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Commentary and Perspective   |    
Commentary on an article by Joseph F. Styron, PhD, et al.: “Preoperative Predictors of Returning to Work Following Primary Total Knee Arthroplasty”
Thomas Parker Vail, MD
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The author did not receive any outside funding or grants in support of his research for or preparation of this work. The author, or a member of his immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (DePuy).

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Jan 05;93(1):e2 1-1. doi: 10.2106/JBJS.J.01581
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As the volume of total knee replacements increases and the indications for this surgery expand to include younger age groups, it is clear that surgical treatment of arthritis in the form of knee replacement surgery will impact the adult working population. Time out from work has very important economic implications, which underscore the importance of studying this group of patients. The authors of this study completed a very interesting analysis of prospectively collected data focused on factors that impact the likelihood of returning to work after total knee replacement. While the stated goal of this research was to provide information to clinicians helping patients to set expectations, it turns out that the motivation, if not the expectations, of these patients is an important determinant of the final result. The results and conclusions of this analysis will be of particular interest to health-care providers, employers, and patients alike, as they demonstrate that there are factors within the control of each of these stakeholders that impact the length of time that a patient is out of work after knee replacement surgery.
The patients in this study were selected from a representative cohort taken from both academic and community settings, which makes the findings more generalizable to the overall population of patients treated with knee replacement. To be included in the study, the patient only had to be employed at the time of enrollment and to be intending to return to work postoperatively. One confounder that the reader should keep in mind is that return to work included return to part-time work and return to work was "considered a positive outcome regardless of whether the participant met his or her preoperative job demands." Nevertheless, return to work was stratified in terms of return to part-time work or return to full-time work. The authors did attempt to analyze the physical demands of the workplace, although the impact of physical demands was "evaluated only when work responsibilities had not been modified preoperatively or postoperatively."
Despite the limitations due to the complexity of evaluating what actually happens in the workplace, and what accommodations are made, the findings have interesting implications regarding the workplace culture. In particular, the authors found that the "sense of urgency about returning to work" could lead to a return in 46.8% of the time taken by those without a sense of urgency. Also, important support for optimizing the physical characteristics of the workplace is derived from the finding that "individuals employed at a handicap accessible workplace returned in 73.6% of the time taken by patients not employed at a handicap accessible workplace."
Although having a more physically demanding job did lengthen the time to return to work (for every standard deviation increase in work demands, a patient could anticipate taking 11.6% longer to return to work), an important finding of this study is that patients were able to return to physically demanding jobs. The results also imply that a more flexible workplace and self-employment might lead to an earlier return to part-time work. The study does not answer questions about regional variation, socioeconomic strata, and race, but it does suggest that females return to work faster than males independent of the physical demands of the job. No doubt the highly significant "sense of urgency" is influenced by many personal and job-related factors.

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