Abstract
Background
No reports have been published about participation in sports activity and subjective health status after total hip arthroplasty via the anterolateral approach in the supine position (ALS-THA) in Japanese patients. This study assessed sports activity participation and subjective health status, as well as factors potential associated with these variables, in patients who underwent ALS-THA.
Methods
Of 698 patients who underwent total hip arthroplasty at our institution between 2013 and 2018, questionnaires were sent to 355 patients under 80 years old who had undergone ALS-THA and 242 responded. Patients were asked about their subjective health status, participation in sports activity, the EuroQol 5-dimensions 5-level (EQ-5D-5L), the University of California Los Angeles (UCLA) activity scale score and the Forgotten Joint Score (FJS). Patient characteristics and hospitalization information were also collected. Patients’ subjective health status was categorized as “healthy” or “unhealthy”. Univariate and multivariate logistic regression analyses were performed to determine factors associated with participation in sports activity after ALS-THA and a “healthy” status.
Results
The pre- and postoperative sports activity participation rates were 54.0% and 57.8%, respectively. Most patients (76.8%, n = 182) were considered “healthy”. Age (P = .019) and UCLA activity score (P < .001) were significantly associated with sports activity after ALS-THA. FJS (P = .002) and EQ-5D-5L (P = .004) were significantly associated with a “healthy” status.
Conclusion
Patients participating in sports activity after ALS-THA are older and have higher UCLA activity scores and patients considered “healthy” have higher FJS and EQ-5D-5L scores.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12891-022-05886-6.
Keywords: Total hip arthroplasty, Anterolateral-supine approach, Sports activity, Subjective health status
Background
The “red zone” is the difference between life expectancy and healthy life expectancy (HLE) [1]. Reducing this period—that is, extending HLE—is important worldwide. Limiting sports activity reduces not only physical activity, but also quality of life and HLE [2]. Meanwhile, participation in sports activity is associated with lower mortality rates in middle and old age [3]. Furthermore, mortality related to lack of exercise is more severe than that related to obesity [4]. Accordingly, orthopaedic diseases are reported to limit physical activity [5] and hence impair HLE.
Total hip arthroplasty (THA) is a well-accepted treatment for hip osteoarthritis (OA) that can improve physical function and quality of life [6]. Bayliss et al. reported that the 20-year survival rate after THA for patients over 60 years old is 89.7% [7]. In addition, the long-term mortality rate of elderly patients who have undergone THA appears to be lower than that of elderly people from the general population [8]. Patients expect to participate in sports activity postoperatively [9]. A previous study investigated sports activity before and after THA via the posterior and lateral approach [10]. THA via the anterolateral approach in the supine position (ALS-THA) is performed using a minimally invasive approach based on the anterior Watson-Jones approach and, when compared to THA via the conventional posterior or lateral approach, ALS-THA yields better outcomes in terms of physical function and earlier discharge from hospital [11].
Despite the reported benefits of ALS-THA, no reports have been published about sports activity participation and subjective health status in Japanese patients who have undergone ALS-THA. Scott et al. investigated health status during the waiting period before surgery using the EuroQol 5-dimensions 5-level (EQ-5D-5L) score, and reported that a health status “worse than death” was associated with worse outcomes after surgery [12]. In our previous study on patients who underwent curved periacetabular osteotomy, we reported that 72.1% participated in sports activity postoperatively, and 74.1% and 38.8% of patients were “very satisfied” or “somewhat satisfied” with their current life and sports activity, respectively [13]. Therefore, this study examined sports activity participation, satisfaction with daily life and sports activity, factors potentially associated with postoperative participation in sports activity and subjective health status in patients who underwent ALS-THA, as well as factors potentially associated with subjective health status.
Methods
Study design and patients
This retrospective case series study was performed with approval from our institutional ethics committee. Among 698 patients who underwent primary THA at our institution between January 1, 2013, and January 31, 2018, 355 with OA (297 patients) or idiopathic femoral head necrosis (58 patients) who were younger than 80 years and underwent ALS-THA were recruited. Four surgeons made the diagnosis using radiographs and performed operations for the 355 patients. Patients who died or had mobility-limiting conditions, including severe cerebrovascular disease, cardiovascular disease, mental health disorders and dementia, were excluded. The remaining 335 patients were sent a questionnaire on their sports activity, to which 242 (72.9%) responded. However, 5 patients provided incomplete responses to the questionnaire, so 237 patients were finally included in this study (Fig. 1). All patients provided informed consent to participate in this study as per the instructions enclosed with the questionnaire.
Fig. 1.
Patient enrollment flowchart. ALS-THA, total hip arthroplasty via the anterolateral-supine approach in the supine position; THA, total hip arthroplasty
Questionnaire (Additional file 1)
In this study, participation in sports activity was defined as voluntary exercise. Sports activity was categorized as low, intermediate or high impact, as previously described [14]. The questionnaire comprised four sections. In the first section, patients were asked about their subjective health status [15]. The second section surveyed participation in sports activity and satisfaction with daily activities and sports activity before ALS-THA. Patients were specifically asked about whether they participated in sports activity during the 3 years before ALS-THA, the types and frequencies thereof, and their satisfaction with daily life and sports activity. The third section surveyed participation in sports activity after ALS-THA. Patients were also asked about whether they participated in sports activity as well as the types and frequencies thereof. If a patient did not participate in sports activity, they were asked why and whether they hoped to do so. The fourth section surveyed current satisfaction with daily life and sports activity, the University of California Los Angeles (UCLA) activity score [16, 17], the Forgotten Joint Score (FJS) [18], the Japanese version of the EQ-5D-5L [19, 20] and the EQ Visual Analogue Scale (EQ-VAS) [19, 20]. The EQ-VAS ranges from 0 to 100, corresponding to “worst imaginable health state” and “best imaginable health state”, respectively.
