Orthopedics

Feature Article 

Return to Work After Total Joint Arthroplasty: A Predictive Model

Alexander J. Rondon, MD, MBA; Timothy L. Tan, MD; Max R. Greenky, MD; Matthew M. Kheir, BS; Carol Foltz, PhD; James J. Purtill, MD

Abstract

Returning to work after surgery is a primary concern of patients who are contemplating total joint arthroplasty (TJA). The ability to return to work has enormous influence on the patient's independence, financial well-being, and daily activities. The goal of this study was to determine the independent patient variables that predict return to work as well as to create a predictive model. From June 2017 to December 2017, a total of 391 patients who underwent primary TJA (243 hips, 148 knees) were prospectively enrolled in the study to obtain information on return to work after surgery. Patients were sent a series of questions in a biweekly survey. Information was collected on the physical demands of their occupation, the number of hours spent standing, the limitations to return to work, and the use of assistive devices. Bivariate analysis was performed, and a multiple linear regression model was created. Most (89.6%) patients returned to work within 12 weeks of surgery. Patients who underwent total hip arthroplasty returned to work earlier than those who underwent total knee arthroplasty (5.56 vs 7.79 weeks, respectively). Analysis showed the following independent predictors for faster return to work: self-employment, availability of light-duty work, male sex, and higher income. Predictors for slower return to work included a physically demanding occupation (at least 50% physical duties), knee arthroplasty, longer length of stay, and a job requiring more hours spent standing. This model reported an adjusted R2 of 0.332. The findings provide an objective predictive model of the patient- and procedure-specific characteristics that affect postoperative return to work. Surgeons should consider these factors when counseling patients on their postoperative expectations. [Orthopedics. 2020;43(5):e415–e420.]

Abstract

Returning to work after surgery is a primary concern of patients who are contemplating total joint arthroplasty (TJA). The ability to return to work has enormous influence on the patient's independence, financial well-being, and daily activities. The goal of this study was to determine the independent patient variables that predict return to work as well as to create a predictive model. From June 2017 to December 2017, a total of 391 patients who underwent primary TJA (243 hips, 148 knees) were prospectively enrolled in the study to obtain information on return to work after surgery. Patients were sent a series of questions in a biweekly survey. Information was collected on the physical demands of their occupation, the number of hours spent standing, the limitations to return to work, and the use of assistive devices. Bivariate analysis was performed, and a multiple linear regression model was created. Most (89.6%) patients returned to work within 12 weeks of surgery. Patients who underwent total hip arthroplasty returned to work earlier than those who underwent total knee arthroplasty (5.56 vs 7.79 weeks, respectively). Analysis showed the following independent predictors for faster return to work: self-employment, availability of light-duty work, male sex, and higher income. Predictors for slower return to work included a physically demanding occupation (at least 50% physical duties), knee arthroplasty, longer length of stay, and a job requiring more hours spent standing. This model reported an adjusted R2 of 0.332. The findings provide an objective predictive model of the patient- and procedure-specific characteristics that affect postoperative return to work. Surgeons should consider these factors when counseling patients on their postoperative expectations. [Orthopedics. 2020;43(5):e415–e420.]

Returning to work after surgery is a primary concern of patients who are contemplating total joint arthroplasty (TJA). The ability to return to work has an enormous influence on the patient's independence, financial well-being, and other activities. Many variables affect both the ability to return to work after TJA and the timing of return. Surgeons often use their knowledge and clinical experience to provide patients with information on returning to work.

