Author (year) | Arthroplasty | Study design | Sample size & characteristics | Data collection period (follow-up & time after surgery) | Type of (sports) activity | Measurement method | Outcome variables of interest | Recommendation |
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Amstutz and Le Duff [19] USA | THA | Survey | N = 661 Metal-on-metal hybrid HRA, female 30%, age 51.9 yrs. (14–78), BMI 26.5 (16.7–46.5) | Time after surgery: 10.1 [1–18] yrs | 17 general sports activities | Questionnaire | Type, frequency & duration of sporting activities, Survivorship (revision for aseptic failure or wear), Impact & hip cycle scores | Return to sports is safe if treated with well-designed and well-implanted HRA. |
Bradley, Moul [20] Great Britain | THA | Survey | N = 109 British Hip Society members | _ | 22 general sports activities | Web-based questionnaire | Level of impact (low, intermediate, high), Recommendation (allowed, allowed w experience, not allowed, undecided) | Low-impact sports allowed. Medium-impact sports, ± half of surgeons do not allow high-weight/low-repetition weight-lifting, ice-skating/roller blading. Rowing not allowed by minority of surgeons. High-impact and contact sports, road jogging, martial arts, high-impact aerobics not allowed. |
Clifford and Mallon [21] USA | THA & TKA | Expert opinion | N = 2 Orthopedic surgeons | _ | 36/37 general sports activities | Consensus | Perceived impact (low, potentially low, intermediate, high) | Low-impact activities allowed, allowed w experience, medium-impact allowed w experience, high-impact not allowed. |
Healy, Iorio [22] USA | THA & TKA | Literature review & survey | N = 54 Hip Society members, N = 58 Knee Society members | – | 42 general sports activities | Questionnaire | Recommended/allowed, allowed w experience, no opinion, not recommended | Low-contact/impact sports activity recommended. High-contact/impact activity discouraged |
Klein, Levine [23] USA | THA & TKA | Survey | N = 87 Hip Society members, N = 518 American Association of Hip & Knee Surgeons | _ | 37 general sports activities | Web-based questionnaire | Allowed, allowed w experience, not allowed, undecided | Low-impact activity allowed, medium-impact allowed or allowed w experience, high-impact not allowed |
Laursen, Andersen [24] Denmark | THA & TKA | Survey | N = 45 Heads of orthopedic departments (performing ≥100 THAs or TKAs per year) | _ | 31 general sports activities | Questionnaire | Participate regardless of previous experience w activity, participate if person had experience w activity before surgery, do not participate in activity. | 87% allow sports, 55% allow high-impact sports post-THA (35% if not experienced), 38% allow high-impact sports post-TKA (22% if not experienced) |
McGrory, Stuart [25] USA | THA & TKA | Review & survey | N = 28 Mayo Clinic orthopedic surgeons, N = 13 consultants, N = 15 fellows or residents | _ | 28 general sports activities | Computerized literature search to identify citations pertaining to sports and prosthetic hip/knee surgery published between 1966 and 1993. Questionnaire | Recommended, not recommended, depends | No-impact/low-impact sports encouraged, high-impact prohibited. Results of survey in line with outcome of literature review |
Meester, Wagenmakers [26] Nether-lands | THA & TKA | Survey | N = 117 Dutch Orthopaedic Association members (orthopedic surgeons) | – | 40 general sports activities | Web-based survey, distinction made between ages < 65/> 65 | Allowed, allowed w experience, discouraged, no advice. Knowledge about and application of international health-enhancing PA recommendations | Low-impact sports allowed. Most ball sports not recommended. Martial arts/contact/high-impact sports discouraged. Majority of surgeons discuss PA. Familiarity with PA recommendations is lacking. |