Patient information
The following demographic and clinical characteristics were collected from medical records: age at surgery, sex, body mass index, hospitalization duration, range of motion, lower-leg muscle strength, 10-m gait speed and Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ) [21]. Range of motion, lower-leg muscle strength and 10-m gait speed (comfortable and maximum) were assessed by physical therapists 1-2 days before surgery and before discharge. The JHEQ consists of three subscales: pain, movement and mental; higher scores indicate higher quality of life.
Operative technique and postoperative rehabilitation protocol
The surgical technique was a version of the ALS-THA technique reported by Pfluger et al. modified by an orthopedic surgeon (one of the co-authors: NT). Specifically, the modification was to make oblique skin incisions in both skin and fascia to create a figure-4 shape on both lower limbs. Therefore, even if the lower limb is extended after the implant is installed, no extra incision is needed. The retractor to the wound is a special retractor holder that includes weights that maintain muscle elasticity. As a Y-zone process, the distal fascia is clearly divided between the vastus lateralis and gluteus medius. Then, after the THA is placed, because the bilateral lower limbs have already been disinfected and protected with elastic bandages, it is easy to confirm the accurate correction of the leg length discrepancy of the bilateral lower limbs, which is more clinically appropriate. In addition, all patients had a drain placed in the affected THA area. Postoperative rehabilitation was performed in a wheelchair on the first postoperative day, while gait training started the day after. Most patients were discharged home 10 to 14 days postoperatively. However, 38 patients who wanted to continue rehabilitation or had difficulties that prevented discharge home were transferred to a rehabilitation hospital.
Statistical analysis
The analysis in this study was based on 237 patients who completed the questionnaire (Fig. 1). Continuous variables are presented as mean ± standard deviation (SD). McNemar’s test was performed to compare pre- and postoperative sports activity participation rates as well as satisfaction with daily life and sports activity. Patients who participated in sports activity postoperatively and who did not were categorized into the participation and nonparticipation groups, respectively. In addition, patients were categorized into the “healthy” and “unhealthy” groups according to the questionnaire results [15]. Specifically, patients who indicated that their subjective health was affecting their daily life or that they were not “healthy” were classified as “unhealthy”, whereas the others were classified as “healthy”. To determine the factors associated with postoperative participation in sports activity and a “healthy” status, univariate and multiple logistic regression analyses were performed. The following variables were included in the multiple logistic regression analysis to determine the factors associated with postoperative participation in sports activity: age, sex, body mass index, comfortable 10-m gait speed at discharge, FJS, EQ-5D-5L, EQ-VAS and UCLA activity score. Meanwhile, the following variables were included in the multiple logistic regression analysis to determine the factors associated with a postoperative “healthy” status: preoperative hip abductor muscle strength, preoperative comfortable 10-m gait speed, FJS, EQ-5D-5L and UCLA activity score. All statistical analyses were performed using IBM SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA). P-values less than 0.05 were considered statistically significant.
Results
The questionnaire was filled out 34.3 ± 11.8 months from the date of surgery. The mean age of patients who responded to the questionnaire was 64.0 ± 9.7 years (range 23–79). The pre- and postoperative sports activity participation rates were 54.0% and 57.8%, respectively. Among the patients who participated in sports activity preoperatively, 82.8% of them returned to sports activity postoperatively.
The types of pre- and postoperative sports activity performed are shown in Fig. 2. Regarding the impacts of the sports activity in which patients participated preoperatively, they were predominantly low-impact sports (n = 83, 64.9%), whereas 25 (19.5%) and 20 (15.6%) performed medium- and high-impact ones, respectively. A similar pattern was observed regarding postoperative sports activity: 110 (79.7%), 17 (12.3%) and 11 (8.0%) patients performed low-, medium- and high-impact sports activity, respectively. Patients participated in 2.7 ± 1.2 and 2.2 ± 1.2 types of sports activity pre- and postoperatively, respectively.
Fig. 2.
Types of sports activities participated in before and after ALS-THA (multiple answers allowed)
Patients started sports activity 7.8 ± 8.1 months from the day of surgery. Moreover, patients participated in sports activities 2.5 ± 1.9 and 2.7 ± 2.0 times per week pre- and postoperatively, respectively. The reasons for participating and not participating in sports activity are presented in Tables 1 and 2, respectively. In addition, among the 94 patients who did not participate in sports activity postoperatively, 56 (59.6%) wanted to do so, but 34 (60.7%) of them did not because of a “fear of damaging the hip joint” or “lack of confidence”.
Table 1.
Reasons for participating in sports activity
| Reasons | Patients’ ratio (%) |
|---|---|
| For health | 56.9 |
| To improve or maintain physical strength | 46.0 |
| For enjoyment or distraction | 41.6 |
| To be free of pain | 38.7 |
| Because of a lack of exercise | 35.8 |
| To move as desired | 33.6 |
| To enjoy exercise | 18.2 |
Table 2.
