Scand J Med Sci Sports 2015: 25 (Suppl. 2): 1–2 doi: 10.1111/sms.12507
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Editorial Good news for skiers with total knee arthroplasty
Skiing is a highly enjoyable activity that is undertaken by many throughout life, particularly by those fortunate enough to reside close to ski areas. However, with ageing, the locomotor apparatus and cardiovascular system deteriorates. Osteoarthritis (OA) is one of the main causes of disability among the elderly and a major contributor to physical inactivity. Paradoxically, physical activity ameliorates cartilage degeneration in aged animals (Musumeci et al., 2015). About 9% of the population is diagnosed with symptomatic knee OA by the age of 60 years (Losina et al., 2013) and nearly half of the population by age 85 (Murphy et al., 2008). However, cartilage damage and osteophytes can be detected with magnetic resonance imaging in radiographically normal knees, in half the population aged 50–79 (Hayashi et al., 2014). Total knee arthroplasty (TKA) is often indicated at advanced stages of the disease with rather good outcomes in terms of pain relief, locomotion, and quality of life. After knee replacement, most patients can increase their physical activity levels and even return to sport participation. To minimize the risk of prosthesis loosening, polyethylene wear, and periprosthetic fractures, low-impact activities are usually recommended to TKA patients. In this issue of the SJMSS, the effects of a 12-week exercise intervention using downhill skiing in elderly TKA patients are reported using a multidisciplinary approach combining clinical, physiological, biomechanical, and psychological assessments. The intervention program consisted of 2–3 days skiing per week, which included actual downhill periods and exercise of at least 1 h at a mean intensity of 76% of maximum heart rate (Kösters et al., 2015a). The impact of the intervention on clinical outcomes was considered excellent and no injuries were reported during the intervention phase (Hofstaedter et al., 2015). Although aerobic capacity was not improved, an increase in the proportion of type I muscle fibers was observed in vastus lateralis after the intervention (Kristensen et al., 2015). Muscle strength increased in the operated leg during static and dynamic contractions, and asymmetry indices in muscle strength during isokinetic single limb strength testing decreased (Pötzelsberger et al., 2015b). The latter was associated with an enhanced muscle mass, while no significant architectural changes were observed (Narici et al., 2015; Rieder et al., 2015). Interestingly, the intervention resulted in a more symmetric distribution of loads
between legs during walking because of increased loading of the operated leg (Pötzelsberger et al., 2015a). The distribution of loads during skiing, as assessed in a different group of patients, was also symmetric (Pötzelsberger et al., 2015c). Although the patellar tendon cross-sectional area (CSA) was larger in the operated leg than in the non-operated leg at baseline, no differences between legs were observed in tensile stiffness and Young’s modulus at baseline. After the intervention, tensile stiffness and CSA were increased in patellar tendons (Kösters et al., 2015b). Biomarkers indicating neuromuscular junction degeneration and muscle atrophy were increased in these patients and were not ameliorated after the intervention (Narici et al., 2015). Positive effects were observed in glucose homeostasis, despite no significant changes in inflammatory biomarkers, plasma lipids, and mitochondrial proteins (Kristensen et al., 2015). During the intervention, the total amount of physical activity was increased without negative impact on perceived pain, exertion or knee function, while subjective well-being was enhanced (Würth et al., 2015). However, physical self-concept did not change significantly with the intervention (Amesberger et al., 2015). Overall, this issue represents the most comprehensive analysis so far on the effects of skiing with TKA. The intervention resulted in positive muscle and tendon adaptations, greater strength, and better coordination, during walking and skiing. Systemic adaptations seem of lower magnitude, with an improvement in glucose homeostasis, without significant effects on VO2max or in other cardiovascular risk factors. Nevertheless, physical activity was substantially increased and life satisfaction as well. Although no injuries were observed during skiing and no negative effects could be seen on implants, the risk of falls and collisions should be carefully assessed and minimized. Special emphasis should be placed on reducing the risk of periprosthetic fractures, which are associated with increased mortality and disability. This study is a good starting point by showing that patients with TKA can perform skiing safely. However, the subjects participating in this study were experienced skiers. Skiing with good weather is an amazing activity and it is to be expected that a former skier would like to continue skiing after knee replacement. The good news is that this seems to be safe if done under controlled conditions. It remains unknown if
1
Editorial women may reach similar levels of safety. Long-term follow-up periods with a greater number of subjects are required to definitively establish the effects of skiing on the prosthesis and to determine the incidence of injuries and predisposing factors. Until then, former male skiers with TKA can be allowed guided skiing at moderate intensity, so long as the state of the prosthesis is regularly monitored and the risk of fall minimized.
