Driving after orthopedic surgery

On the Road Again: Return to Driving Following Minor Hand Surgery

BACKGROUND

Patient return-to-driving following minor hand surgery is unknown. Through daily text message surveys, we sought to determine return-to-driving after minor hand surgery and the factors that influence return-to-driving.

METHODS

One hundred five subjects undergoing minor hand surgery received daily text messaging surveys postoperatively to assess: (1) if they drove the day before and if so; (2) whether they wore a cast, sling, or splint. Additional patient-, procedure-, and driving-related data were collected.

RESULTS

More than half of subjects, 54 out of 105, returned to driving by the end of postoperative day #1. While patient-related factors had no effect on return-to-driving, significant differences were seen in anesthesia type, procedure laterality, driving assistance, and distance. Return-to-driving was significantly later for subjects who had general anesthetic compared to wide awake local anesthetic with no tourniquet (4 ± 4 days vs 1 ± 3 days, P = 0.020), as well as for bilateral procedures versus unilateral procedures (5 ± 5 days vs 1 ± 3 days, P = 0.046). Lack of another driver and driving on highways led to earlier return-to-driving (P = 0.040 and, P = 0.005, respectively).

CONCLUSIONS

Most patients rapidly return to driving after minor hand surgery. Use of general anesthetic and bilateral procedures may delay return-to-driving. Confidential real-time text-based surveys can provide valuable information on postoperative return-to-driving and other patient behaviors.

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.

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.

Understanding clinician strategies for discussing driving fitness with patients: An initiative to improve provider-patient discussions about safe driving

Objective: A frequently overlooked factor contributing to traffic crashes is driver medical conditions, including cognitive and physical impairments, which can compromise individuals' ability to drive safely. Clinicians are in a critical position (and often legally mandated) to identify patients with impairments that may affect their driving ability and counsel them on appropriate next steps. However, prior studies revealed that provider-patient discussions about driving occurred relatively infrequently and that clinician recommendations about when patients could resume driving varied substantially (Chen et al. 2008; Drazkowski et al. 2010). This research aimed to document current driver fitness assessment practices among neurology and neurosurgery clinicians at an academic medical center, with the overall purpose of informing quality improvement efforts.Methods: A cross-sectional, anonymous survey was distributed to physicians and advanced practice providers working in the neurosurgery and neurology departments of a large, Pennsylvania-based academic medical center. Survey question domains included: 1) frequency of discussions about driving, 2) comfort discussing driving with patients, 3) criteria used to assess patient fitness to drive, 4) driver rehabilitation program referral practices, and 5) Pennsylvania Department of Transportation (PennDOT) reporting.Results: The survey revealed that although most providers (68%) had high levels of perceived responsibility for counseling patients about driving, a minority regularly discussed driving issues with their patients (19% prior to discharge, 49% during clinic visits). In addition, only about half (54%) of providers reported having ever filed a report about a patient with the PennDOT, despite Pennsylvania's mandatory driver reporting law. Likelihood of PennDOT reporting was found to be strongly associated with provider knowledge of Pennsylvania unsafe driver reporting laws (p < 0.001).Conclusions: These findings highlight a need to enhance standard of care practices related to driver screening, counseling, and reporting. Overall, providers recognized the importance of their role in advising patients about safe driving and desired standardized protocols for guiding conversations about driving with patients, PennDOT reporting, and referring patients to driver rehabilitation services.

Surgical site, gender, and place of residence influence the time to resume driving after total joint arthroplasty

BACKGROUND

For a large proportion of the population, especially those residing in the countryside, the use of a car for daily activities is indispensable. Following a TKA or THA procedure, the overseeing physician will usually recommend refraining from driving, sometimes up to 12 weeks after surgery with a major social and economical impact on patient's life.

OBJECTIVE

Considering the legal stipulations in Germany regarding fitness to drive a motor vehicle, the aim of this study is to determine the time point when patients after total knee arthroplasty (TKA) or total hip arthroplasty (THA) take up driving again postoperatively. Further, we assessed the replaced joint, side, gender, place of residence and physician's recommendations influencing the patient in making the decision to start driving again.