Reasons for not participating in sports activity
| Reasons | Patients’ ratio (%) |
|---|---|
| Fear of damaging hip joint | 42.0 |
| Lack of confidence | 35.0 |
| Unable to move as desired | 23.0 |
| No time for sports activity | 22.0 |
| Pain | 13.0 |
| Do not enjoy sports activity | 5.0 |
Compared with the nonparticipation group, the participation group had significantly older age, better subjective health, higher FJS and higher UCLA activity score (Table 3). Multivariate logistic regression analysis showed that age (P = 0.019) and UCLA activity score (P < 0.001) were factors significantly associated with postoperative participation in sports activity (Table 4).
Table 3.
Univariate logistic regression analysis of factors potentially associated with postoperative participation in sports activity
| Parameters | Participation group (n = 137) | Nonparticipation group (n = 100) | Odds ratio (95%CI) | P-values |
|---|---|---|---|---|
| Age (years) | 65.3 ± 8.8 | 62.4 ± 10.5 |
1.032 (1.004–1.060) |
0.025 |
| Sex (male/female) | 21/116 | 22/78 |
0.642 (0.331–1.246) |
0.190 |
| Body mass index (kg/m2) | 23.6 ± 3.8 | 24.2 ± 3.4 |
0.957 (0.892–1.027) |
0.222 |
| Hospitalization days (day) | 14.7 ± 4.7 | 15.7 ± 6.1 |
0.964 (0.919–1.012) |
0.144 |
| Preoperative range of motion (°) | ||||
| Flexion | 91.0 ± 17.4 | 92.9 ± 18.5 |
0.994 (0.980–1.009) |
0.423 |
| Abduction | 18.8 ± 8.6 | 18.5 ± 8.9 |
1.005 (0.976–1.035) |
0.742 |
| Adduction | 10.9 ± 9.0 | 9.8 ± 4.9 |
1.025 (0.979–1.072) |
0.294 |
| External rotation | 28.1 ± 12.2 | 29.8 ± 12.1 |
0.989 (0.968–1.010) |
0.292 |
| Internal rotation | 15.7 ± 11.9 | 14.7 ± 12.7 |
1.007 (0.986–1.028) |
0.535 |
| Hip abductor muscle strength (%BW) | ||||
| Preoperative | 20.1 ± 8.1 | 19.1 ± 9.7 |
1.014 (0.984–1.044) |
0.379 |
| Discharge | 18.2 ± 6.9 | 17.1 ± 7.7 |
1.018 (0.977–1.061) |
0.402 |
| Comfortable 10-m gait speed (m/s) | ||||
| Preoperative | 1.0 ± 0.3 | 1.0 ± 0.2 |
1.279 (0.460–3.561) |
0.637 |
| Discharge | 0.9 ± 0.5 | 0.8 ± 0.2 |
2.585 (0.824–8.108) |
0.103 |
| Maximum 10-m gait speed (m/s) | ||||
| Preoperative | 1.4 ± 0.4 | 1.3 ± 0.4 |
1.323 (0.654–2.675) |
0.437 |
| Discharge | 1.2 ± 0.3 | 1.1 ± 0.3 |
2.329 (0.933–5.814) |
0.070 |
| JHEQ | 60.6 ± 14.0 | 59.0 ± 15.3 |
1.008 (0.989–1.026) |
0.416 |
| Forgotten joint score (points) | 71.5 ± 22.0 | 62.0 ± 24.9 |
1.017 (1.005–1.030) |
0.008 |
| EQ-5D-5L (0.01 point per increase) | 0.9 ± 0.1 | 0.8 ± 0.2 |
1.024 (1.002–1.046) |
0.033 |
| EQ VAS (mm) | 85.7 ± 12.1 | 80.1 ± 16.7 |
1.027 (1.006–1.049) |
0.011 |
| UCLA activity score | 5.8 ± 1.8 | 4.1 ± 1.3 |
2.166 (1.627–2.883) |
< 0.001 |
Continuous values are expressed as mean ± SD. CI, confidence interval; SD, standard deviation; JHEQ, Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire; EQ-5D-5L, EuroQol 5-dimensions 5-level; EQ VAS, EuroQol visual analogue scale; UCLA, University of California, Los Angeles
Table 4.
Multivariate logistic regression analysis of factors potentially associated with postoperative participation in sports activity
| Parameters | Odds ratio | 95% confidence interval | P-value | |
|---|---|---|---|---|
| Age | 1.060 | 1.010–1.110 | 0.019 | |
| Sex | 0.763 | 0.246–2.360 | 0.638 | |
| Body mass index | 1.010 | 0.907–1.130 | 0.843 | |
| Comfortable 10-m gait speed at discharge | 2.020 | 0.366–11.100 | 0.421 | |
| Forgotten joint score | 0.997 | 0.978–1.020 | 0.762 | |
| EQ-5D-5L (0.01 point per increase) | 1.000 | 0.970–1.030 | 0.925 | |
| EQ-VAS | 1.020 | 0.982–1.050 | 0.354 | |
| UCLA activity score | 1.960 | 1.440–2.670 | < 0.001 | |
EQ-5D-5L, EuroQol 5-dimensions 5-level; EQ-VAS, EuroQol visual analogue scale; UCLA, University of California, Los Angeles
Regarding satisfaction with daily life and sports activity, the numbers of patients who reported being “very satisfied” or “somewhat satisfied” increased significantly after surgery (both P < 0.001; Table 5).