Today, an increasing number of patients undergo arthroplasty before retirement, with projections estimating that more than 50% of the arthroplasty population is younger than 65 years.1 In the United States, approximately 1.5 million people between 50 and 65 years have undergone total knee arthroplasty (TKA).2 With the increase in the retirement age, questions about returning to work are very pertinent for patients who are contemplating TJA. Earlier studies reported a range of rates for return to work after primary TKA (40% to 97%)3–8 and primary total hip arthroplasty (THA) (74% to 96%).8–11 However, to the current authors' knowledge, this study is the largest single-institution investigation to consider patient-specific and procedure-specific predictors for return to work in previously working TJA patients. The literature in this area has been limited primarily because the data require prospective collection to reduce recall bias.6,12–14

The goal of this prospective study was to determine independent patient variables that predict return to work as well as to create a predictive model. After controlling for confounding demographic, medical, and social variables, the authors sought to identify independent risk factors for prolonged return to work after both THA and TKA. They hope that their findings will provide valuable information for surgeons when counseling patients about returning to work after TJA.

Materials and Methods

After institutional review board approval was obtained, a total of 391 patients who had undergone primary TJA (148 knees, 243 hips) at a single institution between June 2017 and December 2017 were prospectively enrolled. Patients who underwent primary THA for hip fracture, revision TKA, or revision THA and those who were not employed or were retired before surgery were excluded. An electronic survey was developed and administered to patients to obtain information on return to work after TJA. The authors recorded the laterality of the procedure, the type of procedure, the surgical approach, insurance status, narcotic use, preoperative ambulatory status, assistive device use, living status, age, sex, body mass index, occupation, physicality of occupation (100% desk work, 50% desk work and 50% physical work, or 100% physical work), number of hours spent standing at work, self-employment status, and limitations to return to work. The survey questionnaire asked patients when they returned to work in weekly increments. The survey was e-mailed every 2 weeks from the date of arthroplasty for 12 weeks with an electronic survey program (REDCAP, Nashville, Tennessee).

All TKA procedures were performed with a medial parapatellar approach, with all components cemented. For THA, procedures were performed with a direct lateral (modified Hardinge), direct anterior (Smith-Petersen), or posterior (Southern-Moore) approach. All THA procedures were performed with cementless press-fit components. Differences in time of return to work with respect to THA approach were not assessed.

An electronic chart query was performed to identify comorbidities and demographic information. All patients were treated with the same postoperative pain and rehabilitation protocols. All patients were discharged with an assistive device (ie, cane, walker). Patients were instructed that they could return to work when they no longer required pain medication. Surgeons did not specifically designate a time at which patients could return to work. Patient demographic data are shown in Table 1.

Demographic Data on Return to Work After Total Joint ArthroplastyDemographic Data on Return to Work After Total Joint Arthroplasty

Table 1:

Demographic Data on Return to Work After Total Joint Arthroplasty

Statistical Analysis

Time to return to work was analyzed with preliminary bivariate logistic regression analyses to determine whether various preoperative and patient variables were significantly related to the binary outcome (return to work). Variables that were related to the outcome in the bivariate analyses (P<.25, as recommended by Hosmer and Lemeshow,15 because lower P values, such as .05, can omit important predictors) were considered for inclusion in the final predictive models for return to work after TKA and THA. The predictive set was reduced to eliminate factors that were correlated or that caused multicollinearity before the final model was run. The remaining predictors were entered into a final multivariate logistic regression. All analyses were conducted with SPSS version 23 (IBM, Armonk, New York).

Results

Most (89.6%, 349 of 391) patients returned to work within 12 weeks of surgery. Patients who underwent THA returned to work earlier than those who underwent TKA (5.56 weeks vs 7.79 weeks, respectively; P<.001) (Figure 1). Patient occupations included actor, chef, professional (eg, professor, lawyer, accountant, physician), physical laborer, and teacher. Of the patients, 40.7% (159 of 391) had white collar occupations (100% desk work), and 18.9% (74 of 391) had labor-intensive occupations (100% physical work), with a mean reported 3.5 hours (SD, 2.6 hours) spent standing at work. The self-employment rate was 19.2% (75 of 391), light-duty work was available for 36.1% (141 of 391), and 94.6% (370 of 391) used some form of assistive device postoperatively. On average, patients used an assistive device for 4.7 weeks (SD, 3.4 weeks) postoperatively, reporting 5.1 weeks (SD, 3.6 weeks) after TKA and 4.4 weeks (SD, 3.2 weeks) after THA. Of note, 56 patients (14.3%) had an emergency department visit during the 90-day global postoperative period (Tables 12).

