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A high physical activity level after total knee arthroplasty does not increase the risk of revision surgery during the first twelve years: A systematic review with meta-analysis and GRADE

Open AccessPublished:October 05, 2022DOI:https://doi.org/10.1016/j.knee.2022.08.004

      Abstract

      Background

      High physical activity (HPA) levels after total knee arthroplasty (TKA) might be related to increased wear and subsequent aseptic loosening, negatively affecting TKA survival. This systematic review studied the association between activity levels and risk of revision surgery at medium (3–10 years) and long term (>10 years) follow up in patients with TKA.

      Methods

      Databases (PubMed, Embase) were searched up to 12 October 2021. Studies comparing low physical activity (LPA) and HPA levels in TKA patients and related risk of revision surgery were eligible for inclusion. After data extraction and evaluation of methodological quality, a meta-analysis was performed. Quality of evidence was assessed using the GRADE framework. PROSPERO registration: CRD42020194284.

      Results

      Five cohort studies and one case–control study met the inclusion criteria, involving 4811 TKA procedures in 4263 patients (mean follow up 4–12 years). Five studies were of moderate methodological quality and one of low quality. Meta-analysis demonstrated no association between HPA level and an increased risk of all-cause revision surgery (risk ratio (RR) 0.62, 95 % confidence interval (CI) 0.24–1.63, level of certainty: very low) or revision surgery due to aseptic loosening (RR 1.33, 95 % CI 0.34–5.24, level of certainty: moderate). Only one study reported on survivorship, with an improved survivorship for the HPA group (odds ratio of 2.4, 95 % CI 1.2–4.7, level of certainty: low).

      Conclusion

      During the first 12 postoperative years after TKA, there seems to be no increased risk for revision surgery for patients with a HPA level compared with patients with an LPA level.

      Keywords

      Abbreviations:

      ADL (Activities of Daily Living), BMI (Body Mass Index), CI (Confidence Interval), GRADE (Grading of Recommendations Assessment, Development and Evaluation), HPA (High Physical Activity), IADL (Instrumental Activities of Daily Living), LPA (Low Physical Activity), LEAS (Lower-Extremity Activity Scale), MAQ (Modifiable Activity Questionnaire), MET (Metabolic Equivalent of Task), OR (Odds Ratio), PAS (Physical Activity Survey), PE (Polyethylene), PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis), RR (Risk Ratio), TKA (Total Knee Arthroplasty), TKRAQ (Total Knee Replacement Activity Questionnaire), UCLA (University of California Los Angeles (activity questionnaire))

      1. Introduction

      Implant survival of total knee arthroplasty (TKA) at medium (3–10 years) and long term (>10 years) is influenced by surgical factors (e.g., alignment [
      • Fang D.M.
      • Ritter M.A.
      • Davis K.E.
      Coronal alignment in total knee arthroplasty: just how important is it?.
      ], fixation technique [
      • Rand J.A.
      • Trousdale R.T.
      • Ilstrup D.M.
      • Harmsen W.S.
      Factors affecting the durability of primary total knee prostheses.
      ], design [
      • Kremers H.M.
      • Sierra R.J.
      • Schleck C.D.
      • Berry D.J.
      • Cabanela M.E.
      • Hanssen A.D.
      • et al.
      Comparative survivorship of different tibial designs in primary total knee arthroplasty.
      ]) and patient factors (e.g., weight [
      • Mulhall K.J.
      • Ghomrawi H.M.
      • Mihalko W.
      • Cui Q.
      • Saleh K.J.
      Adverse effects of increased body mass index and weight on survivorship of total knee arthroplasty and subsequent outcomes of revision TKA.
      ]). High physical activity (HPA) levels, often associated with younger patients or with increasing functional demands from older patients [
      • Witjes S.
      • van Geenen R.C.I.
      • Koenraadt K.L.M.
      • van der Hart C.P.
      • Blankevoort L.
      • Kerkhoffs G.M.M.J.
      • et al.
      Expectations of younger patients concerning activities after knee arthroplasty: are we asking the right questions?.
      ,
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ], is also thought to be an important, patient-related factor influencing implant survival [
      • Healy W.L.
      • Sharma S.
      • Schwartz B.
      • Iorio R.
      Athletic activity after total joint arthroplasty.
      ,
      • Swanson E.A.
      • Schmalzried T.P.
      • Dorey F.J.
      Activity recommendations after total hip and knee arthroplasty: a survey of the American Association for Hip and Knee Surgeons.
      ,
      • Vail T.P.
      • Mallon W.J.
      • Liebelt R.A.
      Athletic activities after joint arthroplasty.
      ,
      • Gallo J.
      • Goodman S.B.
      • Konttinen Y.T.
      • Wimmer M.A.
      • Holinka M.
      Osteolysis around total knee arthroplasty: A review of pathogenetic mechanisms.
      ]. HPA levels can result in increased wear, inducing foreign body responses leading to aseptic loosening [
      • Gallo J.
      • Goodman S.B.
      • Konttinen Y.T.
      • Wimmer M.A.
      • Holinka M.
      Osteolysis around total knee arthroplasty: A review of pathogenetic mechanisms.
      ,
      • Sundfeldt M.
      • Carlsson L.V.
      • Johansson C.B.
      • Thomsen P.
      • Gretzer C.
      Aseptic loosening, not only a question of wear: a review of different theories.
      ], which is the most common reason for revision surgery at medium and long term [
      • Sharkey P.F.
      • Lichstein P.M.
      • Shen C.
      • Tokarski A.T.
      • Parvizi J.
      Why are total knee arthroplasties failing today–has anything changed after 10 years?.
      ,
      • Schroer W.C.
      • Berend K.R.
      • Lombardi A.V.
      • Barnes C.L.
      • Bolognesi M.P.
      • Berend M.E.
      • et al.
      Why are total knees failing today? Etiology of total knee revision in 2010 and 2011.
      ]. TKA patients with aseptic loosening are in need of revision surgery, often associated with less satisfactory outcomes. To date, the association between activity levels and implant failure in TKA remains unclear.
      Following the primary procedure, the orthopaedic surgeon provides advice on physical activities to the patient [
      • Dagneaux L.
      • Bourlez J.
      • Degeorge B.
      • Canovas F.
      Return to sport after total or unicompartmental knee arthroplasty: An informative guide for residents to patients.
      ]. Unfortunately, current guidelines on activity recommendation after TKA are based on expert opinion and surveys only [
      • Healy W.L.
      • Sharma S.
      • Schwartz B.
      • Iorio R.
      Athletic activity after total joint arthroplasty.
      ,
      • Swanson E.A.
      • Schmalzried T.P.
      • Dorey F.J.
      Activity recommendations after total hip and knee arthroplasty: a survey of the American Association for Hip and Knee Surgeons.
      ,
      • Thaler M.
      • Khosravi I.
      • Putzer D.
      • Hirschmann M.T.
      • Kort N.
      • Tandogan R.N.
      • et al.
      Twenty-one sports activities are recommended by the European Knee Associates (EKA) six months after total knee arthroplasty.
      ]. Recently, Straat et al. [
      • Straat A.C.
      • Coenen P.
      • Smit D.J.M.
      • Hulsegge G.
      • Bouwsma E.V.A.
      • Huirne J.A.F.
      • et al.
      Development of a personalized m/eHealth algorithm for the resumption of activities of daily life including work and sport after total and unicompartmental knee arthroplasty: A multidisciplinary Delphi study.
      ] applied the Delphi method to reach consensus regarding recommendations for 27 physical activities following TKA for patients with an average, quick or slow recovery rate. Based on the statement by the Knee Society (2005), sports such as swimming, golf and normal walking are allowed, but doubles tennis is only recommended for experienced players and jogging is not recommended [
      • Healy W.L.
      • Sharma S.
      • Schwartz B.
      • Iorio R.
      Athletic activity after total joint arthroplasty.
      ].
      Two TKA retrieval studies showed a relation between activity levels and wear of polyethylene (PE) inserts [
      • Lavernia C.J.
      • Sierra R.J.
      • Hungerford D.S.
      • Krackow K.
      Activity level and wear in total knee arthroplasty: a study of autopsy retrieved specimens.
      ,
      • Rohrbach M.
      • Lüem M.
      • Ochsner P.E.
      Patient and surgery related factors associated with fatigue type polyethylene wear on 49 PCA and DURACON retrievals at autopsy and revision.
      ]. In contrast, a recent clinical study showed no increased risk of revision surgery in active patients after TKA [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ]. To our knowledge, the risk of revision surgery related to activity level after TKA was not the primary focus of previous systematic reviews or relevant studies on this topic were excluded following their inclusion criteria. Therefore, this systematic review was conducted to study the association between activity levels and the risk of revision surgery at medium (3–10 years) and long term (>10 years) follow up in patients with primary TKA.