Table 5.
Patient satisfaction with daily life and sports activity
| Daily life (%) | Sports activity (%) | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Preoperative | Postoperative | Preoperative | Postoperative | |||||||
| Very satisfied | 34.4 | 50.0 | 9.0 | 19.8 | ||||||
| Somewhat satisfied | 32.8 | 34.0 | 28.1 | 32.8 | ||||||
| Neither | 9.8 | 9.8 | 31.1 | 30.5 | ||||||
| Somewhat dissatisfied | 15.3 | 5.7 | 19.8 | 10.7 | ||||||
| Very dissatisfied | 7.7 | 0.5 | 12.0 | 6.2 | ||||||
Regarding subjective health status, there were 182 “healthy” patients (76.8%) and 55 “unhealthy” ones (23.2%). The postoperative sports activity participation rates of these two groups were 61.0% and 47.3%, respectively (P = 0.073). Furthermore, compared with the “unhealthy” patients, the “healthy” ones had a significantly wider preoperative hip abductor range of motion; greater pre- and postoperative hip abductor muscle strength; faster preoperative gait speed; and higher FJS, EQ-5D-5L, EQ-VAS, and UCLA activity scores upon completing the questionnaire (Table 6). In addition, logistic regression analysis showed that FJS (P = 0.002) and EQ-5D-5L (P = 0.004) were factors significantly associated with a “healthy” status (Table 7).
Table 6.
Univariate logistic regression analysis of factors potentially associated with subjective health status
| Parameters | “Healthy” (n = 182) |
“Unhealthy” (n = 55) |
Odds ratio (95%CI) | P-values |
|---|---|---|---|---|
| Age (years) | 63.9 ± 9.8 | 64.6 ± 9.3 |
0.992 (0.961–1.024) |
0.623 |
| Sex (male/female) | 35/147 | 8/47 |
1.399 (0.607–3.225) |
0.431 |
| Body mass index (kg/m2) | 23.8 ± 3.6 | 23.9 ± 3.9 |
0.998 (0.991–1.083) |
0.956 |
| Hospitalization days (day) | 14.9 ± 5.2 | 15.9 ± 5.6 |
0.966 (0.916–1.019) |
0.200 |
| Preoperative range of motion (°) | ||||
| Flexion | 92.3 ± 17.5 | 90.2 ± 19.1 |
1.007 (0.990–1.023) |
0.441 |
| Abduction | 19.3 ± 8.5 | 16.6 ± 9.0 |
1.037 (1.000–1.076) |
0.048 |
| Adduction | 10.7 ± 8.2 | 9.5 ± 4.9 |
1.032 (0.972–1.096) |
0.301 |
| External rotation | 29.0 ± 11.8 | 28.2 ± 13.4 |
1.006 (0.981–1.031) |
0.657 |
| Internal rotation | 15.7 ± 12.0 | 15.9 ± 13.1 |
0.994 (0.970–1.019) |
0.644 |
| Hip abductor muscle strength (%BW) | ||||
| Preoperative | 20.3 ± 8.6 | 17.6 ± 9.3 |
1.039 (1.000–1.079) |
0.049 |
| Discharge | 17.7 ± 8.0 | 14.2 ± 7.5 |
1.069 (1.012–1.129) |
0.018 |
| Knee extension muscle strength (%BW) | ||||
| Preoperative | 35.9 ± 14.2 | 32.9 ± 14.3 |
1.017 (0.994–1.040) |
0.162 |
| Discharge | 29.6 ± 13.5 | 26.5 ± 13.0 |
1.014 (0.985–1.044) |
0.343 |
| Comfortable 10-m gait speed (m/s) | ||||
| Preoperative | 1.0 ± 0.3 | 0.9 ± 0.2 |
4.345 (1.286–14.678) |
0.018 |
| Discharge | 0.9 ± 0.5 | 0.8 ± 0.3 |
1.986 (0.538–7.333) |
0.304 |
| Maximum 10-m gait speed (m/s) | ||||
| Preoperative | 1.4 ± 0.4 | 1.2 ± 0.4 |
3.441 (1.469–8.063) |
0.004 |
| Discharge | 1.1 ± 0.3 | 1.1 ± 0.4 |
1.937 (0.661–5.681) |
0.228 |
| Participation rate of sports activity (%) | ||||
| Preoperative | 52.7 | 58.2 |
0.802 (0.436–1.476) |
0.479 |
| Postoperative | 61 | 47.3 |
1.744 (0.950–3.201) |
0.073 |
| JHEQ (points) | 62.6 ± 13.6 | 51.2 ± 14.4 |
1.056 (1.032–1.081) |
< 0.001 |
| Forgotten joint score (points) | 75.0 ± 18.8 | 47.8 ± 24.3 |
1.058 (1.039–1.078) |
< 0.001 |
| EQ-5D-5L(0.01 point per increase) | 0.9 ± 0.1 | 0.7 ± 0.2 |
1.100 (1.065–1.137) |
< 0.001 |
| EQ VAS (mm) | 87.0 ± 11.4 | 73.6 ± 17.4 |
1.067 (1.040–1.095) |
< 0.001 |
| UCLA activity score | 5.4 ± 1.9 | 4.3 ± 1.5 |
1.514 (1.191–1.924) |
0.001 |
Continuous values are expressed as mean ± SD. CI, confidence interval; SD, standard deviation; JHEQ, Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire; EQ-5D-5L, EuroQol 5-dimensions 5-level; EQ VAS, EuroQol visual analogue scale; UCLA, University of California, Los Angeles
Table 7.
