November 2018

Vexing Question: How Soon Should Patients Drive After Lower-Extremity Surgery?

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The answer doesn’t come easily; official guidelines are lacking. Ultimately, patients bear responsibility for the decision, but you can still offer them valuable advice for keeping safe.

By Keith Loria

“Doctor, when can I start driving again?”

That’s a common question patients ask when they’re headed for lower-extremity surgery. But it’s not always an easy one to answer.

In fact, many orthopedic surgeons find it difficult to provide an honest assessment of patients’ ability to resume driving. One study showed that approximately 67% are uneasy counseling patients, for a variety of clinical, ethical, and medicolegal reasons, and 10% refuse to provide any answer outright.1

Adam Miller, MD, a foot and ankle orthopedic surgeon at Beacon Orthopaedics & Sports Medicine in Cincinnati, Ohio, said the decision on when to begin driving after lower-extremity surgery is often a collaborative one, involving provider and patient.

“We must feel they are not putting themselves or others at risk, and the patient must be confident in their ability to resume driving,” he said. “This often varies widely, depending on the extent of the injury or condition. For example, it takes 9 weeks following ankle fracture to regain ability to drive safely.”

“… if they’re not walking comfortably or can’t negotiate weight from one foot to another, they should not drive …”

But people are stubborn

No matter how problematic a foot, knee, or hip injury, many patients want to continue driving without regard to the damage that can be done. Not only is the decision to drive after a lower-extremity orthopedic injury or surgery fraught with legal and safety issues: It can cause further injury.

Ricardo Cook, MD, an orthopedist in Olney, Maryland, notes that, after surgery to a lower-right, and even sometimes a lower-left, extremity, patients aren’t able to operate a vehicle carefully until they’re fully recovered (although with a minor lower-extremity injury, such as a toe or ankle sprain, they are likely able to drive as long as they are walking well).

“Determining whether a patient can drive after surgery depends on the diagnosis, whether the treatment was surgical or nonsurgical, and whether it affected an upper or lower extremity (or both),” Cook said. “The biggest factors in deciding whether a patient can drive after surgery are whether they would be able to effectively put pressure on the brakes and if they could stop urgently in an emergency situation. Also, if they’re not walking comfortably or can’t negotiate weight from one foot to another, they should not drive.”

Whether a patient has had knee arthroscopy, reconstruction of the anterior cruciate ligament, total hip arthroplasty, total knee arthroplasty, or even just a fracture, driving after surgery of a lower extremity can be challenging and outright dangerous. David Geier, MD, an orthopedic surgeon and sports medicine specialist in Charleston, South Carolina, said there are no definitive guidelines regarding the proper length of time that a recovering patient needs to wait before driving.

“I’ve never used a strict timeline,” Geier explained. “There’s a lot of give and take based on the patient, whether it’s an injury to their right or left side and the type of surgery required,” he said. “Even with a non-operative extremity, you have to still think about things like how quickly the patient could get out of a car in an emergency.”

The problem with getting behind the wheel

In the report of a study, published in the Journal of the AAOS (American Academy of Orthopaedic Surgeons), investigators revealed that impairment of driving ability is typically measured by a change in the time needed to perform an emergency stop.2 The findings were that braking function returns to normal at:

  • 4 weeks after knee arthroscopy
  • 6 weeks after initiation of weight bearing after a major lower-extremity fracture
  • 9 weeks after surgical management of an ankle fracture.

The authors also concluded that patients can drive safely 4 to 6 weeks after right total hip arthroplasty or total knee arthroplasty.

Miller explained that the main concern with patients returning to driving is being unable to make that emergency stop when necessary, and that this inability could compromise their safety and the safety of others on the road. Two other safety concerns: Patients who are in pain might be reluctant to press the pedals firmly for fear of it being painful, and those driving a car with a manual transmission require both feet to operate the vehicle.

And there’s a final concern with driving too soon after surgery: Once patients begin to operate a motor vehicle, they’re handling a potential weapon.

“A car can be a danger to yourself and your community,” Cook said, “so if they’re not fully capable of safely and comfortably controlling that potential weapon following surgery, they should not be driving.”

It is important to limit or prohibit driving altogether until the patient feels ready; returning to driving too soon can prolong recovery by delaying and disrupting healing and causing pain and inflammation. Furthermore, in cases of surgical reconstruction, the affected area might not be ready to undergo the impacts delivered by driving.