METHODS

92 eligible participants, contained within the frame of a prospective experimental observational study, were contacted via telephone 12 weeks after surgery and interviewed using a structured questionnaire. The answers were statistically analysed using SPSS® Version 26 for Windows.

RESULTS

Male participants resumed driving between the 6th and 7th week post-surgery, female participants resumed driving between the 8th and 9th week post-surgery. For 58.6% of patients the reason for the first post-operative use of a vehicle was medical: the journey to physical therapy or to a doctor's appointment. There were statistically significant differences regarding operated side, gender and place of residence. TKA impaired patients the most. Patients recovering from a TKA drove considerably later. Patients recovering from a right sided TKA had an increased risk (9 times) not to become an "early driver". Female patients who underwent TKA had an increased risk by a factor of 21 of becoming a "late driver". In the ageing population, surgeons, physical therapists and rehabilitation professionals need to consider new approaches in providing options for patients' mobility. Interestingly, there is a different need for early use of own vehicle in rural regions whereas in cities patients start driving later. There are clear differences between gender and surgical site.

CONCLUSIONS

The rehabilitation following a right sided TKA proved a challenge with regard to the reuptake of driving. This should be taken into account when planning the course of therapy for patients who are driving regulary. Female patients could benefit from special training.

TRIAL REGISTRATION

retrospectively registered, DRKS00018693 https://www.drks.de/drks_web/navigate.do?navigationId=trial . HTML&TRIAL_ID=DRKS00018693.

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.

Doctor, when can I drive?-the range of elbow motion while driving a car

BACKGROUND

Immobilization of the upper extremity after an acute injury or postoperatively affects an individual's ability to safely operate a motor vehicle. The elbow is particularly sensitive to immobilization, with subsequent stiffness leading to functional limitations. Most activities of daily living are successfully achieved within a "functional arc" of elbow motion between 30° and 130° of flexion. No objective guidelines exist regarding the range of motion needed to safely operate a vehicle. In this study, we measured the range of motion of right and left elbows while driving a manual-transmission car.

MATERIALS AND METHODS

Using electro-goniometers, we measured the flexion and extension, as well as pronation and supination, of the right and left elbows in 20 healthy, right hand-dominant subjects while driving a car. These measurements were recorded on (1) city streets, (2) country roads, and (3) highways.

RESULTS

For city streets, the range of motion in terms of flexion and pronation/supination was 15°-105° and 0°-45°/0°-35°, respectively, for the right elbow and 20°-95° and 0°-45°/0°-40°, respectively, for the left. For country roads, it was 10°-100° and 0°-40°/0°-35°, respectively, for the right elbow and 20°-95° and 0°-30°/0°-30°, respectively, for the left. For highways, it was 5°-100° and 0°-40°/0°-35°, respectively, for the right elbow and 20°-90° and 0°-30°/0°-25°, respectively, for the left. Mean pronation was significantly higher for the right elbow (P < .01).

CONCLUSION

This study describes the range of elbow motion identified to drive a car with a manual transmission and a left-sided steering wheel. Mean pronation of the right elbow is significantly higher than that of the left. Further studies are needed to investigate the relevance of movement restrictions as they relate to handedness, steering-wheel side, and driving impairment.

A Review of the Effect of Lower-Extremity Pathology on Automobile Driving Function

The effect of lower-extremity pathology and surgical intervention on automobile driving function has been a topic of contemporary interest in the medical literature. The objective of this review was to summarize the topic of driving function in the setting of lower-extremity impairment. Included studies involved lower-extremity immobilization devices, elective and traumatic lower-limb surgery, chronic musculoskeletal pathology, and diabetes as it relates to the foot and ankle, focusing on the effect each may have on driving function. We also discuss the basic US state regulations with respect to impaired driving and changes to automobile structure that can be made in the setting of lower-extremity pathology.

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.

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.