Ollivier, Frey [27] France | THA | Matched case control study | N = 70 persons doing high-impact sports compared to N = 140 persons doing lower-impact activities | 11 yrs. (10–15 yrs) | High-impact sports UCLA score 9–10 & low-impact sports UCLA score 1–4 | HHS, HOOS, radiographic analysis (wear rate) and aseptic loosening/need for revision. | Function; dislocation rate; linear wear; survivorship (revision for mechanical failure/radiographic signs of aseptic loosening). Independent risk factors for failure. | Persons doing high-impact sports have better function than persons doing low-impact sports. High-impact sports can lead to mechanical failures. |
Payo-Ollero, Alcalde [28] Spain | THA | Retrospective cohort study | N = 46, n = 13 female (58 hips) age 41 yrs. (37–48) | Average follow-up 7.5 years (1–11) | General sports activities | Telephone questionnaire | Sports recommended or advised against | Low-impact sports recommended (swimming, static biking, daily walking) Sports w high impact on hip not recommended. Contact sports allowed w previous experience. |
Swanson, Schmalzried [29] USA | THA & TKA | Survey | N = 139 American Association for Hip and Knee Surgeons members (orthopedic surgeons) | – | 15 general sports activities | Questionnaire | Unlimited, occasional [1–2 times/month], discouraged | Low-impact sports allowed. No consensus on medium-impact sports. High-impact sports discouraged. THA recommendations more liberal compared to TKA. |
Thaler, Khosravi [30] Europe | THA | Survey | N = 150 European Hip Society members | – | 47 general sports activities | Web-based questionnaire | Allowed, allowed if experienced, not allowed, no opinion. 4 time frames: within 6 weeks post-THA, 6–12 weeks post-THA, 3–6 months post-THA, more than 6 months post-THA. | Most physical activities were allowed 6 months post-THA. Experience in performing a distinct sport activity did not influence the recommendations to return to previous sports activities. Handball, soccer, football, basketball, full-contact sports, and martial arts not allowed. |
Thaler, Khosravi [31] Europe | TKA | Survey | N = 120 European Knee Associates members (surgeons) | – | 47 general sports activities | Web-based questionnaire | Allowed, allowed if experienced. Not allowed, no opinion. 4 time frames: within 6 weeks post-TKA, 6–12 weeks post-TKA, 3–6 months post-TKA. more than 6 months post-TKA. | Consensus for recommendation to allow 5 different sports in first 6 weeks, 7 sports at 6–12 weeks, 14 sports at 3–6 months, and 21 out of 47 activities 6 months postop. Number of sports recommended increases stepwise over postop time frames. |
Vu-Han, Gwinner [32] Germany | TKA | Survey | N-101 German Arthroplasty Society members (surgeons) |  | 30 general sports activities | Questionnaire | Recommendation: undecided, not recommended, w training, w.o. limitations | 53.5% of surgeons recommend high-impact sports with adequate training, 36.6% do not recommend it at all, 5.9% recommend high-impact sports w.o. limitations. Most low-impact sports recommended after 3 months, while high-impact sports require at least 6 months of rehabilitation or rather not recommended at all. |
Vu-Han, Hardt [33] Germany | THA | Survey | N = 99 German Arthroplasty Society members (surgeons) | – | 30 general sports activities | Questionnaire | Recommendation: undecided, not recommended, w training, w.o. limitations | Low-impact sports recommended w.o. limitations and within 3 months post-THA. Return to high-impact sports advised by 51.5% of surgeons if the person received adequate training, 8.1% w.o. limitations, 34.3% did not recommend high-impact sports at all (3% left it up to the person). For high-impact sports, most experts recommended at least 6 months before return to sports. Basketball, boxing, soccer, gymnastics, handball, hockey, squash, climbing, volleyball, tennis and slope-skiing mostly not recommended or only w adequate training. Walking, swimming, hiking and level biking were activities the vast majority of surgeons recommended w.o. limitations or training. Recommendations seemed to vary for ballroom dancing, cross-country biking, bowling, dancing, e-scooters, fitness/weights, golf, horseback riding, jogging. Pilates, cross-country skiing, table tennis and yoga recommended w.o. limitations or w adequate training. |