      2. Material and methods

      This systematic review was conducted according to the PRISMA statement of Preferred Reporting Items for Systematic reviews and Meta-Analysis [
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      • PRISMA Group
      Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
      ]. The protocol for this systematic review was registered in PROSPERO (Identification number: CRD42020194284).

      2.1 Search strategy

      The electronic databases PubMed and Embase were searched for publications from their start date through to 12 October 2021, with the help of a clinical librarian. In addition, reference lists of selected studies were hand searched to identify additional records. In the databases the following keywords (and related synonyms) were used to build a sensitive, systematic search strategy: “Arthroplasty, Replacement, Knee” [MeSH]; activity; sports [MeSH]; loosening; wear; survival. Within each category (domain, determinant and outcome), the synonyms were combined with “OR.” The three categories were combined with “AND”. The search strategy for each electronic database is presented in the Appendix.

      2.2 Study eligibility criteria

      Studies were included if: (1) patients received primary TKA surgery; (2) recreational and sports activity levels were measured postoperatively with a well-defined activity instrument; (3) the study described at least two distinctly different activity levels; (4) activity levels were compared related to the risk of revision surgery; (5) revision rate at medium- (3–10 years) or long-term follow up (>10 years) was presented, with a minimum mean follow up of 3 years; and (6) the association between physical activity level and revision rate was presented in detail (i.e., number of revisions instead of correlation only). In addition, (7) included study designs were cohort or case–control studies written in English, Dutch or German. Studies were excluded if: (1) a constrained or high-flexion knee prosthesis was implanted; (2) the TKA procedure followed an osteotomy or intra-articular knee fracture; (3) TKA procedures were simultaneously bilateral; (4) measured activity levels were restricted to activities of daily living (ADL) only (i.e., walking, stair climbing); and (5) the publication concerned a retrieval study.
      The primary outcome was the rate of revision surgery of TKA at medium- (3–10 years) or long-term follow up (>10 years) in patients with an HPA level compared with patients with a low physical activity (LPA) level. Secondary outcomes were the rate of aseptic loosening and implant survivorship related to the measured physical activity level.

      2.3 Study selection

      After removal of duplicates all titles and abstracts were screened independently by two authors (AK, WvdW) for eligibility. Disagreements were resolved by discussion. Next, the full-text manuscripts of the selected records were screened independently by these two authors. In case of doubt, consensus was reached by discussion. If full-text manuscripts were not available, authors were contacted via email and a request was placed on ResearchGate. The web application Rayyan QCRI was used for study management. A flow diagram of the selection of studies [
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      • PRISMA Group
      Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
      ] is presented in Fig. 1.
      Figure thumbnail gr1
      Fig. 1Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) flow diagram for study inclusion.

      2.4 Data extraction and risk of bias assessment

      The following characteristics of the included studies were extracted by one author (AK) and independently checked by a second author (WvdW): (1) study information: author, year and country; (2) study design with follow up duration; (3) patient inclusion and exclusion criteria; (4) activity instrument and cut-off for at least HPA and LPA groups; (5) details on the study population: size, sex, age, body mass index (BMI) and diagnosis; (6) type of HPA; (7) TKA details: design, method of fixation (with or without cement) and PE insert; (8) risk of revision with calculations of risk ratio (RR) or odds ratio (OR) with 95 % confidence interval (CI); (9) reasons for revision; and (10) implant survival. Disagreements between both authors were resolved by discussion. Relevant authors were contacted via email to obtain missing data.
      The risk of bias in each study was evaluated independently by two authors (AK, WvdW) and differing opinions for item scores were resolved by discussion. The Critical Appraisal Skills Programme (2018) CASP Cohort Study Checklist or Case Control Study Checklist was used, depending on study design [

      Critical Appraisal Skills Programme. CASP Checklists; 2018. Available at: https://casp-uk.net/casp-tools-checklists/ [last accessed 1 February 2022].

      ]. This quality assessment method consists of 11 (case–control) or 12 (cohort) items divided into three sections: (a) validity of study results; (b) specific results; and (c) application and implications. Items were assessed with ‘yes’ (+, good quality), ‘can’t tell’ (?) or ‘no’ (−, deficiency in methodology). The criteria for defining a study as low, moderate or high quality were arbitrarily defined (see Table 1, Table 2), because to the best of our knowledge cut-off values for CASP checklists are not mentioned in the literature.
      Table 1Methodological quality cohort studies

      Critical Appraisal Skills Programme. CASP Checklists; 2018. Available at: https://casp-uk.net/casp-tools-checklists/ [last accessed 1 February 2022].

      .
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ,
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ,
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ,
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      Classification was based on sections A and B. High quality (low risk of bias): section A two positive (+) scores, section B maximum of two ‘can’t tell (?)’-items; low quality (high risk of bias): section A ≤ 1 positive score, section B ≥ 4 items rated as ‘no’ (−) or ‘can’t tell’; studies scoring in between these two categories were rated as moderate quality.
      Table 2Methodological quality case–control study

      Critical Appraisal Skills Programme. CASP Checklists; 2018. Available at: https://casp-uk.net/casp-tools-checklists/ [last accessed 1 February 2022].

      .
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      Classification was based on section A. High quality (low risk of bias): ≤ 1 ‘can’t tell (?)’-item; low quality (high risk of bias): ≥ 4 items rated as ‘no’ (−) or ‘can’t tell’; studies scoring in between these two categories were rated as moderate quality.

      2.5 Synthesis of results

      A narrative synthesis was used for description of data from the selected studies. Feasibility of a meta-analysis was explored by comparing included studies on homogeneity regarding their exposure – at least HPA versus LPA – and outcome measures, for instance all-cause revision, revision surgery due to aseptic loosening and survivorship. If a meta-analysis was appropriate, an overall estimate of the RR with a 95 % CI was calculated, including I2 as measure of consistency, using a random effects model in Cochrane’s Review Manager 5.3. The results are presented as forest plots including the contribution of each study (weight) to the overall effect (Mantel–Haenszel).

