The Journal of Arthroplasty 30 (2015) 627–630

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When Is It Safe for Patients to Drive after Right Total Hip Arthroplasty? Victor H. Hernandez, MD, MS , Alvin Ong, MD, Fabio Orozco, MD, Anne M. Madden, Zachary Post, MD Rothman Institute, Egg Harbor Township, New Jersey

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Article history: Received 9 September 2014 Accepted 10 November 2014 Keywords: Total hip arthroplasty Driving Outcomes Total hip replacement Brake reaction time Drive

a b s t r a c t Old studies recommend 6 weeks post-operative before patients can return to driving safely. This is a prospective study assessing brake reaction time (BRT) after THA. 38 patients underwent a pre-operative, 2, 4 and 6 weeks post-operative BRT test. General linear repeated measurement was used. The mean pre-operative reaction time was 0.635 ± 0.160 seconds SD and 2-week was 0.576 ± 0.137 seconds SD (P = 0.029); 33 patients (87%) were able to reach their baseline time by 2 weeks. The remaining five patients (13%) reached their baseline at the 4-week post-operative. No differences were found with respect to age, gender, and the use of assistive devices. With new techniques in THA, most of patients return to normal times within the 2-week. © 2014 Elsevier Inc. All rights reserved.

Total hip arthroplasty (THA) is a common procedure. Over 300,000 are performed in the United States yearly, with expectations that the frequency will increase dramatically in coming years [1]. Return to normal activity and lifestyle is common and expected. Advances in surgical technique and pain management have decreased patient length of stay in the hospital after surgery as well as accelerated recovery. Modern patient expectations have also changed. A common question from THA patients involves how soon they are able to return to driving. This is an important question because it implies recovery and mobility, and has significant social and economic impact for patients and society. Most surgeons give recommendations for returning to driving after THA based on two studies [2,3] published over a decade ago. In both of these studies, the brake reaction time (BRT) returned to baseline between the 4th and the 8th week after THA. However, in the past 10 years, major advances in THA have resulted in improved outcomes for THA patients in the immediate post-operative period. These advances, including muscle sparing surgical approaches, better pain management and rapid recovery protocols, may have a profound effect on return of BRT baseline. The ability to drive is based on the patients’ sensory, motor, and cognitive ability. This implies the ability to keep both hands on the steering wheel while applying adequate grip, and adequate strength to activate the brake pedal with an optimal reaction time [4]. The brake reaction time (BRT) is measured based on the total time that a person takes to apply the brake of the vehicle after receiving a stimulus

The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2014.11.015. Reprint requests: Victor Hugo Hernandez, MD, MS, Rothman Institute, 2500 English Creek Avenue, Building 1300, Egg Harbor Township, NJ 08234. http://dx.doi.org/10.1016/j.arth.2014.11.015 0883-5403/© 2014 Elsevier Inc. All rights reserved.

to stop the vehicle. This can be measured precisely, objectively and reproducibly in an experimental setting. The purpose of this study was to prospectively evaluate driving safety after THA through the measurement of BRT. Our hypothesis is that patient who undergoes THA with contemporary techniques will return to their baseline before the 4th postoperative week and, thus, return to safe driving much sooner than previously thought possible. Methods and Material After IRB approval, 38 patients who were scheduled for, and underwent, right THA were prospectively evaluated between October 2013 and June 2014 at our institution. Driving performance was evaluated using the BRT that measured brake time after a stimulus. BRT is the sum of the reaction time that it takes the driver to perceive the sensory stimulus, move the right foot from accelerator pedal to the brake pedal, and the time that it takes to apply sufficient pressure to brake (initiate a stop of the vehicle). Every patient in our study underwent right THA. All patients underwent a preoperative assessment to establish a baseline of their BRT. Then, all patients underwent a THA using a muscle sparing approach with a modern press-fit acetabular and femoral component. All patients were treated with the same postoperative pain and rehabilitation protocols and received identical follow-up. Everybody underwent preoperative medical evaluation to diminish the risks of postoperative delirium, urinary retention, and pulmonary and cardiac complications. All patients were managed with spinal anesthesia, a program of multimodal pain management (including minimal use of narcotics) and a rapid mobilization physical therapy protocol. Aspirin was used for DVT prophylaxis and early discharge was utilized whenever possible. The inclusion and exclusion criteria are described in Table 1. Patient demographics were recorded including: age, BMI, co-morbid conditions

