- Email: [email protected]
When Is It Safe for Patients to Drive After Right Total Knee Arthroplasty?
Accepted Manuscript When is it Safe for Patients to Drive after Right Total Knee Arthroplasty? Victor H. Hernandez, MD, MS, Alvin Ong, MD, Fabio Orozco, MD, Anne Marie Madden, Zachary Post, MD PII:
S0883-5403(16)30126-7
DOI:
10.1016/j.arth.2016.04.027
Reference:
YARTH 55153
To appear in:
The Journal of Arthroplasty
Received Date: 8 January 2016 Revised Date:
11 April 2016
Accepted Date: 21 April 2016
Please cite this article as: Hernandez VH, Ong A, Orozco F, Madden AM, Post Z, When is it Safe for Patients to Drive after Right Total Knee Arthroplasty?, The Journal of Arthroplasty (2016), doi: 10.1016/ j.arth.2016.04.027. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
When is it Safe for Patients to Drive after Right Total Knee Arthroplasty? Victor H Hernandez, MD,MS**; Alvin Ong, MD*; Fabio Orozco, MD*; Anne Marie
SC
RI PT
Madden *; Zachary Post, MD*
**University of Miami- Miller School of Medicine. Orthopaedics. 1400 NW 12th
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Ave. Suite 4036, Miami, FL 33136
* Rothman Institute, 2500 English Creek Avenue, Building 1300, Egg Harbor
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Corresponding Author:
TE D
Township, NJ 08234
Victor Hugo Hernandez, MD,MS.
AC C
Assistant Professor – Orthopedics University of Miami – Miller School of Medicine 1400 NW 12th Avenue – Suite #4036 Miami, FL. 33136
Phone (305) 689-5195 Fax (305) 689-3928 [email protected]
ACCEPTED MANUSCRIPT
When is it Safe for Patients to Drive after Right Total Knee Arthroplasty?
2
Abstract.
3
Introduction:
4 5 6 7 8
Advances in surgical technique and pain management have changed TKA. How soon after TKA are patients able to return to driving is a common question. Most surgeons prescribe 6 to 8 weeks post-op based on old literature. Our hypothesis is that patient who undergoes TKA with contemporary techniques will return to their baseline before the 6th post-operative week.
9
Methods
SC
RI PT
1
After IRB approval, 50 patients with right TKA were prospectively evaluated. All patients underwent a preoperative Brake Reaction Time (BRT), 2, 4 and 6 weeks post-op. At each testing we ask them if they felt that they were ready to drive.
13
Results
14 15 16 17
47 patients completed the study protocol. Mean pre-op BRT was 0.692 seconds. At 2weeks post-op, the BRT was 0.631 seconds. 39 (80%) reached their baseline by 2 weeks and the remaining 10 (20%) reached it at the 4-week post-op. Confounding variables revealed no differences between groups.
18 19 20
From the group that returned to baseline at 2 weeks, 67 % patients stated they felt they were ready to drive, 21 % patients said they weren’t sure and 12 % patients stated they were not ready to drive.
21
Conclusion
22 23 24 25
BRT returned to baseline in the majority of patients by the 2nd week post-op and in all patients by the 4th week. Patient perception of driving ability can predict return of BRT. These findings have allowed us to encourage patients to re-evaluate their driving ability between the 2nd to 4th post-op weeks after TKA.
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Keywords:
28
Recovery, Total knee Arthroplasty, Total Knee Replacement, Driving, Outcomes.
29 30
1
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Introduction:
32
Total Knee Arthroplasty (TKA) is a common procedure for patients with advanced
33
arthritis. Improvements in surgical technique and pain management protocols have
34
accelerated recovery and changed patient expectations. [1,15,16] A common question
35
involves how soon patients are able to return to driving, secondary to the patient’s need to
36
return to activities of daily living and independence. Most surgeons recommend driving
37
between the 6th to 8th weeks post-surgery based on studies previously published over a
38
decade ago [2,3], There is new literature that shows that using minimal invasive
39
techniques and new protocols the waiting time has decrease (4 weeks), but these studies
40
lack of statistical power to drive conclusions [12,13,14]. This question is important
41
because the ability to return to safe driving implies recovery and mobility, and has
42
significant social and economic impact for patients and society. Our group has previously
43
published results on return to safe driving after Total Hip Arthroplasty (THA). [11] Our
44
study showed that patients returned to driving faster than in previous studies.
45
Historically, TKA publications demonstrated great variability in return to driving.
