Return to driving after total hip and knee arthroplasty – the perspective of employed patients

Abstract

Purpose

To address the paucity of research on patient perspectives regarding return to driving after Total Hip and Total Knee arthroplasty (THA; TKA), and how this impacts on return-to-work.

Materials and Methods

Employed participants, who had undergone THA or TKA, took part in semi-structured telephone interviews. They were asked about support received regarding driving, who provided this information, and the impact of this on their return to driving and consequently work.

Results

Thirty-eight people were interviewed. Although sources of information and advice were available, patients struggled to know who to approach. Interviewees reported variations and contradictions in the advice given on when they could safely return to driving after surgery. Of note, there was little difference in the advice given to those who had undergone THA compared to TKA. Many participants devised their own plan for returning to driving

Conclusions

There is inconsistency in driving advice provided after THA and TKA. Consequently, patients make their own decisions about how and when to drive, and develop strategies to accelerate the process. Greater clarity is required from healthcare professionals on time frames for driving post-surgery and for advising patients on their responsibilities around informing the DVLA and insurance companies of their surgery.

IMPLICATIONS FOR REHABILITATION

• Healthcare professionals should be aware of medico-legal requirements when advising patients about their legal responsibilities regarding driving after joint arthroplasty.

• Given the pivotal role of driving in the resumption of work after joint arthroplasty, there needs to be greater importance placed on the provision of explicit advice and support on driving for those undergoing orthopaedic surgery.

• As driving is a complex skill, the advice given to patients should be individualised.

• Factors to be considered should be the type of vehicle driven e.g., automatic/manual transmission; height of the vehicle from the ground; the side of the surgery; any medication prescribed which might impact on driving, and consideration of any comorbidities.

Keywords:

• Driving
• total hip arthroplasty
• total knee arthroplasty
• advice
• work

Introduction

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common and widely performed surgeries for the alleviation of pain and recovery of function in patients with osteoarthritis [1]. The number of patients undergoing THA/TKA in the United Kingdom (UK) is steadily increasing [2] while the average age of patients is decreasing: it has been estimated that more than half of those undergoing surgery are under 65 years of age [3]. For many of these patients, there is a pressing need to continue driving in order to access work, leisure pursuits and amenities.

Despite this, the information and advice for patients on returning to driving is varied. In their patient information, Versus Arthritis (formerly Arthritis UK) specify a minimum six-week post-surgical abstinence from driving. Patients with a vehicle with automatic transmission are advised that they could return “earlier” if they are not taking “strong painkillers,” but do not indicate when this might be [4,5]. The UK National Health Service (NHS) website advises that patients can resume driving “when you can bend your knee enough to get in and out of a car and control the car properly.” It is suggested that this would be around four to six weeks’ after surgery, but patients are advised to check individually with their physiotherapist or doctor whether this is safe for them [6]. The Royal College of Surgeons (RCS) also provide advice on driving after THA/TKA. However, their information is different for each surgery. For THA it suggests that driving should be avoided for the first six weeks after surgery, but notes that patients may be able to drive earlier if they have a car with automatic transmission. It further suggests the patient should discuss this individually with their surgeon [7]. The advice for TKA is less comprehensive, suggesting 8 weeks abstinence from driving with no mention of a reduction in this time if the patient drives a vehicle with automatic transmission [8]. The RCS further specifies that the patient should inform their vehicle insurance company if they have had either a THA or TKA.

Yet, despite this existing advice and information, a number of previous studies have highlighted the lack of clear clinical guidelines on when patients should consider a return to driving post-surgery [9–11]. In Great Britain (GB), the Driver and Vehicle Licensing Agency (DVLA) is the organisation responsible for maintaining a database of drivers and a database of vehicles. Their guidelines suggest that patients only need to notify the authorities of their THA/TKA if they are still unable to drive at three months post-surgery. There are no legally binding times of absence from driving prescribed by the DVLA however, in their guide for medical professionals, they state that “licence holders wishing to drive after surgery should establish with their own doctors when it would be safe to do so.” This implies that the onus is on the patient to seek guidance from a health professional on when they should resume driving [12].

