Clinical Sports Medicine Update

Return to Sports After Total M

Hip Arthroplasty
An Umbrella Review for Consensus Guidelines
Christopher B. Sowers,* MD, Alberto C. Carrero,y MD, John W. Cyrus,* MLIS,
Jeremy A. Ross,y MD, Gregory J. Golladay,y MD, and Nirav K. Patel,yz MD, FRCS
Investigation performed at Virginia Commonwealth University, Richmond, Virginia, USA

Background: Current recommendations on safe return to sports (RTS) after total hip arthroplasty (THA) are subjective and based
on studies of varying quality.
Purpose: The aim of this study was to synthesize systematic reviews and meta-analyses on post-THA RTS to propose practice
guidelines identifying which sports can be resumed, when they can be resumed, and what risks are present.
Study Design: Systematic review; Level of evidence, 4.
Methods: This umbrella review followed the Joanna Briggs Institute (JBI) protocol and PRISMA (Preferred Reporting Items for
Systematic Reviews and Meta-Analyses) guidelines. The Embase, Medline, and Cochrane databases were searched. Included
studies were either systematic reviews or meta-analyses addressing primary or secondary outcomes. Outcomes of interest
included safe sports after THA, time to RTS, prognostic indicators of RTS, reasons patients do not RTS, percentage of patients
who RTS, implant complications, and objective classification of sports by impact level. Included reviews had data extracted and
were assessed for methodological quality using the JBI protocol. The authors defined RTS as ‘‘returning to a sport the patient
participated in at any point preoperatively.’’
Results: Patients demonstrated a trend toward lower-impact sports postoperatively. Sports were classified as low (eg, walking),
moderate (eg, downhill skiing), or high impact (eg, soccer). A total of 82% (range, 55%-104%) of patients were able to RTS at
a mean time of 6 months (range, 4-7 months). The best prognostic indicator for RTS was previous experience in that sport. The
main reason patients did not RTS was surgeon recommendation. Aseptic loosening was the most cited complication after RTS.
Conclusion: Most patients are able to return to preoperative levels of low- (eg, walking) and moderate-impact (eg, hiking) sports
between 7 and 12 months after THA. Patients planning a return to high-impact (eg, singles tennis) sports should be counseled on
the possible risks of traumatic injuries and aseptic loosening and monitored closely.
Keywords: return to sport; sports; total hip arthroplasty; hip replacement; umbrella review

Total hip arthroplasty (THA) is a highly successful opera- second, how to determine which sports are permissible.
tion with decades of research supporting improvements Previous literature has used expert opinion to subjectively
in patient pain, quality of life, and functional abilities post- classify sports into low-, moderate-, and high-impact activ-
operatively. Recent data indicate that younger and more ities.6,27 Vail et al27 considered repetitive loading, potential
active patients are seeking surgical treatment for hip oste- for violent impacts, and the magnitude of forces exerted on
oarthritis,19 are often involved in athletics, and frequently the joint when formulating their subjective classification
have high expectations for postoperative physical activity. system in 1996. More recently, surveys of the American
It is important to establish realistic expectations for return Hip Society, American Association of Hip and Knee Sur-
to sports (RTS), considering patient satisfaction is closely geons, and British Hip Society were used to categorize
intertwined with meeting preoperative expectations.10 RTS recommendations after THA into ‘‘allowed,’’ ‘‘allowed
Making recommendations on RTS after THA is a 2-fold with experience,’’ ‘‘not allowed,’’ or ‘‘undecided’’ for sports
issue: first, how to classify the impact level of sport, and after THA.3,12,17 Surveys were used because of a lack of
prospective, objective data from which to draw conclusions.
As a result, a subjective classification system and expert
opinion became the basis for recommendations regarding
The American Journal of Sports Medicine
RTS after THA.
2023;51(1):271–278
DOI: 10.1177/03635465211045698 There has been a more recent effort to objectively study
Ó 2021 The Author(s) sport-specific outcomes resulting in systematic reviews