Time to return to work stratified by 1-week increments and arthroplasty cohort. Abbreviations: THA, total hip arthroplasty; TJA, total joint arthroplasty; TKA, total knee arthroplasty; RTW, return to work.

Figure 1:

Time to return to work stratified by 1-week increments and arthroplasty cohort. Abbreviations: THA, total hip arthroplasty; TJA, total joint arthroplasty; TKA, total knee arthroplasty; RTW, return to work.

Categorization of Postoperative Emergency Department Visits

Table 2:

Categorization of Postoperative Emergency Department Visits

Multivariate analysis showed the following independent predictors for faster return to work: self-employment (standardized coefficient [SC], −11.9 days, P<.001), availability of light-duty work (SC, −10.2 days, P<.001), male sex (SC, −7.8 days, P=.003), and higher income (per $10,000) (SC, −0.9 days, P=.025). Additionally, independent predictors for longer return to work included an occupation with at least 50% physical duties (SC, 7.6 days, P<.001), knee arthroplasty (vs hip) (SC, 5.8 days, P=.047), longer length of stay (SC, 4.4 days [per length of stay day], P=.010), and more hours spent standing (SC, 1.2 days [per hour], P=.046). This model reported an adjusted R2 value of 0.332 (Table 3).

Multivariate Model for Return to Work After Total Joint Arthroplasty

Table 3:

Multivariate Model for Return to Work After Total Joint Arthroplasty

Discussion

After TJA, patients are eager to return to work, given the benefits of financial well-being, improved mental state, and enhanced quality of life.16,17 Setting appropriate patient expectations for the ability to return to work after surgery is a necessary component of preoperative counseling. The current study provides arthroplasty surgeons with a model to better predict when a patient can expect to return to work based on patient-specific, employment-specific, and procedure-specific risk factors. Male sex, higher income, self-employment, white collar occupation (100% desk job), lower physical requirements (not 100% physical job), availability of light-duty work, reduced hours spent standing, hip procedure (vs knee), and reduced hospital stay were significant predictors for faster return to work.

The rate of return to work after TJA has been studied, with the orthopedic literature reporting a wide range of findings.18 In a retrospective review of 173 patients who underwent TKA, Kievit et al3 reported rates of return to work of 50% within 12 weeks, 59% within 6 months, and 70% overall; however, in contrast to the current results, they reported no correlation between job physicality and return to work. Clyde et al9 reported a rate of return to work of 70.2%, with a mean time of 16.4 weeks after primary TJA in patients who were receiving workers' compensation. Similar to the current study, those with physically demanding jobs had reduced rates of return to work (67.1% for physical jobs vs 84.8% for sedentary jobs, P=.050).9 In a prospective study of 162 patients who underwent primary TKA, Styron et al6 reported a 72.2% rate of return to work within 3 months, with female sex, higher mental health and physical function scores, and handicap-accessible workplaces associated with faster return to work. Comparable to the current study, physically demanding occupations were associated with slower return to work. In contrast to the current results, in a prospective study of 289 patients who underwent TKA, Scott et al14 reported that approximately half of patients who were between 50 and 60 years old returned to work. Several smaller retrospective studies also reported a wide range of rates of return to work after TJA (59% to 85%)13,14,19–22; however, all of these studies included fewer than 90 patients. The current study reported that most patients (87.8% for TKA and 90.1% for THA) returned to work within 12 weeks of surgery.