“It is essential for patients to be non-weight bearing on the affected extremity following the procedure so that proper healing can occur,” Miller said. “If physician recommendations are ignored, the healing process can be slowed, and in some cases, additional damage may be caused. Since driving requires the patient to put weight through the leg and foot, it can cause a delay in healing for certain conditions.”

Risk rises when a cast, brace, or boot is part of the picture

Wearing a cast, brace, or boot significantly plays into the difficulties—and dangers—of driving. When one learns to drive, it’s an instinctual, habit-forming process. People develop reflexes and patterns of movement that become ingrained.

“A cast or boot can significantly disrupt that reflexive instinct,” Cook noted, “because wearing one of those things doesn’t give you the tactile sensation you’re used to, and you could inadvertently hit the accelerator rather than the brake.”

Geier said that he is shocked at the number of patients who, after being fitted with a cast, brace, or boot, tell him that they can simply drive with their right foot on the gas pedal and the left foot on the brake; this adaptation, they tell him, makes driving with one of these accessories possible in their eyes.

“This is a terrible idea,” Geier cautioned. “Really, for any type of immobilization where they are wearing something, I am going to discourage them from driving. If it’s something like an ankle sprain, where they are in a boot and they think they can control the car, maybe we’ll have a discussion about removing the boot when driving, although I warn them against ever driving with the boot because it’s so clumsy, they might miss the brake and be in danger of an accident.”

The problem is, studies3 have shown that many patients are unaware that driving with a cast or brace has the potential to be unsafe, with fewer than 33% percent of patients consulting their surgeon for permission to return to driving.4

Fractures are the biggest question mark, especially those that heal in a boot, because boots are, in fact, designed to come off for showering and exercising.

“People are typically allowed to put a little weight on that,” Geier said. “I am usually OK with them taking the boot off and switching to a shoe only when they are in a car, but the minute they get out, the boot needs to be back on before they take a step.”

The authors of the Journal of the AAOS study2 cited earlier warned that, first, drivers should never drive with a cast or brace on the right leg and, second, those who argue for the 2-foot technique are flirting with disaster.

The researchers in that study found that2:

  • wearing any kind of immobilization on the right ankle causes a much slower braking time
  • braking reaction time was slower with the 2-footed technique than with any other method of applying the brakes
  • any type of right-knee immobilization greatly slows braking time.

Miller confirmed that wearing an immobilization device on the right lower extremity while driving leads to delayed braking time and might cause the driver to press the wrong pedal inadvertently.

“The driver may therefore be considered an impaired driver for insurance purposes,” he said. “If the brace is needed for weight-bearing activities only, the patient may be able to take the device off to drive and apply it once they get to the destination. This should be discussed with your foot and ankle doctor beforehand.”

The study authors did theorize that someone could drive a vehicle with an automatic transmission if the left lower extremity is immobilized—but stopped short of recommending this practice.2 But with widely available ride-share options today, it simply isn’t worth endangering one’s self and others by trying to drive with both feet instead of letting the body heal until it’s feasible to drive with only the right foot again.

Laura E. Sansosti, DPM, clinical assistant professor in the Departments of Biomechanics and Surgery at Temple University School of Podiatric Medicine, Philadelphia, Pennsylvania, is adamant about telling patients that they cannot drive with a right-sided surgery until their recovery is complete and they are back in regular shoe gear. Sansosti was part of a recent Temple University study that looked at lower-extremity injuries and brake-response times and driving function, in which study participants wore regular shoe gear, surgical shoe gear, or a controlled ankle movement (CAM) walker boot.5

“What we found was that brake-response times were significantly slower in patients who wore a surgical shoe and, especially, in the CAM boot cohort—going above the safe-brake response threshold, which a lot of sources list as 0.7 seconds,” Sansosti explained. “Those in the boot were above that threshold,” she said. “Additionally, the frequency of that abnormally slow brake time was higher. Also, the frequency of inaccurate brake times (such as hitting the accelerator at the same time) was higher.”

For 2 vehicles travelling at 55 mph, when one driver had regular shoe gear and the other had surgical shoe gear or a boot, the difference in brake-response time translated to approximately a 13-foot physical stopping difference. This is a significant distance in a real-world scenario—possibly, the difference between having an uneventful trip and being in a crash or worse. (Editor’s note: the average width of a pedestrian crosswalk is 6 feet.)