271
272 Sowers et al The American Journal of Sports Medicine

and meta-analyses about RTS after THA. As the level of specifically not including a Methods section or having
evidence has increased, there is an obligation to transition a lack of data analysis.
from the multiple, differing, survey-based guidelines to
consolidated recommendations based on objective studies.
The aim of this study was to synthesize systematic reviews Methodological Quality Assessment
and meta-analyses on post-THA RTS to propose practice
Studies were assessed for methodological quality using the
guidelines identifying which sports can be resumed,
clinical appraisal checklist detailed in the JBI umbrella
when they can be resumed, and what risks are present.
review protocol. The checklist consists of 11 questions spe-
cifically directed at assessing systematic reviews for use in
an umbrella review.2 We used a binary scoring system by
METHODS which a study received a score of zero unless it clearly
addressed the question at hand, with the comprehensive
We conducted an umbrella review of systematic reviews assessment questions and scoring methodology detailed
and meta-analyses on RTS after THA published between in Appendix Table A2 (available online). Studies were
January 1, 2009, and October 31, 2019. Our study utilized determined high quality if they were graded 9 to 11 points,
the design by the Joanna Briggs Institute (JBI) on moderate quality for 6 to 8 points, and low quality for \6
umbrella reviews2 and the PRISMA (Preferred Reporting points. We thought this assessment method sufficiently
Items for Systematic Reviews and Meta-Analyses) guide- took into consideration the inevitable heterogeneity of
lines for reporting systematic reviews.21 the included systematic reviews and meta-analyses, which
look at qualitative outcome measures. Formal assessment
tools of heterogeneity are not routinely used for such
Search Strategy umbrella reviews but rather for individual studies.

One author (J.W.C.) searched the Embase, Medline, and

Cochrane databases on October 31, 2019, using a combina- Data Extraction
tion of keywords and controlled vocabulary for ‘‘hip arthro-
Data were extracted by the lead author (C.B.S.) using the
plasty’’ and ‘‘return to sport.’’ The full details of the search
JBI umbrella review protocol for qualitative and quantita-
strategy are included in Appendix Table A1 (available in
tive studies.2 The standardized data extraction included
the online version of this article). A validated search filter
(1) study characteristics: publication year, type of review,
was applied to the results to identify only systematic
participant details, databases searched, date range of
reviews and meta-analyses.22
search, date range of included studies, and number and
type of studies; (2) results: primary and secondary out-
comes; and (3) critical analysis: appraisal instrument
Screening, Inclusion/Exclusion Criteria study utilized, method of analysis, strengths and weak-
nesses, and methodological quality. The comprehensive
We included only studies published within the past 10
data extraction can be found in Appendix Tables A3 to
years to limit reviews that may have included outdated
A5 (available online). As part of the qualitative synthesis,
prostheses, protocols, and techniques for THA that would
the significance of each paper was assessed with regard
confound conclusions. Two authors (C.B.S., A.C.C.) inde-
to recommendations for RTS after THA. The significance
pendently screened articles for inclusion in the study.
of a paper considers the strength of the conclusions in con-
Duplicates and non–English language papers were
junction with the methodological quality.
excluded. The remaining studies were reviewed, first by
title and abstract, then by full text. Inclusion criteria
were as follows: systematic review or meta-analysis, title Outcomes of Interest
discussed sports participation or physical activity after
THA, or title discussed a secondary outcome after THA The primary variable of interest was objective determina-
(eg, risk factors for aseptic loosening after THA). Exclusion tion of sports that are safe to participate in after THA.
criteria were failure to address a primary or secondary out- The secondary variables were percentage of patients who
come for the post-THA population in the full text or failure RTS, objective classification of sports by impact levels,
to meet standards as a systematic review or meta-analysis, time to RTS postoperatively, prognostic indicators of

z
Address correspondence to Nirav K. Patel, MD, FRCS, VCU Medical Center, Department of Orthopaedic Surgery, West Hospital, 1200 E Broad Street,
9th Floor, Richmond, VA 23298, USA (email: [email protected]).
*Virginia Commonwealth University, School of Medicine; Richmond, Virginia, USA.
y
Department of Orthopaedic Surgery, VCU Health, Richmond, Virginia, USA.
Submitted March 12, 2021; accepted June 7, 2021.
One or more of the authors has declared the following potential conflict of interest or source of funding: J.A.R. has received hospitality payments from
Medical Device Business Services and Zimmer Biomet Holdings. G.J.G. has received research support from KCI, Cerus, and OrthoSensor and holds stock,
receives royalties, and received consulting fees from OrthoSensor. N.K.P. has received education support from Liberty Surgical, Smith & Nephew, and
Arthrex and hospitality payments from Styker and Medical Device Business Services. AOSSM checks author disclosures against the Open Payments Data-
base (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
AJSM Vol. 51, No. 1, 2023 Return to Sports After Total Hip Arthroplasty 273

The studies were published between 2013 and 2018. The

qualitative and quantitative information from the JBI stan-
Identification

Records idenfied through

database searching dardized data extraction is detailed in Appendix Tables A3
(n = 268)
to A5 (available online).