Maternal car driving capacity after birth: a pilot prospective study randomizing postnatal women to early verses late driving in a driving simulator

Background: Women are commonly advised to avoid driving following cesarean section (CS), however, this advice is based upon little evidence.Aims: We aimed to assess a woman's capacity to drive a car postbirth using a driving simulator to objectively examine driving behavior and competencies.Materials and methods: We conducted a pilot, prospective, randomized study from a tertiary referral hospital in Sydney, Australia. Postnatal women who were regular drivers and had given birth by vaginal delivery (VD), elective cesarean section (ElCS) or emergency cesarean section (EmCS) were randomized to early (2-3 weeks post birth) or late (5-6 weeks post birth) driver simulator testing. Driving performance was measured by reaction time to simulated impediments, awareness, attention, braking ability, traffic infringements, and accidents. Analysis was by intention to treat. Outcomes were assessed using contingency analysis via two-sample t-tests and Wilcoxen rank-sum tests.Results: 66 women were randomized and 38 attended simulator testing (57.6%; 19 early, 19 late; 8 VD, 14 ElCS, 16 EmCS). There was no difference in reaction times, driver awareness, braking times, or traffic infringements by early versus late testing (all p > .05), nor by mode of birth (p > .05) amongst the women who completed driver testing. At 7-8 weeks, all women were driving, without an accident.Conclusions: Although the study is limited by small sample size, there was no difference in driving capability by early versus late driving time since birth, nor by mode of birth. Further research is needed, but we cannot provide evidence to discourage well women from driving from 2-3 weeks post birth.

U.S. State Driving Regulations Relevant to Foot and Ankle Surgeons

The effect of lower extremity pathology and surgery on automobile driving has been a topic of contemporary interest, because these conditions can be associated with impaired driving function. We reviewed the U.S. driving laws relative to foot and ankle patients, for the 50 U.S. states (and District of Columbia). We aimed to address the following questions relative to noncommercial driving regulations: does the state have regulations with respect to driving in a lower extremity cast, driving with a foot/ankle immobilization device, driving with acute or chronic lower extremity pathology or disability, those who have undergone foot and/or ankle surgery, and those with diabetes? Full state-specific answers to the preceding questions are provided. Most states had no explicit or specific regulations with respect to driving in a lower extremity cast, a lower extremity immobilization device, or after foot and/or ankle surgery. Most states asked about diabetes during licensing application and renewal, and some asked specifically about lower extremity neuropathy and amputation. Most did not require physicians to report their patients with potentially impaired driving function (Pennsylvania and Oregon excepted) but had processes in place to allow them to do so at their discretion. Most states have granted civil and/or criminal immunity to physicians with respect to reporting (or lack of reporting) of potentially impaired drivers. It is our hope that this information will be useful in the development of future investigations focusing on driving safety in patients with lower extremity dysfunction.

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.

Driving After Microinvasive Total Hip Arthroplasty

BACKGROUND

Patients undergoing total hip arthroplasty (THA) are often advised to avoid driving for 6 weeks postoperation. This is based on patients having to maintain postoperative hip precautions and studies investigating brake reaction time (BRT) following THA using conventional techniques. The aim of this study was to assess patients' ability to drive in the early postoperative period following microinvasive THA by assessing BRT.

METHODS

Hundred consecutive patients undergoing SuperPATH^® THA in 2015 who drove automobiles preoperatively were included in this prospective cohort study. BRT was measured preoperatively and at day 1 or 2 postoperation using a driving simulator. A subset of 25 consecutive patients had repeat BRT testing at 2 weeks postoperation. Five BRT measures were taken at each time point. Differences in the patient's mean and best BRT at each time point were assessed using the paired t-test.

RESULTS

The study cohort included 50 men and 50 women with mean age 63 years (range 25-86). The mean preoperative BRT was 0.63 s (range 0.43-1.44), with a mean difference of -0.1 s (range -0.57 to 0.33, P < .0001) at day 1 or 2 postoperation. The 2-week mean and best BRTs were also better than paired preoperative readings with a mean improvement of 0.15 s (range -0.78 to -0.004, P < .0001).

CONCLUSION

BRT reaches preoperative values by day 2 following microinvasive THA. Patients may be suitable to drive earlier than the previously recommended 6 weeks postoperation.