46
Spalding et al. demonstrated that the Brake Reaction Time (BRT) returned to baseline 8
47
weeks after surgery for the right knee. [2] Pierson showed in a study done almost 10
48
years later, that most patients improved their BRT at 6 weeks post-op. [3] Both of these
49
studies were performed more than a decade ago. Since then, TKA has seen improvements
50
in surgical techniques, as well as pre and post-operative care, and recent studies has
51
demonstrated a faster recovery of BRT at 4 weeks [12,13,14]. The purpose of our study
52
is to prospectively evaluate the BRT after TKA. Our hypothesis is that patients who
53
undergo TKA with contemporary techniques will return to their baseline sooner than
54
previously reported.
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2
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55 Methods and Material
57
After IRB approval, 50 patients who were scheduled for, and underwent, right TKA were
58
prospectively evaluated between July and October 2014 at our institution. Driving
59
performance was evaluated using the BRT, which measured brake time after a stimulus.
60
BRT is the sum of the reaction time that it takes for a driver to perceive a sensory
61
stimulus, move the right foot from accelerator pedal to the brake pedal, and the time that
62
it takes to apply sufficient pressure to brake (initiate a stop of the vehicle). All patients
63
underwent a preoperative assessment to establish a baseline of their BRT. Then, all
64
patients underwent a right TKA using the mid-vastus approach. All patients were treated
65
with the same postoperative pain and rehabilitation protocols and received identical
66
follow-up. Preoperative medical evaluation was done to diminish the risks of
67
postoperative delirium, urinary retention, and pulmonary and cardiac complications. All
68
patients were managed with spinal anesthesia, a program of multimodal pain
69
management (including minimal use of narcotics) and a rapid mobilization physical
70
therapy protocol. Aspirin was used for DVT prophylaxis and early discharge was utilized
71
whenever possible.
72
Patient demographics were recorded including: age, gender, BMI, and co-morbid
73
conditions. A history was obtained to rule out the use of pre-operative and post-operative
74
narcotics at the time of testing. Patients were then re-tested at 2, 4, 6 and 8 weeks post-
75
operatively, or until their BRT was equal to or less than their pre-operative score.
76
Furthermore, all patients received a questionnaire at each follow-up visit with the
77
following statement, “Based on my reaction time, I think I am ready to drive”, from this
AC C
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56
3
ACCEPTED MANUSCRIPT
78
statement patients selected from the following answers: (1) Yes, (2) No. (3) I don’t know.
79
Patients were allowed to drive when the post-operative reaction time was equal to or less
80
than their pre-operative brake reaction time baseline.
RI PT
81 Model/Testing Equipment
83
The RT-2S brake reaction timer (Advanced Therapy Products, Inc. Richmond, VA) was used
84
for our study. (Figure 1) The RT-2S is a lightweight and portable brake reaction time
85
simulator that assists driving evaluators in assessing driving safety. Parnell et al have
86
previously validated the RT-2S.[10] The BRT has been previously described. [11]
87
All patients followed a standardized procedure that consisted of sitting in a chair
88
(adjusted individually for each patient) at a desk with the foot pedal on the ground in
89
front of his/her right foot, and the light box in front of the patients within a viewing
90
distance on the desk.
91
Patients were instructed to place their right foot on the accelerator pedal and keep it
92
depressed to maintain the illumination of the green lamp.
93
instructed to move their right foot from the accelerator pedal to the brake pedal and
94
depress the brake pedal as rapidly as possible when the red lamp on the test light box
95
illuminated. We randomly controlled timing between the illumination of the red and
96
green lamps for two, three, or four seconds. During testing, each subject was given one
97
practice test and three trial times that were collected for data analysis.
99
M AN U
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The patients were then
AC C
98
SC
82
Statistical analysis
4
ACCEPTED MANUSCRIPT
The SPSS 21 (IBM; Armonk, NY) was used to analyze the data. General linear repeated
101
measurement was used for analysis. A difference of p<0.05 was considered significant.
102
Power Analysis.
103
A power analysis was performed to calculate the number of individuals needed. The
104
nationally recommended safe brake time standard is 1.25 seconds which is based upon
105
several scientific studies looking at BRT in all types of patients, surgical and non-surgical
106
alike.[7,4] The normal brake time was estimated to be 1 sec. A Bonferroni correction
107
(i.e., alpha = 0.05) was used for the power analysis. In order to detect a 20% increase in
108
braking time (1,200 sec), with a standard deviation of 0.250 sec, thirty-five patients were
109
needed to obtain a power of 0.8.