J. A. L. Calbet1,2 Department of Physical Education, University of Las Palmas de Gran Canaria, Campus Universitario de Tafira s/n, Las Palmas de Gran Canaria, Canary Islands, Spain, 2 Research Institute of Biomedical and Health Sciences (IUIBS), Las Palmas de Gran Canaria, Canary Islands, Spain 1
References Amesberger G, Müller E, Würth S. Alpine Skiing With total knee ArthroPlasty (ASWAP): physical self-concept, pain and life satisfaction. Scand J Med Sci Sports 2015: (Suppl. 2): 82–89. Hayashi D, Felson DT, Niu J, Hunter DJ, Roemer FW, Aliabadi P, Guermazi A. Pre-radiographic osteoarthritic changes are highly prevalent in the medial patella and medial posterior femur in older persons: Framingham OA study. Osteoarthritis Cartilage 2014: 22: 76–83. Hofstaedter T, Fink C, Dorn U, Pötzelsberger B, Hepperger C, Gordon K, Müller E. Alpine Skiing With total knee ArthroPlasty (ASWAP): clinical and radiographic outcomes. Scand J Med Sci Sports 2015: 25 (Suppl. 2): 10–15. Kösters A, Pötzelsberger B, Dela F, Dorn U, Hofstaedter T, Fink C, Müller E. Alpine Skiing With total knee ArthroPlasty (ASWAP): study design and intervention. Scand J Med Sci Sports 2015a: 25 (Suppl. 2): 3–9. Kösters A, Rieder F, Wiesinger HP, Dorn U, Hofstaedter T, Fink C, Müller E, Seynnes OR. Alpine Skiing With total knee ArthroPlasty (ASWAP): effect on tendon properties. Scand J Med Sci Sports 2015b: 25 (Suppl. 2): 67–73. Kristensen M, Pötzelsberger B, Schreiber P, Bergdahl A, Hansen CN, Andersen
2
JL, Narici M, Salvioli S, Conte M, Müller E, Dela F. Alpine Skiing With total knee ArthroPlasty (ASWAP): metabolism, inflammation and skeletal muscle fiber characteristics. Scand J Med Sci Sports 2015: 25 (Suppl. 2): 40–48. Losina E, Weinstein AM, Reichmann WM, Burbine SA, Solomon DH, Daigle ME, Rome BN, Chen SP, Hunter DJ, Suter LG, Jordan JM, Katz JN. Lifetime risk and age at diagnosis of symptomatic knee osteoarthritis in the US. Arthritis Care Res (Hoboken) 2013: 65: 703–711. Murphy L, Schwartz TA, Helmick CG, Renner JB, Tudor G, Koch G, Dragomir A, Kalsbeek WD, Luta G, Jordan JM. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum 2008: 59: 1207–1213. Musumeci G, Castrogiovanni P, Trovato FM, Imbesi R, Giunta S, Szychlinska MA, Loreto C, Castorina S, Mobasheri A. Physical activity ameliorates cartilage degeneration in a rat model of aging: a study on lubricin expression. Scand J Med Sci Sports 2015: 25: e222–e230. Narici M, Conte M, Salvioli S, Franceschi C, Selby A, Dela F, Rieder F, Kösters A, Müller E. Alpine Skiing With total knee ArthroPlasty (ASWAP): impact on molecular and architectural features of
musculo-skeletal ageing. Scand J Med Sci Sports 2015: 25 (Suppl. 2): 33–39. Pötzelsberger B, Lindinger SJ, Stöggl T, Buchecker M, Müller E. Alpine Skiing With total knee ArthroPlasty (ASWAP): effects on gait asymmetries. Scand J Med Sci Sports 2015a: 25 (Suppl. 2): 49–59. Pötzelsberger B, Stöggl T, Lindinger SJ, Dirnberger J, Stadlmann M, Buchecker M, Hofstaedter T, Gordon K, Müller E. Alpine Skiing With total knee ArthroPlasty (ASWAP): effects on strength and cardiorespiratory fitness. Scand J Med Sci Sports 2015b: 25 (Suppl. 2): 16–25. Pötzelsberger B, Stöggl T, Scheiber P, Lindinger SJ, Seifert J, Fink C, Müller E. Alpine Skiing With total knee ArthroPlasty (ASWAP): symmetric loading during skiing. Scand J Med Sci Sports 2015c: 25 (Suppl. 2): 60–66. Rieder F, Kösters A, Wiesinger HP, Dorn U, Hofstädter T, Fink C, Seynnes OR, Müller E. Alpine Skiing With total knee ArthroPlasty (ASWAP): muscular adaptations. Scand J Med Sci Sports 2015: 25 (Suppl. 2): 26–32. Würth S, Finkenzeller T, Pötzelsberger B, Müller E, Amesberger G. Alpine Skiing With total knee ArthroPlasty (ASWAP): physical activity, knee function, pain, exertion, and well-being. Scand J Med Sci Sports 2015: 25 (Suppl. 2): 74–81.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Editorial Good news for skiers with total knee arthroplasty
Skiing is a highly enjoyable activity that is undertaken by many throughout life, particularly by those fortunate enough to reside close to ski areas. However, with ageing, the locomotor apparatus and cardiovascular system deteriorates. Osteoarthritis (OA) is one of the main causes of disability among the elderly and a major contributor to physical inactivity. Paradoxically, physical activity ameliorates cartilage degeneration in aged animals (Musumeci et al., 2015). About 9% of the population is diagnosed with symptomatic knee OA by the age of 60 years (Losina et al., 2013) and nearly half of the population by age 85 (Murphy et al., 2008). However, cartilage damage and osteophytes can be detected with magnetic resonance imaging in radiographically normal knees, in