Exercise recommendations after total joint replacement

A review of the current literature and proposal of scientifically based guidelines.

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.

Markus S. Kuster, Department of Orthopaedic Surgery and Traumatology, Kantonsspital, St. Gallen, Switzerland.

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 de-lamination 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.

Conclusion

Patients should be motivated to remain physically active after total joint replacement for general health, prevention of cardiac problems and also for improvement of bone quality and prosthesis fixation. However, the activity recommendations should be assessed for each patient.

Active patients who would like to maintain or even improve cardio-respiratory fitness will have to exercise three to four times weekly for 30 to 40 minutes. These aerobic activities should be of low-impact, such as swimming, cycling, Aqua-Fit or power walking. For patients who would like to continue sport on an occasional and therefore recreational basis, activities with higher joint loads, such as skiing, tennis and hiking can be recommended.

Patients should also be alerted to joint load reducing measures such as the use of ski-poles during hiking, the use of cable cars for the descent, skiing on flatter slopes and avoiding icy conditions, the use of diagonal instead of skating techniques during cross- country skiing, cycling with low loads and higher frequencies and increasing saddle height.

It is also unwise to start technically demanding activities such as skiing, mountain hiking, mountain biking, horse riding and tennis after total joint replacement as the joint loads and the risk for injuries are generally higher for these activities in unskilled individuals. Based on design differences between hip and knee replacements it is also prudent to be more conservative after TKA than after THA for activities that exhibit high joint loads in knee flexion such as jogging, or mountain hiking.

References

Exercise recommendations after total joint replacement: a review of the current literature and proposal of scientifically based guidelines, Kuster MS. Sports Med. 2002;32(7):433-45. doi: 10.2165/00007256-200232070-00003.

The Unhappy Total Knee Replacement, A Comprehensive Review and Management Guide, Michael T. Hirschmann, Roland Becker, Editors. Springer 2015. ISBN: 978-3-319-08099-4. PDF