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Editor’s Spotlight/Take 5: When is it Safe to Drive After Total Ankle Arthroplasty?

Leopold, Seth S. MD

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Clinical Orthopaedics and Related Research: January 2020 - Volume 478 - Issue 1 - p 4-7
doi: 10.1097/CORR.0000000000001069

When we talk about driving after orthopaedic surgery, the conversation really has two parts: When do patients return to driving, and when should they?

One recent, high-quality survey study [13] suggests that a high proportion of patients returned to driving after major lower-extremity reconstructions within a couple weeks of surgery and another systematic review [3] found that some resumed driving within days.

I’m going to try to keep a neutral tone and say this as scientifically as I can: That’s nuts.

We know that most patients who were opioid-naïve prior to undergoing THA and TKA are still using narcotic analgesics a month after surgery (and the proportion is higher among those who took opioids before surgery) [4], and that opioid use is associated with an increased risk of fatal motor-vehicle accidents [7] as well as with increased culpability in such crashes [1]. And, of course, being off of narcotics is just one element of driving readiness; medical impairment (as is present in the weeks following surgery) [15], and things like brake-response time and brake pressure—which may not normalize for a month or longer after major surgery [3]—are some of the many others. While the senior author of that last study expressed in an interview that the patient is responsible to decide when to resume driving [5], others suggest that relying on patients’ judgment is neither scientific nor prudent [14], as human psychology suggests that they are likely to overestimate their abilities and underestimate the risks [6].

This matters to surgeons mainly because we care about the health and well-being of our patients. But I hasten to add that it also matters to us because physicians are considered “mandatory reporters” in some states (that is, we are responsible to report patients to the state if we believe their level of impairment meets the state’s threshold) [11], and because patients have successfully sued their physicians for car accidents that occur after surgery [2].

With this as background, I’m excited to present some of the highest-quality experimental evidence I’ve read on this topic in this month’s Clinical Orthopaedics and Related Research® [9]. A team lead by Steven M. Raikin MD, from the Rothman Institute in Philadelphia, PA, USA, found that nearly 10% of patients did not pass a brake-reaction time test 6 weeks after undergoing right-sided total ankle arthroplasty, tending to reinforce the concern that patients who drive within a few weeks of major lower-limb surgery really are taking a big risk. Since surgeons are not going to give a driving test, Dr. Raikin’s team also found some easy-to-identify parameters that were associated with failing the test they administered: More pain (and even a little bit counts: those who passed had a median VAS score of 1 out of 10, while those who failed had a median of 3), and greater joint stiffness.

Since every patient considering lower-extremity reconstruction is going to ask when it is safe to return to driving after surgery, I urge every reader of CORR® to join me in the Take 5 interview with Dr. Raikin that follows. His team’s findings have implications far beyond ankle arthroplasty, and the answers he provides, quite literally, may save lives.

Take 5 Interview with Steven M. Raikin MD, senior author of “When is it Safe to Drive After Total Ankle Arthroplasty?”

Seth S. Leopold MD:Congratulations on this well-done study. If you had the chance, what would you say to patients who return to driving within a couple of weeks of major lower-extremity reconstruction, as appears to be relatively common[3, 13]?

Steven M. Raikin MD: Thank you for your kind words and for publishing our study in CORR. I spend at lot of time warning patients about returning to driving after right ankle surgery. The reality here is that these ankle procedures are different from knee and hip arthroplasty as discussed in the papers you referenced. Most patients after ankle arthroplasty are in a splint for at least 2 weeks after surgery, making driving impossible. After the splint they are in a CAM boot, often non-weight bearing. The sheer hassle of having to get into the car with crutches and then having to take the boot off to drive tends to be a big deterrent for these patients. I also find patients undergoing total ankle arthroplasty (TAA) to be highly invested in their outcomes and concerned about causing pain or reconstructive complications. This may be a function of the fact that it is a less-common operation than TKA or THA, and also because they have more restrictions after surgery. I explain to them that the problem is not the driving but the ability to brake suddenly and aggressively if needed. This can be limited by pain, strength, and mental hesitation. These factors seem to deter most of my patients from driving in the first 6 weeks after TAA.

Dr. Leopold:Considerable work—both experimental and observational—has been done on this topic, but the problem is that orthopaedic surgeons do too many different operations. To what degree can we generalize, such that knee or hip surgeons might learn from research about driving in patients having ankle surgery, or that shoulder surgeons might learn from research in hip patients?