Diabetic Driving Studies-Part 1: Brake Response Time in Diabetic Drivers With Lower Extremity Neuropathy

Although the effect of lower extremity pathology and surgical intervention on automobile driving function has been a topic of contemporary interest, we are unaware of any analysis of the effect of lower extremity diabetic sensorimotor neuropathy on driving performance. The objective of the present case-control investigation was to assess the mean brake response time in diabetic drivers with lower extremity neuropathy compared with that of a control group and a brake response safety threshold. The driving performances of participants were evaluated using a computerized driving simulator with specific measurement of the mean brake response time and frequency of abnormally delayed brake responses. We analyzed a control group of 25 active drivers with neither diabetes nor lower extremity neuropathy and an experimental group of 25 active drivers with type 2 diabetes and lower extremity neuropathy. The experimental group demonstrated a 37.89% slower mean brake response time (0.757 ± 0.180 versus 0.549 ± 0.076 second; p < .001), with abnormally delayed responses occurring at a greater frequency (57.5% versus 3.5%; p < .001). Independent of a comparative statistical analysis, the observed mean brake response time in the experimental group was slower than the reported safety brake response threshold of 0.70 second. The results of the present investigation provide original data with respect to abnormally delayed brake responses in diabetic patients with lower extremity neuropathy and might raise the potential for impaired driving function in this population.

Diabetic Driving Studies-Part 2: A Comparison of Brake Response Time Between Drivers With Diabetes With and Without Lower Extremity Sensorimotor Neuropathy

We have previously demonstrated an abnormally delayed mean brake response time and an increased frequency of abnormally delayed brake responses in a group of neuropathic drivers with diabetes compared with a control group of drivers with neither diabetes nor lower extremity neuropathy. The objective of the present case-control study was to compare the mean brake response time between 2 groups of drivers with diabetes with and without lower extremity sensorimotor neuropathy. The braking performances of the participants were evaluated using a computerized driving simulator with specific measurement of the mean brake response time and the frequency of the abnormally delayed brake responses. We compared a control group of 25 active drivers with type 2 diabetes without lower extremity neuropathy and an experimental group of 25 active drivers with type 2 diabetes and lower extremity neuropathy from an urban U.S. podiatric medical clinic. The experimental group demonstrated an 11.49% slower mean brake response time (0.757 ± 0.180 versus 0.679 ± 0.120 second; p < .001), with abnormally delayed reactions occurring at a greater frequency (57.5% versus 35.0%; p < .001). Independent of a comparative statistical analysis, diabetic drivers with neuropathy demonstrated a mean brake response time slower than a suggested safety threshold of 0.70 second, and diabetic drivers without neuropathy demonstrated a mean brake response time faster than this threshold. The results of the present investigation provide evidence that the specific onset of lower extremity sensorimotor neuropathy associated with diabetes appears to impart a negative effect on automobile brake responses.

Diabetic Driving Studies-Part 3: A Comparison of Mean Brake Response Time Between Neuropathic Diabetic Drivers With and Without Foot Pathology

We have previously demonstrated an abnormally delayed mean brake response time and an increased frequency of abnormally delayed brake responses in a group of neuropathic diabetic drivers compared with a control group of drivers with neither diabetes nor lower extremity neuropathy. The objective of the present case-control study was to compare the mean brake response time between neuropathic diabetic drivers with and without specific diabetic foot pathology. The braking performances of the participants were evaluated using a computerized driving simulator with specific measurement of the mean brake response time and the frequency of abnormally delayed brake responses. We analyzed a control group of 20 active drivers with type 2 diabetes, lower extremity neuropathy, and no history of diabetic foot pathology and an experimental group of 20 active drivers with type 2 diabetes, lower extremity neuropathy, and a history of diabetic foot pathology (ulceration, amputation, and/or Charcot neuroarthropathy) from an urban U.S. podiatric medical clinic. Neuropathic diabetic drivers without a history of specific foot pathology demonstrated an 11.11% slower mean brake response time (0.790 ± 0.223 versus 0.711 ± 0.135 second; p < .001), with abnormally delayed reactions occurring at a similar frequency (58.13% versus 48.13%; p = .0927). Both groups demonstrated a mean brake response time slower than a suggested threshold of 0.70 second. The results of the present investigation provide evidence that diabetic patients across a spectrum of lower extremity sensorimotor neuropathy and foot pathology demonstrate abnormal automobile brake responses and might be at risk of impaired driving function.