Methodological Quality Assessment

Records aer duplicates removed
(n = 231) The methodological assessment of the 7 included studies is
detailed in Appendix Table A2 (available online). The qual-
ity, as assessed by the JBI protocol,2 ranged from 3 to 11.
Screening

Three studies were high,1,5,14 2 were moderate,4,15 and 2

Records screened Records excluded
(n = 231) (n = 205) were low in methodological quality.22,23 Six of the 7 included
studies failed to assess publication bias.4,5,14,15,22,23

Full-text arcles excluded, with

reasons
Significance
Eligibility

Full-text arcles assessed

(n = 11):
for eligibility
(n = 26)
Wrong cohort (not post-THA): 3 The significance of each paper, which considers the
Wrong outcome (no RTS): 5
No full text available: 3
strength of the conclusions in conjunction with the method-
ological quality, is detailed in the final column of Table 1.
The 3 studies of high methodological quality were all objec-
Studies included in Arcles deemed literature tive in study design and comprehensive in scope, leading to
qualitave synthesis reviews (n = 8)
strong conclusions. They were considered highly signifi-
Included

(n = 15)
cant for the purposes of our review.1,5,14 There were 2 stud-
ies determined to be of moderate significance. The Buza
et al4 study was of moderate methodological quality and
Studies included in was comprehensive in nature, although it lacked objective
quantitave synthesis
(n = 7) data analysis and was largely a review of current litera-
ture. Similarly, the Oljaca et al22 study proposed several
unique changes to the classification of sports impact, nota-
Figure 1. PRISMA (Preferred Reporting Items for Systematic
bly reclassifying jogging as moderate impact and classify-
Reviews and Meta-Analyses) flow diagram.21 RTS, return to
ing both singles and doubles tennis as moderate impact.
sports; THA, total hip arthroplasty.
These proposed changes were backed by a strong discus-
sion, but the review was low in methodological quality
RTS, implant complications, and reasons patients do not because of a lack of objective evidence. The remaining 2
RTS. studies were of minimal impact in making recommenda-
tions for RTS after THA because they lacked objective
data analysis.15,23
RESULTS

Search Results Primary Outcome

The initial search retrieved 268 studies, of which 37 were The studies that reported on sports that were safe to
duplicates, leaving 231 for screening. Another 205 studies resume after THA were consistent in concluding that
were excluded based on a title that did not involve the pri- patients demonstrated a trend toward lower-impact sports
mary or secondary outcomes. A total of 26 full-text articles postoperatively. When comparing sports participation
were assessed for eligibility, and 11 were excluded (Figure based on impact level, Hoorntje et al14 found that low-,
1). The remaining 15 studies were included in the qualita- moderate-, and high-impact sports participation was 62%,
tive synthesis. Of note, 8 of these studies3,5,9,11,14,16,19,27 24%, and 14%, respectively, before surgery, compared
were excluded from the quantitative synthesis, as they with 69%, 23%, and 9%, respectively, after THA. Table 1
did not include an adequate Methods section or provide summarizes the findings from the individual studies.
sufficient data analysis. Data were extracted using the
JBI standardized method from the remaining 7 stud-
Secondary Outcomes
ies1,4,5,14,15,22,23 for quantitative analysis.
The studies that reported on the secondary outcomes had
Characteristics of Included Reviews more heterogeneous results. The recommended time to
RTS postoperatively depended on the sport, with a mean
The 7 included studies were all systematic reviews,1,4,5,14,15,22,23 time of 6 months (range, 4-7 months).14 However, objective
with Hoorntje et al14 also performing a meta-analysis. measurements in physical activity were found to be consid-
There were 67,810 patients in total who received a THA. erably less in the post-THA cohort compared with healthy
274 Sowers et al The American Journal of Sports Medicine

