Abstract
In this systematic review, our aim was to explore whether or not patients are able to return to athletic activity following lower limb joint replacement. We also investigated any evidence as to whether participation in athletic activity post-joint replacement increases complications and reduces implant survival.
A PubMed, Embase and Sports Discus search was performed using the MeSH terms ‘Sport’, ‘Athletic’, ‘Athlete’, ‘Physical’, ‘Activity’, ‘Arthroplasty’, ‘Total Hip Replacement’, ‘Hip Resurfacing’, ‘Total Knee Replacement’, ‘Unicompartmental Knee Replacement’ and ‘Unicondylar Knee Replacement’. From this search, duplications were excluded, the remaining abstracts were reviewed and any unrelated to the search terms were excluded. The remaining abstracts had their full papers reviewed.
Following joint replacement, participation in sporting activity is common principally determined by pre-operative patient activity levels, BMI and patient age. The type of joint replaced is of less significance. Total time spent performing activity does not change but tends to be at a lower intensity. There is little evidence in the literature of an association between high activity levels and early implant failure.
Cite this article: Bone Joint J 2014;96-B:923–7.
Lower limb joint replacement (JR) is a common and successful operation for patients with intractable hip and knee pain with associated functional disability.1,2 Degenerative joint disease is increasing and has been mirrored in a rise in demand for surgery.3,4 Historically, surgical outcomes following JR were assessed through rates of mortality, operative complications and implant survival. However, more sophisticated measures have been developed to accurately reflect health gains with improved pain and functional scores.5-7 Scoring systems have evolved to assess more advanced post-operative function including, to some degree, athletic activity.8 Few studies have explicitly investigated outcomes in patients aged under 50 years or the prevalence of joint disease and JR outcomes in populations involved in regular athletic activity.
The prevalence of degenerative joint disease increases with age, obesity9 and occupational physical loading.10 The association between athletic activity and osteoarthritis has been established by epidemiological studies.11-14 Athletes requiring JR will have high expectations of maintaining activity following surgery. Patient satisfaction following joint surgery correlates highly with patient expectations rather than a measure of absolute function15 and therefore surgeons must be aware of relevant evidence to be adequately able to counsel patients wishing to return to sport after JR.
Studies have investigated the ability of patients to participate in athletic activity after JR and some have described an increase in participation16 while others have described a reduction.17 However, criticism has been levelled at these reports for being poorly designed, under-powered and having short follow-ups. Also evidence of complications and implant survival in athletic populations has not been explicitly described.18
The purpose of this systematic review is to explore whether or not patients are able to return to athletic activity post-JR and whether that return increases complications and reduces implant survival.
Materials and Methods
We included all studies relevant to participation in athletic activity following lower limb JR involving the hip or knee, including total joint replacement (TJR), unicompartmental knee replacement (UKR), patellofemoral joint replacement (PFJR) and hip resurfacing (HR). We decided not to include ankle joint replacement because of a relatively little long-term follow-up data in comparison with hip and knee replacements. We considered all case series and cohort studies that reported results with validated scoring systems, complication rates and implant survival data. Any studies that were found without validated scoring systems were scrutinised for their study design and some were included after discussion (see below). We excluded any review articles. We did not exclude any study on the basis of length of follow-up or number of participants.
We used a Medline search for all articles published in any language, but any studies that did not have an English translation were subsequently excluded. We used the following Medical Subject Headings (MeSH) terms for our literature search in combination with Boolean operators (in upper cases): 1) ‘Sport’ OR ‘Athletic’ OR ‘Athlete’ OR ‘Physical’ OR ‘Activity’ AND 2) (i)‘Arthroplasty’, (ii)‘Total Hip Replacement’, (iii)‘Hip Resurfacing’, (iv)‘Total Knee Replacement’, (v)‘Unicompartmental Knee Replacement’, (vi)‘Unicondylar Knee Replacement’ and (vii)‘Patellofemoral Joint Replacement’. The results of the Medline search were cross-checked with the Embase and Sports Discus databases and any duplicate papers were excluded. The remaining papers were independently assessed by two authors (SJ, SD) for suitability for inclusion. The titles and abstracts of search results were reviewed and if there was doubt regarding the suitability of the study, the full article was retrieved for further scrutiny. All final decisions, in the case of uncertainty were made by the senior author (FSH). The citations within any article were also scrutinised for any missing papers following the initial search.
