When Can I Drive After Orthopaedic Surgery? A Systematic Review

Rapid Return to Braking After Anterior and Posterior Approach Total Hip Arthroplasty

BACKGROUND

Little is known about the effect of surgical approach on return to braking after total hip arthroplasty (THA), and few studies have investigated braking after THA with modern surgical techniques and rehabilitation protocols.

METHODS

In a prospective comparative design, we enrolled 65 patients who received right-sided primary THA at our institution from April 2018 through March 2020, 34 with a direct anterior approach (DAA) and 31 with a posterior approach (PA). Braking tests measuring brake reaction time (BRT) and brake pedal depression (BPD) were administered to patients preoperatively and at 1, 2, and 4 weeks postoperatively using a realistic driving simulator. BRT and BPD were compared between groups and preoperatively versus postoperatively using mixed-effects models.

RESULTS

Preoperative BRT averaged 638 msec in the DAA group and 604 msec in the PA group (P = 0.31). At 1 week postoperatively, the DAA group had significantly prolonged BRT compared with preoperatively (694 msec, P = 0.02). No significant difference was observed in the PA group (633 msec, P = 0.31). Both groups had returned to baseline by 2 weeks, and both had significantly faster BRT at 4 weeks compared with preoperatively (583 msec for DAA, P = 0.01; 537 msec for PA, P < 0.001). BPD was similar between groups, and there were no significant differences between preoperative and postoperative BPD at any time point.

CONCLUSIONS

With modern surgical techniques, BRT after right-sided THA returns to baseline levels approximately 2 weeks after surgery. There seems to be a quicker return to preoperative BRT observed in patients with a PA.

Who crashes their car following wrist fracture?

BACKGROUND

Wrist fractures are common injuries associated with high disability in the early recovery period. The impact of wrist fractures on safe return to drive is not understood.

PURPOSE

(1) To compare the proportion of adults who were drivers in car crashes before and after wrist fracture; (2) To examine potential factors (demographic and/or clinical) associated with increased odds of being a driver in a car crash following wrist fracture.

STUDY DESIGN

Retrospective cohort study.

METHODS

Three state-wide government datasets (MainRoads Western Australia [WA], Hospital Morbidity Data Collection and the Emergency Department Data Collection) were used to obtain and link demographic, clinical and car crash information relating to adults with a wrist fracture sustained between 2008 and 2017. McNemar's tests were used to compare the proportion of drivers in a car crash within the 2 years prior to and following the fracture date. Multivariable logistic regressions were used to identify if any variables were associated with increased odds of crashing in the post-fracture period.

RESULTS

Data relating to 37,107 adults revealed a 3.3% (95% CI 3.0%-3.6%, p < 0.05) decrease in the proportion of drivers in a car crash following wrist fracture, persisting for the entire 2 years post-fracture, when compared to the proportion who crashed before their fracture. Those with more severe wrist fracture injury patterns had 79%(95% CI 1.07-3.0, p = 0.03) higher odds of having a crash in the first 3 months following their injury, compared to those with isolated wrist fracture injuries.

CONCLUSIONS

These results inform and update return to drive recommendations. The reduced proportion of drivers involved in crashes following wrist fracture persisted for 2 years; longer than the expected physical recovery timeframe. It is important that hand therapists actively educate the sub-group of adults with more severe wrist fracture injury patterns of the increased likelihood of car crash for the 3 months following their fracture.

Return to Driving Is Safe 6 Weeks After Anterior Cervical Surgery for Symptomatic Cervical Degenerative Disc Disease

STUDY DESIGN

Prospective Cohort Study.

OBJECTIVES

This study aims to determine the timing and clinical parameters for a safe return to driving.

SUMMARY OF BACKGROUND DATE

Returning to driving after cervical spine surgery remains a controversial topic, with no clear consensus on how to best assess a patient's fitness to drive. Previous studies using brake reaction time or subjective questionnaires recommend a return to driving 6 weeks after surgery.

METHODS

Patients above 18 years of age who underwent anterior cervical spine surgery for symptomatic cervical degenerative disk disease and possessed a valid motorcar driving license were recruited from 2018 to 2020. Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA) scores, range of motion, and functional strength of the cervical spine were collected preoperatively and at 2-, 4-, 6- and 12 weeks postsurgery. Patients underwent a standard functional driving assessment protocol at the institution to determine their fitness to drive. This comprised of a clinic-based off-road screening tests and on-road driving test in a real-world environment.

RESULTS

Twenty-one patients were recruited. The mean age was 56.6±8.9 years. Eighty-one percent of the patients passed the on-road driving assessment at 6 weeks. Patients who passed the driving assessment had lower mean NDI scores, 3.4±3.1 versus 10.8±8.0 ( P =0.006), and higher mean mJOA scores 16.1±0.6 versus 15.0±1.8 ( P =0.045). Patients who passed the driving assessment also had higher functional cervical flexor strength, 21.1s±5.8s versus 13.0s±10.2s ( P =0.042) in a supine position but not correlated with a range of motion of the spine in all directions.

CONCLUSION

Most patients undergoing single or dual-level anterior cervical surgery for symptomatic cervical degenerative disk disease demonstrate the ability to pass a standardized driving assessment and are safe to return to driving more than 6 weeks after surgery. Driving ability appears to be correlated with NDI scores ≤3 ( P =0.006), mJOA scores ≥16 ( P =0.045), and cervical flexion endurance of ≥21s ( P =0.042).

LEVEL OF EVIDENCE

Level II.

Licensed and Liable. Insurance, Road Regulations, and Driving After Hip and Knee Arthroplasty Surgery

BACKGROUND

There is a reliance on surgeons to provide advice to patients regarding safe return to driving following hip or knee arthroplasty. Concerns arise that misinformation may place the surgeon in a position of potential legal implication. The purpose of this article is to inform surgeons of their role in accordance with advice from insurance companies and transport regulatory bodies.

METHODS

We sought the stipulations from 5 of the top 10 insurance companies in the United States, Canada, Australia, and the United Kingdom and the transport regulatory body of each country with regards to guidelines on driving after arthroplasty surgery.

RESULTS

The transport regulatory bodies of the countries evaluated do not provide explicit recommendations regarding return to driving after hip or knee arthroplasty and place the responsibility of determining fitness to drive on the treating doctor. Insurance company policies do not contain specifics pertaining to driving after surgery and in most cases defer to the treating doctor to make this decision. Guidelines are available in Canada and America with suggested timeframes on return to driving following arthroplasty surgery.

CONCLUSION

Advice regarding return to driving following hip or knee arthroplasty should be individualized for each patient; ultimately the patient must feel safe to drive knowing that they have a legal responsibility to remain in control of the vehicle at all times. It is recommended that surgeons document any discussion regarding return to driving and should not feel that they are contravening any prescriptive regulation by allowing driving when appropriate.

