Do clinical or patient characteristics influence return to driving a car after a total knee or hip arthroplasty? a systematic review of the literature

      Purpose: Recommendations for return to driving a car after a total knee arthroplasty (TKA) or a total hip arthroplasty (THA) are ambiguous. In fact, previous systematic reviews reported that it takes approximately 4 weeks to return to driving in the United States following a right-sided TKA or THA; however, such timeframes are dependent on patient and clinical factors. Although several reviews have published on time frame and laterality, none specifically examined potential covariates that can influence return to driving. The purpose of this study is to systematically review patient characteristics and clinical determinants that may influence return to driving status and time frames following a primary TKA or THA.
      Methods: This systematic review was completed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Final electronic database searches were completed in October 2019 in Medline/PubMed, Medline/OVID, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library using the following keywords: “joint arthroplasty”, “hip arthroplasty”, “knee arthroplasty”, and variations where “arthroplasty” was replaced by “replacement”. Outcome terms included “brake time,” “braking,” “reaction time,” “driving,” and “automobile.” Manuscripts of prospective and non-randomized studies that recruited primary knee or hip arthroplasty patients to examine return to driving outcomes were included. The Methodological Index for Non-Randomized Studies (MINORS) was used to measure study quality. Study selections and quality assessments were completed by 2 authors with disagreements resolved through discussion, and, if needed, a third reviewer. Data extracted included: study title, author(s), country, year, study design, sample size, inclusion and exclusion criteria, age, BMI, gender, statistical analyses, driving measure, follow-up time, surgical approach, laterality, and postoperative management.
      Results: A total of 23 eligible studies were identified, including 12 TKA studies (n = 654) (Figure 1) with mean patient ages between 43 to 82 years, 9 THA studies (n = 922) with mean ages between 34 to 85 years, and 2 combined TKA and THA studies (TKA, n = 815; and THA, n = 685), yielded MINORS scores between 6 to 12 (Table 1). Return to driving was measured in 17 studies with driving simulators, using pre and postoperative response times; in 4 studies, with self-reported outcomes, and in 1 study with both approaches. Most patients achieved or exceeded preoperative response times between 1 to 8 weeks following a TKA and 2 days to 8 weeks following a THA, and/or self-reported return to driving between 1 week to 6 months (Table 1). Clinical Factors. TKA approaches were varied with mostly cemented techniques, Day 1 rehabilitation focused on mobility and weight-bearing and return to driving between 2 to 6-weeks (Table 2). For THA, the return to driving time occurred between 4 to 6 weeks for patients receiving the posterior approach, 3 to 4 weeks for the anterior approach, and 2 days to 4 weeks for the lateral approach (Table 2). Patient Characteristics. Influences on return to driving time included being female in 5 (71.4%) of TKA and 2 (25%) of THA studies, age in 1 (16.7%) of TKA and 1 (20%) of THA study, self-perceived readiness in the 2 (100%) TKA and the 4 (100%) THA studies, pain in the 3 (100%) TKA studies, assistive device use in 1 (50%) of TKA and 1 (33.3%) of THA study, and physical function in the 2 (100%) TKA and the 2 (100%) THA studies (Table 3).
      Conclusions: Our study results were consistent with previous published reports indicating that return to driving a car after a primary TKA or THA is highly variable, and most commonly occurs around 4 weeks, but can range between 2 to 8 weeks. Various patient and clinical factors can influence return to driving for a TKA or THA. For TKAs, the patient’s gender, pain levels, and assistive device use contributed to return to driving time. Meanwhile, for THAs, the surgical technique had some influence. Both for TKAs and THAs, in addition to laterality, the patient's self-perceived readiness and physical function influenced return to driving. The heterogeneous nature of the reviewed studies prevented a meta-analysis that could be beneficial for examining the strongest contributing factor(s) to determine return to driving a car following a primary TKA or THA. Regardless, this study presents current insight on patient and clinical factors beyond generalized timeframes for return to driving a car post TKA or THA, which can guide clinical recommendations and patient and clinician expectations.