Braking Reaction Time After Right-Knee Anterior Cruciate Ligament Reconstruction: A Comparison of 3 Grafts

PURPOSE

To determine when patients recover the ability to safely operate the brakes of an automobile after a right-knee anterior cruciate ligament reconstruction (ACLR).

METHODS

A computerized driving simulator was used to determine braking ability after an isolated right-knee ACLR. Thirty healthy volunteers were tested at 1 visit to determine normal mean values, and 27 treatment subjects were tested at 1 week, 3 weeks, and 6 weeks after ACLR. Nine study subjects were treated with a patella tendon (BPTB) autograft, 9 were treated with a hamstring (HS) autograft, and 9 were treated with a tibialis anterior (TA) allograft. The driving simulator collected data on brake reaction time (BRT), brake travel time (BTT), and total brake time (TBT) at each visit.

RESULTS

The control group generated a BRT of 725 milliseconds, BTT of 2.87 seconds, and TBT of 3.59 seconds. At week 1, all treatment patients had significant differences compared with controls for BRT, BTT, and TBT, except the BTT of the HS group. At week 3, all measures for the allograft group and the BRT for both autograft groups were no longer significantly different compared with controls, but significant differences were found for TBT in the HS and BPTB groups (P = .03, P = .01). At week 6, BRT, BTT, and TBT were no longer significantly different for either the HS group or BPTB group.

CONCLUSIONS

Patients who underwent a right-knee ACLR with a TA allograft regained normal braking times by week 3 postoperatively. In contrast, those treated with a BPTB or HS autograft demonstrated significantly delayed braking times at 3 weeks but returned to normal braking ability by week 6. Those treated with an autograft had an earlier return of normalized BRT than BTT.

LEVEL OF EVIDENCE

Level III, case-control series.

When Can I Drive After Orthopaedic Surgery? A Systematic Review

BACKGROUND

Patients often ask their doctors when they can safely return to driving after orthopaedic injuries and procedures, but the data regarding this topic are diverse and sometimes conflicting. Some studies provide observer-reported outcome measures, such as brake response time or simulators, to estimate when patients can safely resume driving after surgery, and patient survey data describing when patients report a return to driving, but they do not all agree. We performed a systematic review and quality appraisal for available data regarding when patients are safe to resume driving after common orthopaedic surgeries and injuries affecting the ability to drive.

QUESTIONS/PURPOSES

Based on the available evidence, we sought to determine when patients can safely return to driving after (1) lower extremity orthopaedic surgery and injuries; (2) upper extremity orthopaedic surgery and injuries; and (3) spine surgery.

METHODS

A search was performed using PubMed and EMBASE^®, with a list of 20 common orthopaedic procedures and the words "driving" and "brake". Selection criteria included any article that evaluated driver safety or time to driving after major orthopaedic surgery or immobilization using observer-reported outcome measures or survey data. A total of 446 articles were identified from the initial search, 48 of which met inclusion criteria; abstract-only publications and non-English-language articles were not included. The evidence base includes data for driving safety on foot, ankle, spine, and leg injuries, knee and shoulder arthroscopy, hip and knee arthroplasty, carpal tunnel surgery, and extremity immobilization. Thirty-four of the articles used observer-reported outcome measures such as total brake time, brake response time, driving simulator, and standardized driving track results, whereas the remaining 14 used survey data.

RESULTS

Observer-reported outcome measures of total brake time, brake response time, and brake force postoperatively suggested patients reached presurgical norms 4 weeks after right-sided procedures such as TKA, THA, and ACL reconstruction and approximately 1 week after left-sided TKA and THA. The collected survey data suggest patients resumed driving 1 month after right-sided and left-sided TKAs. Patients who had THA reported returning to driving between 6 days and 3 months postoperatively. Observer-reported outcome measures showed that patients' driving abilities often are impaired when wearing an immobilizing cast above or below the elbow or a shoulder sling on their dominant arm. Patients reported a return to driving on average 2 months after rotator cuff repair procedures and approximately 1-3 months postoperatively for total shoulder arthroplasties. Most patients with spine surgery had normal brake response times at the time of hospital discharge. Patients reported driving 6 weeks after total disc arthroplasty and anterior cervical discectomy and fusion procedures.