Doctor when can I drive? A systematic review and meta-analysis of return to driving after total hip arthroplasty

BACKGROUND/OBJECTIVE

Advice given to patients on driving resumption after total hip arthroplasty (THA) is inconsistent. Due to a lack of clear guidelines, surgeons' recommendations range between 4-8 weeks after surgery to resume driving. Delays in driving return can have detrimental social and economic impact. However, it is important to ensure patients only resume driving once safe. This study presents a systematic review and meta-analysis of driving simulation studies after THA to establish when patients can safely return to driving postoperatively.

METHODS

A systematic review and meta-analysis using PRISMA guidelines was undertaken. Titles and abstracts were screened for inclusion, data was extracted, and studies assessed for bias risk. Review Manager, was used for statistical analysis. Values for brake reaction time (BRT) were included for meta-analysis.

RESULTS

14 articles met the inclusion criteria. Of these, 7 measured BRT and were included in the meta-analysis. Pooled means of both right and left THA showed BRT around or above preoperative baseline at 1 week, 2 weeks and 3 weeks, and below baseline at 6 weeks, 12 weeks, 32 weeks and 52 weeks. Of these, the pooled means at 6, 32, and 52 weeks were significant (p < 0.05).Studies not meeting meta-analysis inclusion criteria were included in a qualitative analysis, examining self-reported postoperative driving return times which ranged from 6 days to over a year or in rare cases, never. Majority of patients (n = 960) self-reported driving return within approximately 6 weeks (pooling of mean values 32.9 days).

CONCLUSIONS

The mean return to driving time recommended in the literature was 4.5 weeks. Based upon BRT meta-analysis, a return to baseline braking performance was noted at 6 weeks postoperatively. However, driving is a complex skill, and patient recommendation should be individualised based on factors such as vehicle transmission type, THA technique, surgical side, medication and comorbidities.

Meniscal Suture Influence on Driving Ability 6 Weeks after Anterior Cruciate Ligament Reconstruction with Hamstring Autograft

The purpose of this study was to determine if driving ability 6 weeks after anterior cruciate ligament (ACL) reconstruction is affected by the addition of a meniscal suture. It was also hypothesized that no differences in the driving performance would be found between right or left knee surgery subgroups. A total of 82 people participated in this prospective cohort study: 36 healthy controls, 26 patients undergoing isolated ACL (iACL) reconstruction with hamstring autograft, and 20 patients undergoing ACL and meniscal suture (ACL-MS) reconstruction. ACL-MS group followed a weight-bearing and movement restriction protocol during the first 2 postoperative weeks, whereas patients undergoing iACL could start range-of-motion exercises and full weight-bearing ambulation on the first postoperative day. A driving simulator that reproduced real-life driving conditions was used to evaluate driving ability. The software analyzed multiple driving and braking variables. Driving performance in the sixth postoperative week was compared with that of a healthy control group. Subgroup analysis considering additional procedures (iACL, ACL-MS) and the side of the operated knee (right, left) was also performed. No statistically significant differences were found in the demographic characteristics nor in the driving performance (collisions, p = 0.897; sidewalk invasions, p = 0.749; pedestrian impact, p = 0.983) between iACL, ACL-MS, and control groups. No statistically significant differences were found in right-left subgroup analysis. The results of the present study show that patients in their sixth postoperative week after right or left ACL reconstruction showed similar driving performance as compared with a healthy control group, regardless of associating or not a meniscal suture, suggesting it is safe to resume driving 6 weeks after the mentioned surgeries.

Return to Driving After Hip Arthroscopy: A Systematic Review and Meta-analysis

Background:

Hip arthroscopy is an increasingly common procedure; however, recommendations for safely returning to driving after hip arthroscopy vary among surgeons.

Purpose:

To systematically review and analyze the current available evidence on the optimal time to safely return to driving after hip arthroscopy.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A systematic review and meta-analysis was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Two authors independently conducted a literature search throughout August 2021 using the PubMed, Google Scholar, Embase, and Cochrane databases. A total of 1425 articles were reviewed, and 5 articles were included. All included articles used brake reaction time (BRT) as an observer-reported outcome measure. A meta-analysis was performed to compare pre- and postoperative BRT values. Study sample sizes and mean BRT values were collected per each included study. First, data were analyzed for the right and left hips combined; then, a subgroup analysis stratified by laterality was performed. The BRT values were divided according to time periods of measurement: preoperatively and 2, 4, 6, and 8 weeks postoperatively.

Results:

The included studies evaluated safety to return to driving after hip arthroscopy in 160 patients. Of these, 142 patients were treated for femoroacetabular impingement, while 18 patients underwent hip arthroscopy for other diagnoses. The mean weighted age was 33.7 ± 9.0 years, 47.5% of the patients were female, and the right hip was affected in 71.2%. The preoperative range of BRT was 566 to 1960 ms, and postoperative BRT range was 567 to 1840 ms at 1 to 2 weeks and 523 to 1860 ms at 3 to 12 weeks. Meta-analysis found the studies to be moderately heterogenic ( P = .06). There were no statistically significant differences in BRT between the preoperative period and at 2, 4, 6, and 8 weeks postoperatively.

Conclusion:

Return to driving is likely safe as early as 2 to 4 weeks after right-sided hip arthroscopy, and 2 weeks after a left-sided procedure, as driving performance returns to the preoperative level.

Registration:

CRD42021274460 (PROSPERO identifier).

Driving reaction time following periacetabular osteotomy

INTRODUCTION

Periacetabular osteotomy (PAO) is increasingly being used to treat young adults with symptomatic hip dysplasia. Currently there is a lack of evidence to guide return to driving after this procedure. This study aimed to identify the length of time required after a Periacetabular Osteotomy procedure before a patient can safely return to driving.

METHODS

All patients undergoing PAO were assessed for suitability for the study. Inclusion criteria were: currently driving with a valid licence; and being able to attend follow-up assessment. Baseline driving reaction time was assessed using a driving simulator preoperatively. The simulation was repeated 5 times for each patient and reaction times recorded (Thinking time, Action time and Total reaction time for braking at 30 mph). The driving simulation was repeated using the same methods at 6 weeks and 12 weeks postoperatively. Pre- and postoperative times were compared.

RESULTS

26 patients were included (24 females, 2 males) with a mean age of 32 (range 19-50) years. The mean preoperative times were: Thinking time 0.48, Action time 0.21, Total time 0.69 seconds. At 6 weeks postoperatively, mean Action time increased to 0.26 seconds (p = 0.012) and mean Total time increased to 0.78 seconds (p = 0.013). By 12 weeks post procedure, there was no significant difference in reaction times compared to baseline (mean Thinking time 0.47 seconds, Action time 0.23, Total time 0.72; p > 0.05).

CONCLUSIONS

Most patients may not be safe to drive at 6 weeks following PAO procedures but should be safe to drive at 12 weeks postoperatively. Individual patient factors should also be taken into consideration.