      2.6 Grade

      The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework for prognostic studies was used to assess the quality of evidence for included studies regarding the association between HPA level and three outcomes: all-cause revision, revision surgery due to aseptic loosening and survivorship [
      • Huguet A.
      • Hayden J.A.
      • Stinson J.
      • McGrath P.J.
      • Chambers C.T.
      • Tougas M.E.
      • et al.
      Judging the quality of evidence in reviews of prognostic factor research: Adapting the GRADE framework.
      ]. The framework was drafted by one author (AK) and independently checked by a second author (PK). Four levels of quality were used: high, moderate, low and very low, with high meaning ‘we are very confident that the true effect lies close to that of the estimate of the effect’ [
      • Balshem H.
      • Helfand M.
      • Schünemann H.J.
      • Oxman A.D.
      • Kunz R.
      • Brozek J.
      • et al.
      GRADE guidelines: 3. Rating the quality of evidence.
      ]. Very low means ‘we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect’ [
      • Balshem H.
      • Helfand M.
      • Schünemann H.J.
      • Oxman A.D.
      • Kunz R.
      • Brozek J.
      • et al.
      GRADE guidelines: 3. Rating the quality of evidence.
      ]. The starting point for the quality of evidence of the studies was ‘high’, given the inclusion of studies aimed to investigate the association between physical activity and revision surgery [
      • Huguet A.
      • Hayden J.A.
      • Stinson J.
      • McGrath P.J.
      • Chambers C.T.
      • Tougas M.E.
      • et al.
      Judging the quality of evidence in reviews of prognostic factor research: Adapting the GRADE framework.
      ]. Next, downgrading the quality of evidence was based on the following five factors: (1) study limitations (majority of studies having a high risk of bias or the minority of studies having a prospective study design); (2) inconsistency (I2 > 50 %); (3) indirectness (not fully representative population, not specifically aseptic loosening as outcome); (4) imprecision (less than 10 revision surgeries per study; or 95 % CI of the effect size includes 1, unless the boundaries of the lower and upper limit of the 95 % CI are smaller than 0.8–1.2, indicating high certainty of no effect of HPA on the outcome measure; or the range of the 95 % CI is larger than 0.5 (effect size < 1) or larger than 2 (effect size > 1), indicating uncertainty regarding the effect of HPA); and (5) publication bias present (yes). Finally, study findings with moderate or large effect sizes (i.e., upper limit of 95 % CI risk estimate < 0.5 or lower limit 95 % CI risk estimate > 2) and the presence of an exposure–response relationship in the majority of studies (yes) resulted in upgrading the quality of evidence [
      • Huguet A.
      • Hayden J.A.
      • Stinson J.
      • McGrath P.J.
      • Chambers C.T.
      • Tougas M.E.
      • et al.
      Judging the quality of evidence in reviews of prognostic factor research: Adapting the GRADE framework.
      ].

      3. Results

      3.1 Study selection

      The electronic and hand searches combined yielded 2265 articles. After removing 663 duplicates, 1602 articles remained for screening on title and abstract. Forty-five full-text articles were reviewed of which 39 were excluded. Six studies [
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ,
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ,
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ,
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      ,
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ] met all inclusion criteria and were eligible for meta-analysis. See Fig. 1 for a flow diagram of the study selection process.

      3.2 Study characteristics

      The six included studies [
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ,
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ,
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ,
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      ,
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ] involved a total of 4263 patients (min–max: 52 [
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ] − 2016 [
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ]) with 4811 TKA procedures, and follow up varied from a mean of 4 [
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ] to 12 years [
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      ]. Six distinct activity questionnaires were used to measure activity levels. In addition, the HPA characteristics showed some variation between studies. One study included patients mostly involved in low-impact activities with low or moderate intensity, such as walking (65 %) and gardening (77 %) [
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ]. A second study reported low- to moderate-impact activities (walking 89 %, swimming 53 %, and training with strength-training equipment 46 %) in the HPA group with a very high frequency (average of 11 times a week) [
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ]. A third study reported low- to moderate-impact activities such as walking (42.5 %), cycling (37.5 %) and downhill skiing (10.0 %) with a minimum of three times a week [
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      ]. In the fourth study the HPA group had a mean postoperative Lower-Extremity Activity Scale (LEAS, 1–18) score of 13.7 (standard deviation (SD) ± 2.7) with 5.6 % of these patients reporting the highest possible LEAS outcome of 18 (vigorous sports participation) [
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ]. In the remaining two studies [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ] HPA patients participated in high-impact sports such as jogging or running, tennis, water-skiing and martial arts, but different cut-offs were used to define the HPA group (University of California Los Angeles (UCLA, 1–10) activity questionnaire score ≥ 6 [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ] versus UCLA score ≥ 8 [
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ]). All study characteristics, including reported implant characteristics, are presented in Table 3.
      Table 3Study characteristics.
      StudyStudy designInclusion and exclusion criteriaActivity instrument and

      cut-off
      Study population

      HPA detailsTKA details

      Bercovy et al.
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).




      (2015)



      France
      Prospective cohort



      Mean 7.5 years FU

      (min–max 5–13 years; 123 knees with >10 years FU)
      Inclusion:

      ­ Unilateral or staged bilateral TKA

      ­ Complete assessment at ≥5 years FU



      Exclusion:

      Severe psychiatric, neurologic or locomotor disability
      UCLA activity score (1–10)



      LPA: UCLA ≤7

      HPA: UCLA ≥8
      Included: 584 knees (482 patients)

      Age: 70.6 (min–max 40.1–91.2)

      Female: 65.9 %

      BMI: 29.6 (19.8–47.6)

      Diagnosis: OA 91.8 %/ON 2.9 %/

      RA 2.7 %/post-traumatic 2.6 %



      Analysed: 494 knees (403 patients):

      LPA: 347 knees/HPA: 147 knees



      No separate characteristics presented for LPA and HPA groups

      UCLA 8 (97 knees): golf, backpacking, dancing

      UCLA 9 (31 knees): tennis, water-skiing, downhill skiing, etc.

      UCLA 10: (18 knees): marathon running, parasailing, martial arts

      1 knee: unknown

      ROCC with sacrificing PCL



      38 (6.6 %) cemented femoral components

      391 (66.9 %) cemented tibial components



      PE: compression moulded



      Crawford et al.
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.




      (2020)



      USA
      Prospective cohort



      Mean 11.4 years FU (min–max 5.1–15.9 years, SD: 1.9 years; 1745 knees ≥10 years FU)



      Inclusion:

      ­ ≥5 years FU or earlier revision surgery



      Exclusion:

      No postoperative UCLA score
      UCLA activity score
      Questionnaire presented in article.
      (1–10)



      LPA: UCLA ≤5

      HPA: UCLA ≥6

      LPA: 1210 knees (978 patients)

      Age
      Significant difference, P < 0.001.
      : 64.9

      Female
      Significant difference, P < 0.001.
      : 72.7 %

      BMI
      Significant difference, P < 0.001.
      : 34.6

      Diagnosis: not reported



      HPA: 828 knees (633 patients)

      Age
      Significant difference, P < 0.001.
      : 62.3

      Female
      Significant difference, P < 0.001.
      : 53.7 %

      BMI
      Significant difference, P < 0.001.
      : 32.8

      Diagnosis: not reported
      UCLA 6 (604 knees, 29.6 %)

      UCLA 7 (114 knees, 5.6 %)

      UCLA 8 (76 knees, 3.7 %)

      UCLA 9 (28 knees, 1.4 %)

      UCLA 10 (6 knees, 0.3 %)



      No detailed sports participation per patient

      Vanguard, no details on exact type



      100 % cemented



      PE: compression moulded

      Jones et al.
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.