110
Results
111
From the total group of 50 patients, two patients were unable to participate in the
112
postoperative evaluation due to the continued use of narcotics at the time of testing.
113
Another patient declined to be tested post operatively and was excluded from the study.
114
A total of 47 patients completed the study, study patients had a mean age of 67.5 Y/O +/-
115
10 SD, the mean BMI was 32.59 SD +/- 7, and 61.7 % were females. The mean pre-op
116
reaction time was 0.692 +/-0.15 sec SD (Range: 0.510 to 1.1 sec). The mean 2-week
117
reaction time was 0.631 sec +/- 0.16 sec SD (Range: 0.429 to 1.3 sec) (p= 0.004). Of the
118
47 study patients, 39 (83 %) were able to reach their baseline time (or better) by 2 weeks,
119
and 12.8 % were using an assistance device at the time they reached their baseline, no
120
difference was found between the need of an assistance devices against their BRT. The
121
remaining eight patients (17 %) reached their baseline at the 4-week post-op test (table
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1). However, all 47 patients in this study had a BRT at 2 weeks below recommended
123
safe brake time standard of 1.25 sec. Evaluation of confounding variables revealed no
124
differences with respect to age, gender, BMI and the use of assistive devices (cane,
125
walker or crutches) in the group, but there was significant difference (p = 0.02) in pre-
126
operative pain, (2 Vs 4 on pain scale). (Table 1)
127
Based on the patient surveys, a significant correlation was found between the ability to
128
drive and patient –perception, of the 39 patients that returned to baseline at 2 weeks, 26
129
(67%) stated that they felt they were ready to drive at that time. 8 patients said they were
130
not sure and 5 (17 %) patients stated that they were not ready to drive. (p<0.001)
131
From the group that did not reach their baseline at 2 weeks, all 8 (100%) patients did not
132
feel they were ready to drive. However, at 4 weeks, 7 (88%) felt they were ready to drive
133
and only one was not sure. (p < 0.001)
134
DISCUSSION:
135
TKA is an excellent option for end-stage knee arthritis with great reported results. Over
136
the last decade, advances in surgical techniques, as well as, advances in perioperative
137
management have accelerated the recovery time for the majority of patients.
138
Driving after surgery is an important task. It is a measure of recovery and return to
139
independence. Driving after TKA done with modern techniques has not been well
140
studied. The purpose of this study was to assess return to safe driving after TKA using a
141
validated instrument and in a prospective well-designed study.
142
We found that the BRT improved, on average, from the preoperative value to the 2-week
143
post-operative value by 0.064 sec, 83 % (39) of our patients were able to return to their
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baseline brake response times, or better, by 2 weeks post-op. Left-sided surgery were
145
excluded from this study because it does not significantly affect BRT. [4] If the left leg
146
was involved, it has been suggested that driving may resume 1 week after surgery.[2,3,4]
147
Eight patients did not reach their baseline by 2 weeks post-op, but all of them were able
148
to reach it at the 4-week post-op test. However, even the 8 patients who did not return to
149
their baseline by two weeks were still under the nationally recommended safe brake time
150
standard of 1.25 seconds, which is based upon several scientific studies looking at
151
BRT.[7,4] Therefore, all patients in this study had BRT at 2 weeks below nationally
152
recommended safe brake time standards.
153
When we compared the two groups, the one that that did not reach the baseline at 2
154
weeks came to surgery with significantly worst pain (p = 0.02) scores and worst
155
preoperative BRT scores. This is in correlation with previous studies that showed worse
156
BRT scores in people with advance osteoarthritis.[5]
157
Our findings represent a substantial improvement from current recommendations. We
158
found brake reaction time returned to baseline or better in the vast majority of patients
159
undergoing contemporary TKA between 2 and 4 weeks after surgery, and all patients
160
achieved a safe BRT by 2 weeks according to a nationally recognized guideline. In
161
addition, patient perception of driving ability accurately predicted return of BRT to
162
baseline.
163
It must be stated that driving ability cannot be based solely on the BRT as the only factor
164
in allowing patients to drive after TKA. With that said, it is a simple and a powerful tool
165
in determining whether a person is able to safely react to a braking stimulus and apply the
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7
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brake in safe manner and has valid implications for when patients are able to safely return
167
to driving a vehicle. These findings have allowed us to encourage patients to re-evaluate
168
their driving ability as soon as 2 weeks after TKA.
RI PT
166
169 170
SC
171 References.
173
1. Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint
174
replacement demand in the United States: updated projections to 2021. J Bone Joint Surg
175
Am. 2014 Apr 16;96(8):624-30.