TABLE 1
Summary of Umbrella Review Findingsa

Study Primary Outcome Secondary Outcomes Significance

Arnold et al (2016)1  Not reported  1 yr postop has objective High; objective improvement in
improvement in physical activity physical activity lags
subjective improvements
postoperatively
Buza et al (2013)4  Avoid high-impact sports  Large decline in high-impact sports Moderate; summarizes
(singles tennis, contact because of concern for wear literature, makes
sports) because of risk of (leading to aseptic loosening) recommendations, unique
periprosthetic fracture or biomechanical approach to
loosening sports classification
 Increased wear rates with
moderate-impact sports
(jogging)
 Safe return to low-impact
sports (walking, swimming,
cycling)
Cherian et al (2015)5  Avoid impact sports after  Male sex and high activity levels High; strong evidence
THA because of increased associated with increased risk of identifying 2 risk factors for
risk of aseptic loosening aseptic loosening after THA aseptic loosening
Hoorntje et al (2018)14  Shift from high- to low-  RTS in 28 weeks High; counsel, rather than rule
impact sports after THA  Positive prognostic indicators: out, return to high-impact
 Some patients participate in preoperative participation in sports with consideration of
moderate- and high-impact sports, patient motivation to RTS prognostic indicators
sports postoperatively  High experience level noted in
 Survey trends: recent patients returning to high-impact
surveys allowed more sports, sports
high-volume surgeons  Main reason patient did not RTS =
allowed more sports surgeon advice
 High-impact sports =  82% return to pre-symptom level;
downhill skiing, ice skating, 104% return to presurgical level;
tennis, running, judo overall, 100% RTS
 80% 15-yr survival in high-activity
patients; low risk of dislocation or
fracture
 Vail et al27 for impact classification
Jassim et al (2014)15  Shift toward lower-impact  Klein et al17 for timeline to RTS (3- Minimal; patients can expect to
sports 6 months) RTS but more studies needed
 Klein et al17 for  Positive prognostic indicators: to determine long-term
recommendations on safe younger age, male sex, lower BMI, consequences in highly active
sports participation in sports individuals
preoperatively
 RTS = 54%-98% (for all TJA)
 At midterm, active patients have no
increase in failure but radiographic
evidence of wear
Oljaca et al (2018)22  Low- and moderate-impact  RTS: 43% (THA and TKA), 55% Moderate; comparing objective
sports (golf, tennis, bicycling) (THA) data with recommendations
allowed  Change expert recommendations on based on expert opinion
 Contact and high-impact jogging and tennis: confirms golf is safe, advocates
sports (American football, s Jogging: no increase of short- for allowing jogging and tennis
basketball) discouraged term implant failure (singles and doubles)
s Singles and doubles tennis:
same forces
Papaliodis et al (2017)23  Golf is safe to return to after  Return to golf in 4 months Minimal; it may be possible to
THA  Anecdotal report of 10 golfers return to high level of
returning to professional golf competition (high forces, high
activity levels)

a
BMI, body mass index; RTS, return to sports; THA, total hip arthroplasty; TJA, total joint arthroplasty; TKA, total knee arthroplasty.
AJSM Vol. 51, No. 1, 2023 Return to Sports After Total Hip Arthroplasty 275

