Return to work following lower limb arthroplasty

Abstract

Osteoarthritis causes significant problems in the working age population. Total hip and knee replacements are successful operations and consequently are increasingly offered at younger ages. Moreover, people are being encouraged to work to older ages so that these operations are increasingly likely to occur during a person’s working life with the recipient needing to return to work post-operatively. Currently, there is no evidence-based guidance for when and how people can expect to return to different types of work after surgery. The aims of this thesis were to identify factors which impact the time it takes to return to work, and explore the lived experiences of working-aged individuals undergoing lower limb arthroplasty.
We used a mixed methodology approach: a systematic review; a prospective cohort study; and a qualitative study.
In the systematic review, we found 23 studies suitable for inclusion. However, there was marked heterogeneity of how return to work was measured, ranging from mean or median times, or proportions of patients returning by a fixed time point. Consequently, lack of comparable data prevented data synthesis. However, we found that most people are able to return to work after lower limb arthroplasty. There was some evidence to suggest that earlier RTW was associated with: younger age at time of surgery; possibly male gender; higher levels of educational attainment; (possibly) returning to work that is less physically demanding; (possibly) being self-employed; some surgical techniques; unrestricted post-operative rehabilitation and not being off sick pre-operatively.
Benefitting from an existing cohort study of outcomes after lower limb arthroplasty (COASt), we set up a new prospective cohort study (RTW-COASt). Our aim was to recruit people pre-operatively who wished to return to work after their operation and to follow their journey at several time points until 6 months post-operatively. We recruited 53 participants to the prospective cohort study, amongst whom 47 (89%) returned to work within 6 months of surgery. Median time to RTW was 60 days (IQR 44-74): 62 days (range 10-165) after hip arthroplasty; and 55.5 days (range 19-174) after knee arthroplasty. Six individuals (11%) returned to work within 30 days and 16 within 7 weeks. Factors associated with earlier time to return to work were: younger age; better score for EQ-5D usual activities pre-operatively; not needing to stand/walk at work for > 2 hours day and; and expecting to be able to return to work within 7 weeks. There was no indication of harm after returning to work early, either within 30 days or 49 days of surgery.
The lived experiences of RTW-COASt participants were then investigated through qualitative research. Everyone recruited to RTW-COASt was eligible for the qualitative study providing that they had reached the 6-month post-operative milestone. In total, 13 of RTW-COASt participants took part. We chose to use semi-structured interviews to explore what was important to them when deciding when to RTW. Four key themes were identified: trust that the replaced joint has healed; self-efficacy to achieve a successful RTW; the importance of appropriate healthcare support within a positive patient-healthcare professional partnership; and support from the workplace to which the patient needs to return. These themes were inter-related and reciprocal. In particular, we found that healthcare professionals can have an important influence directly and indirectly on timing of return to work, by enhancing confidence in the replaced joint, creating positive expectations about return to work, increasing the patient’s self-efficacy but also by being perceived as available if needed post-operatively. Employers too had an important role in supporting the return to work journey. More research is needed to understand why some people had the impression that they needed to be 100% healed before they could return to work.
In conclusion, a large multi-site long term study is needed to address the important issues highlighted in this thesis. The routine collection of a standardised set of RTW variables is recommended in research and clinical settings. The impact of beliefs and expectations on RTW times warrants further investigation, and if confirmed, allows the potential for healthcare professionals to intervene and improve RTW outcomes for patients.

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Identifiers

ORCID for Karen Walker-Bone: orcid.org/0000-0002-5992-1459

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