      (2004)



      USA

      Case–control, retrospectively matched



      Mean 4 years FU of activity (min–max 1–10 years, SD: 2 years)







      Inclusion:

      Unilateral or bilateral TKA

      Age ≥25 years

      Cases: revision surgery

      Controls: no history of revision TKA



      Exclusion:

      Implant failure

      ≤2 years after TKA

      History of knee infection, resection arthroplasty, lower extremity arthrodesis or amputation

      ≥1 revision surgery
      Structured telephone interview using MAQ and YALE PAS to assess:

      (a) Leisure activity

      (b) Occupational activity

      (c) IADL



      Total historical physical activity = (a) + (b)



      All outcomes in MET-hours per week; high-intensity activities: ≥6 MET

      52 knees (52 patients)

      Age 70.5 (SD: 8.9; min–max 47–85)



      Cases: 26 knees (26 patients)

      Female: 65 %

      BMI: 30.3 (SD: 6.4)

      Diagnosis: OA

      Total historical physical activity: median 44.5 MET-hours per week (min–max

      0–137)



      Controls: 26 knees (26 patients)

      Female: 65 %

      BMI: 30.3 (SD: 8.4)

      Diagnosis: OA

      Total historical physical activity: median 55.1 MET-hours per week (min–max

      0–278)

      High-intensity leisure and occupational activities: median 0 % in cases and controls



      High-impact leisure activities: 0 cases (0 %) and 2 controls (8 %)



      Most frequent leisure activity:

      Cases = walking (65 %)

      Controls = gardening (77 %)



      Most frequent occupational activities:

      Cases = retirement (42 %) and homemaker (39 %)

      Controls = retirement (54 %) and homemaker (23 %)

      Cases: 20 (80 %) PCL-retaining

      6 (23 %)

      cemented femoral components

      15 (58 %) cemented tibial components



      Controls: 13 (52 %) PCL-retaining

      18 (69 %, P<0.05) cemented femoral components

      26 (100 %) cemented tibial components



      PE: no details reported

      Mont

      et al.
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.




      (2007)



      USA
      Prospective, matched cohort



      Mean 7 years FU (min–max

      4–14 years)
      Inclusion:

      Unilateral or bilateral TKA

      ≥4 years FU

      Charnley A or B



      Exclusion:

      No details provided

      Screening question: “rate your usual activity/energy level”



      Then classification with the use of the self-developed TKRAQ
      Questionnaire presented in article.
      calculation of weighted activity score based on frequency and impact points



      LPA: very low activity to moderately active on question and TKRAQ <9



      HPA: active to extremely active on question and TKRAQ ≥9
      144 knees (114 patients)



      LPA: 72 knees (57 patients)

      Age: 71 (min–max 41–85)

      Female: 65.3 %

      BMI: 28.3 (16–42)

      Diagnosis: OA 98.2 %/ON 1.8 %

      Mean weighted activity score: 3.7
      Significant difference, P < 0.001.


      (0–8)



      HPA: 72 knees (57 patients)

      Age: 69 (min–max 45–86)

      Female: 65.3 %

      BMI: 29.5 (23–42)

      Diagnosis: OA 98.2 %/RA 1.8 %

      Mean weighted activity score: 14.7
      Significant difference, P < 0.001.


      (9–27)
      Walking (89 %), swimming (53 %), weight machines (training with strength training equipment, 46 %), gardening activities (44 %), stationary biking (37 %), dancing (32 %), cycling
      Estimation from figure in article.
      (21 %), hiking
      Estimation from figure in article.
      (19 %), tennis
      Estimation from figure in article.
      (18 %), carpentry/construction
      Estimation from figure in article.
      (16 %), golf
      Estimation from figure in article.
      (9 %), jogging
      Estimation from figure in article.
      (7 %), yoga
      Estimation from figure in article.
      (7 %), bowling
      Estimation from figure in article.
      (4 %), ice-skating
      Estimation from figure in article.
      (2 %) and skiing
      Estimation from figure in article.
      (2 %)



      Average: 11 times a week
      PCL-retaining only



      Equal distribution of fixation method in HPA and LPA, no further details



      PE: no details reported
      Ponzio

      et al.
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.




      (2018)



      USA



      Prospective, matched cohort



      Mean FU not reported (min–max 5–10 years)



      Inclusion:

      Unilateral TKA

      Complete pre- and 2 years postoperative measurements



      Exclusion:

      No OA

      History of ipsilateral knee surgical procedure

      LEAS ≤6
      LEAS activity score (1–18)



      LPA: LEAS 7–12



      HPA: LEAS 13–18
      2016 knees (2016 patients)



      LPA: 1008 knees (1008 patients)

      Age: 66.3 (SD: 9.0)

      Female: 43.5 %

      BMI: 28.4 (SD: 4.9)

      Diagnosis: OA

      Mean LEAS baseline 9.1
      Significant difference, P < 0.001.
      (SD: 1.7)

      Mean LEAS 2 years FU 11.6 (SD: 2.9) with

      n = 727



      HPA: 1008 knees (1008 patients)

      Age: 66.3 (SD: 9.1)

      Female: 43.5 %

      BMI: 28.3 (SD: 5.0)

      Diagnosis: OA

      Mean LEAS baseline 14.6
      Significant difference, P < 0.001.
      (SD: 1.2)

      Mean LEAS 2 years FU 13.7 (SD: 2.7) with

      n = 772

      No details about physical activity of patients with LEAS

      13–17



      Baseline LEAS 18 (daily vigorous sports participation): LPA 0 %, HPA 3.5 %



      2 years FU LEAS 18 (daily vigorous sports participation):

      LPA 0.83 %, HPA 5.6 %

      Design: not reported



      Fixation method and PE: no details reported

      Valle

      et al.
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.




      (2017)



      Germany
      Prospective cohort



      Mean 12 years FU



      Inclusion:

      No details provided



      Exclusion:

      Persistent pain NRS >2

      Reoperation between index surgery and study inclusion

      Extension deficiency

      <100° knee flexion
      Unspecified standardized questionnaire: practising sports yes/no



      LPA: no sports activity



      HPA: sports participation ≥3 times a week
      130 patients (LPA: 42, HPA: 88)

      Age: 69.2

      Female: 47.7 %

      BMI: not reported

      Diagnosis: not reported



      7 years FU, LPA: 27, HPA: 60

      12 years FU, LPA: 21, HPA: 46, total 67 patients, no characteristics presented for LPA/HPA

      7 years FU: walking (42.5 %), cycling (37.5 %), swimming (35.0 %), golf (15.0 %), Nordic walking (12.5 %), cross-country skiing (15.0 %) and downhill skiing (10.0 %)



      12 years FU: not presented

      Design: not reported



      100 % cemented



      PE: no details reported

      BMI, body mass index in kg/m2; FU, follow up; HPA, high-physical-activity group; IADL, instrumental activities of daily living; LPA, low-physical-activity group; LEAS, Lower-Extremity Activity Scale; MAC, Modifiable Activity Questionnaire; MET, metabolic equivalent; NRS, Numeric Rating Scale; OA, osteoarthritis; ON, osteonecrosis; PAS, Physical Activity Survey; PCL, posterior cruciate ligament; PE, polyethylene; RA, rheumatoid arthritis; ROCC, Rotating Concave–Convex; SD, standard deviation; TKA, total knee arthroplasty; TKRAQ, Total Knee Replacement Activity Questionnaire; UCLA, University of California Los Angeles activity score.
      * Significant difference, P < 0.001.
      a Questionnaire presented in article.
      b Estimation from figure in article.

      3.3 Methodological quality

      The methodological quality of five studies was rated as moderate [
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ,
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ,
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ,
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ] and for one study as low [
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      ]. The quality assessment for each study is presented in Table 1 (cohort studies) and Table 2 (case–control study).