CONCLUSIONS

The available evidence provides a best-case scenario for when patients can return to driving. It is important for observer-reported outcome measures to have normalized before a patient can consider driving, but other factors such as strength, ROM, and use of opioid analgesics need to be considered. This review can provide a guideline for when physicians can begin to consider evaluating these other factors and discussing a return to driving with patients. Survey data suggest that patients are returning to driving before observer-reported outcome measures have normalized, indicating that physicians should tell patients to wait longer before driving. Further research is needed to correlate observer-reported outcome measures with adverse events, such as motor vehicle accidents, and clinical tests that can be performed in the office.

LEVEL OF EVIDENCE

Level III, therapeutic study.

PROMIS Computer Adaptive Tests Compared With Time to Brake in Patients With Complex Lower Extremity Trauma

OBJECTIVES

To compare the PROMIS Physical Function and Pain Interference Computer Adaptive Tests (PROMIS PF CAT and PROMIS PI CAT) with time to brake (TTB) in patients with complex lower extremity traumas for evaluating whether patients can safely return to driving.

DESIGN

Prospective.

SETTING

Level-1 trauma center.

PATIENTS

Sixty-three patients with lower extremity injuries to the pelvis, acetabulum, hip, femur, knee, tibia/fibula, ankle, and foot within 15 weeks of treatment.

INTERVENTION

The TTB of patients with complex lower extremity trauma were tested at various time points postoperatively on a computerized driving simulator. Patients concurrently completed PROMIS PF CAT and PROMIS PI CAT.

MAIN OUTCOME MEASURE

Correlations between TTB, PROMIS PF CAT, and PROMIS PI CAT.

RESULTS

The mean TTB for the healthy control group was 0.61 seconds. There was a statistically significant correlation between time since treatment and TTB (B = -0.008 s/d; P = 0.041) for right-sided lower extremity injuries below the knee (tibia/fibula, ankle, foot). TTB for right-sided injuries below the knee also significantly correlated with PROMIS PI CAT (B = 0.022; P = 0.029). The PROMIS PI CAT value was 43 when the healthy control group TTB was equal to 0.61 seconds.

CONCLUSIONS

This study suggests that the PROMIS PI CAT can be used as an adjunct to the TTB in assessing whether a patient can safely return to driving.

Changes in Driving Performance Following Shoulder Arthroplasty

BACKGROUND

With this study, we sought to quantify perioperative changes in driving performance among patients who underwent anatomic or reverse shoulder arthroplasty.

METHODS

Using a driving simulator, 30 patients (20 anatomic and 10 reverse total shoulder arthroplasties) were tested preoperatively and at 2 weeks (PO2), 6 weeks (PO6), and 12 weeks (PO12) postoperatively. The total number of collisions, centerline crossings, and off-road excursions (when the vehicle traversed the lateral road edge), and scores on a visual analog scale (VAS) for pain and the Shoulder Pain and Disability Index (SPADI) were recorded at each driving trial.

RESULTS

The mean number of collisions increased from 5.9 preoperatively to 7.4 at PO2 and subsequently decreased to 5.6 at PO6 and 4.0 at PO12 (p = 0.0149). In addition, the number of centerline crossings decreased from 21.4 preoperatively to 16.3 at PO12 (p < 0.05). Multivariate analysis of the data demonstrated that increased VAS for pain scores, older age, and less driving experience had a negative impact on driving performance.

CONCLUSIONS

Driving performance returned to preoperative levels at 6 weeks after shoulder arthroplasty. By 12 weeks postoperatively, patients demonstrated improved driving performance compared with preoperative performance. On the basis of our findings, clinicians can suggest a window of 6 to 12 weeks postoperatively for the gradual return to driving. However, for patients of older age, with less driving experience, or with greater pain, a return to driving at closer to 12 weeks postoperatively should be recommended.

