No association between preoperative physical activity level and time to return to work in patients after total hip or knee arthroplasty: A prospective cohort study

Early functional recovery outcomes and return to work after primary total hip arthroplasty: a novel patient reported outcomes questionnaire

PURPOSE

Clinical and patient reported outcomes are often collected before and after the procedure to benchmark and study outcomes for patients. These outcomes and scores are useful for tracking patient outcomes after surgery, however, the fact that these commonly used measures typically provide information about a patient's level of pain and function at a single point in time is a limitation.

METHODS

We present early functional recovery and return to work outcomes after primary THA from a novel questionnaire administered in a global, multi-center, prospective clinical study.

RESULTS

By 6 and 12 weeks post-op, a large proportion of study subjects were able to perform functional recovery outcomes after their THA: walk without an aid (74%; 94%); drive (76%; 97%); basic activities of daily living (94%; 99%); perform light household duties (91%; 96%); perform moderate-to-heavy household duties (54%; 86%); go up and down a flight of stairs (92%; 99%); put on socks/stockings (77%; 93%); bend down to pick up an object from the floor (87%; 97%); stand up from a chair (96%; 99%); perform leisure recreational activities (54%; 84%); perform primary goal identified pre-THA (69%; 86%). 60% were able to return to work by 12 weeks post-op. These questions showed strong association with the Forgotten Joint Score.

CONCLUSION

Excellent patient reported early functional recovery outcomes and satisfaction were observed at 6- and 12-weeks post-op in this cohort and is the first reported data using a novel PRO.

CLINICAL TRIAL REGISTRATION

NCT03189303, registered June 14, 2017.

Eight of ten patients return to daily activities, work, and sports after total knee arthroplasty

BACKGROUND

Besides return to work (RTW) and return to sports (RTS), patients also prefer to return to daily activities (RTA) such as walking, sleeping, grocery shopping, and domestic work following total knee arthroplasty (TKA). However, evidence on the timelines and probability of patients' RTA is sparse.

AIM

To assess the percentage of patients able to RTA, RTW, and RTS after TKA, as well as the timeframe and influencing factors of this return.

METHODS

A retrospective cohort study with prospectively collected data was conducted at a medium-sized Dutch orthopedic hospital. Assessments of RTA, RTW, and RTS were performed at 3 mo and/or 6 mo following TKA. Investigated factors encompassed patient characteristics, surgical characteristics, and preoperative patient-reported outcomes.

RESULTS

TKA patients [n = 2063; 66 years old (interquartile range [IQR]: 7 years); 47% male; 28 kg/m2 (IQR: 4 kg/m2)] showed RTA ranging from 28% for kneeling to 94% for grocery shopping, with 20 d (IQR: 27 d) spent for putting on shoes to 74 d (IQR: 57 d) for kneeling. RTW rates varied from 62% for medium-impact work to 87% for low-impact work, taking 33 d (IQR: 29 d) to 78 d (IQR: 55 d). RTS ranged from 48% for medium-impact sports to 90% for low-impact sports, occurring within 43 d (IQR: 24 d) to 90 d (IQR: 60 d). One or more of the investigated factors influenced the return to each of the 14 activities examined, with R² values ranging from 0.013 to 0.127.

CONCLUSION

Approximately 80% of patients can RTA, RTW, and RTS within 6 mo after TKA. Return is not consistently influenced by predictive factors. Results help set realistic pre- and postoperative expectations.

Return to Sports and Return to Work After Total Hip Arthroplasty: A Systematic Review and Meta-analysis

BACKGROUND

Return to work (RTW) and sports (RTS) are critical gauges to improvement among patients after total hip arthroplasty (THA). This study aimed to determine rates, timelines, and prognostic factors associated with RTW and RTS outcomes after primary THA.

METHODS

A systematic review was conducted on MEDLINE, EMBASE, and CENTRAL databases with 57 studies meeting inclusion/exclusion criteria. The risk of bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions and risk of bias in randomized trials (RoB2) tools. Meta-analysis and pooled analysis were conducted, with forest plots to summarize odds ratios and 95% confidence interval (CI).

RESULTS

The pooled RTW rate across all studies was 70% (95% CI, 68%-80%), with rates varying significantly from 11% to 100%. The mean time to RTW was 11.2 weeks (range 1-27). A time point analysis showed increasing RTW rates with a maximum rate at 2 years of 90%. Increased age (p < 0.001) and preoperative heavy labor (p = 0.005) were associated with lower RTW rates. The RTS rate ranged from 42% to 100%, with a pooled rate of 85% (95% CI, 74%-92%). The mean time to RTS was 16.1 weeks (range 8-26). The RTS ranged from 20% to 80% with a pooled proportion of 56% (95% CI, 42%-70%, I2 = 90%) for high-intensity sports and from 75% to 100% for low-intensity sports with a pooled proportion of 97% (95% CI, 83-99, I2 = 93%).