All papers were examined for details concerning the size of the study, the joints involved, outcome scores used and length of follow-up. Each study then had their design evaluated, with respect to level of evidence, and description of their findings based on preferably validated outcome scores, ability to participate in sports, the types of activity studied and the identification of any complications and implant survival relating to sporting activity. We aimed to only include studies that described specific sporting activities and used validated scores. However, they were included if collectively we felt the data constructively contributed to overall conclusions.
Results
A total of 42 suitable papers were identified as relevant for analysis. The flow diagram in Figure 1 19 demonstrates the process of identifying the relevant papers.
Fig. 1
Flow chart depicting the search process in identifying suitable papers for analysis (Adapted from PRISMA guidelines for systematic reviews).19
The total number of patients in all the included studies was 10758, with a mean of 256 patients per study (22 to 2085). The mean age of all participants was 61.7 years (42 to 71.5). The mean follow-up length of the studies was 4.7 years (1 to 10.5).
Of the studies, 17 investigated knees alone (12 TKR,17,20-30 three UKR,31-33 two both,34,35) 20 studies investigated hips alone (12 THR,16,36-46 seven HR,47-53 one both54) and four studies investigated both hip and knee joints.55-58
The most popular joint outcome scoring systems were the Knee Society Score (KSS) 59 (used by ten studies) and the Oxford Knee Score (OKS)60 (six studies) for the knee. The most popular hip outcome scoring systems were the Harris Hip Score (HHS)61 (eight studies) and Oxford Hip Score (OHS)62 (six studies). The most popular athletic activity-rating scores were the University of California Los Angeles (UCLA)63 (15 studies) and the 4-level Saltin-Grimby Physical Activity Level Scale (SGPALS)36 (six studies). The SGPALS, although not commonly reported has been shown to possess good validity and reliability in epidemiological studies when compared with the UCLA score.64 The most popular general health indices were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score65 (five studies) and the Short Form 12(SF-12) (four studies).66 The rest used generalised or sports-specific outcome questionnaires to evaluate particular skills within sports, such as golf swing or tennis serve. Overall, 31 of the studies used validated outcome questionnaires 17,21,22,25-35,37,41-48,50-54,56-58 and 13 of these compared pre-operative with post-operative scores17,21,29,31,32,35,43,48,50,51,53,56,58; all of these demonstrated statistically significant improvement in post-operative scores.
In total, eight studies gave descriptions of joint replacement outcomes for specific sports (four for golf20,28,38,43 two for tennis,23,39 one for running,51 one for skiing,40) 22 studies discussed a number of general activities 16,17,21,25,26,29,30,32-37,41,46,49,50,53,54,55,57; these were a mixture of high-impact, such as tennis and jogging, or low-impact, such as walking, swimming and cycling. A further 12 alluded to activity in general but made no mention of specific sports.22,24,31,42,44,45,47,48,52,56,58,67
The rate of return to sport varied widely and was described as between 54% and 98% across the papers. Lower rates were seen in less recent studies without validated activity outcome questionnaires.16,36,37 Higher levels of activity were associated with lower ages,26,29,51,53,55,57,58 male gender,25,26,41,44,55,57,58 lower BMI,22,26,58 participation in sport pre-operatively,55,58 and absence of other joint pain.26,55,58 For example, Williams et al58 demonstrated that male gender gave an odds ratio (OR) of 4.84 and a higher pre-operative UCLA score gave an OR of 1.61 for a UCLA score of 7 or more after surgery. Dahm et al26 reported that patients over the age of 70 years had lower mean UCLA scores compared with patients under the age of 70 years (6.8 vs 7.5, p < 0.001).
In studies comparing performance and return to sport between different types of joint replacement, greater numbers of UKR patients performed better in comparison to TKR patients.34,35 There was no difference in performance between THR and HR patients,54 nor between knee and hip replacements in five studies54,56-58,67 although one study showed a more frequent return to sport in THR patients compared with TKR patients.55
Although few studies explicitly investigated implant survival in sporting populations, none of the studies reported an increase in rates of complication associated with sporting activity with respect to less-active controls. A total of three studies did note an increase in polyethylene wear with increased activity, but no increase in revision rate.22,40,45 In those explicitly investigating revision rates, none found an increase in rates in sporting populations24,33,37 and none found an increase in revision risk associated with increased UCLA activity score.44,52
Discussion
With operations apparently being performed on progressively younger patients, functional demands on implants are increasing, with many people wanting to maintain high levels of activity. We have shown that the majority of patients, in particular those who are young and active pre-operatively without multiple joint pathologies, are able to return to sporting activity after JR, with some qualification.