Multivariate logistic regression analysis of factors potentially associated with a “healthy” status
| Parameters | Odds ratio | 95% confidence interval | P-value |
|---|---|---|---|
| Preoperative hip abductor muscle strength | 1.007 | 0.955–1.062 | 0.801 |
| Preoperative comfortable 10-m gait speed | 1.321 | 0.221–7.884 | 0.760 |
| Forgotten joint score | 1.036 | 1.013–1.060 | 0.002 |
| EQ-5D-5L (0.01 point per increase) | 1.055 | 1.017–1.094 | 0.004 |
| UCLA activity score | 1.065 | 0.817–1.388 | 0.640 |
EQ-5D-5L, EuroQol 5-dimensions 5-level; UCLA; University of California, Los Angeles
Discussion
In this study, we investigated participation in sports activities and subjective health status of patients who underwent ALS-THA, and examined the factors involved with them. Overall, 54% and 57.8% of the 237 patients who underwent ALS-THA participated in sports activity pre- and postoperatively, respectively. In comparison, previous studies on THA approaches besides the ALS approach reported that 15.5–92.0% and 30.5–83.0% of patients participated in sports activity pre- and postoperatively, respectively [22–26]. Postoperative participation in sports activity is associated with characteristics such as age, the level of impact of sports activity, recommendations from physicians to participate in sports activity [14], fear of wear or dislocation of an artificial joint [27], and the physical therapy program after discharge [22, 26]. Hara et al. reported that 30.5% of Japanese patients participated in sports activity after THA via the posterior approach [23], which is lower than the rate of 57.8% after ALS-THA as reported here. In this regard, the ALS approach is reported to result in better improvement in physical function [28] and incur a lower risk of dislocation [29] than the conventional posterior approach. Therefore, the discrepancy in the rates of sport activities postoperatively may be due to the difference in the risk of early complications.
In this study, participation in low-impact sports activity, such as walking, increased postoperatively. In contrast, participation in high-impact sports activity decreased from 21 patients preoperatively to 12 postoperatively. Although there are becoming less restrictions on participation in high-impact sports activities [30], such a shift to low-impact sports activity postoperatively has been reported in several studies [22, 31]. High-impact sports activity are also reported to increase the risk of adverse events such as early loosening and excessive wear of artificial joint, although patients who participated in such activities in that study had higher physical function than those who did not [32]. Thus, the reduced postoperative participation in high-impact sports activity in the present study might reflect patients’ fears of adverse events. Further study is required to clarify the factors influencing participation in high-impact sports activity after ALS-THA.
Among patients who did not participate in sports activity postoperatively, psychological factors were more common explanations for this (60.7%) than pain or other physical factors. This is corroborated by a previous study reporting that many patients did not participate in sports activity postoperatively for psychological reasons rather than pain in the operated hip [27]. Although some patients participated in various kinds of exercise or sports activity to maintain their physical function postoperatively, psychological factors indeed hindered participation. Therefore, to increase participation in sports activity after ALS-THA, clinical staff must understand patients’ anxiety or reluctance to do so and provide evidence-based information to support them.
In this study, older age at the time of surgery and higher UCLA activity score were factors significantly associated with postoperative participation in sports activity. In contrast, several studies have reported younger age at the time of surgery as a factor linked to postoperative participation in sports activity [23, 27, 33–35]. One possible explanation for this discrepancy is that, compared with younger patients, older retired patients have more opportunities and time to participate in sports activity [36]. In our study, 22.0% of the patients who did not participate in sports activity also reported that they did not have time to do so. In some cases, older patients are more likely to participate in low-impact sports activity because there are low barriers to entry for such activities. In the current study, 85.5% of patients who participated in sports activity after surgery did so only for low-impact activities. Furthermore, a high postoperative UCLA activity score is reported to be associated with postoperative participation in sports activity [23, 27, 33–35]. Similar results were shown in Japanese patients with ALS-THA. Therefore, our results indicate that elderly Japanese patients who underwent ALS-THA with high activity levels can easily participate in sports activity postoperatively, especially low-impact ones. This finding might be useful for clinicians advising elderly patients who are concerned about participating in sports activity after ALS-THA.
Compared with patients considered “unhealthy”, FJS and EQ-5D-5L were factors significantly associated with a “healthy” status. Recently, an increasing number of studies using patient-reported outcome measures among those who have undergone THA have been reported [37, 38]. HLE increases with exercise, sports participation, maintenance of activities of daily living and high activity levels [39, 40]. Likewise, higher FJS is associated with better overall health and maintenance of activities of daily living [18, 41]. In addition, patients with higher physical function before THA are reported to have better physical function and higher activity levels after THA [24]. Thus, increasing preoperative physical function might increase the likelihood of a patient feeling “healthy” postoperatively. Specifically, as preoperative physical therapy administered by a physical therapist is effective for improving physical function [42], preoperative physical therapy is necessary to extend HLE postoperatively. In Japan, secondary OA from dysplastic hips accounts for more than 80% of cases [43], and secondary OA from hip dysplasia requires caution because the symptoms gradually worsen. Therefore, based on the results of this study, which to the best of our knowledge is the first to examine subjective health status after ALS-THA, it is possible that higher preoperative physical function is better for extended HLE after ALS-THA. As such, we suggest exercise therapy and patient education by a physical therapist before activities of daily living are restricted because of pain or deteriorated physical function due to hip OA.