CONCLUSION

Most patients RTW and RTS after THA in an increasing manner as time passes with rates more than 85% after 1 year. These rates may be greatly affected by various factors, most notably age, the intensity of the sport, and the type of work performed. In general, young patients, low-demand work or sports can be resumed as soon as 4 to 6 weeks after surgery, but with increased restrictions as the intensity increases. This information should be used by practitioners to manage postoperative expectations and provide appropriate recommendations to patients.

LEVEL OF EVIDENCE

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

Novel Use of an Accelerometer to Assess Load Asymmetry Over Time After Hip Resurfacing Arthroplasty

INTRODUCTION

There is limited knowledge regarding usage of wearable technology to guide return to sport after hip resurfacing arthroplasty (HRA). This study evaluated the use of accelerometers to identify when symmetry is restored between operative and non-operative limbs.

METHODS

A total of 26 primary HRA patients performed five validated physical tests before, 3 and 6 months after HRA: broad jump, double leg vertical jump (DLVJ), hop test, lateral single leg jump (LSLJ), and vertical single leg jump (VSLJ). Impact load and average intensity data (g-force units) were collected using accelerometers. Strength data (pounds (lbs.)) for internal and external rotation was collected with a dynamometer. Univariate and correlation analyses analyzed interlimb asymmetries.

RESULTS

At pre-operation, there were significant impact load asymmetries for DLVJ (P=.008), hop test (P=.021), and LSLJ (P=.003), and intensity asymmetry for DLVJ (P=.010) and LSLJ (P=.003). At 3 months, there was impact load asymmetry for DLVJ (P=.005) and LSLJ (P=.005), and intensity asymmetry for broad jump (P=.020), hop test (P=.042), and LSLJ (P=.005). There were significant strength asymmetries at pre- and 3 months post-operation for internal (P=.013) and external rotation (P=.037). All significant asymmetries indicated the non-operative leg had greater output. No significant asymmetries were found for any exercises at 6 months post-operation. An increase in Harris Hip Score was significantly associated with a decrease in impact asymmetry (r_s = -0.269, P=.006).

DISCUSSION AND CONCLUSION

Impact loads and strength reach interlimb symmetry at 6 months post-HRA. Wearable accelerometers provide useful metrics to distinguish limb asymmetries for recovery monitoring.

Return to work following primary total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND

Total hip arthroplasty (THA) is increasingly common in younger patients, who are more likely to be working preoperatively. There is a need for an updated review of the literature regarding the rate and time to return to work (RTW), which is important when counseling patients, and also from an economic standpoint.

METHODS

A systematic review and meta-analysis of the literature was performed on January 20, 2022, and studies reporting the rate and/or time to RTW after THA were included. Two authors independently selected relevant papers. RTW was extracted and analyzed using fixed-effects or random-effects models where appropriate.

RESULTS

A total of 48 studies were included in the final analysis. We found that 70.7% of patients were working after primary THA. Among patients who were working before surgery, this rate increases to 87.9%, while 28.1% of patients who were not working preoperatively started working after surgery. Younger patients were more likely to RTW, while patients with a physically demanding job were less likely to RTW. Minimally invasive techniques were reported to yield a higher rate of RTW and an earlier time to RTW.

CONCLUSION

We found that the majority of patients return to work after THA, and some patients are able to start working after surgery. Compared to previous reviews, patients seem to have a higher rate and earlier RTW. The overall trend of the literature suggests that patients are returning to work earlier and at a higher rate compared to previous reviews.

Return to Work after Primary Total Knee Arthroplasty under the Age of 65 Years: A Systematic Review

A growing number of patients undergoing total knee arthroplasty (TKA) is at working age and need to return to work (RTW) after surgery. The aim of this systematic review is to give an overview of the literature regarding RTW after TKA and beneficial and limiting factors influencing this process. A systematic search in four electronic databases was conducted in November 2019 to identify studies describing RTW after primary TKA in patients aged 65 years or younger. Study characteristics and data on work status before and after surgery were extracted. All studies were assessed for risk of bias. Fourteen studies published between 2009 and 2019 were included in this review, accounting for a total of 3,073 patients. The percentage of patients working after TKA ranged from 36 to 89%, and the fraction of patients working before and returning to work after surgery ranged from 40 to 98%. Mean time of RTW ranged from 7.7 to 16.6 weeks. Most important factors associated with a slower or no RTW were a more physical nature of employment and preoperative absence from work. The majority of patients undergoing TKA returned to work postoperatively. However, comparison between studies is seriously hampered by the wide variation regarding the definition and timeframe used to measure the work status. Therefore, standardized outcome measures for studies investigating RTW after TKA are warranted. We identify this review as level-I evidence (systematic review of level-I and level-II studies).