      3.4 Results of individual studies

      3.4.1 All-cause revision surgery

      Five studies [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ,
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ,
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      ,
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ] presented results regarding HPA level in relation to the risk of all-cause revision surgery. Two studies indicated a protective effect (RR 0.09 and 0.42) of HPA levels at medium- (mean 7.5 years) [
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ] and long-term (mean 11.4 years) [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ] follow up. In both studies a small proportion of patients, 1.7 % (34 knees [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ]) and 9.9 % (49 knees [
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ]), participated in high-impact sports such as jogging and tennis. Bercovy et al. [
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ] reported no revisions (0 %) in the HPA group and 12 all-cause revisions (3.5 %, P = 0.022) in the LPA group. In the study by Crawford et al. [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ] the all-cause revision in the HPA group was 1.7 % compared with 4.0 % in the LPA group (P = 0.003), while the revision for aseptic failure was 1.3 % in the HPA group compared to 3.0 % in the LPA group (P = 0.015).
      Two studies reported a comparable risk of revision in the HPA and LPA groups at mid-term follow up (mean 4 years [
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ], OR of 0.99; OR of 0.18 and RR of 0.32) and long-term follow up (mean 12 years [
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      ], RR of 0.64). The study of Valle et al. [
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      ] observed a lower risk of revision in the HPA group (15.2 %) than in the LPA group (23.8 %, P = 0.495), without reaching statistical significance. Reasons for revision were not reported. The case–control study by Jones et al. [
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ] found no association between leisure activity (OR 0.99, 95 % CI 0.99–1.02), occupational activity (OR 0.99, 95 % CI 0.99–1.01) or instrumental activities of daily living (IADL that allow an individual to live independently, such as cooking, cleaning and laundry; OR 1.00, 95 % CI 1.00–1.01) and the risk of revision surgery. The same result was seen for total historical physical activity (past leisure and occupational activity combined) in their adjusted multivariate model. The corresponding OR was 0.99 (95 % CI 0.99–1.01) with no association with the risk of revision surgery. Basically, for the cases a median of 44.5 Metabolic Equivalent of Task (MET)-hours of total historical physical activity per week (average number of hours per week for each activity, multiplied by the activity’s metabolic equivalent, min–max: 0–137) was reported. This is less compared with the controls (median 55.1, min–max: 0–278). No case (0 %) and only two controls (7.7 %) engaged in high-impact leisure activities, resulting in an OR of 0.18 (95 % CI 0.01–4.05) and a RR of 0.32 (P = 0.49) [
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ].
      In contrast, one study showed a higher risk (RR 2.00) of revision in the HPA group, at 5–10 years following TKA (mean follow up not presented) [
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ]. The all-cause revision risk in the HPA group was 3.2 % compared with 1.6 % in the LPA group, P = 0.019 [
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ]. However, in the multivariable model, LEAS level and activity level (HPA compared to LPA) were no risk factors for revision surgery and only age > 64 years at the time of TKA remained significant (OR = 2.51, P = 0.014) [
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ].

      3.4.2 Revision surgery due to aseptic loosening

      Four studies [
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ,
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ,
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ] reported on results regarding HPA level and the risk of revision surgery due to aseptic loosening. Two studies [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ] reported a lower (although not statistically significant) risk for the HPA group (RR 0.34, 95 % CI 0.02–6.46 [
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ] and RR 0.73, 95 % CI 0.13 –3.98 [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ]). Bercovy et al. [
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ] had no revisions (0 %) in the HPA group and three revisions (0.9 %) in the LPA group for aseptic loosening (P = 0.558). In the study of Crawford et al. [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ], this outcome was 0.24 % in the HPA group compared with 0.33 % in the LPA group (P = 1.00). One study showed no difference (RR 1.00) between HPA and LPA groups, because Mont et al. [
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ] recorded no revision for aseptic loosening in either the HPA or LPA patient cohorts (P = 1.00). The fourth study showed a significant, opposite effect of an eight-times higher risk of aseptic loosening for the HPA group [
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ]. This study by Ponzio et al. [
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ] reported 0.8 % (n = 8) revisions due to aseptic loosening in the HPA group versus 0.1 % (n = 1) in the LPA group (P = 0.039).

      3.4.3 Survivorship

      Two studies examined survivorship [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ], of which one compared survivorship between the HPA and LPA groups [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ]. Crawford et al. [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ], after controlling for age, sex, preoperative pain, Knee Society clinical and functional scores and BMI, reported an OR of 2.4 (95 % CI 1.2–4.7) for improved survivorship in the HPA group. This study also reported a better 12-year survivorship for aseptic loosening in the HPA group compared with the LPA group (98.4 % vs 96.3 %, respectively, P = 0.02) [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ]. All study results are presented in Table 4.
      Table 4Study results.
      StudyRisk of revisionReasons for revisionSurvivorship
      Bercovy et al.
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).




      RR
      Calculated using raw data extracted from article.
      all-cause, HPA group: 0.09

      95 % CI 0.01–1.58
      Zero-cell correction by adding a fixed value (0.5) to all cells of study results table, in accordance with the meta-analysis.
      , P+=0.022 *



      RR
      Calculated using raw data extracted from article.
      aseptic loosening, HPA group: 0.34

      95 % CI 0.02–6.46
      Zero-cell correction by adding a fixed value (0.5) to all cells of study results table, in accordance with the meta-analysis.
      , P+=0.558

      All-cause: 12 knees (all in LPA) due to aseptic loosening (n = 2)/early fixation failure (n = 1)/late sepsis (n = 7)/fracture with implant revision (n = 2)

      No details provided: 3 knees

      All cases mean 13 years survivorship



      All-cause: 97.5 % (95 % CI, 96.3–98.8)

      Aseptic loosening: 99.4 % (95 % CI, 98.8–100)

      Crawford et al.
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      RR
      Calculated using raw data extracted from article.
      all-cause, HPA group: 0.42

      95 % CI 0.23–0.75, P=0.003



      RR
      Calculated using raw data extracted from article.
      aseptic failure, HPA group: 0.45

      95 % CI 0.23–0.87, P=0.015



      RR
      Calculated using raw data extracted from article.
      aseptic loosening, HPA group: 0.73

      95 % CI 0.13–3.98, P+=1.00

      Infection: LPA n = 13, HPA n = 3

      Aseptic failure: LPA n = 36, HPA n = 11

      Aseptic loosening: LPA n = 4, HPA n = 2









      HPA: OR 2.4 (95 % CI 1.2–4.7, P=0.011)



      All-cause 12-year survivorship:

      LPA: 95.3 % (95 % CI 94.6–96)

      HPA: 98 % (95 % CI 97.4–98.6, P=0.003)



      Aseptic loosening 12-year survivorship:

      LPA: 96.3 % (95 % CI 95.6–97)

      HPA: 98.4 % (95 % CI 97.9–98.9, P=0.02)

      Jones et al.
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.


      Total historical physical activity: OR 0.99

      (95 % CI 0.99–1.01)



      Leisure: OR 0.99 (95 % CI 0.99–1.02)

      Occupational: OR 0.99 (95 % CI 0.99–1.01)

      IADL: OR 1.00 (95 % CI 1.00–1.01)



      RR
      Calculated using raw data extracted from article.
      all-cause, HPA group: 0.32

      95 % CI 0.03–4.08
      Zero-cell correction by adding a fixed value (0.5) to all cells of study results table, in accordance with the meta-analysis.
      , P+=0.49

      Cases: PE failure (42 %); component loosening (38 %); patellar instability (12 %); arthrofibrosis (4 %); oversized components (4 %).



      Controls: no revisions
      Not applicable









      Mont et al.
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.