176
2. Spalding TJ, Kiss J, Kyberd P, Turner-Smith A, Simpson AH. Driver reaction times
177
after total knee replacement. JBJS [Br]. 1994;76:754–6.
178
3. Pierson JL, Earles DR, Wood K. Brake response time after total knee arthroplasty:
179
when is it safe for patients to drive? J Arthroplasty. 2003;18:840–3.
180
4. Rod Fleury, T., Favrat, B., Belaieff, W. et al. Resuming motor vehicle driving
181
following orthopaedic surgery or limb trauma. Swiss Med Wkly. 2012; 142: w13716
182
5. Hofmann UK, Jordan M, Rondak I, Wolf P, Kluba T, Ipach I. Osteoarthritis of the
183
knee or hip significantly impairs driving ability (cross-sectional survey).BMC
184
Musculoskelet Disord. 2014 Jan 17;15:20.
185
7.Green, Marc. “How long does it take to stop?” Methodological analysis of driver
186
perception-brake times. Transp Hum Factors. 2000; 2: 195
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172
8
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10. Meredith Parnell, Stephanie Robinson, Kristin Stone, Kristin Whitley, Anne
188
Dickerson, Timothy Reistetter. On the Road to Safety: Standardizing the RT-2S Brake
189
Reaction Time Tester. (2007)ROADI, East Carolina University. http://www.ecu.edu/cs-
190
dhs/ot/upload/AOTA_Brake_Reaction_Poster.pdf
191
11. Hernandez VH, Ong A, Orozco F, Madden AM, Post Z. When is it safe for patients to
192
drive after right total hip arthroplasty?. J Arthroplasty. 2015 Apr; 30(4):627-30.
193
12. Liebensteiner MC, Kern M, Haid C, Kobel C, Niederseer D, Krismer M. Brake
194
response time before and after total knee arthroplasty: a prospective cohort study. BMC
195
Musculoskeletal Disorders 2010.
196
13. Dalury DF, Tucker KK, Kelley TC. When Can I Drive?: Brake Response Times After
197
Contemporary Total Knee Arthroplasty. Clinical Orthopaedics and Related Research.
198
2011;469(1):82-86.
199
14. Huang HT, Liang J, Hung W, Chen Y, Guo L, Wu W. Timeframe for return to
200
driving for patients with minimally invasive knee arthroplasty is associated with knee
201
performance on functional tests. BMC Musculoskeletal Disorders 2014. 15:198
202
15. Ibrahim MS, Khan MA, Nizam I, Haddad FS. Peri-operative interventions producing
203
better functional outcomes and enhanced recovery following total hip and knee
204
arthroplasty: an evidence-based review. BMC Medicine 2013. 11:37
205
16. Mallory TH, Lombardi AV, Fada RA, Dodds KL, Adams JB: Pain management for
206
joint arthroplasty: preemptive analgesia. J Arthroplasty. 2002, 17: 129-133.
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187
9
LOS Pain scale*
4 Wks. 2 Wks. 4 Wks. 2 Wks. 4 Wks. 2 Wks. 4 Wks. 2 Wks.
11.76 9.95 8.01 6.88 .916 .942 2.6 2.0
69.88 67.08 33.43 32.42 1.63 1.51 3.77 1.50
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BMI
SD
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Age
BRT Reached Mean
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Table1. Difference between the cohort that reached the baseline at two weeks and the one
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that reached at the 4 weeks. * p < 0.02
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Table 2. Enhanced recovery program for unilateral total hip arthroplasty followed at the at the time of the study
RI PT
1. Preoperative management
a. Preoperative education b. Preoperative medical clearance and risk stratification. 2. In-Hospital management
AC C
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TE D
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SC
a. Spinal anesthesia b. Multimodal analgesia, avoiding the use of extended-release epidural morphine and patient controlled analgesia. c. Preoperative analgesia i. IV acetaminophen 1000mg (withhold in case of liver disease) ii. Celecoxib 400 mg po within 2 hours preoperatively iii. Pregabalin 75 mg po q 12 h 2 hours preoperatively d. Postoperative dosing i. Acetaminophen 650 mg po q 6 hr ii. Celecoxib 200mg po q 12 h iii. Pregabalin 75mg po q 12 h iv. PRN Medication • Oxycodone IR 10mgs po Q4hr • Ultram 50 mg po q 6hr • Toradol 30 mg IV q 6hr prn e. No use of benzodiazepines or antihistamine during postoperative period f. Early in-hospital mobilization and physical therapy, same day of surgery.