Patients value their own pain over braking safety when deciding when to return to driving: a discrete choice experiment on lower extremity injuries

Objective

To quantify patient preferences towards time to return to driving relative to compromised reaction time and potential complication risks.

Design

Cross-sectional discrete choice experiment.

Setting

Academic trauma center.

Patients

Ninety-six adult patients with an operative lower extremity fracture from December 2019 through December 2020.

Intervention

None.

Main Outcome Measurement

Patient completed a discrete choice experiment survey consisting of 12 hypothetical return to driving scenarios with varied attributes: time to return to driving (range: 1 to 6 months), risk of implant failure (range: 1% to 12%), pain upon driving return (range: none to severe), and driving safety measured by braking distance (range: 0 to 40 feet at 60 mph). The relative importance of each attribute is reported on a scale of 0% to 100%.

Results

Patients most valued a reduced pain level when resuming driving (62%), followed by the risk of implant failure (17%), time to return to driving (13%), and braking safety (8%). Patients were indifferent to returning to driving at 1 month (median utility: 28, interquartile range [IQR] -31 to 80) or 2 months (median utility: 59, IQR: 41 to 91) postinjury.

Conclusion

Patients with lower extremity injuries demonstrated a willingness to forego earlier return to driving if it might mean a decrease in their pain level. Patients are least concerned about their driving safety, instead placing higher value on their own pain level and chance of implant failure. The findings of this study are the first to rigorously quantify patient preferences toward a return to driving and heterogeneity in patient preferences.

Level of Evidence

V.

Patients Generally May Return to Driving 4 Weeks After Hip Arthroscopy and 6 Weeks After Knee Arthroscopy: A Systematic Review and Meta-analysis

PURPOSE

To consolidate the evidence from the available literature and undertake a meta-analysis to provide a reference for physicians to make evidence-based recommendations to their patients regarding the return to driving after hip or knee arthroscopic procedures.

METHODS

A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The OVID, Embase, and Cochrane databases were searched through June 2020 for articles containing keywords and/or MeSH (Medical Subject Headings) terms "hip arthroscopy" and "knee arthroscopy" in conjunction with "total brake response time" or "reaction time" in the context of automobile driving. A title review and full article review were performed to assess quality and select relevant articles. A meta-analysis of qualifying articles was undertaken.

RESULTS

Eight studies met the inclusion criteria for meta-analysis of brake reaction time (BRT). Meta-analysis of all knee BRTs showed times slower than or equal to baseline BRTs through 5 weeks, with a trend of improving BRTs from 6 to 10 weeks (weeks 8 and 10 were significant, P < .05). Among all hip BRTs, week 2 showed times slower than baseline BRTs, but after week 4, a trend toward faster BRTs was observed through week 8 (week 8 was significant, P < .05).

CONCLUSIONS

BRTs met baseline or control values and continued to improve after 6 weeks after knee arthroscopy and after 4 weeks after hip arthroscopy. On the basis of these results, it would be safe to recommend a return to driving at 6 weeks after knee arthroscopic procedures and 4 weeks after hip arthroscopic procedures.

CLINICAL RELEVANCE

These results can be used by surgeons to base their recommendations on to provide guidance for their patients on the resumption of driving. Although BRT is an important aspect of driving ability, there are additional factors that need to be taken into consideration when making these recommendations, including cessation of opioid analgesics, strength of the surgical limb, and range of motion.

Effect of total hip arthroplasty on brake reaction time and braking force

INTRODUCTION

The correct moment for return to driving after total hip arthroplasty (THA) remains unclear. Until today no uniform recommendation exists on the ability to perform an emergency brake.The aim of this prospective study was to investigate the braking ability of patients before and after THA implantation based on brake reaction time in milliseconds (BRT) and braking force in N (BF).

METHODS

In total, 25 patients (15 men, 10 women, mean age 51.3 ± 10.1 years) were treated with THA on the right side. Inclusion criteria consisted of a valid driving licence, frequent road participation and at least 2 years of driving experience. Exclusion criteria were underlying neurological disorders as well as severe complaints in the lumbar spine and the right knee joint. The brake ability was evaluated for emergency braking with a car simulator and a measuring sole. Measurements were performed preoperatively, 6 days, 2, 4 and 6 weeks after surgery.

RESULTS

Preoperatively, the mean BRT was 671.3 ± 123.5 ms and the BF 455.4 ± 185.0 N. Significant differences were observed at 6 days and 2 weeks after surgery, (BRT 836.4 ± 219.7 ms, respectively, BRT 735.0 ± 186.7 ms, and BF 302.6 ± 154.9 N, respectively, BF 375.5 ± 149.3 N, p < 0.05). Only 4 weeks after, no significant differences were seen compared to pre-operative with a BRT of 647.0 ± 91.9ms (p = 0.354) and BF of 435.9 ± 177.4 (p = 0.843). Furthermore, the BRT improved significantly after 6 weeks (607.4 ± 87.6; p = 0.005).

CONCLUSIONS

The braking force is significantly reduced, and the brake reaction time is prolonged directly after surgery for at least 2 weeks. After 4 weeks, no statistically significant differences were measured, although special care should still be taken during return to activity.

Patients perspective on treatment and early rehabilitation after an ankle fracture: A longitudinal qualitative study

Worldwide, ankle fractures are among the most common fractures encountered in emergency departments. To inform healthcare professionals about what is important to patients when organizing an individualized, high-quality treatment plan, patient perspectives on treatment, care, and early rehabilitation are highly relevant. This longitudinal interview study aims to explore the perspectives of patients with surgically (ST) and conservatively (CT) treated ankle fractures within ten days and six weeks after an ankle fracture. Fourteen patients were interviewed using a semi-structured interview guide. Data were analyzed according to qualitative content analysis. Findings revealed themes regarding pain, independence, information, and worries about the future. Initially, all patients had a pragmatic attitude toward the future, but this attitude was significantly different after 6 weeks as many of the ST patients were still in pain and were more worried about the future. Patients' feelings of uncertainty were linked to a lack of information. Our findings indicate a need for further research to develop a more specific description of symptoms patients should expect as treatment progresses for patients with ankle fractures. With the goal of decreasing psycho-social concerns regarding mobility, autonomy, and working ability post fracture.

Return-to-Driving Recommendations After Lower-Extremity Orthopaedic Procedures

Following lower-extremity orthopaedic surgery, recommendations for safe return to driving include at least 6 to 12 weeks for a right ankle fracture, 2 days to 2 weeks for a right ankle arthroscopy, 6 to 9 weeks for a total ankle arthroplasty, 6 to 7 weeks for a right Achilles tendon rupture repair, 1 to 4 weeks for a right total knee arthroplasty, 2 weeks for a left total knee arthroplasty, 3 to 6 weeks for a right anterior cruciate ligament repair, and 1 to 4 weeks for a total hip arthroplasty. Important individual factors such as extent of injury, laterality of injury, current driving habits, type of vehicle transmission (manual or automatic), and medical comorbidities must be taken into consideration. State laws vary widely and often use vague language to describe the legal responsibilities that orthopaedic surgeons have when providing return-to-driving recommendations.