      RR
      Calculated using raw data extracted from article.
      aseptic loosening, HPA group: 1.00

      95 % CI 0.06–15.69
      Zero-cell correction by adding a fixed value (1.0) to all cells of study results table, in accordance with the meta-analysis.
      , P+=1.00

      HPA and LPA groups: no revisions100 % at mean FU of 7 years

      (min–max. 4–14)
      Ponzio et al.
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      RR
      Calculated using raw data extracted from article.
      all-cause, HPA group: 2.00

      95 % CI 1.10–3.62, P=0.019



      RR
      Calculated using raw data extracted from article.
      aseptic loosening, HPA group: 8.00

      95 % CI 1.00–63.85, P+=0.039**
      All-cause: LPA n = 16, HPA n = 32

      Aseptic loosening: LPA n = 1, HPA n = 8







      Valle et al.
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      RR
      Calculated using raw data extracted from article.
      all-cause, HPA group: 0.64

      95 % CI 0.23–1.78, P+=0.495
      Reasons not reported
      CI, confidence interval; FU, follow up; HPA, high-physical-activity group; IADL, instrumental activities of daily living; LPA, low-physical-activity group; OR, odds ratio; PE, polyethylene; RR, relative risk.
      P+ = P-value calculated from original data and Fisher’s exact test instead of Chi-squared in case a cell has an expected count < 5.
      * Although the P-value is significant on an α = 0.05 level, the 95 % CI is not significant due to the applied zero-cell correction technique.
      ** This P-value is different from the P-value of 0.238 reported by the authors, who did a within-group comparison using n = 48 patients with a revision.
      a Calculated using raw data extracted from article.
      b Zero-cell correction by adding a fixed value (0.5) to all cells of study results table, in accordance with the meta-analysis.
      c Zero-cell correction by adding a fixed value (1.0) to all cells of study results table, in accordance with the meta-analysis.

      3.5 Synthesis of results

      The meta-analysis, based on one low- [
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      ] and three moderate-quality [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ,
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ] cohort studies, and on one moderate-quality case–control study [
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ], showed that an HPA level was not a risk factor for all-cause revision surgery (RR 0.62, 95 % CI 0.24–1.63, Fig. 2).
      Figure thumbnail gr2
      Fig. 2Forest plot of the association between high physical activity level and the risk of all-cause revision surgery, expressed as a risk ratio. CI, confidence interval; HPA, high physical activity; M−H, Mantel–Haenszel.
      The meta-analysis regarding the risk of revision surgery due to aseptic loosening, based on four moderate-quality cohort studies [
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ,
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ,
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ], showed no association between HPA and an increased risk of revision surgery (RR 1.33, 95 % CI 0.34–5.24, Fig. 3).
      Figure thumbnail gr3
      Fig. 3Forest plot of the association between high physical activity level and the risk of revision surgery due to aseptic loosening, expressed in a risk ratio. CI, confidence interval; HPA, high physical activity; M−H, Mantel–Haenszel. Due to the reporting of no events in both arms in the study of Mont et al.
      [
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ]
      , zero-cell correction has been applied in this study by adding a fixed value of 1.0 to all cells of the study results table.
      Implant survivorship was reported by one study only [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ]. Therefore, no meta-analysis was possible. As reported above, this study reported an improved survivorship for the HPA group with an OR of 2.4 (95 % CI 1.2–4.7).

      3.6 Grade

      The evidence for the prognostic factor HPA level on the risk of all-cause revision surgery was rated as of very low quality, based on three downgrades and no upgrades (Table 5). This means that ‘We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect’ [
      • Balshem H.
      • Helfand M.
      • Schünemann H.J.
      • Oxman A.D.
      • Kunz R.
      • Brozek J.
      • et al.
      GRADE guidelines: 3. Rating the quality of evidence.
      ].
      Table 5GRADE framework
      • Huguet A.
      • Hayden J.A.
      • Stinson J.
      • McGrath P.J.
      • Chambers C.T.
      • Tougas M.E.
      • et al.
      Judging the quality of evidence in reviews of prognostic factor research: Adapting the GRADE framework.
      regarding the association between a high physical activity level and three outcomes.
      Possible downgradesPossible upgradesOverall quality
      OutcomeRisk of biasInconsistencyIndirectnessImprecisionPublication bias strongly suspectedModerate/

      large effect size present

      Dose–response present
      # Studies with high risk of

      bias
      # Prospective cohort studiesHeterogeneity (I2>50 %)OutcomePatients

      #Total cases; #studies with cases <10 Significant effect (risk estimate,

      95 % CI)
      All-cause revision
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ,
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ,
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      ,
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      1/54/576 % ↓Yes ↓No161; 0/5

      RR 0.62 (0.24–1.63)



      No0.62





      NRVery low
      Revision surgery due to aseptic loosening
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ,
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ,
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      0/44/431 %NoNo18; 4/4

      RR 1.33 (0.34–5.24)

      No1.33





      NRModerate
      Survivorship
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      0/11/1NAYes ↓No63; 0/1

      OR 2.4 (1.2– 4.7, range 3.5)

      No



      2.4

      NRLow
      CI, confidence interval; NA, not applicable; NR, not reported; downgrade; #, number.
      In contrast, the rating of the evidence for HPA level on the risk of revision surgery due to aseptic loosening was of moderate quality, based on one downgrade (due to imprecision) and no upgrades. In GRADE terminology, this means ‘We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different’ [
      • Balshem H.
      • Helfand M.
      • Schünemann H.J.
      • Oxman A.D.
      • Kunz R.
      • Brozek J.
      • et al.
      GRADE guidelines: 3. Rating the quality of evidence.
      ].
      The level of certainty for HPA on implant survivorship was rated as ‘low’, based on two downgrades and no upgrades. This means that ‘Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect’ [
      • Balshem H.
      • Helfand M.
      • Schünemann H.J.
      • Oxman A.D.
      • Kunz R.
      • Brozek J.
      • et al.
      GRADE guidelines: 3. Rating the quality of evidence.
      ].