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Figure 1. The RT-2S brake reaction timer (Advanced Therapy Products, Inc. Richmond, VA) Consist of pedals, a timer, and a light box.
S0883-5403(16)30126-7
DOI:
10.1016/j.arth.2016.04.027
Reference:
YARTH 55153
To appear in:
The Journal of Arthroplasty
Received Date: 8 January 2016 Revised Date:
11 April 2016
Accepted Date: 21 April 2016
Please cite this article as: Hernandez VH, Ong A, Orozco F, Madden AM, Post Z, When is it Safe for Patients to Drive after Right Total Knee Arthroplasty?, The Journal of Arthroplasty (2016), doi: 10.1016/ j.arth.2016.04.027. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
When is it Safe for Patients to Drive after Right Total Knee Arthroplasty? Victor H Hernandez, MD,MS**; Alvin Ong, MD*; Fabio Orozco, MD*; Anne Marie
SC
RI PT
Madden *; Zachary Post, MD*
**University of Miami- Miller School of Medicine. Orthopaedics. 1400 NW 12th
M AN U
Ave. Suite 4036, Miami, FL 33136
* Rothman Institute, 2500 English Creek Avenue, Building 1300, Egg Harbor
EP
Corresponding Author:
TE D
Township, NJ 08234
Victor Hugo Hernandez, MD,MS.
AC C
Assistant Professor – Orthopedics University of Miami – Miller School of Medicine 1400 NW 12th Avenue – Suite #4036 Miami, FL. 33136
Phone (305) 689-5195 Fax (305) 689-3928 [email protected]
ACCEPTED MANUSCRIPT
When is it Safe for Patients to Drive after Right Total Knee Arthroplasty?
2
Abstract.
3
Introduction:
4 5 6 7 8
Advances in surgical technique and pain management have changed TKA. How soon after TKA are patients able to return to driving is a common question. Most surgeons prescribe 6 to 8 weeks post-op based on old literature. Our hypothesis is that patient who undergoes TKA with contemporary techniques will return to their baseline before the 6th post-operative week.
9
Methods
SC
RI PT
1
After IRB approval, 50 patients with right TKA were prospectively evaluated. All patients underwent a preoperative Brake Reaction Time (BRT), 2, 4 and 6 weeks post-op. At each testing we ask them if they felt that they were ready to drive.
13
Results
14 15 16 17
47 patients completed the study protocol. Mean pre-op BRT was 0.692 seconds. At 2weeks post-op, the BRT was 0.631 seconds. 39 (80%) reached their baseline by 2 weeks and the remaining 10 (20%) reached it at the 4-week post-op. Confounding variables revealed no differences between groups.
18 19 20
From the group that returned to baseline at 2 weeks, 67 % patients stated they felt they were ready to drive, 21 % patients said they weren’t sure and 12 % patients stated they were not ready to drive.
21
Conclusion
22 23 24 25
BRT returned to baseline in the majority of patients by the 2nd week post-op and in all patients by the 4th week. Patient perception of driving ability can predict return of BRT. These findings have allowed us to encourage patients to re-evaluate their driving ability between the 2nd to 4th post-op weeks after TKA.
TE D
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AC C
26
M AN U
10 11 12
27
Keywords:
28
Recovery, Total knee Arthroplasty, Total Knee Replacement, Driving, Outcomes.
29 30
1
ACCEPTED MANUSCRIPT
Introduction:
32
Total Knee Arthroplasty (TKA) is a common procedure for patients with advanced
33
arthritis. Improvements in surgical technique and pain management protocols have
34
accelerated recovery and changed patient expectations. [1,15,16] A common question
35
involves how soon patients are able to return to driving, secondary to the patient’s need to
36
return to activities of daily living and independence. Most surgeons recommend driving
37
between the 6th to 8th weeks post-surgery based on studies previously published over a
38
decade ago [2,3], There is new literature that shows that using minimal invasive
39
techniques and new protocols the waiting time has decrease (4 weeks), but these studies
40
lack of statistical power to drive conclusions [12,13,14]. This question is important
41
because the ability to return to safe driving implies recovery and mobility, and has
42
significant social and economic impact for patients and society. Our group has previously
43
published results on return to safe driving after Total Hip Arthroplasty (THA). [11] Our
44
study showed that patients returned to driving faster than in previous studies.
45
Historically, TKA publications demonstrated great variability in return to driving.