Return to Driving After Foot and Ankle Surgery: A Novel Survey to Predict Passing Brake Reaction Time

Introduction. Brake reaction time (BRT) is an accepted method for establishing recommendations for safe return to driving by the National Highway Traffic Safety Administration. Other than performing a BRT test in clinic, there is no established clinical tool to help physicians differentiate safe from unsafe drivers once patients reach general recovery milestones. The purpose is to present individual recommendations to the patient through a novel, validated survey evaluating safe return to driving after orthopaedic surgery of the right foot and ankle. Methods. A total of 171 patients undergoing 1 of 3 specific foot and ankle procedures were prospectively enrolled. A 4-question survey and BRT were completed 6 weeks postoperatively. The following questions were asked: (1) "I think my brake reaction time is slower than most drivers my age," (2) "I think my brake reaction time is faster than most drivers my age," (3) "I think my brake reaction time is about the same as most drivers my age," (4) "Based on what I think my brake reaction time is, I think I am ready to drive." Internal consistency was determined with Cronbach's α and item total correlation. External validity was determined by Spearman's correlation coefficient. A BRT less than 0.850 s was considered as a pass. Results. Of 171 patients, 162 (95%) with ages ranging from 21 to 83 years achieved a passing BRT by 7.6 weeks. After removing 1 question because of internal inconsistency, the optimal threshold for predicting passing BRT was 10/15 points or higher, which had 99% probability of success that a patient would pass the BRT (95% CI = 96%, 100%). Conclusion. This novel, 3-question driving readiness survey can accurately predict a passing BRT Achilles rupture repair, total ankle arthroplasty, and hallux valgus correction performed in the right foot and ankle as early as 6 weeks postoperatively.Level of Evidence: Level II: Comparative study.

Return to Driving After Anterior Cruciate Ligament Reconstruction: A Systematic Review

Background

Guidelines for return to driving after anterior cruciate ligament reconstruction (ACLR) have not been established.

Purpose

To review the literature pertaining to driving after ACLR and provide evidence-based guidelines to aid clinicians in counseling patients about driving after ACLR.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Two independent reviewers searched PubMed, EMBASE, and the Cochrane Library using the terms anterior cruciate ligament, ACL, drive, and driving. Studies reporting on functional recovery after ACLR were included when data regarding return to driving were reported.

Results

Five studies were included. Two studies included patients who underwent right-sided ACLR. Of these, 1 study evaluated bone-patellar tendon-bone autograft and reported that brake response time (BRT) returned to normal approximately 4 to 6 weeks postoperatively. The other study found that BRT returned to normal 3 weeks after allograft ACLR, but 6 weeks elapsed after autograft ACLR before values were not significantly different than controls. One study reported that patients who underwent left-sided hamstring tendon autograft ACLR demonstrated BRTs similar to controls within 2 weeks, while those with right-sided ACLR had significantly slower BRTs until 6 weeks postoperatively. Another study including patients who underwent either right- or left-sided ACLR and employed a manual transmission simulator found that 4 to 6 weeks should elapse after ACLR with hamstring tendon autograft. Survey data from 1 study demonstrated that the mean time for patients to resume driving was 13 and 10 days after right- and left-sided ACLR, respectively.

Conclusion

BRT returned to normal values approximately 4 to 6 weeks after right-sided ACLR and approximately 2 to 3 weeks after left-sided ACLR. According to 1 study in this review, ACLR laterality should be disregarded for patients who drive manual transmission automobiles, as a 4- to 6-week time period was required for driving ability to reach the level of healthy controls. Future studies should aim to elucidate the influence of graft choice and transmission type on return to driving after ACLR.

Reaction time and brake pedal force after total knee replacement: timeframe for return to car driving

PURPOSE

This prospective cohort study aimed to examine objective and subjective parameters in patients who underwent total knee replacement (TKR) to assess from when on driving a car can be deemed safe again.

METHODS

Thirty patients (16 women, 14 men, age 66 ± 11 years) who received TKR of the right knee and 45 healthy controls (26 women, 19 men, age 32 ± 9 years) were asked to perform an emergency braking manoeuvre using a driving simulator. Brake pedal force (BPF), neuronal reaction time (NRT), brake reaction time (BRT), and subjective parameters (pain, subjective driving ability) were measured preoperatively as well as 5 days, 3-4, and 6 weeks after TKR.

RESULTS

Preoperative NRT was 506 ± 162 ms, BRT 985 ± 356 ms, and BPF 614 ± 292 N. NRT increased to 561 ± 218 ms, BRT to 1091 ± 404 ms and BPF decreased to 411 ± 191 N 5 days after TKR. Three weeks after surgery, NRT was 581 ± 164 ms and BRT 1013 ± 260 ms, while BPF increased to 555 ± 200 N. Only BPF showed significant differences (p < 0.01). In week 6, all parameters were restored to baseline levels; patients showed significant pain decrease and evaluated their driving ability as "good" again.

CONCLUSION

BPF was the only parameter displaying a significant postoperative decrease. However, preoperative patients' baseline levels and subjective confidence in driving ability were only reached 6 weeks after the operation. These results indicate that a minimum waiting period of 6 weeks should be considered before patients can safely participate in road traffic at their individual preoperative safety level again.

LEVEL OF EVIDENCE

II.

Allowed Activities After Primary Total Knee Arthroplasty and Total Hip Arthroplasty

It is essential for total knee arthroplasty patients to return to their previous level of activity to maintain a healthy lifestyle. This article reviews the current recommendations regarding return to physical activity after total knee arthroplasty and trying to find the balance between levels of activity and prosthetic joint preservation. In general, most total joint replacement patients are able to return to their previous level of activity and to a lesser extent to sports. This article discuss patients' actual levels of activity including their return to work and sport and the factors that influence meeting their expectations for surgery.

Modeled Wide-Awake, Local-Anesthetic, No-Tourniquet Surgical Procedures Do Not Impair Driving Fitness: An Experimental On-Road Noninferiority Study

BACKGROUND

The use of wide-awake, local-anesthetic, no-tourniquet (WALANT) surgical techniques is increasingly common, and patients commonly ask whether they may drive home following these procedures. The impact of a numb hand and bulky dressing on driving fitness is unknown, and there is no literature to guide surgeons when counseling these patients. Thus, the primary objective of the present study was to determine driving fitness following a modeled-WALANT procedure.