A variety of sports of different intensities and impact on replaced joints have been found in the reports we have analysed. Although the majority have shown that patients are more inclined to return to low- rather than high-impact activities, there has been no clear consensus on whether this is a rational position for patients or their surgeons. Some of the suggestions made to explain this tendency include pain in the replaced joint, a personal feeling of apprehension or instructions from the operating surgeon. Klein et al68 sought consensus amongst surgeons on acceptable sporting activities post-THR. From orthopaedic consultants belonging to the Hip Society and the American Association of Hip and Knee Surgeons who were surveyed, it was agreed that swimming, golf and cycling were permissible, while contact sports and jogging were not. They found that 91% of the 614 respondents would allow their patients to return to sporting activity six months post-surgery, with one third allowing activity at three months, supporting an earlier survey conducted by McGrory et al.69 The surgical opinions expressed in these studies were based on experience rather than on evidence, and therefore the reason for a patients’ inability to return to high-impact activities is still not clear.
Papalia et al70 investigated published reports involving sport after TKR and found high rates of return-to-sport, with no significant differences between TKR and UKR cohorts. They felt that because of study heterogeneity and a lack of consistent outcome scoring systems, definitive comparisons on physical outcome post-surgery could not be made. The authors called for more randomised controlled studies into the subject. Vogel et al71 also concluded that sport was possible after JR, but noted that patients tended to be restricted to low-impact activities. Our study has built on the findings of these by providing more recent papers and more explicitly describing implant survival in sporting populations after TJR.
The limitations of this study are common to other systematic reviews; in particular that some papers may not have been found with our search criteria. This may have been due to the initial search terms or exclusion of those papers with no English translation available. However, from examining the bibliographies of other studies, we do not appear to have missed any studies that would have significantly altered our conclusions.
With the studies we have reviewed, there is significant heterogeneity with respect to the outcome scores used. Many have used sports questionnaires, designed by the authors, which have not been validated.16,20,23,24,36,38,39,40,49,55,67 Such instruments are prone to recall bias as many rely on a patient’s ability to describe sporting activity several years before the study was carried out.
Early studies in this review have not used validated outcome scoring systems, which has made rigorous comparison with other studies impossible. Many of the studies have used more generic scoring systems, such as WOMAC and SF-12 which are not joint-specific, and do not allow comparison between joints or the different implants. Finally, the majority of the studies do not exceed ten-years of follow-up. While we have shown that implant-survival is not reduced in active patients, the length of follow-up is not yet adequate to make definitive conclusions on this matter.
In conclusion, we have identified from the literature that following JR, patients are able to return to sporting activity. The intensity of activity to which patients return tends to be less than before surgery. We have not seen, at mid-term at least, an increase in implant failure in active patients, although some studies have found higher radiological wear in active populations. We recommend more long-term prospective studies to see if these findings are maintained or change significantly in order to allow patients considering JR to be better informed regarding their post-operative prognosis for athletic participation.