Witjes, Hoorntje [34] Nether lands | TKA & UKA | Survey | N = 82 Physiotherapists | – | 32 general sports activities | Web-based questionnaire | Recommended, recommended w experience, possible but not recommended, impossible | Low-impact sports recommended. Medium/high-impact sports not recommended/considered impossible. More liberal in return to sports post-UKA than post-TKA. |
Specific activities | ||||||||
 Gschwend, Frei [35] Switzerland | THA | Case control study | Group A: N = 50 regular alpine skiing and/or cross-country skiing, age 65 yrs. (47–84), weight 77 kg (44–100), height 1.73 m (148–193) Group B: N = 50, did no winter sports, age 65 yrs. (42–79), weight 78 kg (52–110), height 1.72 m (150–189) | 10 yrs., measurements at 5 and 10 yrs | Alpine skiing and/or cross-country skiing | 5-yr measurement: physical examination, questionnaire (hip, back, knee pain), radiographic examination (presence/location & extent of radiolucent lines, migration, tilting, subsidence). Rate of polyethylene wear (method Scheier et al. (1976)). 10-yr measurement: questionnaire/clinical/radiographic examination | Loosening & wear | Controlled alpine and/or cross-country skiing has no negative effect on acetabular or femoral component of hip replacements. Short-radius turns on steep slopes or moguls must be avoided. |
 Hara, Nakashima [36] Japan | THA | Laboratory study | N = 9 33% female, age 66 yrs. (55–84), BMI 25.0 kg/m2 (17.5–30.2) | Time after surgery: 4.8 [0.5–13.7] yrs | Golf | Kinematics | Hip kinematics during golf swing (hip movements, liner-to-neck contact & cup-head translation) | Golf is admissible due to dynamic hip stability. |
 Kloen, De Man [37] Netherlands | THA | Cohort study & literature review | N = 9 alpine skiers, 34% female, age 59.4 yrs. (47–70), weight 73 kg (52–95) | 5.9 (1–13 yrs) | Alpine skiing | HHS, self-constructed questionnaire (downhill skiing-specific issues), radiographic analysis (weight-bearing AP/pelvic view, AP/lateral hip view) | Loosening, migration & wear | Downhill skiing is feasible, but ski with long turns on groomed slopes. |
 Mont, Rajadhaksha [38] USA | TKA | Survey | N = 33 (46 TKAs), United States Tennis Association high-level tennis players, 15% female, age 64 yrs. (30–79) | Time after surgery 7 yrs. (2–18) | High-level tennis | Questionnaire on clinical data of the TKA, general & sport-specific questions on tennis. | Surgeon’s advice on playing tennis. Years playing tennis, level, frequency, single/double. Stiffness and pain in mobility parameters (e.g. hitting, running, ground strokes, moving forward after serves to volley). | 21% of surgeons approve playing tennis, 45% recommend only doubles, 55% oppose playing any tennis. High-level players were able to perform at preop level post-TKA. Players were satisfied with the TKA and ability to resume playing tennis. |
 Mont, LaPorte [39] USA | THA | Survey | N = 58 (65 THAs), United States Tennis Association players, 14% female, age 70 yrs. (47–89) | Time after surgery 8 yrs. (2–22) | Competitive tennis | Questionnaire on clinical data of the THA, general & sport-specific questions on tennis. | Surgeon’s advice on playing tennis. Years playing tennis, level, frequency, single/double. Stiffness and pain in mobility parameters (e.g. stroke by stroke, from follow-through to shifting weight into their stroke, mobility around the court). | 14% of surgeons approve playing tennis, 34% recommend only doubles, 52% oppose playing any tennis. Players were extremely satisfied with their THA and their increased ability to participate in tennis. This select group of competitive players were able to perform at a better level post-THA than preoperatively. |