METHODS

Twelve right-handed individuals (6 male and 6 female) with an average age of 50 years (range, 38 to 64 years) were enrolled. An instrumented vehicle was used to obtain driving kinematic and behavioral data, thus allowing for a multidimensional assessment of driving fitness. Participants first performed a drive to establish baseline kinematic metrics. The route included both public streets and a closed course. Several driving tasks were assessed, including reverse parking, parallel parking, and perpendicular parking. The total course length was 18 miles (29 kilometers) and took 45 to 55 minutes to complete. After the first drive, 10 mL of 1% lidocaine was injected in the volar aspect of the right wrist and another 10 mL was injected into the right carpal tunnel to model the anesthetic used for a WALANT carpal tunnel release, and a bulky soft dressing was applied. The modeled-WALANT drive included an identical route and tasks, in addition to a surprise event to evaluate emergency responsiveness. Driving metrics were analyzed for noninferiority of the modeled-WALANT state to baseline driving.

RESULTS

The modeled-WALANT state showed noninferiority to baseline driving on all 11 analyzed dimensions of driving behavior compared with the control drives. In the modeled-WALANT state, participants drove more conservatively, braked harder, and steered more smoothly. All participants safely performed the 3 parking tasks and emergency response maneuver. Driving fitness in the modeled-WALANT state was noninferior to driving fitness in the preoperative drive.

CONCLUSIONS

A modeled-WALANT state has no clinically relevant negative impact on driving fitness, and thus surgeons should not discourage patients from driving home after unilateral WALANT surgical hand procedures.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Clinical Considerations for Return to Driving a Car following a Total Knee or Hip Arthroplasty: A Systematic Review

Aim

The purpose of this study is to systematically review patient characteristics and clinical determinants that may influence return to driving status and time frames following a primary TKA or THA and provide an update of the current literature.

Methods

This review was completed per the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Final electronic database searches were completed in October 2019 in Medline/PubMed, Medline/OVID, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library using preselected search terms. Manuscripts of prospective and nonrandomized studies that examined the return to driving a car after a primary knee or hip arthroplasty patients were included. The Methodological Index for Non-Randomized Studies was used to measure study quality. Two authors selected studies and assessed their qualities. All disagreements were resolved through discussion and, as needed, a third reviewer. Data on study title, author(s), country, year, study design, sample size, inclusion and exclusion criteria, age, BMI, gender, statistical analyses, driving measure, follow-up time, surgical approach, laterality, and postoperative management were extracted from each study.

Results

A total of 23 studies were eligible, including 12 TKA studies (n = 654) with mean ages between 43 and 82 years, 9 THA studies (n = 922) with mean ages between 34 and 85 years, and 2 combined TKA and THA (TKA, n = 815; THA, n = 685), yielded MINORS scores between 6 and 12. Most patients achieved or exceeded preoperative response times between 1 and 8 weeks following a TKA and 2 days to 8 weeks following a THA, and/or self-reported return to driving between 1 week and 6 months. Influences on return to driving time included laterality and pain, but gender was mixed. Discussion/

Conclusions

Study results were consistent with previous systematic reviews in that return to driving a car after a primary TKA or THA is highly variable, and most commonly occurs around 4 weeks, but can range between 2 and 8 weeks. While various patient and clinical factors can influence return to driving for a TKA or THA, the most common contributing facts were pain and laterality. The heterogeneous nature of the studies prevented a meta-analysis for determining contributions of return to driving following a primary TKA or THA. Regardless, this study updates previous systematic reviews and presents insight on patient and clinical factors beyond generalized timeframes for return to driving a car. This information and results from future studies are essential to guide clinical recommendations and patient and clinician expectations for return to driving a car after a primary TKA or THA.

Is it safe for patients to drive after intra-articular knee injection?

BACKGROUND

Intra-articular knee injection is a central component in the current management of knee pain. While this is a routinely performed outpatient procedure, institutional policies for driving post injection differ. This study examines brake response times (BRTs) before and after intra-articular knee injection. Our hypothesis is that BRTs would not significantly differ and thus patients driving ability/safety is unaffected.

METHODS

Forty-five patients previously listed for right intra-articular knee injection were prospectively evaluated. Patients underwent baseline assessment of BRT prior to injection. All patients received 10 ml of fluid consisting of one milliliter of 10 mg/ml triamcinolone mixed with nine milliliters of 0.5% levobupivacaine. BRT was re-examined on the same day prior to discharge home. Pre- and post-injection BRTs were examined using the same machine and assessor.

RESULTS

The mean age of the cohort was 64.0 ± 12.4 and compromised of 37.8% males. There was no significant difference in the mean pre- and post-injection braking time (0.83 ± 0.29 vs 0.78 ± 0.30 s, p = .42), or in the rate of failed braking time (11.1% vs 6.7%, p = .46).

CONCLUSION

This study found that BRT did not significantly differ before and after the intra-articular injection, nor did it cause an increased number of patients failing their BRTs. These findings suggest patients should not be prevented from driving after intra-articular knee injection.

When Can I Drive? Predictors of Returning to Driving After Total Joint Arthroplasty

INTRODUCTION

A common question by patients considering total joint arthroplasty (TJA) is when can I return to driving. The ability to return to driving has enormous effect on the independence of the patient, ability to return to work, and other activities of daily living. With advances in accelerated rehabilitation protocols, newer studies have questioned the classic teaching of waiting 6 weeks after TJA. The goal of this prospective study was to determine specific patient predictors for return to driving and create individualized models able to estimate return to driving based on patient risk factors for both total knee arthroplasty (TKA) and total hip arthroplasty (THA).

METHODS

From July 2017 to January 2018, 554 primary TKA and 490 primary THA patients were prospectively enrolled to obtain information regarding return to driving. Patients were sent a survey every 2 weeks regarding their return to driving. Additional information regarding vehicle type, transmission, and involvement in motor vehicle accidents was collected. Bivariate analysis was done followed by the creation of a multiple linear regression models to analyze return to driving after TKA and THA.

RESULTS

The majority (98.2%, 1,025/1,044) of patients returned to driving within 12 weeks of surgery. On average, patients returned to driving at 4.4 and 3.7 weeks for TKA and THA (P < 0.001), respectively. The rate of motor vehicle accidents was 0.7% (7/1,044) within 12 weeks after surgery with no injuries reported. After multivariate analysis, baseline return to driving began at 10.9 days for TKA and 17.1 days for THA. The following predictors added additional time to return to driving for TJA: not feeling safe to drive, limited range of motion, female sex, limitations due to pain, other limitations, discharge to a rehabilitation facility, right-sided procedures, limited ability to break, preoperative anemia, and preoperative use of a cane.

DISCUSSION

Important predictors identified for return to driving were sex, joint laterality, limited ability to walk or ability to break, and feeling safe. Surgeons should consider these factors when counseling patients on their postoperative expectations regarding driving after TJA.

[Evaluation of driving fitness in patients with musculoskeletal disorders : A systematic review]

OBJECTIVE

Driving a motor vehicle is one of the most important aspects of personal mobility in our society. However, there is a lack of evidence regarding driving fitness after orthopedic or trauma surgery-related diseases. Aim of this systematic review was to support the treating physician to determine the individual driving fitness in patients with musculosceletal disorders.