      4. Discussion

      The most important finding of this systematic review was that meta-analysis showed no association between an HPA level and an increased risk of all-cause revision surgery or revision surgery due to aseptic loosening. The single study reporting implant survivorship even showed an improved survivorship with HPA level. The evidence for HPA level on the risk of all-cause revision surgery was of very low quality according to GRADE, but of moderate quality regarding the risk of revision surgery due to aseptic loosening and of low quality for implant survivorship.
      Two previously published systematic reviews also had an interest in the association between activity levels and the risk of revision surgery. Jassim et al. [
      • Jassim S.S.
      • Douglas S.L.
      • Haddad F.S.
      Athletic activity after lower limb arthroplasty: a systematic review of current evidence.
      ] explored whether patients were able to return to athletic activity after TKA, with a secondary aim to evaluate implant survival. They found no increased risk of implant failure in active patients, based on a retrieval study [
      • Lavernia C.J.
      • Sierra R.J.
      • Hungerford D.S.
      • Krackow K.
      Activity level and wear in total knee arthroplasty: a study of autopsy retrieved specimens.
      ] (not included in this review) and a case–control study by Jones et al. [
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ] (included in this review). The second systematic review focused on which host factors (e.g., sex, BMI and activity levels) affect aseptic loosening after TKA. With respect to activity levels, they were unable to include studies due to strict eligibility criteria [
      • Cherian J.J.
      • Jauregui J.J.
      • Banerjee S.
      • Pierce T.
      • Mont M.A.
      What host factors affect aseptic loosening after THA and TKA?.
      ]. After completion of both reviews [
      • Jassim S.S.
      • Douglas S.L.
      • Haddad F.S.
      Athletic activity after lower limb arthroplasty: a systematic review of current evidence.
      ,
      • Cherian J.J.
      • Jauregui J.J.
      • Banerjee S.
      • Pierce T.
      • Mont M.A.
      What host factors affect aseptic loosening after THA and TKA?.
      ] more studies on this topic were published, of which four were included in this systematic review.
      Besides patient studies, there are implant retrieval studies which examined the relation between activity levels and wear of PE inserts. Lavernia et al. [
      • Lavernia C.J.
      • Sierra R.J.
      • Hungerford D.S.
      • Krackow K.
      Activity level and wear in total knee arthroplasty: a study of autopsy retrieved specimens.
      ] reported on 28 TKA implants retrieved during autopsy in which patients with higher activity levels (UCLA activity score 5–6) had more wear of PE inserts than those with less activity (UCLA activity score 1–4). In this retrieval study no patients with UCLA > 6 were included. Rather surprisingly, increased wear was associated with the preoperative UCLA score but not with the postoperative UCLA score [
      • Lavernia C.J.
      • Sierra R.J.
      • Hungerford D.S.
      • Krackow K.
      Activity level and wear in total knee arthroplasty: a study of autopsy retrieved specimens.
      ]. Rohrbach et al. [
      • Rohrbach M.
      • Lüem M.
      • Ochsner P.E.
      Patient and surgery related factors associated with fatigue type polyethylene wear on 49 PCA and DURACON retrievals at autopsy and revision.
      ] found substantial wear in PE inserts in both autopsy and revision retrievals (n = 49), and a higher activity level was associated with increased wear (P = 0.025). They concluded that wear was promoted by activity over time [
      • Rohrbach M.
      • Lüem M.
      • Ochsner P.E.
      Patient and surgery related factors associated with fatigue type polyethylene wear on 49 PCA and DURACON retrievals at autopsy and revision.
      ]. Although these retrieval studies show that insert PE wear is increased with HPA levels, the majority of the clinical patient studies included in this review [
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ,
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ,
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ,
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      ] do not show higher revision rates with higher activity.
      The included studies of this review provided limited information [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Bercovy M.
      • Langlois J.
      • Beldame J.
      • Lefebvre B.
      Functional results of the ROCC® mobile bearing knee. 602 Cases at midterm follow-up (5 to 14 years).
      ] or no details at all [
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ,
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ,
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      ,
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ] on PE insert characteristics. Cross-linking and additives such as vitamin E have improved wear and ageing properties [
      • Chakravarty R.
      • Elmallah R.
      • Cherian J.
      • Kurtz S.
      • Mont M.
      Polyethylene wear in knee arthroplasty.
      ,
      • Dion N.T.
      • Bragdon C.
      • Muratoglu O.
      • Freiberg A.A.
      Durability of highly cross-linked polyethylene in total hip and total knee arthroplasty.
      ]. In addition to materials used, the studies contain little information about technical aspects of the TKA procedure and these have an unquestionable influence on the result. This might explain, to a certain extent, the observed differences in revision rates which ranged from 0 % to 23.8 %. Specifically, the study of Valle et al. [
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      ] reported high revision rates in both the HPA (15.2 %) and LPA groups (23.8 %), without providing any clarification. Although this study had the longest follow up (mean 12 years), the revision percentages were much higher compared with the study by Crawford et al. (0.24–4.0 %) [
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ] who had an almost similar follow up duration (mean 11.4 years).
      A strength of the present review is the extensive search with the help of a clinical librarian. A second strength is that the association between HPA level and three outcomes (all-cause revision, revision surgery due to aseptic loosening and survivorship) was studied. The results were evaluated using both meta-analysis and GRADE. Some limitations must be considered. First, the variety of questionnaires that was used in the included studies to measure activity level. These studies reported use of reliable, validated questionnaires [
      • Zahiri C.A.
      • Schmalzried T.P.
      • Szuszczewicz E.S.
      • Amstutz H.C.
      Assessing activity in joint replacement patients.
      ,
      • Naal F.D.
      • Impellizzeri F.M.
      • Leunig M.
      Which is the best activity rating scale for patients undergoing total joint arthroplasty?.
      ,
      • Kriska A.M.
      • Knowler W.C.
      • LaPorte R.E.
      • Drash A.L.
      • Wing R.R.
      • Blair S.N.
      • et al.
      Development of questionnaire to examine relationship of physical activity and diabetes in Pima Indians.
      ,
      • Dipietro L.
      • Caspersen C.J.
      • Ostfeld A.M.
      • Nadel E.R.
      A survey for assessing physical activity among older adults.
      ,
      • De Abajo S.
      • Larriba R.
      • Marquez S.
      Validity and reliability of the Yale Physical Activity Survey in Spanish elderly.
      ,
      • Saleh K.J.
      • Mulhall K.J.
      • Bershadsky B.
      • Ghomrawi H.M.
      • White L.E.
      • Buyea C.M.
      • et al.
      Development and validation of a lower-extremity activity scale. Use for patients treated with revision total knee arthroplasty.
      ] and a self-developed questionnaire with unknown psychometric properties [
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ]. Valle et al. [
      • Valle C.
      • Sperr M.
      • Lemhöfer C.
      • Bartel K.E.
      • Schmitt-Sody M.
      Does sports activity influence total knee arthroplasty durability? Analysis with a follow-up of 12 years.
      ] presented no details on the questionnaire used. It is important to realize that even validated activity questionnaires do not encompass all dimensions of activity. For example, the UCLA scores highest activity but without measuring duration and intensity. Secondly, the definition of high-level activity was heterogeneously defined throughout all studies. Patients in the HPA group participated in sports with clearly varying impact, from both low-impact sports (e.g., walking, swimming) to high-impact sports (e.g., running, tennis). Thirdly, confounding factors may influence TKA implant survival. Several prognostic factors are associated with an increased risk for revision surgery following TKA, such as younger age, uncemented components and implant malalignment [
      • Jasper L.L.
      • Jones C.A.
      • Mollins J.
      • Pohar S.L.
      • Beaupre L.A.
      Risk factors for revision of total knee arthroplasty: a scoping review.
      ], and taking this into account is important. Four [
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ,
      • Crawford D.A.
      • Adams J.B.
      • Hobbs G.R.
      • Berend K.R.
      • Lombardi A.V.
      Higher activity level following total knee arthroplasty is not deleterious to mid-term implant survivorship.
      ,
      • Jones D.L.
      • Cauley J.A.
      • Kriska A.M.
      • Wisniewski S.R.
      • Irrgang J.J.
      • Heck D.A.
      • et al.
      Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
      ,
      • Ponzio D.Y.
      • Chiu Y.-F.
      • Salvatore A.
      • Lee Y.-Y.
      • Lyman S.
      • Windsor R.E.
      An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: Increased revision in active patients at five to ten years.
      ] of six studies reported confounding factors (e.g., age, sex and BMI) used for matching of study groups and/or adjusting risk calculations. However, confounding factors related to the implant, such as type of PE, TKA design (retaining or sacrificing the posterior cruciate ligament) and method of fixation were scarcely [
      • Mont M.A.
      • Marker D.R.
      • Seyler T.M.
      • Gordon N.
      • Hungerford D.S.
      • Jones L.C.
      Knee arthroplasties have similar results in high- and low-activity patients.
      ] or not used for this purpose. Also, meta-analysis takes into account study population size, but not confounders.
      According to our results, there should be a reconsideration of activity recommendations after TKA. In contrast to current consensus, TKA patients who want to participate in more intense recreational and sports activities should not be deterred from doing so. Patients can be encouraged to remain physically active after TKA, even at a higher level, in which physical activity can contribute to improvements of physical and mental health [
      • Healy W.L.
      • Sharma S.
      • Schwartz B.
      • Iorio R.
      Athletic activity after total joint arthroplasty.
      ,
      • Garber C.E.
      • Blissmer B.
      • Deschenes M.R.
      • Franklin B.A.
      • Lamonte M.J.
      • Lee I.-M.
      • et al.
      American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise.
      ,
      • Jones D.L.
      A public health perspective on physical activity after total hip or knee arthroplasty for osteoarthritis.
      ]. In counselling patients on postoperative physical activities, it is the authors opinion that if patients want to undertake technically demanding activities, such as downhill skiing or singles tennis, preoperative experience in these activities is advised [
      • Kuster M.S.
      Exercise recommendations after total joint replacement: A review of the current literature and proposal of scientifically based guidelines.
      ].
      More long-term, high-quality studies assessing the relationship between activity levels and revision surgery are needed to corroborate our results. Future studies related to physical activity after TKA should report activities in more detail. Activity type, frequency, duration and intensity are of more interest, than solely use of self-reported activity questionnaires. Alternatives might be patient-reported highest exercise-related activity, which can be expressed as a rate of energy expenditure using MET values [
      • Ainsworth B.E.
      • Haskell W.L.
      • Herrmann S.D.
      • Meckes NATHANAEL
      • Bassett D.R.
      • Tudor-locke CATRINE
      • et al.
      2011 Compendium of Physical Activities: a second update of codes and MET values.
      ]. Also, use of unobtrusive wearable sensors might provide more objective data related to quantify activity levels [
      • Small S.R.
      • Bullock G.S.
      • Khalid S.
      • Barker K.
      • Trivella M.
      • Price A.J.
      Current clinical utilisation of wearable motion sensors for the assessment of outcome following knee arthroplasty: A scoping review.
      ]. Furthermore, a distinction could be made between occupational physical activity and leisure time physical activity, because evidence suggests a contrast in health effects in these different domains of physical activity [
      • Coenen P.
      • Huysmans M.A.
      • Holtermann A.
      • Krause N.
      • van Mechelen W.
      • Straker L.M.
      • et al.
      Do highly physically active workers die early? A systematic review with meta-analysis of data from 193 696 participants.
      ].