Dr. Raikin: Unfortunately, I believe the results of this study do not generalize well to other procedures in other areas of the body. Each area has its own concerns and limitations. Shoulder or hand surgery may be limited by the ability to control the steering wheel, hip arthroplasty by concerns about potential hip dislocation, knee arthroplasty by limited knee ROM, and ankle arthroplasty by pain, ROM, and even loosening of the components. The ankle is the most utilized area for braking maneuvers (both in terms of motion and strength). Even in foot and ankle surgery, slight differences in return to driving ability have been seen with ankle open reduction and internal fixation, Achilles rupture repairs, and forefoot surgery [8, 12].

Dr. Leopold:As an expert in the topic, how do you navigate the legal hazards of this topic when speaking to patients[2, 11, 15]?

Dr. Raikin: I was told informally by a lawyer that if patient drives before (s)he is released by a physician to do so, that (s)he is legally liable for any accident that occurs, even if (s)he is not at fault. So I put this on the patient. Patients usually come in with a family member for the 6-week visit (as they are unable to drive themselves). At this visit, I explain to the patients and the family members that once the patient feels (s)he is ready to drive (as worded based on our survey, which tended to be accurate in the study), that they go to an empty parking lot and practice with a family member first. Only once the family member would (figuratively) feel safe sitting in the road and having the patient drive towards him or her and slam on the brake should the patient believe (s)he is ready to drive. This seems to share the responsibility between patient and family and anecdotally works well.

Dr. Leopold:What kinds of studies—and how many of them—will it take to get to the point of being able to articulate evidence-based clinical-practice guidelines so that we can move beyond surgeons’ opinions[10] as we make recommendations to patients who are having surgery?

Dr. Raikin: Great question, and unfortunately an impossible one to answer. Not only are there a huge spectrum of different procedures that orthopaedic surgeons do, but there is substantial variability in how each procedure may be performed, which can affect driving safety. Our procedures also are evolving constantly, so what may not be safe today may become safe following some future modification of the operation. This is why we created our questionnaire, which we use to guide patients about driving ability after different foot and ankle procedures. There is clearly the concern about patients overestimating their ability, but I’ve found that explaining the consequences tends to help. From a study perspective, we can only try to group procedures mechanistically, but even this may result in the need for a very large number of studies. Clearly there are two concerns: (1) Preserving the integrity of the surgery itself (that is, not damaging the orthopaedic repair or reconstruction); and, (2) safety of driving (most importantly performing a braking maneuver with adequate response time and strength). As noted in our study [9], small differences in pain and ROM can substantially affect the ability to do this safely. The increased availability of ride-sharing programs, and ultimately self-driving cars, may be the only real answer to this dilemma.

Dr. Leopold:I was concerned about the survey you used asking patients about their driving readiness, and surprised by the findings that patients who failed the objective brake-reaction time test generally were the ones who also felt unsafe. The reason both for my concern and my surprise is that in life (as in surgery), people tend to overestimate their abilities[6]. Why do you suppose that was not the case with the survey you used?

Dr. Raikin: It was made clear to the patients that the survey would not be the determining element as to them being released to drive, but rather that this was an academic exercise. This may have improved patient “honesty” in assessing their own ability to drive. Also, the survey was completed before they underwent physical testing (and they knew this) so they knew they would be still be objectively assessed for driving safety and we were not just going to take their work for readiness.

Interestingly, we used the same survey to assess subjective driving readiness after TAA, Achilles rupture surgery, and hallux valgus surgery, with high correlation between the answers and ability to pass the brake response time test in all instances [8, 12].

Again, in the context of the patient understanding the consequences of his or her choice to return to driving at the appropriate time (as clearly explained by us the physicians), I have not seen patients abuse this privilege nor had any patients involved in vehicular accidents as far as I am aware. The onus is on the physician to ensure that the patient understands the dangers associated with premature driving.

F1
Steven M. Raikin MD

References

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2. Chung F, Assmann N. Car accidents after ambulatory surgery in patients without an escort. Anesth Analg. 2008;106:817–820.
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4. Goesling J, Moser SE, Zaidi B, Hassett AL, Hilliard P, Hallstrom B, Clauw DJ, Brummett CM. Trends and predictors of opioid use following total knee and total hip arthroplasty. Pain. 2016;157:1259-1265.
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12. Reb CW, McDonald E, Shakked RJ, Winters BS, Pedowitz DI, Raikin SM, Daniel JN. Brake response time recovery after achilles tendon repair. Foot Ankle Spec. [Published online ahead of print April 23, 2019]. DOI: 10.1177/1938640019843316.
13. Rondon AJ, Tan TL, Goswami K, Shohat N, Foltz C, Courtney PM, Parvizi J. When can I drive? predictors of returning to driving after total joint arthroplasty. J Amer Acad Orthop Surg. [Published online ahead of print September 18, 2019]. DOI: 10.5435/JAAOS-D-19-00214.
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