MATERIAL AND METHODS

A systematic analysis was performed using the PubMed database. Following a predefined algorithm, all relevant articles published from 2013 to 2018 were included.

RESULTS

The results were categorized according to the affected part of the body into I. lower extremity and II. upper extremity. Also, results were subcategorized into movement restrictions caused by external joint-braces, musculoskeletal diseases, and postoperative conditions.

CONCLUSION

This article supports the treating physician to individually determine the driving fitness in patients with musculoskeletal disorders. However, only a few standardized tests exist to individually determine the driving fitness in patients with musculoskeletal disorders. A particular shortcoming was observed for impairments of the upper extremity.

Prevalence and Safety of Left-Footed Driving Following Right Foot Surgery Patients Including a Driving Simulation

BACKGROUND

For many patients, returning to driving after right foot and ankle surgery is a concern, and it is not uncommon for patients to ask if driving may be performed with their left foot. A paucity of literature exists to guide physician recommendations for return to driving. The purpose of this study was to describe the driving habits of patients after right-sided foot surgery and assess the safety of left-footed driving using a driving simulator.

METHODS

Patients who underwent right foot or ankle operations between January 2015 and December 2015 were retrospectively identified. A survey assessing driving habits prior to surgery and during the recovery period was administered via a REDCap database through email or telephone. Additionally, simulated driving scenarios were conducted using a driving simulator in 20 volunteer subjects to compare characteristics of left- versus right-footed driving.

RESULTS

Thirty-six of 96 (37%) patients who responded to the survey reported driving with the left foot postoperatively. No trends were found associating left-footed driving prevalence and socioeconomic status. In driving simulations, patients exceeded the speed limit significantly more (P < .001) and hit other vehicles more (P < .026) when driving with the right foot than the left. The time to fully brake and fully release the throttle in response to vehicular hazards was significantly prolonged in left-footed driving compared with right (P = .019 and P = .034, respectively).

CONCLUSION

A significant proportion of right foot ankle surgery patients engaged in left-footed driving during postoperative recovery. Driving with both the right and left foot presents a risk of compromised safety. This study provides novel objective data regarding the potential risks of unipedal left-footed driving using a standard right-footed console, which indicates that driving with the left foot may prolong brake and throttle release times. Further studies are warranted for physicians to be able to appropriately advise patients about driving after foot and ankle surgery.

LEVEL OF EVIDENCE

Level IV, case series.

Driving after Upper or Lower Extremity Orthopaedic Surgery

Orthopaedic procedures can affect patients' ability to perform activities of daily living, such as driving automobiles or other vehicles that require coordinated use of the upper and lower extremities. Many variables affect the time needed before a patient can drive competently after undergoing orthopaedic surgery to the extremities. These variables include whether the patient underwent upper or lower extremity surgery, the country in which the patient resides, whether the right or left lower extremity is involved, whether the dominant arm is involved, whether the extremity is in a cast or brace, whether the patient has adequate strength to control the steering wheel, and whether the patient is taking pain medication. The type and complexity of the procedure also influence the speed of return of driving ability. Few studies provide definitive data on driving ability after upper or lower extremity surgery. Patients should be counseled not to drive until they can control the steering wheel and the pedals competently and can drive well enough to prevent further harm to themselves or to others. This review discusses the limited recommendations in the literature regarding driving motorized vehicles after upper or lower extremity orthopaedic surgery.

Doctor, when can I drive? - Range of motion of the knee while driving a car

BACKGROUND

One of the most important activities of daily living is operating a motor vehicle. With increasing age the prevalence of musculoskeletal disorders such as knee osteoarthritis may interfere with an individual's ability to do so safely. Physicians are tasked with determining a patient's ability to drive and yet the necessary joint range of motion required for driving a car has not been characterized.

METHODS

The range of motion of the right and left knees was recorded using electrogoniometers in 20 healthy subjects while driving a car on three route types (a) city streets, b) country roads and c) highways). Special emphasis was placed on the left knee associated with changing a gear.

RESULTS

The range of motion while driving is 40-80° for the right and 20-85° flexion for the left knee. A significant difference was noted for each side (p < 0.01) with a higher flexion occurring in the left knee (p < 0.01). The average position of the knee while changing a gear (beginning, maximum, ending) was: right: 55°±10°, 62°±10°, 53°±10°; left: 67°±7°, 39°±8°, 66°±8° (mean flexion±standard deviation).

CONCLUSION

This study characterized the knee range of motion that occurs while driving a car. Our data suggests that common driving activities such as accelerating a vehicle or braking can be achieved with the right knee through a limited range of motion. The greater range of motion and the higher flexion of the left knee are mainly attributed to the gear changing. The present data may benefit physicians in their evaluation of driving capability.

Lack of Consensus in Physician Recommendations Regarding Return to Driving After Cervical Spine Surgery

STUDY DESIGN

A cross-sectional study.

OBJECTIVE

The goal of this study is to investigate how surgeons differ in collar and narcotic use, as well as return to driving recommendations following cervical spine surgeries and the associated medico-legal ramifications of these conditions.

SUMMARY OF BACKGROUND DATA

Restoration of quality of life is one of the main goals of cervical spine surgery. Patients frequently inquire when they may safely resume driving after cervical spine surgery. There is no consensus regarding postoperative driving restrictions. This study addresses how surgeons differ in their recommendations concerning cervical immobilization, narcotic analgesia, and suggested timeline of return to driving following cervical spine surgery.

METHODS

Surgeons at the Cervical Spine Research Society annual meeting completed anonymous surveys assessing postoperative patient management following fusion and nonfusion cervical spine surgeries.

RESULTS

Seventy percent of surgeons returned completed surveys (n = 71). About 80.3% were orthopedic surgeons and 94.2% completed a spine fellowship. Experienced surgeons (>15 years in practice) were more likely to let patients return to driving within 2 weeks than less experienced surgeons (47.1% vs. 24.3%, P = 0.013) for multilevel anterior discectomy and fusion (ACDF) and laminectomy with fusion procedures. There were no differences between surgeons practicing inside and outside the USA for prescribing collars or return to driving time. Cervical collars were used more for fusions than nonfusions (57.7% vs. 31.0%, P = 0.001). Surgeons reported 75.3% of patients ask when they may resume driving. For cervical fusions, 31.4% of surgeons allowed their patients to resume driving while restricting them with collars for longer durations. Furthermore, 27.5% of surgeons allowed their patients to resume driving while taking narcotics postoperatively.

CONCLUSION

This survey-based study highlights the lack of consensus regarding patient "fitness to drive" following cervical spine surgery. The importance of establishing evidence-based guidelines is critical, as recommendations for driving in the postoperative period may have significant medical, legal, and financial implications.

LEVEL OF EVIDENCE

5.