controls at 12 months.1 The strongest prognostic indicator Vail et al27 proposed another classification system that sub-
of RTS was preoperative participation in that sport. Addi- jectively grouped sports based on perceived forces at the
tionally, patient motivation, younger age, male sex, and joint, degree of repetitive loading, and potential for violent
lower body mass index (BMI) correlated with a successful impacts.
RTS.14,15 Although there were no objective data on the We believe the Vail et al27 classification system is the
level of competition in which patients participated, there best from which to make recommendations on RTS after
was anecdotal evidence of 10 golfers able to return to pro- THA because, although subjective, it considers the acute
fessional competition postoperatively.23 The main reason forces, long-term loading, and potential for injury that
patients did not RTS was surgeon recommendation,14 can occur from participating in sports. It is the basis for
which, although not explicitly reported by the studies, our recommendations in Table 2, in conjunction with the
relates to concern for trauma (eg, periprosthetic fracture, studies analyzed in this umbrella review. There were sev-
dislocation), implant wear, and aseptic loosening. By con- eral notable differences determined by this review: low-
trast, a smaller percentage of patients were concerned impact aerobics are allowed without experience, while
about increased wear rates.4 The percentage of patients jazz dancing, ballet dancing, and fencing are allowed
who returned to sport varied significantly, with a mean with experience. In making these conclusions, we consid-
of 82% (range, 55%-104%), with the highest value indicat- ered the multiple subjective impact classification systems,
ing that some patients had experience in a sport, yet were objective risks of implant complications during sports, and
not active immediately before surgery, but resumed partic- inherent risk for trauma in that specific sport. Oljaca
ipation postoperatively. This also identifies the varied def- et al22 questioned 2 sports classifications as high impact:
inition of RTS; we define RTS as ‘‘returning to a sport the jogging/running and singles tennis. First, they found
patient participated in at any point preoperatively.’’ Con- a low risk of acute injury associated with jogging/running
sidering this, the most comprehensive studies indicated and recommended reclassifying it as moderate impact
nearly all patients can expect to return to their presurgical because of its controlled and predictable forces. Second,
level of sport,14,15 with many patients able to achieve pre- they suggested that singles and doubles tennis both be
symptom levels of sport.14 classified as moderate impact, as they determined both
Six studies reported on implant complication rates with had similar forces and low short-term risk for complica-
varied findings.4,5,14,15,22,23 While most studies determined tions.22 However, the majority of other studies viewed sin-
that aseptic loosening is the main complication of con- gles tennis as high impact and doubles tennis as moderate
cern,4,5,14,15 2 studies14,15 reported good implant survival impact.12,17,27 Our review determined there was not
for highly active patients at midterm follow-up. Further, enough evidence to change either classification. Ulti-
several studies reported no difference in revision rates mately, a definitive classification system needs to be objec-
when comparing a sporting population to the less active tively determined. Previous studies have utilized both
control.15,22,23 However, all studies cited a lack of sufficient wearable26 and implantable11 sensors to understand the
prospective, long-term data from which to draw conclusive forces experienced by particular joints. D’Lima et al8 found
recommendations. Additionally, 2 studies14,22 reported peak forces at the hip after THA to be 3.3 times one’s body
lower than expected short-term failure rates, concluding weight during walking and 5 times one’s body weight during
they had low concern for acute injuries such as dislocations jogging. Future studies should build on this research to
or periprosthetic fractures. Hoorntje et al14 noted that objectively measure the magnitude of forces at the joint,
higher-volume surgeons tended to be more liberal in their degree of repetitive loading, and rate of impacts for common
allowance of RTS. sports to establish a joint-specific classification system.
The final secondary outcome was classification of sports We found that the timetable for RTS is highly depen-
by impact levels. There were 5 studies4,5,14,15,22 that dent on the sport in question and is longer than previously
reported classifying sports using systems that loosely ref- recommended. It is reasonable to return to low-impact
erenced the subjective classification systems defined by activities, such as walking, as tolerated, with no specific
previous studies.3,12,17,27 Table 2 provides a stoplight chart timetable. Expert opinions have previously suggested
that compares the sports allowed after THA in these pri- that 3 to 6 months is a reasonable time to RTS, with
mary studies. some surgeons allowing RTS as early as 6 to 12 weeks.3,17
However, evidence suggests that an objective return to pre-
vious physical activity levels can take up to 1 year postop-
DISCUSSION eratively.1 Therefore, for RTS that is moderate or high
impact, requiring significant coordination or muscular
Based on our umbrella review, we conclude that all low- strength, we recommend a patient gradually RTS at
impact sports should be ‘‘allowed,’’ moderate-impact sports approximately 7 months with a full return to preoperative
should be ‘‘allowed with experience,’’ and high-impact sports sporting levels no sooner than 1 year. To ensure a safe
should be ‘‘not recommended’’ after THA. Unfortunately, we RTS, a multidisciplinary approach involving physical ther-
were unable to establish an objective classification system. apy and trainers is suggested to lead sport-specific exer-
McGrory et al20 made the first recommendations on RTS cises and make the final assessment of range of motion,
after THA through a survey of surgeons at the Mayo Clinic. strength, and coordination for sports.24 Objective measures
Two later studies12,17 developed classification systems based of strength and balance might be employed to assist in
on surveys of expert opinions and are most commonly cited. guiding appropriate timing for RTS.
276 Sowers et al The American Journal of Sports Medicine

TABLE 2
Stoplight Chart of Safe Sports After THA by Studya

Vail Healy Klein Clifford Bradley

Sport Umbrella et al (1996)27 et al (2008)12 et al (2007)17 and Mallon (2005)6 et al (2017)3