46
Spalding et al. demonstrated that the Brake Reaction Time (BRT) returned to baseline 8
47
weeks after surgery for the right knee. [2] Pierson showed in a study done almost 10
48
years later, that most patients improved their BRT at 6 weeks post-op. [3] Both of these
49
studies were performed more than a decade ago. Since then, TKA has seen improvements
50
in surgical techniques, as well as pre and post-operative care, and recent studies has
51
demonstrated a faster recovery of BRT at 4 weeks [12,13,14]. The purpose of our study
52
is to prospectively evaluate the BRT after TKA. Our hypothesis is that patients who
53
undergo TKA with contemporary techniques will return to their baseline sooner than
54
previously reported.
AC C
EP
TE D
M AN U
SC
RI PT
31
2
ACCEPTED MANUSCRIPT
55 Methods and Material
57
After IRB approval, 50 patients who were scheduled for, and underwent, right TKA were
58
prospectively evaluated between July and October 2014 at our institution. Driving
59
performance was evaluated using the BRT, which measured brake time after a stimulus.
60
BRT is the sum of the reaction time that it takes for a driver to perceive a sensory
61
stimulus, move the right foot from accelerator pedal to the brake pedal, and the time that
62
it takes to apply sufficient pressure to brake (initiate a stop of the vehicle). All patients
63
underwent a preoperative assessment to establish a baseline of their BRT. Then, all
64
patients underwent a right TKA using the mid-vastus approach. All patients were treated
65
with the same postoperative pain and rehabilitation protocols and received identical
66
follow-up. Preoperative medical evaluation was done to diminish the risks of
67
postoperative delirium, urinary retention, and pulmonary and cardiac complications. All
68
patients were managed with spinal anesthesia, a program of multimodal pain
69
management (including minimal use of narcotics) and a rapid mobilization physical
70
therapy protocol. Aspirin was used for DVT prophylaxis and early discharge was utilized
71
whenever possible.
72
Patient demographics were recorded including: age, gender, BMI, and co-morbid
73
conditions. A history was obtained to rule out the use of pre-operative and post-operative
74
narcotics at the time of testing. Patients were then re-tested at 2, 4, 6 and 8 weeks post-
75
operatively, or until their BRT was equal to or less than their pre-operative score.
76
Furthermore, all patients received a questionnaire at each follow-up visit with the
77
following statement, “Based on my reaction time, I think I am ready to drive”, from this
AC C
EP
TE D
M AN U
SC
RI PT
56
3
ACCEPTED MANUSCRIPT
78
statement patients selected from the following answers: (1) Yes, (2) No. (3) I don’t know.
79
Patients were allowed to drive when the post-operative reaction time was equal to or less
80
than their pre-operative brake reaction time baseline.
RI PT
81 Model/Testing Equipment
83
The RT-2S brake reaction timer (Advanced Therapy Products, Inc. Richmond, VA) was used
84
for our study. (Figure 1) The RT-2S is a lightweight and portable brake reaction time
85
simulator that assists driving evaluators in assessing driving safety. Parnell et al have
86
previously validated the RT-2S.[10] The BRT has been previously described. [11]
87
All patients followed a standardized procedure that consisted of sitting in a chair
88
(adjusted individually for each patient) at a desk with the foot pedal on the ground in
89
front of his/her right foot, and the light box in front of the patients within a viewing
90
distance on the desk.
91
Patients were instructed to place their right foot on the accelerator pedal and keep it
92
depressed to maintain the illumination of the green lamp.
93
instructed to move their right foot from the accelerator pedal to the brake pedal and
94
depress the brake pedal as rapidly as possible when the red lamp on the test light box
95
illuminated. We randomly controlled timing between the illumination of the red and
96
green lamps for two, three, or four seconds. During testing, each subject was given one
97
practice test and three trial times that were collected for data analysis.
99
M AN U
TE D
EP
The patients were then
AC C
98
SC
82
Statistical analysis
4
ACCEPTED MANUSCRIPT
The SPSS 21 (IBM; Armonk, NY) was used to analyze the data. General linear repeated
101
measurement was used for analysis. A difference of p<0.05 was considered significant.
102
Power Analysis.
103
A power analysis was performed to calculate the number of individuals needed. The
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nationally recommended safe brake time standard is 1.25 seconds which is based upon
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several scientific studies looking at BRT in all types of patients, surgical and non-surgical
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alike.[7,4] The normal brake time was estimated to be 1 sec. A Bonferroni correction
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(i.e., alpha = 0.05) was used for the power analysis. In order to detect a 20% increase in
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braking time (1,200 sec), with a standard deviation of 0.250 sec, thirty-five patients were
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needed to obtain a power of 0.8.