Evaluation of driving skills after anterior cruciate ligament reconstruction with hamstring autograft

BACKGROUND

There are no well-established guidelines for safe driving after injury or surgical treatment. The purpose of this study was to assess the aptitude to regain driving skills and brake reaction abilities after anterior cruciate ligament (ACL) surgery.

METHODS

This study compared the driving abilities and skills at four to six weeks after surgery of 31 patients who underwent ACL reconstruction with hamstring autograft with 31 healthy volunteers. Multiple variables, including pedestrian impact, car crash, red traffic light violations, visual reaction time, and other driving abilities were measured with a validated driving simulator.

RESULTS

There was no statistically significant between-group difference with respect to skill, driving ability, and brake reaction times (P > 0.05). The differences between right and left knees were also not statistically significant (P > 0.05). However, patients with a right ACL reconstruction had a higher number of collisions with fixed objects (2.82 vs. 1.84, P = 0.239) and pedestrian impacts (0.23 vs. 0.00 P = 0.221), and had slower brake reaction times (585.69 vs. 456.02 ms, P = 0.069). The Tegner score was similar in each group (7.19 in ACL reconstruction group vs. 6.8 in control group, P = 0.092) and the Lysholm score improved as compared with the presurgical measurement (53.48 vs. 89.61, P < 0.001).

CONCLUSIONS

Anterior cruciate ligament surgery with hamstring autograft did not result in a decrease in driving performance and safety at four to six weeks after surgery with respect to skill, ability to drive, and brake response time.

Patient Safety: Driving After Foot and Ankle Surgery

This article provides a review of the existing literature regarding driving limitations following lower extremity orthopedic surgery. Medicolegal requirements and insurance recommendations are often vague and subject to interpretation. Several studies have examined the impact of surgery and immobilization on brake reaction time. This study summarizes the findings of these studies. Additionally, the authors consider the impact of lower extremity amputations and peripheral vascular disease on driving. Literature regarding opioid use, obesity, sleep apnea, increasing age, and distraction is also reviewed. An improved understanding of these topics will enhance the orthopedic surgeon's ability to counsel patients and optimize their safety.

A Systematic Summary of Systematic Reviews on the Topic of the Rotator Cuff

BACKGROUND

The number of systematic reviews and meta-analyses published on the rotator cuff (RC) has increased markedly.

PURPOSE

To quantify the number of systematic reviews and meta-analyses published on the RC and to provide a qualitative summary of the literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search for all systematic reviews and meta-analyses pertaining to the RC published between January 2007 and September 2017 was performed with PubMed, MEDLINE, and the Cochrane Database of Systematic Reviews. Narrative reviews and non-English language articles were excluded.

RESULTS

A total of 1078 articles were found, of which 196 met the inclusion criteria. Included articles were summarized and divided into 15 topics: anatomy and function, histology and genetics, diagnosis, epidemiology, athletes, nonoperative versus operative treatment, surgical repair methods, concomitant conditions and surgical procedures, RC tears after total shoulder arthroplasty, biological augmentation, postoperative rehabilitation, outcomes and complications, patient-reported outcome measures, cost-effectiveness of RC repair, and quality of randomized controlled trials.

CONCLUSION

A qualitative summary of the systematic reviews and meta-analyses published on the RC can provide surgeons with a single source of the most current literature.

Examination of Early Functional Recovery After ACL Reconstruction: Functional Milestone Achievement and Self-Reported Function

Background:

Few studies have documented early functional recovery after anterior cruciate ligament (ACL) reconstruction.

Purpose:

To quantify the time to early functional milestone achievement and change in function over 12 weeks after ACL reconstruction and to identify demographic characteristic predictors of the outcomes.

Study Design:

Prospective, longitudinal, observational study.

Level of Evidence:

Level 4.

Methods:

A total of 182 patients (95 females, 87 males; mean ± SD age, 28 ± 12 years; mean ± SD body mass index [BMI], 25 ± 4 kg/m²) who received primary, unilateral, ACL reconstruction were included. Testing occurred before surgery as well as 1, 2, 4, 8, and 12 weeks postsurgery. Outcomes included demographic characteristics, self-reported functional milestone achievements and responses on the Short Musculoskeletal Function Assessment (SMFA) questionnaire. Time to functional milestone achievement was calculated, and patients were categorized into “faster” or “prolonged” recovery groups based on the median value. Longitudinal change in SMFA subscale scores (daily activities and mobility) as well as demographic predictors of functional recovery group assignment and postsurgical change in SMFA subscale scores were examined.

Results:

Median time for discontinuing narcotic pain medication was 9 days, while that for discontinuing crutches was 15 days. Time to return to work occurred at a median of 11 days, return to school at 7 days, and return to driving at 11 days. Both SMFA subscale scores significantly decreased (improved) over time, with the greatest change occurring between 1 and 4 weeks postsurgery. The demographic predictor of faster functional recovery for discontinuation of narcotic pain medication was surgery with allograft; those for return to work were higher age, male sex, decreasing BMI, and sedentary/light occupational demand; and those for return to driving were higher age, male sex, and surgery on the left side of the body.

Conclusion:

Functional recovery occurs rapidly over the first month after ACL reconstruction for most patients. Nonmodifiable demographic characteristics may influence recovery time for specific functional milestones.

Clinical Relevance:

Results can be used to counsel patients on early functional recovery after ACL reconstruction.

Return to Driving After Arthroscopic and Related Surgery: Before Patients Start, How Do We Know They Can Stop?

When can patients safely drive after surgery? It is neither scientific nor prudent to rely on patients' judgment. A goal is to develop objective data to support evidence-based decision making and lower the rate of postoperative complications, including motor vehicle accidents. In addition, it is obvious and evidence-based that patients should not drive while wearing an arm sling, and while the evidence is mixed, we advise that patients should not return to driving while taking opioid pain medications.

Defining the upper extremity range of motion for safe automobile driving

BACKGROUND

There are no guidelines for return to driving following upper extremity injury. A greater comprehension of the role of the upper extremity in driving is required to assist clinicians in their fitness-to-drive assessments. This research aims to assist clinicians by analyzing the motion at the upper extremity in safe automobile driving.

METHODS

Thirty-six participants were recruited to the Monash University Accident Research Centre's driving simulator. They were tested in a realistic driving simulation using highway scenarios and traffic hazards. An OptiTrack™ motion tracking system recorded participants' upper limb movements.

FINDINGS

The following ranges of motion were recorded (left and right arm mean whole numbers): The shoulder flexed from 14 to 54°, abducted to 18°and adducted to 9°. Shoulder rotation ranged from 6° external to 32° internal rotation. Elbow flexion ranged from 35° to 72°. Pronation reached 77° and supination to 24°. Wrist flexion reached 34° and extension reached 23°. The wrist deviated to 17°radially and 38° ulnar. To avoid simulated hazards, the steering wheel revolved 57.2° (SD 19.2). The key movements in hazard avoidance are shoulder flexion, shoulder rotation, forearm rotation and wrist deviation.