Golf A A A A A A
Swimming A A A A A A
Walking A A A A A A
Speed walking A A A A A –
Bowling A A A A A A
Cycling (stationary, road) A A A A A A
Table tennis A A – – E –
Calisthenics A A – – E –
Low-impact aerobics A E E A A A
Water aerobics A A – A A –
Ballroom dancing A A A A A A
Weight machines A A E A A –
Stationary skiing A A E A A –
Cross-country skiing A A E E A –
Rowing A A E A A A
Sailing A A – – A –
Hiking E E A A E A
Jazz dancing E A – A E A
Ballet dancing E A – – E A
Free weightlifting E E E E E X
Downhill skiing E E E E E –
Snowboarding E – – X – –
Ice skating/rollerblading E E E E A A
Pilates E – – E – –
Fencing E A Undecided – E –
Horseback riding E E E – A –
Rock climbing E E Undecided – E –
Doubles tennis E E E A E –
Singles tennis X X Undecided Undecided X –
Jogging/running X X X X E X
Contact sports (football, basketball, soccer) X X X X X X
Baseball/softball/cricket X X Undecided X X A
High-impact aerobics X – X X – X
Racquetball/squash X X Undecided X X X
Volleyball X X Undecided – X –
Martial arts X X – Undecided X X
Gymnastics X – Undecided A – –
Waterskiing X X – – E –

a
A = allow; E = allow with experience; X = do not recommend; – = not reported. THA, total hip arthroplasty.

The most significant prognostic factor for RTS is previ- conjunction with the benefits of physical activity, such as
ous experience in that sport.9,14,22 Other positive prognos- improved mental health and quality of life,16 and should
tic factors that showed a lesser correlation include younger encourage RTS on an incremental basis according to symp-
age, male sex, and lower BMI.15 While these latter charac- toms and with realistic goals. Notably, this may include
teristics tend to correlate with more active patients, recommending a lower-impact sport.
previous experience is unique in reflecting a patient’s moti- We identified that the most significant potential compli-
vation as well as sport-specific strength and coordination. cation after RTS is risk of aseptic loosening. While there
Therefore, we recommend weighing previous experience were no data on the timeline for RTS to minimize the
in a specific sport when counseling a patient on RTS. risk of aseptic loosening, bony ingrowth can take up to 9
The main reason patients choose not to RTS is surgeon months.13 Therefore, we recommend delaying return to
advice.14 Other factors less commonly cited are concern for moderate- and high-impact sports until after this time
injury or implant wear.7 While both latter concerns are period. Cherian et al5 found that male patients were at
anticipated, we found a low rate of reported short-term increased risk for aseptic loosening, along with several
implant complications, with modern implants and bearing studies reporting a direct correlation of activity with
surfaces demonstrating low wear rates. Orthopaedic sur- implant wear,4,5,25 which can lead to osteolysis or aseptic
geons should counsel patients on the risks of sports in loosening. However, these studies were unable to comment
AJSM Vol. 51, No. 1, 2023 Return to Sports After Total Hip Arthroplasty 277

on the impact of modern implants because of limitations in

An online CME course associated with this article is avail-
the primary studies.5 While aseptic loosening is almost cer-
able for 1 AMA PRA Category 1 CreditTM at https://
tainly multifactorial, the increased risk seen in the highly
www.sportsmed.org/aossmimis/Members/Education/AJSM
active patients could be due to wear-related osteolysis or
_Current_Concepts_Store.aspx. In accordance with the
increased mechanical load from high activity levels. Mod-
standards of the Accreditation Council for Continuing Med-
ern bearings with very low wear have almost eliminated
ical Education (ACCME), it is the policy of The American
wear-induced osteolysis,18 but the effect of impact during
Orthopaedic Society for Sports Medicine that authors, edi-
activity remains unknown. We recommend counseling
tors, and planners disclose to the learners all financial rela-
patients about the risk of loosening and against return to
tionships during the past 12 months with any commercial
high-impact sports after THA until more evidence exists.
interest (A ‘commercial interest’ is any entity producing,
There are limitations to this review. First, the included
marketing, re-selling, or distributing health care goods or
systematic reviews commonly cited concerns with the pri-
services consumed by, or used on, patients). Any and all
mary studies, including a lack of data analysis, retrospec-
disclosures are provided in the online journal CME area
tive study design, and use of heterogeneous studies with
which is provided to all participants before they actually
small numbers. However, our review utilized a validated
take the CME activity. In accordance with AOSSM policy,
methodological quality assessment tool2 to control for
authors, editors, and planners’ participation in this educa-
bias and low-level evidence in the included reviews. Sec-
tional activity will be predicated upon timely submission
ond, many of the included systematic reviews failed to
and review of AOSSM disclosure. Noncompliance will
include objective data analysis because of low-quality
result in an author/editor or planner to be stricken from
data within the primary studies. This lack of consistent
participating in this CME activity.
reporting made it difficult to compare the preoperative
and postoperative levels of competition in which patients
participated. As such, we examined the significance of
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