1 Wilcock GK . Benefits of total hip replacement to older patients and the community. Br Med J1978;2:37–39. Google Scholar
2 Harris WH , SledgeCB. Total hip and total knee replacement (2). N Engl J Med1990;323:801–807. Google Scholar
3 Birrell F , JohnellO, SilmanA. Projecting the need for hip replacement over the next three decades: influence of changing demography and threshold for surgery. Ann Rheum Dis1999;58:569–572. Google Scholar
4 No authors listed. National Joint Registry, 2014. http://www.njrcentre.org.uk/njrcentre/default.aspx (date last accessed 06 March 2014). Google Scholar
5 Rissanen P , AroS, SlätisP, SintonenH, PaavolainenP. Health and quality of life before and after hip or knee arthroplasty. J Arthroplasty1995;10:169–175. Google Scholar
6 Weiss JM , NoblePC, CondittMA, et al.What functional activities are important to patients with knee replacements?Clin Orthop Relat Res2002;404:172–188. Google Scholar
7 Ethgen O , BruyèreO, RichyF, DardennesC, ReginsterJY. Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature. J Bone Joint Surg [Am]2004;86-A:963–974. Google Scholar
8 Ashby E , GrocottMP, HaddadFS. Outcome measures for orthopaedic interventions on the hip. J Bone Joint Surg [Br]2008;90-B:545–549. Google Scholar
9 Anderson JJ , FelsonDT. Factors associated with osteoarthritis of the knee in the first national Health and Nutrition Examination Survey (HANES I). Evidence for an association with overweight, race, and physical demands of work. Am J Epidemiol1988;128:179–189. Google Scholar
10 Croft P , CoggonD, CruddasM, CooperC. Osteoarthritis of the hip: an occupational disease in farmers. BMJ1992;304:1269–1272. Google Scholar
11 Spector TD , HarrisPA, HartDJ, et al.Risk of osteoarthritis associated with long-term weight-bearing sports: a radiologic survey of the hips and knees in female ex-athletes and population controls. Arthritis Rheum1996;39:988–995. Google Scholar
12 Kujala UM , KaprioJ, SarnaS. Osteoarthritis of weight bearing joints of lower limbs in former élite male athletes. BMJ1994;308:231–234. Google Scholar
13 Elleuch MH , GuermaziM, MezghanniM, et al.Knee osteoarthritis in 50 former top-level soccer players: a comparative study. Ann Readapt Med Phys2008;51:174–178. Google Scholar
14 Tveit M , RosengrenBE, NilssonJÅ, KarlssonMK. Former male elite athletes have a higher prevalence of osteoarthritis and arthroplasty in the hip and knee than expected. Am J Sports Med2012;40:527–533. Google Scholar
15 Noble PC , CondittMA, CookKF, MathisKB. The John Insall Award: Patient expectations affect satisfaction with total knee arthroplasty. Clin Orthop Relat Res2006;452:35–43. Google Scholar
16 Visuri T , HonkanenR. Total hip replacement: its influence on spontaneous recreation exercise habits. Arch Phys Med Rehabil1980;61:325–328. Google Scholar
17 Bradbury N , BortonD, SpooG, CrossMJ. Participation in sports after total knee replacement. Am J Sports Med1998;26:530–535. Google Scholar
18 Golant A , ChristoforouDC, SloverJD, ZuckermanJD. Athletic participation after hip and knee arthroplasty. Bull NYU Hosp Jt Dis2010;68:76–83. Google Scholar
19 Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097. Google Scholar
20 Mallon WJ , CallaghanJJ. Total knee arthroplasty in active golfers. J Arthroplasty1993;8:299–306. Google Scholar
21 Diduch DR , InsallJN, ScottWN, et al.Total knee replacement in young, active patients. Long-term follow-up and functional outcome. J Bone J Surg [Am]1997;79-A:575–582. Google Scholar
22 Lavernia CJ , SierraRJ, HungerfordDS, KrackowK. Activity level and wear in total knee arthroplasty: a study of autopsy retrieved specimens. J Arthroplasty2001;16:446–453. Google Scholar
23 Mont MA , RajadhyakshaAD, MarxenJL, SilbersteinCE, HungerfordDS. Tennis after total knee arthroplasty. Am J Sports Med2002;30:163–166. Google Scholar
24 Jones DL , CauleyJA, KriskaAM, et al.Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study. J Rheumatol2004;31:1384–1390. Google Scholar
25 Chatterji U , AshworthMJ, LewisPL, DobsonPJ. Effect of total knee arthroplasty on recreational and sporting activity. ANZ J Surg2005;75:405–408. Google Scholar
