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

Abstract

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-naı̈ve 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 amonth or longer aftermajor 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 brakereaction 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-toidentify 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. A note from the Editor-In-Chief: In “Editor’s Spotlight,” one of our editors provides brief commentary on a paper we believe is especially important and worthy of general interest. Following the explanation of our choice, we present “Take 5,” in which the editor goes behind the discovery with a one-on-one interview with an author of the article featured in “Editor’s Spotlight.”We welcome reader feedback on all of our columns and articles; please send your comments to eic@clinorthop.org. The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connectionwith the submitted article. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. This comment refers to the article available at: DOI: 10.1097/CORR.0000000000000881. S. S. Leopold MD (✉), Clinical Orthopaedics and Related Research, 1600 Spruce St, Philadelphia, PA 19013 USA, Email: sleopold@clinorthop.org