half the population aged 50–79 (Hayashi et al., 2014). Total knee arthroplasty (TKA) is often indicated at advanced stages of the disease with rather good outcomes in terms of pain relief, locomotion, and quality of life. After knee replacement, most patients can increase their physical activity levels and even return to sport participation. To minimize the risk of prosthesis loosening, polyethylene wear, and periprosthetic fractures, low-impact activities are usually recommended to TKA patients. In this issue of the SJMSS, the effects of a 12-week exercise intervention using downhill skiing in elderly TKA patients are reported using a multidisciplinary approach combining clinical, physiological, biomechanical, and psychological assessments. The intervention program consisted of 2–3 days skiing per week, which included actual downhill periods and exercise of at least 1 h at a mean intensity of 76% of maximum heart rate (Kösters et al., 2015a). The impact of the intervention on clinical outcomes was considered excellent and no injuries were reported during the intervention phase (Hofstaedter et al., 2015). Although aerobic capacity was not improved, an increase in the proportion of type I muscle fibers was observed in vastus lateralis after the intervention (Kristensen et al., 2015). Muscle strength increased in the operated leg during static and dynamic contractions, and asymmetry indices in muscle strength during isokinetic single limb strength testing decreased (Pötzelsberger et al., 2015b). The latter was associated with an enhanced muscle mass, while no significant architectural changes were observed (Narici et al., 2015; Rieder et al., 2015). Interestingly, the intervention resulted in a more symmetric distribution of loads
between legs during walking because of increased loading of the operated leg (Pötzelsberger et al., 2015a). The distribution of loads during skiing, as assessed in a different group of patients, was also symmetric (Pötzelsberger et al., 2015c). Although the patellar tendon cross-sectional area (CSA) was larger in the operated leg than in the non-operated leg at baseline, no differences between legs were observed in tensile stiffness and Young’s modulus at baseline. After the intervention, tensile stiffness and CSA were increased in patellar tendons (Kösters et al., 2015b). Biomarkers indicating neuromuscular junction degeneration and muscle atrophy were increased in these patients and were not ameliorated after the intervention (Narici et al., 2015). Positive effects were observed in glucose homeostasis, despite no significant changes in inflammatory biomarkers, plasma lipids, and mitochondrial proteins (Kristensen et al., 2015). During the intervention, the total amount of physical activity was increased without negative impact on perceived pain, exertion or knee function, while subjective well-being was enhanced (Würth et al., 2015). However, physical self-concept did not change significantly with the intervention (Amesberger et al., 2015). Overall, this issue represents the most comprehensive analysis so far on the effects of skiing with TKA. The intervention resulted in positive muscle and tendon adaptations, greater strength, and better coordination, during walking and skiing. Systemic adaptations seem of lower magnitude, with an improvement in glucose homeostasis, without significant effects on VO2max or in other cardiovascular risk factors. Nevertheless, physical activity was substantially increased and life satisfaction as well. Although no injuries were observed during skiing and no negative effects could be seen on implants, the risk of falls and collisions should be carefully assessed and minimized. Special emphasis should be placed on reducing the risk of periprosthetic fractures, which are associated with increased mortality and disability. This study is a good starting point by showing that patients with TKA can perform skiing safely. However, the subjects participating in this study were experienced skiers. Skiing with good weather is an amazing activity and it is to be expected that a former skier would like to continue skiing after knee replacement. The good news is that this seems to be safe if done under controlled conditions. It remains unknown if
1
Editorial women may reach similar levels of safety. Long-term follow-up periods with a greater number of subjects are required to definitively establish the effects of skiing on the prosthesis and to determine the incidence of injuries and predisposing factors. Until then, former male skiers with TKA can be allowed guided skiing at moderate intensity, so long as the state of the prosthesis is regularly monitored and the risk of fall minimized.