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Table 1 Inclusion and Exclusion Criteria. Inclusion

Exclusion

Diagnosis of end-stage right hip degenerative joint disease Avascular necrosis of the right hip Elective primary THA A valid driver’s license

A diagnosis of posttraumatic arthritis Left THA or left advance degenerative joint disease of the hip Revision or conversion surgery Continued use of narcotics at the time of testing

A vehicle with an automatic transmission

foot pedal on the ground in front of his/her right foot, and the light box in front of the patients within a viewing distance on the desk. Patients were instructed to place their right foot on the accelerator pedal and keep it depressed to maintain the illumination of the green lamp. The patients were then instructed to move their right foot from the accelerator pedal to the brake pedal and depress the brake pedal as rapidly as possible when the red lamp on the test light box illuminated. We randomly controlled timing between the illumination of the red and green lamps for two, three, or four seconds. During testing, each subject was given one practice test and three trial times that were collected for data analysis. Statistical Analysis

and gender. A brief history was obtained to rule out the use of preoperative and post-operative narcotics at the time of testing. Patients were then re-tested at 2, 4, 6 and 8 weeks post-operatively, or until their brake reaction time was equal to or less than their pre-operative score. Furthermore, all patients received a questionnaire at each follow-up visit with the following statement, “Based on my reaction time, I think I am ready to drive”, from this statement patients can chose from the following answers: (1) Strongly disagree, (2) Disagree, (3) Neither, (4) Agree and (5) Strongly agree. Patients were allowed to drive when the post-operative reaction time was equal to or less than their pre-operative brake reaction time baseline.

Model/testing Equipment The RT-2S brake reaction timer (Advanced Therapy Products, Inc. Richmond, VA) was used for our study (Fig. 1). The RT-2S is a lightweight and portable brake reaction time simulator that assists driving evaluators in assessing driving safety. Parnell et al have previously validated the RT2S. They found that the RT-2S simple reaction time tester is an appropriate replacement instrument for the AAA brake reaction timer. In fact, it is believed that the RT-2S more accurately reflects simple reaction times than the AAA brake reaction timer, which is no longer being manufactured [10]. The BRT is measured as the time from stimulus to the time an individual fully depresses the brake pedal. The tester randomly controls the illumination of the red and green lamps simulating stop and go traffic or signal lights. The same tester performed all testing in this study to insure consistency and to prevent inter-tester variability. All patients followed a standardized procedure that consisted of sitting in a chair (adjusted individually for each patient) at a desk with the

The SPSS 21 (IBM; Armonk, NY) was used to analyze the data. General linear repeated measurement was used for analysis. A difference of P b 0.05 was considered significant. Power Analysis A power analysis was performed to calculate the number of individuals needed. The nationally recommended safe brake time standard is 1.25 seconds which is based upon several scientific studies looking at BRT in all types of patients, surgical and non-surgical alike [7,4]. The normal brake time was estimated to be 1 second. A Bonferroni correction (i.e., alpha = 0.05) was used for the power analysis. In order to detect a 20% increase in braking time (1200 seconds), with a standard deviation of 0.250 seconds thirty five patients were needed to obtain a power of 0.8. Results Study patients had a mean age of 62 years ± 10.5 SD. The mean preoperative reaction time was 0.635 ± 0.160 seconds SD (range: 0.402 to 1.1 seconds). The mean 2-week reaction time was 0.576 seconds ± 0.137 seconds SD (range: 0.394 to 1.03 seconds) (P = 0.029). Of the 38 study patients, 33 (87%) were able to reach their baseline time (or better) by 2 weeks (pre-operative 0.645 seconds ± SD 0.166) to 2 weeks 0.558 seconds ± SD 0.199 (P = 0.001). The remaining five patients (13%) reached their baseline at the 4-week post-operative test (pre-operative 0.572 seconds ± SD 0.094) to 2 weeks 0.692 seconds ± SD 0.203, to 4 weeks 0.501 second ± SD 0.596 (P = 0.05). Evaluation of confounding variables revealed no differences with respect to age, gender, and the use of assistive devices in the group. Age distribution can be observed in Fig. 2.