“the main concern with patients returning to driving is being unable to make that emergency stop when necessary”

Real-life examples

After one of Miller’s patients underwent surgical intervention for a right-ankle fracture, he recommended a resumption of driving only after having full weight-bearing, in a boot, for 1 week (but not driving with the boot on), so long as the patient felt confident making an emergency stop.

“Generally, this is between 8 to 10 weeks post-op,” Miller said. “The reason we wait 8 to 10 weeks is to ensure the patient has returned to their full driving capabilities. We don’t want someone to be treated for a right ankle fracture and cause an accident because they tried to drive too soon following treatment.”

Calamitous cautionary tale. A recent case report,6 spearheaded by Michael Symes, BAppSc Physio(Hons), MBBS(Hons), FRACS, FAOrthoA, MPH, an orthopedic surgeon in Sydney, Australia, detailed a serious motor vehicle crash caused by a patient driving in a CAM boot—the first documented case of such an incident.

The authors described a 41-year-old man who underwent successful distraction subtalar arthrodesis for symptomatic failure of his calcaneal open reduction and internal fixation. He later developed early adjacent segment disease in his talonavicular and calcaneocuboid joints, failed nonoperative management, and had the joints repaired by arthrodesis. Two weeks later, the patient was placed into a CAM walker boot and told to remain non-weight bearing.

He didn’t listen. Less than 2 weeks later, the CAM walker boot became entrapped between the accelerator and brake pedal while the patient was driving, causing his car to collide with a tree.

Symes noted that, because CAM walker boots are utilized a great deal after lower-extremity surgery, the lesson of this unfortunate incident is an important one for orthopedic surgeons to keep in mind when discussing risks and dangers with patients fitted with a CAM walker boot after surgery—including that patients should not be driving.

“From a risk management perspective, I recommend that all CAM walker boots come with explicit warnings not to drive,” Symes said. “From an orthopedic surgeon’s perspective, I recommend that this advice should be clearly stated and documented throughout the patient’s perioperative and rehabilitative period as well.”

Test it out: Another example is repair of an anterior cruciate ligament, which Geier said causes weakness that makes lifting the leg difficult—a phenomenon that holds true with any hip or knee surgery.

“From a strength standpoint, if you can’t slam the brakes suddenly, that’s going to be problematic, and that’s the criterion I use,” Geier said. “If you can see them easily do a straight-leg in the office, then I have them test it out in a parking lot to make sure they don’t have any difficulties getting from gas to brake.”

So where does responsibility lie?

“It is, ultimately, the patient’s responsibility to decide when they will return to driving after a surgical procedure,” Miller concluded. “Some patients choose to get behind the wheel earlier than recommended. If a patient hits someone due to a slowed reaction time because of a recent procedure, they are affecting the lives of the other driver and their family as well.”

Keith Loria is a freelance writer who writes regularly for LER.

REFERENCES
  1. Giddins GE, Hammerton A. ‘Doctor, when can I drive?” A medical and legal view of the implications of advice on driving after injury or operation. Injury. 1996;27(7):495-497.
  2. Marecek GS, Schafer MF. Driving after orthopaedic surgery. J Am Acad Orthop Surg. 2013;21(11):696-706.
  3. Chen V, Chacko AT, Costello FV, Desrosiers N, Appleton P, Rodriguez EK. Driving after musculoskeletal injury. Addressing patient and surgeon concerns in an urban orthopaedic practice. J Bone Joint Surg Am. 2008;90(12):2791-2797.
  4. Orr J, Dowd T, Rush JK, Hsu J, Ficke J, Kirk K. The effect of immobilization devices and left-foot adapter on brake-response time. J Bone Joint Surg Am. 2010;92(18):2871-2877.
  5. Sansosti LE, Rocha ZM, Lawrence MW, Meyr AJ. Effect of variable lower extremity immobilization devices on emergency brake response driving outcomes. J Foot Ankle Surg. 2016;55(5):999-1002.
  6. Symes MJ, Escudero M, Abdulla I, Veljkovic A, Paquette S, Younger AS. Boots are not made for driving: a cautionary case report about the dangers of driving in a CAM walker boot and literature review. Foot Ankle Spec. August 6, 2018. https://journals.sagepub.com/doi/full/10.1177/1938640018790057. Accessed November 23, 2018.
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