J. A. L. Calbet1,2 Department of Physical Education, University of Las Palmas de Gran Canaria, Campus Universitario de Tafira s/n, Las Palmas de Gran Canaria, Canary Islands, Spain, 2 Research Institute of Biomedical and Health Sciences (IUIBS), Las Palmas de Gran Canaria, Canary Islands, Spain 1
References Amesberger G, Müller E, Würth S. Alpine Skiing With total knee ArthroPlasty (ASWAP): physical self-concept, pain and life satisfaction. Scand J Med Sci Sports 2015: (Suppl. 2): 82–89. Hayashi D, Felson DT, Niu J, Hunter DJ, Roemer FW, Aliabadi P, Guermazi A. Pre-radiographic osteoarthritic changes are highly prevalent in the medial patella and medial posterior femur in older persons: Framingham OA study. Osteoarthritis Cartilage 2014: 22: 76–83. Hofstaedter T, Fink C, Dorn U, Pötzelsberger B, Hepperger C, Gordon K, Müller E. Alpine Skiing With total knee ArthroPlasty (ASWAP): clinical and radiographic outcomes. Scand J Med Sci Sports 2015: 25 (Suppl. 2): 10–15. Kösters A, Pötzelsberger B, Dela F, Dorn U, Hofstaedter T, Fink C, Müller E. Alpine Skiing With total knee ArthroPlasty (ASWAP): study design and intervention. Scand J Med Sci Sports 2015a: 25 (Suppl. 2): 3–9. Kösters A, Rieder F, Wiesinger HP, Dorn U, Hofstaedter T, Fink C, Müller E, Seynnes OR. Alpine Skiing With total knee ArthroPlasty (ASWAP): effect on tendon properties. Scand J Med Sci Sports 2015b: 25 (Suppl. 2): 67–73. Kristensen M, Pötzelsberger B, Schreiber P, Bergdahl A, Hansen CN, Andersen
2
JL, Narici M, Salvioli S, Conte M, Müller E, Dela F. Alpine Skiing With total knee ArthroPlasty (ASWAP): metabolism, inflammation and skeletal muscle fiber characteristics. Scand J Med Sci Sports 2015: 25 (Suppl. 2): 40–48. Losina E, Weinstein AM, Reichmann WM, Burbine SA, Solomon DH, Daigle ME, Rome BN, Chen SP, Hunter DJ, Suter LG, Jordan JM, Katz JN. Lifetime risk and age at diagnosis of symptomatic knee osteoarthritis in the US. Arthritis Care Res (Hoboken) 2013: 65: 703–711. Murphy L, Schwartz TA, Helmick CG, Renner JB, Tudor G, Koch G, Dragomir A, Kalsbeek WD, Luta G, Jordan JM. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum 2008: 59: 1207–1213. Musumeci G, Castrogiovanni P, Trovato FM, Imbesi R, Giunta S, Szychlinska MA, Loreto C, Castorina S, Mobasheri A. Physical activity ameliorates cartilage degeneration in a rat model of aging: a study on lubricin expression. Scand J Med Sci Sports 2015: 25: e222–e230. Narici M, Conte M, Salvioli S, Franceschi C, Selby A, Dela F, Rieder F, Kösters A, Müller E. Alpine Skiing With total knee ArthroPlasty (ASWAP): impact on molecular and architectural features of
musculo-skeletal ageing. Scand J Med Sci Sports 2015: 25 (Suppl. 2): 33–39. Pötzelsberger B, Lindinger SJ, Stöggl T, Buchecker M, Müller E. Alpine Skiing With total knee ArthroPlasty (ASWAP): effects on gait asymmetries. Scand J Med Sci Sports 2015a: 25 (Suppl. 2): 49–59. Pötzelsberger B, Stöggl T, Lindinger SJ, Dirnberger J, Stadlmann M, Buchecker M, Hofstaedter T, Gordon K, Müller E. Alpine Skiing With total knee ArthroPlasty (ASWAP): effects on strength and cardiorespiratory fitness. Scand J Med Sci Sports 2015b: 25 (Suppl. 2): 16–25. Pötzelsberger B, Stöggl T, Scheiber P, Lindinger SJ, Seifert J, Fink C, Müller E. Alpine Skiing With total knee ArthroPlasty (ASWAP): symmetric loading during skiing. Scand J Med Sci Sports 2015c: 25 (Suppl. 2): 60–66. Rieder F, Kösters A, Wiesinger HP, Dorn U, Hofstädter T, Fink C, Seynnes OR, Müller E. Alpine Skiing With total knee ArthroPlasty (ASWAP): muscular adaptations. Scand J Med Sci Sports 2015: 25 (Suppl. 2): 26–32. Würth S, Finkenzeller T, Pötzelsberger B, Müller E, Amesberger G. Alpine Skiing With total knee ArthroPlasty (ASWAP): physical activity, knee function, pain, exertion, and well-being. Scand J Med Sci Sports 2015: 25 (Suppl. 2): 74–81.