      5. Conclusion

      Most studies showed an equal or lower risk for all-cause revision surgery and for revision surgery due to aseptic loosening, and improved survivorship in highly active patients during the first 12 years after TKA. Meta-analysis demonstrated no association between HPA level and an increased risk of all-cause revision surgery (level of certainty: very low) or revision surgery due to aseptic loosening (level of certainty: moderate). This was based on a total of 4811 TKAs within a modest number of studies, all of moderate to low methodological quality, with a heterogeneous combination of activity measurement tools and definitions of HPA.

      Funding

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. W.vdW. receives financial support from ZimmerBiomet, is editor for ‘Wetenschap in Beweging’ and is committee member of ‘Wetenschap en Innovatie’ of the ‘Nederlandse Orthopaedische vereniging’ and is member of the ‘European Hip Society Scientific Committee”. All other authors declare that they have no competing interests.

      Appendix.

      Search strategy electronic databases

      Tabled 1
      NumberSearchResults
      1“Arthroplasty, Replacement, Knee”[MeSH Terms] OR “Knee replacement”[Title/Abstract] OR “Knee replacements”[Title/Abstract] OR “Knee arthroplasty”[Title/Abstract] OR “Knee arthroplasties”[Title/Abstract] OR “Knee prosthesis”[Title/Abstract] OR “Knee prostheses”[Title/Abstract] OR “Knee implant”[Title/Abstract] OR “Knee implants”[Title/Abstract] OR “Total knee”[Title/Abstract] OR “TKA”[Title/Abstract] OR “TKR”[Title/Abstract]41,952
      2“Sports”[MeSH Terms] OR “Sports”[Title/Abstract] OR “Sport”[Title/Abstract] OR “Activity”[Title/Abstract] OR “Activities”[Title/Abstract] OR “Cycling”[Title/Abstract] OR “Walking”[Title/Abstract] OR “Running”[Title/Abstract] OR “Swimming”[Title/Abstract]3,613,546
      3“Prosthesis Failure”[MeSH Terms] OR “Prosthesis failure”[Title/Abstract] OR “Prosthesis failures”[Title/Abstract] OR “Prostheses failure”[Title/Abstract] OR “Prostheses failures”[Title/Abstract] OR “Aseptic failure”[Title/Abstract] OR “Aseptic failures”[Title/Abstract] OR “Prosthesis survival”[Title/Abstract] OR “Prostheses survival”[Title/Abstract] OR “Mechanical failure”[Title/Abstract] OR “Mechanical failures”[Title/Abstract] OR “Wear”[Title/Abstract] OR “Osteolysis”[Title/Abstract] OR “Loosening”[Title/Abstract] OR “Loosenings”[Title/Abstract] OR “Survival”[Title/Abstract] OR “Survivalship”[Title/Abstract] OR “Survivorship”[Title/Abstract] OR “Bone resorption”[Title/Abstract] OR “Longevity”[Title/Abstract] OR “Failure”[Title] OR “Revision”[Title]1,361,696
      41 AND 2 AND 3785
      Tabled 1
      NumberSearchResults
      1exp knee arthroplasty/ OR 'Knee replacement'.ab,kf,ti. OR 'Knee replacements'.ab,kf,ti. OR 'Knee arthroplasty'.ab,kf,ti. OR 'Knee arthroplasties'.ab,kf,ti. OR 'Knee prosthesis'.ab,kf,ti. OR 'Knee prostheses'.ab,kf,ti. OR 'Knee implant'.ab,kf,ti. OR 'Knee implants'.ab,kf,ti. OR

      'Total knee'.ab,kf,ti. OR 'TKA'.ab,kf,ti. OR 'TKR'.ab,kf,ti.
      55,669
      2exp sport/ OR 'Sport'.ab,kf,ti. OR 'Sports'.ab,kf,ti. OR exp physical activity/ OR

      'Activity'.ab,kf,ti. OR 'Activities'.ab,kf,ti. OR 'Cycling'.ab,kf,ti. OR 'Walking'.ab,kf,ti. OR 'Running'.ab,kf,ti. OR 'Swimming'.ab,kf,ti.
      4,828,127
      3'Prosthesis failure'.ab,kf,ti. OR 'Prosthesis failures'.ab,kf,ti. OR 'Prostheses failure'.ab,kf,ti. OR 'Prostheses failures'.ab,kf,ti. OR 'Aseptic failure'.ab,kf,ti. OR

      'Aseptic failures'.ab,kf,ti. OR 'Prosthesis survival'.ab,kf,ti. OR 'Prostheses survival'.ab,kf,ti. OR 'Mechanical failure'.ab,kf,ti. OR 'Mechanical failures'.ab,kf,ti. OR 'Wear'.ab,kf,ti. OR 'Osteolysis'.ab,kf,ti. OR 'Loosening'.ab,kf,ti. OR 'Loosenings'.ab,kf,ti. OR 'Survival'.ab,kf,ti. OR

      'Survivalship'.ab,kf,ti. OR 'Survivorship'.ab,kf,ti. OR 'Bone resorption'.ab,kf,ti. OR 'Longevity'.ab,kf,ti. OR 'Failure'.ti. OR 'Revision'.ti.
      1,993,042
      41 AND 2 AND 3

      1477

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