The present study has some limitations. First, this study involved a self-administered questionnaire that included questions about medical history. Notably, 27.1% of patients did not reply to the questionnaire. Thus, the results might have been affected by recall and selection biases, necessitating further prospective studies to confirm the results. Second, 81.9% of the study subjects were women. Few Japanese patients are obese, and BMI values are often close to ideal values. In addition, Japanese patients undergoing THA are often due to secondary hip osteoarthritis. Although this sex ratio reflects the higher incidence and progression of OA in Japanese women than in men [44], the results might not be generalizable to other populations. Third, we did not survey some socio-economic factors including working status, educational history and income circumstances etc. Our results suggest that older retired patients may have relatively more opportunities and free time to participate in sports activities, and their impact on participation in sports activities should be further investigated. Finally, this study was conducted prior to the COVID-19 pandemic; Clement et al. reported that the pandemic increased the waiting period for surgery, increased the preoperative “worse than death” status and decreased the quality of life [45]. Therefore, further research on sports activity and health status, including quality of life, during the pandemic is warranted.
Conclusion
Among Japanese patients who underwent ALS-THA, 54.0% and 57.8% participated in sports activity pre- and postoperatively, respectively. Older age and UCLA activity score were factors significantly associated with postoperative participation in sports activity. Furthermore, 76.8% of patients considered “healthy”, and FJS and EQ-5D-5L were factors significantly associated with a “healthy” status. These findings could be useful for advising elderly patients concerned about participating in sports activity and their health after ALS-THA.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
The authors would like to greatly thank Kouji Tsuda, Kiyoshi Tozaki, Sho Kudo, and Hiroaki Kaneda for contributing to the interpretation of data and consideration of adequacy for data. We greatly appreciate the members of the Kitasato University Hospital Department of Rehabilitation for their advice on experimental design and help collecting the data and interpreting the results. We also greatly appreciate the contributions of our patients.
List of abbreviations
- ALS-THA
Total hip arthroplasty via the anterolateral approach in the supine position
- EQ-5D-5L
EuroQol 5-dimensions 5-level
- EQ-VAS
EuroQol Visual Analogue Scale
- FJS
Forgotten Joint Score
- HLE
Healthy life expectancy
- JHEQ
Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire
- OA
Hip osteoarthritis
- SD
Standard deviation
- THA
Total hip arthroplasty
- UCLA
University of California Los Angeles
Authors’ contributions
NT contributed to the study conception. YT and NT contributed to the study design. NT, KU, KF and MM performed the total hip arthroplasty via the anterolateral approach in the supine position. YT, NT, KU, KF, MM and MS contributed to the acquisition of data. Data analysis was mainly performed by YT and NT. YT and NT were major contributors in writing the manuscript and all authors contributed to drafting of the manuscript for important intellectual content. All authors read and approved the final version of the manuscript and have agreed to be personally accountable for their own contributions.
Funding
No external funding was received for this study.
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The retrospective study was approved by Ethics Committee of Kitasato University Hospital (permit number: B18–064) and was performed in accordance with the Declaration of Helsinki. All patients provided informed consent to participate in this study as per the instructions enclosed with the questionnaire.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Olshansky SJ. From lifespan to healthspan. JAMA. 2018;320(13):1323–4. doi: 10.1001/jama.2018.12621. [DOI] [PubMed] [Google Scholar]
- 2.Leskinen T, Stenholm S, Aalto V, et al. Physical activity level as a predictor of healthy and chronic disease-free life expectancy between ages 50 and 75. Age Ageing. 2018;47(3):423–9. doi: 10.1093/ageing/afy016. [DOI] [PubMed] [Google Scholar]
- 3.Samitz G, Egger M, Zwahlen M. Domains of physical activity and all-cause mortality: systematic review and dose-response meta-analysis of cohort studies. Int J Epidemiol. 2011;40(5):1382–400. doi: 10.1093/ije/dyr112. [DOI] [PubMed] [Google Scholar]
- 4.Ekelund U, Ward HA, Norat T, et al. Physical activity and all-cause mortality across levels of overall and abdominal adiposity in European men and women: the European Prospective Investigation into Cancer and Nutrition Study (EPIC) Am J Clin Nutr. 2015;101(3):613–21. doi: 10.3945/ajcn.114.100065. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Myojin T, Ojima T, Kikuchi K, et al. Orthopedic, ophthalmic, and psychiatric diseases primarily affect activity limitation for Japanese males and females: based on the Comprehensive Survey of Living Conditions. J Epidemiol. 2017;27(2):75–9. doi: 10.1016/j.je.2016.09.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ethgen O, Bruyère O, Richy F, et al. 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(5):963–74. doi: 10.2106/00004623-200405000-00012. [DOI] [PubMed] [Google Scholar]
