Patient And Activityrelated Factors

Patients can return to an active lifestyle after successful THR, and these benefits extend beyond recreational pursuit. In one study [5], many patients who were not previously active presurgically developed a healthy habit postoperatively of walking, cycling, swimming, or cross-country skiing. Ries and colleagues [6] noted an improvement in cardiovascular fitness 2 years after surgery, with an increase in maximum workload and oxygen metabolism. Macnicol and coworkers [7] reported improved gait characteristics and oxygen consumption.

Firm rules to summarily limit or allow athletic participation may be too general. A safe return to sports is dependent on patient- and activity-specific risk factors. It is these issues that require careful exploration preoperatively.

Although impact and load from athletics are risk factors for failure, the degree of influence of these factors varies widely. Just as chronological age is related less to wear than activity level [8], how aggressively a patient participates in a sport is as critical as the specific sport he participates in. Patients participate at vastly different levels of intensity, from highly competitive to weekend athlete. Load and risk will likewise be reduced in those pursuing occasional recreation rather than peak fitness [9]. More extreme athletic patients may be encouraged to modify their expectations and levels of participation (Fig. 1). Preoperative expertise is also a factor in minimizing risk. Accomplished athletes can often return to a sport with a lower risk of injury. For example, the expert water skier or surfer engaged in moderate activity after THR is at less risk than a novice attempting to learn the sport.

Sports-specific demands are also important considerations. Factors to evaluate include required flexibility, the amount of repetitive load, and the potential for high impact and contact. Although yoga and Pilates raise a surgeon's concern for hip dislocation, these activities may not be contraindicated (Fig. 2). Although

Fig. 1. THR in 48-year-old patient who returned to tournament-level beach volleyball. Procedure was performed with cementless implants, a large head, and highly crosslinked polyethylene.

Fig. 2. THR in 43-year-old patient who returned to work as a Pilates instructor. Procedure was performed using a Smith-Peterson anterior approach to minimize the risk of dislocation, and a metal-on-metal bearing surface.

some yoga positions extend beyond the limitations of traditional posterior hip precautions, participants can often substitute an alternative position with the instructor's guidance. Regarding martial arts, patients should avoid sparring and high kicks, but may return to technical forms. Surgical technique, approach to the hip, and implant choice may also increase the relative safety of returning to these exercises.

The duration and extent of repetitive load raise wear-related concerns after THR. These discussions involve questioning whether a patient can or should do an activity. A common concern centers on running after THR. A patient is able to run in times of need, and is not limited from running short distances infrequently, as in softball or tennis; however, the repetitive joint reactive forces resulting from jogging raise appropriate concern for the durability of the prosthesis. The bearing surface is prematurely stressed, with repetitive loading up to five times body weight caused by each heel strike [9]. Cardiovascular fitness can be maintained instead with alternative low-impact, closed-chain exercises. Because the joint loads are reduced, patients are encouraged to achieve an aerobic workout with power walking, biking, swimming, the stair climber, and elliptical machines.

The surgeon should also evaluate a return to sports based on the potential for contact. High-contact sports place the joint and bone at risk. One can differentiate, however, between the safety of ice skating versus the heavy contact in hockey. Similar contact-intensive sports such as football and rugby are also best avoided. High impact may also result from uncontrolled falls. Although skiing and surfing are not discouraged for experienced athletes, the intensity of the activities should be modified based on preoperative proficiency [10].

Finally, all patients will require an appropriate period of rehabilitation after surgery to return to sports. Any activity with increased cyclical loading should be avoided until solid ingrowth is achieved in cementless THR. Muscle mass, coordination, balance, and reflexes need to be redeveloped before returning to competitive play. Golfers are advised to resume chipping and putting initially, to work with a golf professional, and to ride the cart for the first 6 months. Tennis players are similarly advised to work on strokes with an instructor, and to advance gradually from doubles to singles play. Although all patients require follow-up, active athletes deserve closer observation with routine radiographs.

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