26 Dahm DL , BarnesSA, HarringtonJR, SayeedSA, BerryDJ. Patient-reported activity level after total knee arthroplasty. J Arthroplasty2008;23:401–407. Google Scholar
27 Mont MA , MarkerDR, SeylerTM, et al.High-impact sports after total knee arthroplasty. J Arthroplasty2008;23:80–84. Google Scholar
28 Jackson JD , SmithJ, ShahJP, WisniewskiSJ, DahmDL. Golf after total knee arthroplasty: do patients return to walking the course?Am J Sports Med2009;37:2201–2204. Google Scholar
29 Marker DR , MontMA, SeylerTM, et al.Does functional improvement following TKA correlate to increased sports activity?Iowa Orthop J2009;29:11–16. Google Scholar
30 Bonnin M , LaurentJR, ParratteS, et al.Can patients really do sport after TKA?Knee Surg Sports Traumatol Arthrosc2010;18:853–862. Google Scholar
31 Fisher N , AgarwalM, ReubenSF, JohnsonDS, TurnerPG. Sporting and physical activity following Oxford medial unicompartmental knee arthroplasty. Knee2006;13:296–300. Google Scholar
32 Naal FD , FischerM, PreussA, et al.Return to sports and recreational activity after unicompartmental knee arthroplasty. Am J Sports Med2007;35:1688–1695. Google Scholar
33 Pietschmann MF , WohllebL, WeberP, et al.Sports activities after medial unicompartmental knee arthroplasty Oxford III-what can we expect?Int Orthop2013;37:31–37. Google Scholar
34 Walton NP , JahromiI, LewisPL, et al.Patient-perceived outcomes and return to sport and work: TKA versus mini-incision unicompartmental knee arthroplasty. J Knee Surg2006;19:112–116. Google Scholar
35 Hopper GP , LeachWJ. Participation in sporting activities following knee replacement: total versus unicompartmental. Knee Surg Sports Traumatol Arthrosc2008;16:973–979. Google Scholar
36 Dubs L , GschwendN, MunzingerU. Sport after total hip arthroplasty. Arch Orthop Trauma Surg1983;101:161–169. Google Scholar
37 Ritter MA , MedingJB. Total hip arthroplasty. Can the patient play sports again?Orthopedics1987;10:1447–1452. Google Scholar
38 Mallon WJ , CallaghanJJ. Total hip arthroplasty in active golfers. J Arthroplasty1992;7Suppl:339–346. Google Scholar
39 Mont MA , LaPorteDM, MullickT, SilbersteinCE, HungerfordDS. Tennis after total hip arthroplasty. Am J Sports Med1999;27:60–64. Google Scholar
40 Gschwend N , FreiT, MorscherE, NiggB, LoehrJ. Alpine and cross-country skiing after total hip replacement: 2 cohorts of 50 patients each, one active, the other inactive in skiing, followed for 5-10 years. Acta Orthop Scand2000;71:243–249. Google Scholar
41 Chatterji U , AshworthMJ, LewisPL, DobsonPJ. Effect of total hip arthroplasty on recreational and sporting activity. ANZ J Surg2004;74:446–449. Google Scholar
42 Beaulé PE , DoreyFJ, HokeR, et al.The value of patient activity level in the outcome of total hip arthroplasty. J Arthroplasty2006;21:547–552. Google Scholar
43 Arbuthnot JE , McNicholasMJ, DashtiH, HaddenWA. Total hip arthroplasty and the golfer: a study of participation and performance before and after surgery for osteoarthritis. J Arthroplasty2007;22:549–552. Google Scholar
44 Sechriest VF 2nd , KyleRF, MarekDJ, et al.Activity level in young patients with primary total hip arthroplasty: a 5-year minimum follow-up. J Arthroplasty2007;22:39–47. Google Scholar
45 Ollivier M , FreyS, ParratteS, FlecherX, ArgensonJN. Does impact sport activity influence total hip arthroplasty durability?Clin Orthop Relat Res2012;470:3060–3066. Google Scholar
46 Schmidutz F , GroteS, PietschmannM, et al.Sports activity after short-stem hip arthroplasty. Am J Sports Med2012;40:425–432. Google Scholar
47 Daniel J , PynsentPB, McMinnDJW. Metal-on-metal resurfacing of the hip in patients under the age of 55 years with osteoarthritis. J Bone J Surg [Br]2004;86-B:177–184. Google Scholar
48 Narvani AA , TsiridisE, NwabokuHC, BajekalRA. Sporting activity following Birmingham hip resurfacing. Int J Sports Med2006;27:505–507. Google Scholar
49 Naal FD , MaffiulettiNA, MunzingerU, et al.Sports after hip resurfacing arthroplasty. Am J Sports Med2007;35:705–711. Google Scholar