- 7.Bayliss LE, Culliford D, Monk AP, et al. The effect of patient age at intervention on risk of implant revision after total replacement of the hip or knee: a population-based cohort study. Lancet. 2017;389(10077):1424–30. doi: 10.1016/S0140-6736(17)30059-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Pedersen AB, Baron JA, Overgaard S, et al. Short- and long-term mortality following primary total hip replacement for osteoarthritis: a Danish nationwide epidemiological study. J Bone Joint Surg Br. 2011;93(2):172–7. doi: 10.1302/0301-620X.93B2.25629. [DOI] [PubMed] [Google Scholar]
- 9.Healy WL, Sharma S, Schwartz B, et al. Athletic activity after total joint arthroplasty. J Bone Joint Surg Am. 2008;90(10):2245–52. doi: 10.2106/JBJS.H.00274. [DOI] [PubMed] [Google Scholar]
- 10.Hoorntje A, Janssen KY, Bolder SBT, et al. The effect of total hip arthroplasty on sports and work participation: a systematic review and meta-analysis. Sports Med. 2018;48(7):1695–726. doi: 10.1007/s40279-018-0924-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Pflüger G, Junk-Jantsch S, Schöll V. Minimally invasive total hip replacement via the anterolateral approach in the supine position. Int Orthop 2007; Suppl 1: S7-11. 10.1007/s00264-007-0434-6. [DOI] [PMC free article] [PubMed]
- 12.Scott CEH, MacDonald DJ, Howie CR. ’Worse than death’ and waiting for a joint arthroplasty. Bone Joint J. 2019;101-B(8):941–50. doi: 10.1302/0301-620X.101B8.BJJ-2019-0116.R1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Takahashi Y, Takahira N, Uchiyama K, et al. Sports activity participation after curved periacetabular osteotomy for acetabular dysplasia. BMC Musculoskelet Disord. 2020;21(1):637. doi: 10.1186/s12891-020-03625-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Klein GR, Levine BR, Hozack WJ, 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 Arthroplasty. 2007;22(2):171–5. doi: 10.1016/j.arth.2006.09.001. [DOI] [PubMed] [Google Scholar]
- 15.Sullivan DF. A single index of mortality and morbidity. HSMHA Health Rep. 1971;86(4):347–54. doi: 10.2307/4594169. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Amstutz HC, Thomas BJ, Jinnah R, et al. Treatment of primary osteoarthritis of the hip. A comparison of total joint and surface replacement arthroplasty. J Bone Joint Surg Am. 1984;66(2):228–41. doi: 10.2106/00004623-198466020-00010. [DOI] [PubMed] [Google Scholar]
- 17.Naal FD, Impellizzeri FM, Leunig M. Which is the best activity rating scale for patients undergoing total joint arthroplasty? Clin Orthop Relat Res. 2009;467(4):958–65. doi: 10.1007/s11999-008-0358-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Behrend H, Giesinger K, Giesinger JM, et al. The “forgotten joint” as the ultimate goal in joint arthroplasty: validation of a new patient-reported outcome measure. J Arthroplasty. 2012;27(3):430–6. doi: 10.1016/j.arth.2011.06.035. [DOI] [PubMed] [Google Scholar]
- 19.Herdman M, Gudex C, Lloyd A, et al. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L) Qual Life Res. 2011;20(10):1727–36. doi: 10.1007/s11136-011-9903-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Shiroiwa T, Ikeda S, Noto S, et al. Comparison of value set based on DCE and/or TTO data: scoring for EQ-5D-5L health states in Japan. Value Health. 2016;19(5):648–54. doi: 10.1016/j.jval.2016.03.1834. [DOI] [PubMed] [Google Scholar]
- 21.Matsumoto T, Kaneuji A, Hiejima Y, et al. Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ): a patient-based evaluation tool for hip-joint disease. The Subcommittee on Hip Disease Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association. J Orthop Sci. 2012;17(1):25–38. doi: 10.1007/s00776-011-0166-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Chatterji U, Ashworth MJ, Lewis PL, et al. Effect of total hip arthroplasty on recreational and sporting activity. ANZ J Surg. 2004;74(6):446–9. doi: 10.1111/j.1445-1433.2004.03028.x. [DOI] [PubMed] [Google Scholar]
- 23.Hara D, Hamai S, Komiyama K, et al. Sports participation in patients after total hip arthroplasty vs periacetabular osteotomy: a propensity score-matched asian cohort study. J Arthroplasty. 2018;33(2):423–30. doi: 10.1016/j.arth.2017.08.035. [DOI] [PubMed] [Google Scholar]
- 24.Ollivier M, Frey S, Parratte S, et al. Pre-operative function, motivation and duration of symptoms predict sporting participation after total hip replacement. Bone Joint J. 2014;96-B(8):1041–6. doi: 10.1302/0301-620X.96B8.32813. [DOI] [PubMed] [Google Scholar]
- 25.Ortmaier R, Pichler H, Hitzl W, et al. Return to sport after short-stem total hip arthroplasty. Clin J Sport Med. 2019;29(6):451–8. doi: 10.1097/JSM.0000000000000532. [DOI] [PubMed] [Google Scholar]
