyond which rates increased slightly. Rates were one quarter to one third lower among alumni expending 2000 or more kcal during exercise per week than among less active men. With or without consideration of hypertension, cigarette smoking, extremes or gains in body weight, or early parental death, alumni mortality rates were significantly lower among the physically active. Relative risks of death for individuals were highest among cigarette smokers and men with hypertension, and attributable risks in the community were highest among smokers and sedentary men. By the age of 80, the amount of additional life attributable to adequate exercise, as compared with sedentariness, was one to more than two years.
A saggital plane biomechanical analysis of I I slow jogging trials yielded joint moments of force. power curves and positive and negative work at each of the joinrs of the lower limb. The following can be summarized: 1. The total moment of force pattern of the lower limb was primarily extensor during stance and flexor during swing. The hip had an extensor peak at 20"". the knee at 40Y, and the ankle at 60"" of stance. 2. The variability of the moment patterns across all trials was considerably less than that seen during natural walking. 3. Two power bursts wereseen at the ankle, absorption early in stance followed by adominant generation peak during late push-off. The average peak of power generation was 800 W with individual maximums exceeding 1500 W. 4. Power patterns for all trials showed the knee to have fivedistinct phases: an initial shock absorbing peak during weight acceptance. a small generation burst during early push-off, a major absorption pattern during late push-08continuing until maximum knee flexion, a third absorption peak decelerating the leg and foot prior to impact,and a final small positive burst as the knee flexors rotate the leg posteriorly to further reduce the forward velocity of the foot prior to heel contact. 5. Power patterns at the hip were neither large nor consistent indicating the dual role of hip flexors and extensors relative to the trunk and lower limb stability. 6. Positive work done by the ankle plantarflexors averaged three times that done by the knee extensors, and in some joggers the ankle muscles generated eight times that of the knee muscles. 7. Over the entire stride the knee muscles absorbed 3.6 times as much energy as they generated: the ankle muscles generated 2.9 times as much as they absorbed.
Up to now, sporting activity after total hip arthroplasty has been limited or terminated completely because of the risk of failure. In the case of younger patients, it is desirable to know whether this attitude is justified. Consequently, an analysis has been made of 110 patients (all male, average age at the time of the operation 55 years, 42 bilateral). Sport was practised in 78 and 56% of the cases prior to an after the operation respectively. The patients with intense sporting activity were examined and the findings compared with those who did not participate in a sporting activity after the operation. The incidence of replacement due to loosening is surprisingly higher among the group of patients with no sporting activity (14.3% to 1.6%). In the light of these findings, there is no need to prohibit sport in these cases. To allow for a gradual resumption of sport, guidelines have been elaborated on the basis of present-day knowledge of quantitative and qualitative hip strain. The short load peaks appearing as the heel touches the ground on walking or running will be attenuated by means of a viscoelastic heel pad.
Various design criteria were examined in combination to find the ideal geometry for a condylar knee replacement. The criteria were the contact stresses on the plastic, femoral-tibial size interchangeability, patella lever arm, laxity and stability and the amount of bone resection required. The variables were the radii of curvature of the femoral and tibial bearing surfaces in the sagittal and frontal planes. Metal toroidal indentors were loaded onto dished surfaces of UHMWPE covering a range of radii and the contact areas measured. Using elasticity equations, the apparent elastic modulus of UHMWPE ranged from 400 to 600 MPa for less conforming to closely conforming surfaces. Using a value of 600 MPa, contact stresses were predicted for a complete spectrum of radii of curvature. Finite element analysis was used to determine the stresses beneath the contact patches when different femoral-tibial sizes were interchanged. A computergraphics program was written to analyse the effects of flexion, rotation and femoral roll-back on the contact point locations. An influential variable was the sagittal curvature of the femoral component, notably the point of transition between the posterior curve of small radius and the distal curve of larger radius. This affected the patella lever arm, the stability, and the bone resection. Interchangeability was primarily dependent upon the relative frontal radii. Contact stresses and contact locations depended upon the combination of sagittal and frontal radii. The most suitable geometrical combinations overall were discussed.
The results of total knee arthroplasty (TKA) in patients who actively exercise have not been previously studied. Golf is a frequent form of exercise for the older population in whom TKAs are usually performed. Members of The Knee Society permit their patients with TKA to play golf, if they desire to do so. They recommend waiting approximately 18 weeks after surgery before beginning to play. Most members of The Knee Society stated that they have no preferences as to the model of knee arthroplasties in golfers, although 35.2% did state that they would use a posterior-cruciate sparing model. After TKA, active golfers in the authors' study (83) invariably experienced a significant rise in their handicap (mean +4.6 strokes) and also a decrease in the length of their drives. Most (86.7%) use a cart while playing, but still a small percentage (15.7%) will have a mild ache in the knee while playing and a larger percentage (34.9%) will have a mild ache in the knee after playing. In addition, golfers with left TKAs have more difficulty with pain during and after play (P < .01) than do golfers with right TKAs. Radiolucencies were also common in our study, occurring in 53.7% of all knees studied and 79.1% of cemented TKAs.
This study examined tibiofemoral contact stresses in 15 commercially available TKR designs, using digitally imaged pressure-sensitive film. The objectives were (1) to determine the correlation between minimization of spatial mean contact stress and minimization of the amount of overloaded (>10 MPa) polyethylene contact area, and (2) to ascertain the difference in contact stresses for machined versus moulded polyethylene inserts. The data showed that there was no statistically significant (design rank-order) correlation of spatial mean contact stress with overloaded polyethylene area. The data also showed that machining cutter preparation of the polyethylene insert caused substantial local contact stress non-uniformities that corresponded to the pattern of grossly visible machining marks.
- McGrory