SLR - February 2020 - Christopher D. Galli
Reference: McDonald E, Pedowitz D, Shakked R, Fuchs D. When is it Safe to Drive After Total Ankle Arthroplasty? Clin Orthop Relat Res. (2020) 478:8-15Scientific Literature Review
Reviewed By: Christopher D. Galli, DPM
Residency Program: Scripps Mercy Hospital - San Diego, CA
Podiatry Relevance: There has been a recent increase in the number of patients receiving total ankle arthroplasties (TAA). These patients require proper postoperative care including instructions on when to return to driving. The ankle plays an important role when it comes to braking and, therefore, evaluating a patient so that they may return to driving is important from both a patient safety and medical-legal perspective. The purpose of this study was to evaluate: (1) Does brake-reaction time return to a safe value within six weeks of TAA? (2) Are there factors associated with a delay of return of brake-reaction time to safe values after TAA?
Methods: Fifty-nine patients who received a Salto Talaris TAA between 2015-2017 were enrolled. Patients who drove at least four days a week were included. Patients with pre-existing conditions that could impair operation of vehicle, DVT, wound healing issues, and consumption of opioids at time of testing were excluded. A control group of 20 volunteer participants matched for age and sex who did not have right lower extremity pathology was used to establish a passing brake-reaction time of 0.850 seconds during a driving-simulation test. This was used to determine if a patient had a passing or failed brake-reaction time at six weeks postoperatively. Testing was repeated weekly until patients achieved a passing time. Secondary study outcomes were evaluated by a driver-readiness survey, VAS for pain, American Orthopaedic Foot and Ankle-Hindfoot score (AOFAS-HF), and ankle plantarflexion and dorsiflexion range of motion with lateral radiographs.
Results: Thirty-five men and twenty-four women participated with a mean age of 63 years. Ninety-two percent (54/59) of patients achieved a passing brake-reaction time with a mean of 0.626 seconds at six weeks postoperatively. The five patients who failed at six weeks had a mean brake-reaction time of 1.120 seconds. These patients achieved a passing break-reaction time at an average of 8.9 weeks after TAA. The failed patients at six weeks had a greater median VAS pain score than those who passed (three vs one) and less ankle joint plantarflexion range of motion (14 degrees vs 24 degrees). Ankle dorsiflexion ROM and the AOFAS-HF score did not differ between the groups. Better brake-reaction times were well correlated with better driver-readiness survey scores. All five patients who failed at six weeks postoperatively had failed driver-readiness survey scores at that time.
Conclusions: Ninety-two percent of patients achieved a safe brake-reaction time within six weeks of TAA. Factors associated with failed brake-reaction time were higher VAS score, limited plantarflexion ROM, and failed score on the driver-readiness survey. The information gathered is clinically useful as it can be used in preoperative planning and provides insight on postoperative evaluation to determine when a patient can return safely to driving. This study had limitations as braking was simulated, brake-reaction time is just one factor in safety for driving, preoperative braking time test not performed, and testing was not performed prior to six weeks to determine whether a patient’s brake-reaction time returns to the normal range earlier.