Due to the continuing younger demographics of THA/TKA patients, a return to activities such as work, sports and driving is increasingly important [13]. Yet there has been little, if any, research specifically examining the patient’s experience of return to driving and the advice received. Abbas et al. [14] reported a wide variation in the time advised for resumption of driving after THA, but did not document the actual advice received by individual patients. One of the central study conclusions was the need for THA patients to be provided with clear advice and guidance. The issue of driving resumption was also explored by Bardgett et al. [15] who investigated patient reported factors impacting on return- to- work (RTW). The need to return to driving was highlighted as a key issue for patients, necessitating the need for appropriate, timely, reliable advice and support. This link between driving and work was further highlighted by McGonagle et al. [16] who cited the limited medical advice or clearance to drive as a factor impeding RTW in almost a fifth of patients who had undergone hip or knee arthroplasty.

We conducted a national study, OPAL [17] (Occupational advice for Patients undergoing Arthroplasty of the Lower limb) study to develop an occupational advice intervention for patients undergoing THA and TKA who wished to RTW. This present study was nested within the larger OPAL study, with the aim of collecting patient reported information specifically on i) advice and support received regarding a return to driving, ii) who had provided the information, iii) how this impacted on their return to driving and to work.

Materials and methods

Ethical approvals for the study were obtained. Patients were recruited to the OPAL study from three UK study sites. The inclusion criteria for OPAL were that they (i) had undergone THA/TKA surgery, (ii) were working prior to THA/TKA surgery (including unpaid/voluntary work), (iii) were intending to RTW and (iv) provided informed consent to be interviewed. The further criterion for this study was that patients were driving prior to their surgery.

We wished to recruit a purposive sample of approximately 10–15 patients in each centre (or a maximum of 45 patients from all centres) to be interviewed at 16 weeks post-surgery. This sample was agreed by the wider OPAL team as being sufficient to achieve data adequacy in order to meet the study aim and was likely to reach saturation [18]. We aimed to recruit equal numbers of patients with THA and TKA

Individual telephone interviews were conducted at a time convenient to the participant.Interviews were conducted by experienced qualitative researchers with backgrounds in rehabilitation, disability, work and driving. Both written and verbal informed consent were obtained prior to interview. We used an interview schedule as a guide to find out about the post-surgical advice and support patients had received, who had given them this information and how this impacted on their return to driving and to work. The interview schedule was developed based on previous “driving” advice literature [4–12], suggestions from the wider OPAL research team and from PPI members of the OPAL study. Versions of the schedule were circulated for comment and amendment. One of the PPI members approved the final version. The schedule may be found in Table 1.

Table 1. Example interview questions and prompts.

Do you need to be able to drive in order to return to work? Do you drive as part of your job? Is driving all of your job, or part of it? Do you need to be able to drive to access your workplace?

How were you managing your driving before you underwent the surgery? Did you need any adaptations or did you moderate your driving? Did pain relief medication impact on your driving? Did your driving problems impact on your decision to have surgery? Did you seek advice on driving prior to surgery?

How soon after surgery did you resume driving? Were you given any advice or information? Is so what, and from whom? Did you speak to the surgeon or other hospital based medical professionals about driving? Did you consult with your GP about when to return to driving?

Did the design of your car make it easier or more difficult to resume driving? Has your car got automatic transmission? If so, did this help? How easy is your car to get in and out of?

Qualitative research methodology was used for analysis purposes [19]. Interviews were digitally recorded and transcribed verbatim. Transcripts were read by two members of the research team who developed a coding structure using a qualitative data package (NVivo10, QSR International) to organise the coded data. Data were analysed thematically using the Framework Method [20] providing the researcher with a structure to manage, analyse and identify themes. The theoretical framework for the qualitative research reflected an essentialist/realist perspective, reporting on the subjective and lived experiences, meanings and reality of the participants, rather than examining the ways on which the broader social context had a bearing on those meanings. Researchers identified potential themes which were then reviewed individually, revised based on discussions, and agreed upon [19].