Fig. 1. The RT-2S brake reaction timer (Advanced Therapy Products, Inc. Richmond, VA) was used for our study.

V.H. Hernandez et al. / The Journal of Arthroplasty 30 (2015) 627–630

Fig. 2. Age distribution and histogram with normal distribution of our population.

Looking specifically at the 5 patients who did not reach their baseline by two weeks post-operative, we found that they were demographically no different from the 33 successful patients, see Table 2. However, the average pre-operative time for these unsuccessful patients (0.572 seconds) was faster than the other group (0.645 seconds), meaning the 5 who failed to reach their pre-operative time at two weeks had a faster time to achieve to be considered successful. Based on the patient survey, of the 33 patients that returned to baseline at 2 weeks, 24 (73%) stated that they felt they were ready to drive at that time. 5 (15%) patients said they were not sure and 4 (12%) patients stated that they were not ready to drive. Of the 5 patients who returned to baseline at 4 weeks, 3 agreed that they were not able to drive at the 2-week mark, the other 2 thought they were able to drive by 2 weeks. All five stated that they thought they were ready to drive at 4 weeks post-operative. Discussion In the last decade, THA surgical procedures and post-operative protocols have changed dramatically. Changes in surgical technique (muscle sparing surgery, minimal invasive techniques for posterior, lateral and, anterior approach), as well as, improved peri-operative and postoperative care have resulted in accelerated recovery and better muscle function [5,6,8,9]. The effect has been to speed the recovery period and improve short-term outcomes. The objective of this study was to investigate if these new techniques and recovery improvements would translate to shortening of the time to safe driving after THA. In our study we actually found that the BRT improved, on average, from the preoperative value to the 2-week post-operative value (0.635 to 0.576 seconds [P = 0.029]). 87% of patients were able to return to their baseline brake response times, or better, by 2 weeks after right sided THA. We excluded left side surgery because previous studies have shown that left hip surgery does not significantly affect TTB when Table 2 Characteristics of the 5 Patients That Did Not Reached Their Baselines at the 2-Weeks. Patient

Age

Gender

Ta-Pre

T 2-W

T 4-W

PL SN MW EC BM

75 52 51 54 64

Female Male Male Female Female

0.703 0.593 0.454 0.598 0.515

1.03 0.638 0.478 0.640 0.674

0.566 0.567 0.449 0.472 0.455

a

T = Time.