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Results
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From the total group of 50 patients, two patients were unable to participate in the
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postoperative evaluation due to the continued use of narcotics at the time of testing.
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Another patient declined to be tested post operatively and was excluded from the study.
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A total of 47 patients completed the study, study patients had a mean age of 67.5 Y/O +/-
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10 SD, the mean BMI was 32.59 SD +/- 7, and 61.7 % were females. The mean pre-op
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reaction time was 0.692 +/-0.15 sec SD (Range: 0.510 to 1.1 sec). The mean 2-week
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reaction time was 0.631 sec +/- 0.16 sec SD (Range: 0.429 to 1.3 sec) (p= 0.004). Of the
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47 study patients, 39 (83 %) were able to reach their baseline time (or better) by 2 weeks,
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and 12.8 % were using an assistance device at the time they reached their baseline, no
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difference was found between the need of an assistance devices against their BRT. The
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remaining eight patients (17 %) reached their baseline at the 4-week post-op test (table
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1). However, all 47 patients in this study had a BRT at 2 weeks below recommended
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safe brake time standard of 1.25 sec. Evaluation of confounding variables revealed no
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differences with respect to age, gender, BMI and the use of assistive devices (cane,
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walker or crutches) in the group, but there was significant difference (p = 0.02) in pre-
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operative pain, (2 Vs 4 on pain scale). (Table 1)
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Based on the patient surveys, a significant correlation was found between the ability to
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drive and patient –perception, of the 39 patients that returned to baseline at 2 weeks, 26
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(67%) stated that they felt they were ready to drive at that time. 8 patients said they were
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not sure and 5 (17 %) patients stated that they were not ready to drive. (p<0.001)
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From the group that did not reach their baseline at 2 weeks, all 8 (100%) patients did not
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feel they were ready to drive. However, at 4 weeks, 7 (88%) felt they were ready to drive
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and only one was not sure. (p < 0.001)
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DISCUSSION:
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TKA is an excellent option for end-stage knee arthritis with great reported results. Over
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the last decade, advances in surgical techniques, as well as, advances in perioperative
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management have accelerated the recovery time for the majority of patients.
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Driving after surgery is an important task. It is a measure of recovery and return to
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independence. Driving after TKA done with modern techniques has not been well
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studied. The purpose of this study was to assess return to safe driving after TKA using a
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validated instrument and in a prospective well-designed study.
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We found that the BRT improved, on average, from the preoperative value to the 2-week
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post-operative value by 0.064 sec, 83 % (39) of our patients were able to return to their
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baseline brake response times, or better, by 2 weeks post-op. Left-sided surgery were
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excluded from this study because it does not significantly affect BRT. [4] If the left leg
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was involved, it has been suggested that driving may resume 1 week after surgery.[2,3,4]
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Eight patients did not reach their baseline by 2 weeks post-op, but all of them were able
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to reach it at the 4-week post-op test. However, even the 8 patients who did not return to
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their baseline by two weeks were still under the nationally recommended safe brake time
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standard of 1.25 seconds, which is based upon several scientific studies looking at
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BRT.[7,4] Therefore, all patients in this study had BRT at 2 weeks below nationally
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recommended safe brake time standards.
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When we compared the two groups, the one that that did not reach the baseline at 2
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weeks came to surgery with significantly worst pain (p = 0.02) scores and worst
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preoperative BRT scores. This is in correlation with previous studies that showed worse
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BRT scores in people with advance osteoarthritis.[5]
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Our findings represent a substantial improvement from current recommendations. We
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found brake reaction time returned to baseline or better in the vast majority of patients
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undergoing contemporary TKA between 2 and 4 weeks after surgery, and all patients
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achieved a safe BRT by 2 weeks according to a nationally recognized guideline. In
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addition, patient perception of driving ability accurately predicted return of BRT to
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baseline.
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It must be stated that driving ability cannot be based solely on the BRT as the only factor
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in allowing patients to drive after TKA. With that said, it is a simple and a powerful tool
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in determining whether a person is able to safely react to a braking stimulus and apply the
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brake in safe manner and has valid implications for when patients are able to safely return
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to driving a vehicle. These findings have allowed us to encourage patients to re-evaluate
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their driving ability as soon as 2 weeks after TKA.
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171 References.
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1. Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint
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replacement demand in the United States: updated projections to 2021. J Bone Joint Surg
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Am. 2014 Apr 16;96(8):624-30.