- 26.Wylde V, Blom A, Dieppe P, et al. Return to sport after joint replacement. J Bone Joint Surg Br. 2008;90(7):920–3. doi: 10.1302/0301-620X.90B7.20614. [DOI] [PubMed] [Google Scholar]
- 27.Huch K, Müller KA, Stürmer T, et al. Sports activities 5 years after total knee or hip arthroplasty: the Ulm Osteoarthritis Study. Ann Rheum Dis. 2005;64(12):1715–20. doi: 10.1136/ard.2004.033266. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Tudor A, Ruzic L, Vuckovic M, et al. Functional recovery after muscle sparing total hip arthroplasty in comparison to classic lateral approach - A three years follow-up study. J Orthop Sci. 2016;21(2):184–90. doi: 10.1016/j.jos.2015.12.010. [DOI] [PubMed] [Google Scholar]
- 29.Sheth D, Cafri G, Inacio MC, et al. Anterior and anterolateral approaches for THA are associated with lower dislocation risk without higher revision risk. Clin Orthop Relat Res. 2015;473(11):3401–8. doi: 10.1007/s11999-015-4230-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Vu-Han T, Hardt S, Ascherl R, et al. Recommendations for return to sports after total hip arthroplasty are becoming less restrictive as implants improve. Arch Orthop Trauma Surg. 2021;141(3):497–507. doi: 10.1007/s00402-020-03691-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Innmann MM, Weiss S, Andreas F, et al. Sports and physical activity after cementless total hip arthroplasty with a minimum follow-up of 10 years. Scand J Med Sci Sports. 2016;26(5):550–6. doi: 10.1111/sms.12482. [DOI] [PubMed] [Google Scholar]
- 32.Ollivier M, Frey S, Parratte S, et al. Does impact sport activity influence total hip arthroplasty durability? Clin Orthop Relat Res. 2012;470(11):3060–6. doi: 10.1007/s11999-012-2362-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Abe H, Sakai T, Nishii T, et al. Jogging after total hip arthroplasty. Am J Sports Med. 2014;42(1):131–7. doi: 10.1177/0363546513506866. [DOI] [PubMed] [Google Scholar]
- 34.Lübbeke A, Zimmermann-Sloutskis D, Stern R, et al. Physical activity before and after primary total hip arthroplasty: a registry-based study. Arthritis Care Res (Hoboken) 2014;66(2):277–84. doi: 10.1002/acr.22101. [DOI] [PubMed] [Google Scholar]
- 35.Williams DH, Greidanus NV, Masri BA, et al. Predictors of participation in sports after hip and knee arthroplasty. Clin Orthop Relat Res. 2012;470(2):555–61. doi: 10.1007/s11999-011-2198-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Galea VP, Rojanasopondist P, Ingelsrud LH, et al. Longitudinal changes in patient-reported outcome measures following total hip arthroplasty and predictors of deterioration during follow-up: a seven-year prospective international multicentre study. Bone Joint J. 2019;101-B(7):768–78. doi: 10.1302/0301-620X.101B7.BJJ-2018-1491.R1. [DOI] [PubMed] [Google Scholar]
- 37.Rolfson O, Kärrholm J, Dahlberg LE, et al. Patient-reported outcomes in the Swedish Hip Arthroplasty Register: results of a nationwide prospective observational study. J Bone Joint Surg Br. 2011;93(7):867–75. doi: 10.1302/0301-620X.93B7.25737. [DOI] [PubMed] [Google Scholar]
- 38.Naal FD, Maffiuletti NA, Munzinger U, et al. Sports after hip resurfacing arthroplasty. Am J Sports Med. 2007;35(5):705–11. doi: 10.1177/0363546506296606. [DOI] [PubMed] [Google Scholar]
- 39.Monma T, Takeda F, Noguchi H, et al. The impact of leisure and social activities on activities of daily living of middle-aged adults: evidence from a National Longitudinal Survey in Japan. PLoS ONE. 2016;11(10):e0165106. doi: 10.1371/journal.pone.0165106. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Monma T, Takeda F, Noguchi H, et al. Exercise or sports in midlife and healthy life expectancy: an ecological study in all prefectures in Japan. BMC Public Health. 2019;19(1):1238. doi: 10.1186/s12889-019-7570-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Thienpont E, Vanden Berghe A, Schwab PE, et al. Joint awareness in osteoarthritis of the hip and knee evaluated with the ‘Forgotten Joint’ Score before and after joint replacement. Knee Surg Sports Traumatol Arthrosc. 2016;24(10):3346–51. doi: 10.1007/s00167-015-3970-4. [DOI] [PubMed] [Google Scholar]
- 42.Fransen M, McConnell S, Hernandez-Molina G, et al. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014; (4): CD007912. 10.1002/14651858.CD007912.pub2. [DOI] [PMC free article] [PubMed]
- 43.Jingushi S, Ohfuji S, Sofue M, et al. Multiinstitutional epidemiological study regarding osteoarthritis of the hip in Japan. J Orthop Sci. 2010;15(5):626–31. doi: 10.1007/s00776-010-1507-8. [DOI] [PubMed] [Google Scholar]
- 44.Iidaka T, Muraki S, Oka H, et al. Incidence rate and risk factors for radiographic hip osteoarthritis in Japanese men and women: a 10-year follow-up of the ROAD study. Osteoarthritis Cartilage. 2019;28(2):182–8. doi: 10.1016/j.joca.2019.09.006. [DOI] [PubMed] [Google Scholar]
- 45.Clement ND, Scott CEH, Murray JRD, et al. The number of patients “worse than death” while waiting for a hip or knee arthroplasty has nearly doubled during the COVID-19 pandemic. Bone Joint J. 2021;103-B(4):672–80. doi: 10.1302/0301-620X.103B.BJJ-2021-0104.R1. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.