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driving an automatic transmission vehicle where all tasks are performed with the right leg [4]. If the left leg was involved, it has been suggested that driving may be resumed 1 week after surgery [2–4]. Only five patients did not reach their baseline by 2 weeks postoperative, but all of them were able to reach it at the 4-week postoperative test. However, even the five patients that did not return to their baseline by two weeks were still under the nationally recommended safe brake time standard of 1.25 seconds which is based upon several scientific studies looking at BRT in all types of patients, surgical and non-surgical alike [7,4]. When we compared the average 2 week brake time from the 33 successful patients to the average for the 5 unsuccessful patients, the unsuccessful group was only 0.134 seconds slower (0.692 compared to 0.558). Therefore we feel that even the 5 patients who failed to achieve their pre-operative base line by two weeks still posted brake time values which much faster than nationally recognized standards and most likely represented values which would enable them to drive safely. Our findings represent a substantial improvement from current recommendations. Interestingly, 73% of our population was able to predict a safe BRT while only 15% were not. Only 4 patients that actually were able to drive felt they were not able to do so safely demonstrating a high correlation between patient’s safe BRT and their perception of their driving ability on our questionnaire. Driving after musculoskeletal procedures has been the topic of several studies. It is an important measure of return to function for both clinicians and patients. However, recommendations for returning to driving after THA are currently based on studies that are out-dated. The first study was performed in the 80s by McDonald et al [2]. They analyzed 25 patients that underwent THA. In their study most of the patients improved to baseline by eight weeks post-operatively. In another study, published in 2003 by Ganz et al [3], the authors studied 19 THA patients and found that, in general, patients reached their preoperative reaction time between the 4th and the 6th post-operative week and continued to improve over time. Green in his review of almost 40 studies about brake reaction time found that the average time to response (BRT) was 1.25 seconds [7,4]. In our population even those that failed to return to their baseline by 2 weeks were still capable of driving safely according to these studies. Utilizing Green’s criteria all patients in our study would be considered safe to drive at the 2 week post-operative time period. Our study did have some limitations including that we used a brake simulator (BRT) instead of an actual vehicle. It must be stated that driving ability cannot be based solely on the BRT as the only factor in allowing patients to return to safe driving after THA. With that said, the BRT is a simple and a powerful tool in determining whether a person is able to safely react to a braking stimulus and apply the brake in safe manner. It has valid implications for when patients are able to safely return to driving a vehicle. We also did not have a control group for patients that underwent traditional THA. Finally our exclusion criteria did not allow evaluation of patients that were using narcotics at the time of brake time evaluation potentially introducing bias, as narcotic dependent patients may not have experienced rapid recovery after surgery. However, based on state law, patients under the influence of narcotics are not allowed to operate a vehicle anyway. In conclusion, we found brake reaction time returned to baseline or better in the vast majority of patients undergoing contemporary THA by 2 weeks after surgery, and all patients achieved a safe BRT according to nationally recognized guideline. In addition, patient perception of driving ability accurately predicted return of brake reaction time to baseline. These findings have allowed us to encourage patients to re-evaluate their driving ability as soon as 2 weeks after THA. These findings are based on our particular population cautions should be take in translate these results to the regular population as well as patient that at the time of follow up is still using narcotics, these patient should not be driving, based on state law, patients under the influence of narcotics are not allowed to operate a vehicle anyway.

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References 1. Kurtz SM, Ong KL, Lau E, et al. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg Am 2014;96(8):624. 2. MacDonald W, Owen JW. The effect of total hip replacement on driving reactions. J Bone Joint Surg Br 1988;70-b:202. 3. Ganz SB, Levin AZ, Peterson MG, et al. Improvement in driving reaction time after total hip replacement. Clin Orthop Relat Res 2003;413:192. 4. Rod Fleury T, Favrat B, Belaieff W, et al. Resuming motor vehicle driving following orthopaedic surgery or limb trauma. Swiss Med Wkly 2012;142:w13716. 5. Rodriguez JA, Deshmukh AJ, Rathod PA, et al. Does the direct anterior approach in THA offer faster rehabilitation and comparable safety to the posterior approach? Clin Orthop Relat Res 2014;472(2):455.

6. Restrepo C, Parvizi J, Pour AE, et al. Prospective randomized study of two surgical approaches for total hip arthroplasty. J Arthroplasty 2010;25(5): 671.e1. 7. Green Marc. “How long does it take to stop?” Methodological analysis of driver perception-brake times. Transp Hum Factors 2000;2(3):195. 8. Procyk S. Initial results with a mini-posterior approach for total hip arthroplasty. Int Orthop 2007;31(Suppl 1):S17. 9. Dorr LD, Maheshwari AV, Long WT, et al. Early pain relief and function after posterior minimally invasive and conventional total hip arthroplasty. A prospective, randomized, blinded study. J Bone Joint Surg Am 2007;89(6):1153. 10. Parnell Meredith, Robinson Stephanie, Stone Kristin, et al. On the Road to Safety: Standardizing the RT-2S Brake Reaction Time Tester. ROADI, East Carolina University; 2007[http://www.ecu.edu/cs-dhs/ot/upload/AOTA_Brake_Reaction_ Poster.pdf].

When is it safe for patients to drive after right total hip arthroplasty?

Old studies recommend 6weeks post-operative before patients can return to driving safely. This is a prospective study assessing brake reaction time (B...
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