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2. Spalding TJ, Kiss J, Kyberd P, Turner-Smith A, Simpson AH. Driver reaction times
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after total knee replacement. JBJS [Br]. 1994;76:754–6.
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3. Pierson JL, Earles DR, Wood K. Brake response time after total knee arthroplasty:
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when is it safe for patients to drive? J Arthroplasty. 2003;18:840–3.
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4. Rod Fleury, T., Favrat, B., Belaieff, W. et al. Resuming motor vehicle driving
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following orthopaedic surgery or limb trauma. Swiss Med Wkly. 2012; 142: w13716
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5. Hofmann UK, Jordan M, Rondak I, Wolf P, Kluba T, Ipach I. Osteoarthritis of the
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knee or hip significantly impairs driving ability (cross-sectional survey).BMC
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Musculoskelet Disord. 2014 Jan 17;15:20.
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7.Green, Marc. “How long does it take to stop?” Methodological analysis of driver
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perception-brake times. Transp Hum Factors. 2000; 2: 195
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10. Meredith Parnell, Stephanie Robinson, Kristin Stone, Kristin Whitley, Anne
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Dickerson, Timothy Reistetter. On the Road to Safety: Standardizing the RT-2S Brake
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Reaction Time Tester. (2007)ROADI, East Carolina University. http://www.ecu.edu/cs-
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dhs/ot/upload/AOTA_Brake_Reaction_Poster.pdf
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11. Hernandez VH, Ong A, Orozco F, Madden AM, Post Z. When is it safe for patients to
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drive after right total hip arthroplasty?. J Arthroplasty. 2015 Apr; 30(4):627-30.
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12. Liebensteiner MC, Kern M, Haid C, Kobel C, Niederseer D, Krismer M. Brake
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response time before and after total knee arthroplasty: a prospective cohort study. BMC
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Musculoskeletal Disorders 2010.
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13. Dalury DF, Tucker KK, Kelley TC. When Can I Drive?: Brake Response Times After
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Contemporary Total Knee Arthroplasty. Clinical Orthopaedics and Related Research.
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2011;469(1):82-86.
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14. Huang HT, Liang J, Hung W, Chen Y, Guo L, Wu W. Timeframe for return to
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driving for patients with minimally invasive knee arthroplasty is associated with knee
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performance on functional tests. BMC Musculoskeletal Disorders 2014. 15:198
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15. Ibrahim MS, Khan MA, Nizam I, Haddad FS. Peri-operative interventions producing
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better functional outcomes and enhanced recovery following total hip and knee
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arthroplasty: an evidence-based review. BMC Medicine 2013. 11:37
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16. Mallory TH, Lombardi AV, Fada RA, Dodds KL, Adams JB: Pain management for
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joint arthroplasty: preemptive analgesia. J Arthroplasty. 2002, 17: 129-133.
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LOS Pain scale*
4 Wks. 2 Wks. 4 Wks. 2 Wks. 4 Wks. 2 Wks. 4 Wks. 2 Wks.
11.76 9.95 8.01 6.88 .916 .942 2.6 2.0
69.88 67.08 33.43 32.42 1.63 1.51 3.77 1.50
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Table1. Difference between the cohort that reached the baseline at two weeks and the one
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that reached at the 4 weeks. * p < 0.02
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Table 2. Enhanced recovery program for unilateral total hip arthroplasty followed at the at the time of the study
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1. Preoperative management
a. Preoperative education b. Preoperative medical clearance and risk stratification. 2. In-Hospital management
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a. Spinal anesthesia b. Multimodal analgesia, avoiding the use of extended-release epidural morphine and patient controlled analgesia. c. Preoperative analgesia i. IV acetaminophen 1000mg (withhold in case of liver disease) ii. Celecoxib 400 mg po within 2 hours preoperatively iii. Pregabalin 75 mg po q 12 h 2 hours preoperatively d. Postoperative dosing i. Acetaminophen 650 mg po q 6 hr ii. Celecoxib 200mg po q 12 h iii. Pregabalin 75mg po q 12 h iv. PRN Medication • Oxycodone IR 10mgs po Q4hr • Ultram 50 mg po q 6hr • Toradol 30 mg IV q 6hr prn e. No use of benzodiazepines or antihistamine during postoperative period f. Early in-hospital mobilization and physical therapy, same day of surgery.
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Figure 1. The RT-2S brake reaction timer (Advanced Therapy Products, Inc. Richmond, VA) Consist of pedals, a timer, and a light box.