LEVEL OF EVIDENCE

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

Effect of Variable Lower Extremity Immobilization Devices on Emergency Brake Response Driving Outcomes

The effect of lower extremity pathologic features and surgical intervention on automobile driving function has been a topic of contemporary interest in the orthopedic medical literature. The objective of the present case-control investigation was to assess 3 driving outcomes (i.e., mean emergency brake response time, frequency of abnormally delayed brake responses, and frequency of inaccurate brake responses) in a group of participants with 3 variable footwear conditions (i.e., regular shoe gear, surgical shoe, and walking boot). The driving performances of 25 participants without active right-sided lower extremity pathology were evaluated using a computerized driving simulator. Both the surgical shoe (0.611 versus 0.575 second; p < .001) and the walking boot (0.736 versus 0.575 second; p < .001) demonstrated slower mean brake response times compared with the control shoe gear. Both the surgical shoe (18.5% versus 2.5%; p < .001) and the walking boot (55.5% versus 2.5%; p < .001) demonstrated more frequent abnormally delayed brake responses compared with the control shoe gear. The walking boot (18.0% versus 2.0%; p < .001) demonstrated more frequent inaccurate brake responses compared with the control shoe gear. However, the surgical shoe (4.0% versus 2.0%; p = .3808) did not demonstrate a difference compared with the control shoe gear. The results of the present investigation provide physicians working with the lower extremity with a better understanding on how to assess the risk and appropriately advise their patients who have been prescribed lower extremity immobilization devices with respect to the safe operation of an automobile.

Timeframe for return to driving for patients with minimally invasive knee arthroplasty is associated with knee performance on functional tests

Background

This study hopes to establish the timeframe for a safe return to driving under different speed conditions for patients after minimally invasive total knee arthroplasty and further explores how well various kinds of functional tests on knee performance can predict the patients’ braking ability.

Methods

14 patients with right knee osteoarthritis were included in the present study and instructed to perform three simulated driving tasks at preoperative, 2 weeks postoperative and 4 weeks postoperative.

Results

The results showed that the total braking time at 4 week postoperative has attained the preoperative level at the driving speed 50 and 70 km/hr but not at the driving speed 90 km/hr. It had significantly improving in knee reaction time and maximum isometric force at 4 weeks postoperative. Besides, there was a moderate to high correlation between the scores of the step counts and the total braking time.

Conclusions

Summary, it is recommended that driving may be resumed 4 weeks after a right knee replacement but had to drive at low or moderate speed and the best predictor of safety driving is step counts.

Opportunities for knowledge translation in the decade of road traffic safety

The United Nations has identified road traffic safety as an important objective for the decade 2011-2020. It has implemented a 5-tiered program: improving health care services, improving management of road safety, improving road network safety, improving vehicular safety, and improving road safety legislation. A small body of practical research has been generated by the medical and surgical (including orthopaedic) communities regarding the road traffic safety, but a substantial amount of work remains to be performed. This article will review published research in each of the 5 tiers of the Decade of Action for Road Traffic Safety and will identify areas where research is insufficient or absent, such that new research programming and funding can be developed.

Influence of left- and right-side total hip arthroplasty on the ability to perform an emergency stop while driving a car

OBJECTIVE

To show the possible effect of left- and right-side total hip arthroplasty (THA) on the ability to perform an emergency stop when driving a car.

DESIGN

Inception cohort.

SETTING

A driving simulator using an actual car cabin, specifically developed for the experiment, was used for testing driving ability.

PARTICIPANTS

Patients (N=40; 20 left-side THA/20 right-side THA) were tested preoperatively and in increments of 8 days and 6, 12, and 52 weeks after surgery.

INTERVENTIONS

Left- and right-side THA.

MAIN OUTCOME MEASURES

Reaction time, movement time, total brake response time (TBRT), and maximum brake force.

RESULTS

Eight days postoperatively, measurements on driving performance indicated a slight worsening for all outcome parameters in patients after left-side THA and considerably more worsening in patients after right-side THA. For both patient groups, significant improvements in outcome measures were noted during the 1-year follow-up. Brake force declined significantly in patients with left-side THA (P=.012) and in patients after right-side THA (P<.001). A total of 35% of the patients with right-side THA and 15% with left-side THA could not meet the 600 ms TBRT threshold 6 weeks postoperatively.

CONCLUSIONS

Most patients who underwent right-side THA reached their preoperative baseline 6 weeks after surgery. Most of the patients with left-side THA showed no TBRT limitations 8 days postoperatively. Because of the patients' highly individual rehabilitation course and considering the possible consequences of the premature resumption of driving a motor vehicle, individual examination and recommendation are necessary.