The orthopedic literature has reported on return to work after hip fracture in the working population. In an Australian registry study, Ekegren et al23 reviewed rates of return to work after hip fracture among 291 adults 65 years and younger and noted that 65% of patients returned to work within 12 months. Older patients, those with multiple injuries, and those with more physically demanding occupations required more assistance to return to work. Similarly, smaller studies reported that 73% (24 of 33) and 85% (44 of 52) of patients returned to work after hip fracture.24,25 However, hip fractures occur in a bimodal distribution because of low-energy mechanisms in the elderly population and higher-energy mechanisms in the younger population. Further, hip fracture is treated in the trauma setting, and surgery is rarely elective, in contrast to arthroplasty. Thus, highlighting the importance of providing additional information and identifying risk factors for faster return to work will assist surgeons and patients in preoperative counseling.

Studies also have examined employment-specific predictors of return to work as well as factors in faster return to work. Patients receiving workers' compensation have shown slower return to work and lower functional outcomes in both trauma and arthroplasty populations.9,26,27 Patient motivation, sex, and employer interest also have been shown to improve the rate of return to work after injury.28 A systematic review by Malviya et al29 concluded that age, patient motivation, and employment type were the most important factors in the rate of return to work after arthroplasty. Employer and workplace support also have been shown to improve the rate of return to work after arthroplasty.30 Obtaining a thorough employment history preoperatively is essential for adequately counseling patients on return to work after TJA.

This prospective study was not without limitations. First, the end point of the questionnaire was the 3-month follow-up, and so patients who took longer to return to work may not have been identified. Second, the questionnaire required patient access to e-mail, which may represent a more compliant and younger patient population. Third, additional factors that may affect return to work were not collected in the survey, such as current income or home ownership. Household income was stratified by government-reported average per zip code rather than obtained individually. Therefore, the influence of income may be misrepresented, given potential income variability within zip codes. Finally, these results rely on information provided by patients on work status, which is vulnerable to subjective interpretation of physicality. The authors attempted to reduce recall bias by sending biweekly surveys with an objective questionnaire to control for this limitation.

Conclusion

This prospective study identified the average time of return to work after THA and TKA as well as the independent predictors that influenced return to work. The authors hope that the findings allow surgeons, patients, and employers to set appropriate preoperative expectations for the ability to return to work after surgery.

References

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Demographic Data on Return to Work After Total Joint Arthroplasty

