Many of our patients wonder about what level of activity will be acceptable to their surgeons and also meet their needs following total knee or total hip replacement. I once had a patient ask me “Will I be able to play the piano after physical therapy on my hand”? I replied, “Of course you will”. He popped back, “Great, I never could play before.” As physical therapist we try to return people to their previous level of function (PLOF). This has an impact on our goals for each patient. When it comes to physical activity following total hip or total knee arthroplasty, the current standard of care is to recommend unlimited low-impact activity, according to a paper presented at the November 2008 American Association for Hip and Knee Surgeons (AAHKS) Annual Meeting.
With recent improvements in implant fixation and wear reduction, 95 percent of orthopaedic surgeons who responded to a survey say they place no limitations on swimming, golf, walking on even surfaces, bicycling on level surfaces, or climbing stairs when recommending activities for patients with a well-functioning total hip replacement (THR) or total knee replacement (TKR). Higher-impact activities are more commonly discouraged, and there is a trend towards more activity restrictions following successful TKR.
Nearly all respondents strongly encouraged low-impact activity, patients were discouraged from jogging, difficult skiing, and singles tennis. None of the respondents indicated that they had strong scientific evidence for their recommendations.
Dr. Swanson and his co-researchers, Frederick Dorey, PhD, and Thomas P. Schmalzried, MD, are with the department of orthopaedic surgery at the University of California Los Angeles.
In a different review “Athletic Activity after Total Joint Arthroplasty,” published in the October 2008 issue of the Journal of Bone and Joint Surgery. This study was conducted by William L. Healy, MD; Sanjeev Sharma, MD; Benjamin Schwartz, MD; and Richard Iorio, MD—documents a trend for hip and knee surgeons to allow more athletic activity after joint replacement, but notes that no good evidence exists to support this trend.
“High levels of activity may compromise the durability of joint replacement and reduce implant survival,” says Dr. Healy, the lead researcher. “Implant wear has been shown to be related to how much the joint is used as opposed to the length of time the artificial joint has been in place.”
Innovations such as alternative bearing surfaces, large femoral heads, hip resurfacing, unicompartmental knee replacement, mobile-bearing knee replacement, and high-flexion knee replacement offer the potential for high-demand function with low rates of failure, but these potential benefits have not been proven, the study reports.
“We need to keep in mind that surgeons and patients often assess the success of joint replacement differently,” Dr. Healy says. “Surgeons look at pain, function, survivorship, and the need for revision surgery, while patients consider their pain and activity. If the joint allows them to play their favorite sport without pain, they may not be concerned about needing an additional surgery in the future.”