INTERPRETATION

Shoulder flexion, internal rotation and forearm rotation have been shown to be key upper extremity movements in safe driving. Clinicians can refer to the ranges of motion recorded in this investigation, or the driving task at hand in their fitness-to-drive assessments. The ability to revolve the steering wheel 100° exceeds the 95th percentile of the steering wheel revolution angle required to avoid simulated traffic hazards.

Reaction Time and Brake Pedal Depression Following Arthroscopic Hip Surgery: A Prospective Case-Control Study

PURPOSE

The purpose of this study was to determine whether patients diagnosed with femoroacetabular impingement (FAI) syndrome have prolonged braking times compared with age- and gender-matched controls and how long after surgery braking times return to preoperative baseline.

METHODS

Fifty-nine patients undergoing arthroscopic hip surgery for FAI and 59 age- and gender-matched controls without FAI were enrolled in a prospective comparative study between September 2015 and October 2016. Total brake reaction time (BRT) and brake pedal depression (BPD) were measured for study patients preoperatively, and at 2, 4, and 6 weeks postoperatively. BRT and BPD were compared between study and control patients and between preoperative and postoperative time periods, using mixed effects models.

RESULTS

Patients with FAI had significantly prolonged BRT (but not BPD) prior to surgery compared with controls (568 vs 520 msec, P = .002). For study patients undergoing left hip surgery, there was no difference in BRT or BPD between preoperative measurements and any postoperative time point, including the first postoperative appointment at 2 weeks (563 vs 566 msec, P = .89). Patients undergoing right hip surgery had significantly prolonged BRT at 2 weeks postoperatively compared with their preoperative baseline (688 vs 573 msec, P < .001). By 4 weeks postoperatively, study patients undergoing right hip surgery had returned to their preoperative baseline (573 vs 594 msec, P = .28). No significant effect was seen based on visual analog scale pain score, opiate usage, or patient-reported outcome scores.

CONCLUSIONS

Patients undergoing arthroscopic surgery of the right hip show significantly prolonged BRT until 4 weeks after surgery, while patients undergoing surgery of the left hip show no postoperative impairment in either BRT or BPD. The clinical relevance of this measured difference (an increase in 10 feet of stopping distance at 60 miles per hour) remains an open question.

LEVEL OF EVIDENCE

Level II, diagnostic, prospective.

Braking Time Following Total Knee Arthroplasty: A Systematic Review

BACKGROUND

Currently, no guidelines exist to assist surgeons in providing recommendations to patients undergoing total knee arthroplasty (TKA) on when it is safe to return to driving. The purpose of this systematic review is to analyze the best available literature to assist surgeons in providing evidence-based recommendations on when it is safe to return to driving after TKA.

METHODS

Following established methodology for the conduct of systematic reviews, a literature search was performed for prospective studies on driving after TKA. Two reviewers screened citations for inclusion, assessed methodological quality, and extracted data.

RESULTS

Nine studies with 330 subjects met the inclusion criteria. Normalization of brake response time, movement time, and reaction time to preoperative baseline was assessed by pooling data across studies between 0 and 4 weeks and >4 weeks after TKA. Patients who underwent left TKA and right TKA showed normalization by 2 and 4 weeks, respectively. The limited studies that evaluated brake response time, movement time, and reaction time prior to 2 weeks postoperatively also showed normalization to preoperative levels.

CONCLUSION

Patients with right TKA have normalization of braking time by 4 weeks, and normalization is as early as 2 weeks following left TKA. Surgeons must consider these recommendations and other patient factors that determine fitness to drive prior to deeming a patient safe to return to driving.

When is it safe to resume driving after total hip and total knee arthroplasty? a meta-analysis of literature on post-operative brake reaction times

AIMS

The aim of this study was to assess the current available evidence about when patients might resume driving after elective, primary total hip (THA) or total knee arthroplasty (TKA) undertaken for osteoarthritis (OA).

MATERIALS AND METHODS

In February 2016, EMBASE, MEDLINE, Web of Science, Scopus, Cochrane, PubMed Publisher, CINAHL, EBSCO and Google Scholar were searched for clinical studies reporting on 'THA', 'TKA', 'car driving', 'reaction time' and 'brake response time'. Two researchers (CAV and JJT) independently screened the titles and abstracts for eligibility and assessed the risk of bias. Both fixed and random effects were used to pool data and calculate mean differences (MD) and 95% confidence intervals (CI) between pre- and post-operative total brake response time (TBRT).

RESULTS

A total of 19 studies were included. The assessment of the risk of bias showed that one study was at high risk, six studies at moderate risk and 12 studies at low risk. Meta-analysis of TBRT showed a MD decrease of 25.54 ms (95% CI -32.02 to 83.09) two weeks after right-sided THA, and of 18.19 ms (95% CI -6.13 to 42.50) four weeks after a right-sided TKA, when compared with the pre-operative value.

CONCLUSION

The TBRT returned to baseline two weeks after a right-sided THA and four weeks after a right-sided TKA. These results may serve as guidelines for orthopaedic surgeons when advising patients when to resume driving. However, the advice should be individualised. Cite this article: Bone Joint J 2017;99-B:566-76.

The effects of below-elbow immobilization on driving performance

INTRODUCTION

There is limited research to guide physicians and patients in deciding whether it is safe to drive while wearing various forms of upper extremity immobilization. The purpose of this study is to evaluate the effect of below-elbow removable splints and fiberglass casts on automobile driving performance.

METHODS

20 healthy subjects completed 10 runs through a closed, cone-marked driving course while wearing a randomized sequence of four different types of immobilization on each extremity (short arm thumb spica fiberglass cast, short arm fiberglass cast, short arm thumb spica splint, and short arm wrist splint). The first and last driving runs were without immobilization and served as controls. Performance was measured based on evaluation by a certified driving instructor (pass/fail scoring), cones hit, run time, and subject-perceived driving difficulty (1-10 analogue scoring).

RESULTS

The greatest number of instructor-scored failures occurred while immobilized in right arm spica casts (n=6; p=0.02) and left arm spica casts (n=5; p=0.049). The right arm spica cast had the highest subject-perceived difficulty (5.2±1.9; p<0.001). All forms of immobilization had significantly increased perceived difficulty compared to control, except for the left short arm splint (2.5±1.6; p>0.05). There was no significant difference in number of cones hit or driving time between control runs and runs with any type of immobilization.

CONCLUSIONS

Drivers should use caution when wearing any of the forms of upper extremity immobilization tested in this study. All forms of immobilization, with exception of the left short arm splint significantly increased perceived driving difficulty. However, only the fiberglass spica casts (both left and right arm), significantly increased drive run failures due to loss of vehicle control. We recommend against driving when wearing a below-elbow fiberglass spica cast on either extremity.