CharacteristicTotal Knee Arthroplasty (n=148)Total Hip Arthroplasty (n=243)Total Joint Arthroplasty (n=391)
Age, mean (SD), y61.6 (7.8)57.8 (9.0)59.2 (8.7)
Body mass index, mean (SD), kg/m231.1 (4.8)29.7 (5.5)30.2 (5.3)
Length of stay, mean (SD), d1.51 (1.00)0.93 (0.66)1.11 (0.87)
Government insurance, No.26 (17.6%)34 (14.0%)60 (15.3%)
Income per zip code, mean (SD)$87,648 ($30,326)$92,555 ($34,491)$90,689 ($33,010)
Right-sided laterality, No.63 (47.7%)124 (51.0%)187 (47.8%)
Bilateral procedure, No.16 (10.8%)6 (2.5%)22 (5.6%)
Surgery at physician-owned hospital, No.84 (56.8%)97 (33.1%)181 (46.3%)
Non-home discharge, No.14 (9.5%)12 (4.9%)26 (6.6%)
Comorbidities, No.
  Cardiac arrhythmias13 (8.8%)14 (5.8%)27 (6.9%)
  Chronic pulmonary disease18 (12.2%)19 (7.8%)37 (9.5%)
  Hypertension7 (4.7%)10 (4.1%)17 (4.3%)
  Diabetes19 (12.8%)11 (4.5%)30 (7.7%)
  Hypothyroidism17 (11.5%)27 (11.1%)44 (11.3%)
  Renal disease3 (2.00%)2 (0.82%)5 (1.30%)
  Rheumatoid arthritis2 (1.4%)10 (4.1%)12 (3.1%)
  Depression12 (8.1%)16 (6.6%)28 (7.2%)
Working questions, No.
  Returned to work141 (95.3%)231 (95.1%)372 (95.1%)
  Returned to work within 12 wk131 (88.5%)221 (90.9%)352 (90.0%)
  Light-duty work available43 (29.1%)98 (40.3%)141 (36.1%)
  Light-duty work within 12 wk41 (95.3%)93 (94.9%)134 (95.0%)
  Self-employed22 (14.9%)53 (21.8%)75 (19.2%)
  Emergency department visit27 (18.2%)29 (11.9%)56 (14.3%)
Standing hours, No.
  ≤8 h140 (94.6%)233 (95.9%)373 (95.4%)
  >8 h8 (5.4%)10 (4.1%)18 (4.6%)
Occupation level, No.
  100% desk work53 (35.8%)106 (43.6%)159 (40.7%)
  50/50 desk/physical work66 (44.6%)92 (37.9%)158 (40.4%)
  100% physical work29 (19.6%)45 (18.5%)74 (18.9%)
Limitations for return to work, No.
  None29 (19.6%)72 (29.6%)101 (25.8%)
  Pain34 (13.0%)30 (12.3%)64 (16.4%)
  Ability to walk48 (32.4%)67 (27.6%)115 (29.4%)
  Unable to drive to work7 (4.7%)28 (11.5%)35 (9.0%)
  Other30 (20.3%)46 (18.9%)76 (19.4%)
Assistive device postoperatively, No.
  None10 (6.8%)11 (4.5%)21 (5.4%)
  Crutches4 (2.7%)18 (7.4%)22 (5.6%)
  Cane78 (52.7%)118 (48.6%)196 (50.1%)
  Walker56 (37.8%)96 (39.5%)152 (38.9%)

Categorization of Postoperative Emergency Department Visits

Reason for Emergency Department VisitNo.

Total Knee Arthroplasty (n=148)Total Hip Arthroplasty (n=243)Total Joint Arthroplasty (n=391)
No.334074
Unrelated medical problem13 (39.4%)11 (27.5%)24 (32.4%)
Postoperative complication9 (27.3%)11 (27.5%)20 (27.0%)
Primary care follow-up questions10 (30.3%)16 (40.0%)26 (35.1%)
Fall1 (3.0%)2 (5.0%)3 (4.1%)

Multivariate Model for Return to Work After Total Joint Arthroplasty

VariableCoefficient, d95% Confidence IntervalP
Constant35.516.2 to 54.9-
Age0.1−0.2 to 0.4.390
Body mass index >30 kg/m23.3−1.9 to 8.5.213
Male=1−7.8−13.0 to −2.6.003
Length of stay4.4−1.1 to 7.7.010
Joint: knee procedure5.80.1 to 11.4.047
Bilateral0.0−11.5 to 11.4.994
Surgery at physician-owned hospital2.5−3.0 to 8.1.368
Income (per $10,000)−0.9−1.6 to −0.1.025
Elixhauser−2.9−3.0 to 2.4.830
Self-employed−11.9−18.4 to −5.5<.001
Non-100% desk work7.61.6 to 13.5.013
100% physical work23.114.4 to 31.7<.001
Standing hours1.20.2 to 2.4.046
Light duty available−10.2−15.6 to −4.8<.001
Assistive device
Cane (ref=no device preoperatively)5.852−1.8 to 13.5.133
Crutches/walker (ref=no device preoperatively)12.481−3.3 to 28.2.120
Authors

The authors are from the Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Alexander J. Rondon, MD, MBA, Rothman Orthopaedic Institute, Thomas Jefferson University, 925 Chestnut St, Philadelphia, PA 19107 ( Reseach@rothmanortho.com).

Received: April 11, 2019
Accepted: June 20, 2019
Posted Online: July 07, 2020

10.3928/01477447-20200619-12

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