50 Banerjee M , BouillonB, BanerjeeC, et al.Sports activity after total hip resurfacing. Am J Sports Med2010;38:1229–1236. Google Scholar
51 Fouilleron N , WavreilleG, EndjahN, GirardJ. Running activity after hip resurfacing arthroplasty: a prospective study. Am J Sports Med2012;40:889–894. Google Scholar
52 Le Duff MJ , AmstutzHC. The relationship of sporting activity and implant survivorship after hip resurfacing. J Bone Joint Surg [Am]2012;94-A:911–918. Google Scholar
53 Girard J , MileticB, DenyA, MigaudH, FouilleronN. Can patients return to high-impact physical activities after hip resurfacing? A prospective study. Int Orthop2013;37:1019–1024. Google Scholar
54 Cowie JG , TurnballGS, KerAM, BreuschSJ. Return to work and sports after total hip replacement. Arch Orthop Trauma Surg2013;133:695–700. Google Scholar
55 Huch K , MüllerKA, StürmerT, et al.Sports activities 5 years after total knee or hip arthroplasty: the Ulm Osteoarthritis Study. Ann Rheum Dis2005;64:1715–1720. Google Scholar
56 Bauman S , WilliamsD, PetruccelliD, ElliottW, de BeerJ. Physical activity after total joint replacement: a cross-sectional survey. Clin J Sport Med2007;17:104–108. Google Scholar
57 Wylde V , BlomA, DieppeP, HewlettS, LearmonthI. Return to sport after joint replacement. J Bone Joint Surg [Br]2008;90-B:920–923. Google Scholar
58 Williams DH , GreidanusNV, MasriBA, DuncanCP, GarbuzDS. Predictors of participation in sports after hip and knee arthroplasty. Clin Orthop Relat Res2012;470:555–561. Google Scholar
59 Insall JN , DorrLD, ScottRD, ScottWN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res1989;248:13–14. Google Scholar
60 Dawson J , FitzpatrickR, MurrayD, CarrA. Questionnaire on the perceptions of patients about total knee replacement. J Bone J Surg [Br]1998;80-B:63–69. Google Scholar
61 Soderman P , MalchauH. Is the Harris hip score system useful to study the outcome of total hip replacement?Clin Orthop Relat Res2001;384:189–197. Google Scholar
62 Dawson J , FitzpatrickR, CarrA, MurrayD. Questionnaire on the perceptions of patients about total hip replacement. J Bone J Surg [Br]1996;78-B:185–190. Google Scholar
63 Naal FD , ImpellizzeriFM, LeunigM. Which is the best activity rating scale for patients undergoing total joint arthroplasty?Clin Orthop Relat Res2009;467:958–965. Google Scholar
64 Aires N , SelmerR, ThelleD. The validity of self-reported leisure time physical activity, and its relationship to serum cholesterol, blood pressure and body mass index. A population based study of 332,182 men and women aged 40-42 years. Eur J Epidemiol2003;18:479–485. Google Scholar
65 Bellamy N , BuchananWW, GoldsmithCH, CampbellJ, StittLW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol1988;15:1833–1840. Google Scholar
66 Ware J Jr , KosinskiM, KellerSD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care1996;34:220–233. Google Scholar
67 Wylde V , LiveseyC, BlomAW. Restriction in participation in leisure activities after joint replacement: an exploratory study. Age Ageing2012;41:246–249. Google Scholar
68 Klein GR , LevineBR, HozackWJ, et al.Return to athletic activity after total hip arthroplasty. Consensus guidelines based on a survey of the Hip Society and American Association of Hip and Knee Surgeons. J Arthroplasty2007;22:171–175. Google Scholar
69 McGrory BJ , StuartMJ, SimFH. Participation in sports after hip and knee arthroplasty: review of literature and survey of surgeon preferences. Mayo Clin Proc1995;70:342–348. Google Scholar
70 Papalia R , Del BuonoA, ZampognaB, MaffulliN, DenaroV. Sport activity following joint arthroplasty: a systematic review. Br Med Bull2012;101:81–103. Google Scholar
71 Vogel LA , CarotenutoG, BastiJJ, LevineWN. Physical activity after total joint arthroplasty. Sports Health2011;3:441–450. Google Scholar
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
This article was primary edited by D. Rowley and first proof edited by G. Scott.
Supplementary material. A table giving full details of the studies analysed with demographics and results is available with the electronic version of this article at http://www.bjj.boneandjoint.org.uk.