Overstretching Expectations May Endanger the Success of the “Millennium Surgery”

Total hip arthroplasty (THA) is an extremely successful treatment strategy. Patient expectations, however, have increased; if not properly guided by surgeons, at present, patients expect next to pain-free restoration of the joint and a fast return to work and sports. While the revision rates after THA also increased in younger patients, knowledge on musculoskeletal loads still remains sparse, and the current recommendations on postoperative rehabilitation are based on expert opinions only. The aim of this study was to unravel biomechanical contact conditions in “working age” (&lt;60 years, 53.5 ± 3.0 years) and “retirement age” (&gt;60 years, 67.7 ± 8.6 years) patients during activities recommended post-THA. We hypothesized that working age patients would show substantially increased hip contact loads compared to older patients. The in vivo joint contact force (Fres) and torsion torque (Mtors), reflecting the main contact load situation, experienced during activities of daily living and sports activities were measured in a unique group of 16 patients with instrumented THA. We summarized patient activities and sports recommendations after THA mentioned within the literature using PubMed (without claim of completeness). The measurements showed that younger working age patients experienced significant (p = 0.050) increased Mtors (21.52 ± 9.11 Nm) than older retirement age patients (13.99 ± 7.89 Nm) by walking. Bowling, as a recommended low-impact sport, was associated with Fres of up to 5436 N and Mtors of up to 108 Nm in the working age group, which were higher than the Fres (5276 N) and Mtors (71 Nm) during high-impact soccer. Based on our results, age was proven to be a discriminator in joint loading, with working age patients presenting with increased loads compared to retirement age patients, already during daily activities. The current patient recommendations have led to further increased joint loadings. If THA cannot be delayed in a patient, we propose counselling patients on a carefully considered return to sports, focusing on low-impact activities, as indicated hereby. The findings from this work illustrate the need to provide critical feedback to patient expectations when returning to work and sports activities. Patients returning to more intensive sports activities should be carefully monitored and advised to avoid as much overloading as possible.

Return to work after primary total hip or knee arthroplasty. First French study. Retrospective study of 241 cases

INTRODUCTION

The quality and reliability of the results of primary total hip or knee arthroplasty (THA, TKA) have allowed indications to be extended to younger, working-age patients, raising the issue of return to work. This question has never been specifically addressed in THA and TKA in a French population. We therefore conducted a retrospective study to determine: (1) the rates and intervals of return to work, and (2) factors affecting return to work and reasons for non-return.

HYPOTHESIS

Rates and intervals of return to work are comparable to those in Western countries as a whole: 1.1-10.5 weeks in THA and 8-12 weeks in TKA.

MATERIAL AND METHOD

A single-center retrospective study included patients aged under 65 at surgery, between 2009 and 2013. A questionnaire collected population and occupational data. The patients' occupational situation was collected at a minimum 1 year postoperatively. During the study period, 289 TKAs or THAs were performed; 241 patients were recontacted, 144 of whom had been working at the time of surgery: 72 THAs and 72 TKAs. The sex-ratio was well balanced: 69 males, 75 females. Mean age was 55.8±8 years (range, 18.6-65.7 years). The mean time from surgery to data collection was 34.5 months (95% CI, 32.2-36.8 months).

RESULTS

In all, 86 patients (57.6%) returned to work, at a mean 124 days (range, 15-540 days; 95% CI, 102.8-144.4 days). At 3 months, 55.4% of patients (n=46) had returned to work, and 97.6% (n=81) at 12 months. In most cases, patients returned to the same occupation.

CONCLUSION

The study hypothesis was not confirmed. French primary THA or TKA patients returned to work later and less frequently than in other Western countries.

LEVEL OF EVIDENCE

IV, retrospective study without control group.

Return to work and productivity loss after surgery: A health economic evaluation

BACKGROUND

We aimed to identify preoperative psychosocial factors associated with return-to-work (RTW) and the associated cost of productivity loss due to work absenteeism following surgery. Research demonstrates a high economic burden from productivity loss after surgery, but the comparative cost of productivity loss relative to income across different operations has not been examined.

MATERIALS AND METHODS

A mixed surgical cohort recruited for a randomized controlled trial were prospectively followed for up to two years following surgery with daily phone assessments to three months, weekly assessments thereafter to six months, then monthly assessments thereafter to determine RTW status, opioid use and pain.

RESULTS

183 of 207 (88.3%) patients in paid employment prior to surgery, who provided at least one day of follow-up, were included in this analysis. The average cost of productivity loss due to work absenteeism was $13 761 (median $9064). Patients who underwent total knee replacement incurred the highest income loss. Medical claims filed before surgery were significantly associated with relative income loss (AOR 5.09; 95% CI 1.73-14.96; p < 0.01) and delayed postoperative RTW. Elevated preoperative PTSD symptoms were associated with delayed RTW (HR 0.78; 95%CI 0.63-0.96; p-value = 0.02) while male gender (HR 1.63; 95%CI 1.11-2.38; p-value = 0.01) was associated with faster postoperative RTW.

CONCLUSION

Surgery places a high economic burden on individuals due to postoperative productivity loss. Multidisciplinary approaches, such as pathways, that facilitate the operation and recovery may mitigate the economic consequences for patients, employers, and the healthcare system.