Results

We recruited thirty-eight participants, who met the inclusion criteria. Of these, 21 had undergone THA and 17 TKA. Eighteen of the interviewees were male with a mean age of 57 years, range 43–76 years. The female participants had a mean age of 59 years, range 44–73. The participants represented a wide range of occupations including: those who were self-employed including farmers and an HGV driver; public servants including teachers and social workers; private sector workers including retail assistants and a funeral director or worked voluntarily (such as a volunteer ambulance driver or carer). Interviews lasted 20–60 min (mean 36 min).

Participants reported on their driving issues, particularly pertaining to their need to drive, either to access their workplace or where driving was part of their work role. Key themes and sub-themes were identified, as shown in Table 2. These themes are presented with illustrative quotations from individual participants.

Table 2. Themes and subthemes identified from patient interviews.

Theme	Subtheme
1. Driving and the decision to undergo surgery	Problems with driving prior to surgery
	Need to drive for work
	Problems with driving influencing decision to undergo surgery
2. Source of driving advice	Advice from the GP
	Advice from the surgeon/health care professional
	Written information – fact sheets, leaflets
	Online information and advice
	Peer support
3. Time taken to return to driving	Vehicle design/transmission
	Insurance
	Problems with driving post-surgery
4. Return to work and driving	Workplace requirements
	Driving to access work
	Driving as part of the job

Driving and the decision to undergo surgery

The decision to have surgery was influenced in some cases by the problems participants were experiencing with their driving. This was particularly the case when the journey to and from work was becoming painful.

But then it got to a point where sometimes I would sit in the car coming home from work, drive home, and then I couldn’t get out of the car. (P1230 – female, THA, 56 years, private sector worker)

One interviewee needed to stop and walk around on their mid-journey into work, with another continuing to drive despite the pain until the point where they could no longer continue.

Problems with driving prior to surgery

Although driving was a problem for many prior to surgery, some of those interviewed did not find it troublesome, either because their journey to work did not involve long distances or because they were experiencing difficulty accessing and exiting their vehicle rather than the driving itself. One interviewee even attributed one particularly difficult journey to a worsening of his joint problems.

…my wife had hurt her back a little bit so I ended up having to drive her car….I felt wrong driving it, but by the time I got up the next morning my leg had gone up like an absolute pudding. And I couldn’t bend it and basically then it was just, I just went off the slippery slope. (P2303– male, TKA, 64 years, private sector worker)

However, some participants reported that driving had become too painful, and for some it was the getting in and out of the car coupled with using the pedals in a manual car that made driving problematic, with one person having to lift their foot onto the pedal.

After I’d done a day’s work even walking round to the car, I had to lift my, because it was my left leg that I’ve had done, I had to lift that into the car. And then because it’s a manual car I had to lift my left leg sometimes onto the pedal, because I couldn’t do it automatically. I just had to lift it onto that. (P1230- female, THA, 56 years, private sector worker)

Other participants chose to drive a vehicle with automatic transmission in order to minimise the problems with driving. One considered a change of vehicle to one with automatic transmission to make driving less problematic, however as this would not have meant that they could return to driving any sooner, they opted instead to use alternative strategies in order to minimize the issues they were experiencing with the commute to work.

.the biggest problem was getting stuck in traffic because I was going to look to change to an automatic, but then I heard that irrespective with an automatic or a manual I wouldn’t be allowed to drive with the operation sort of thing for at least six weeks. So I just stuck with what I had, because basically I was going into the work about an hour sooner so I could avoid the traffic…… So that’s been like that for years so I tended to engineer my way out of things and go to work at different times so I can avoid the traffic. (P2303 – male, TKA, 64 years, private sector worker)

The source of driving advice

Some patients received no advice on when they should consider a return to driving post-surgery. Participants either made their own decisions on when to re-commence driving, testing themselves on the road initially

No, there was no mention at all. I just had this six week marker in my head….I just started to expand and go for longer trips from there on in. So every day, even if it was a very short trip down to a shop, I just built on it. Because it was not from the pain aspect of it, it was more a case of, you know, I haven’t driven for six weeks, so just making sure I’ve got my wits about me and to get back into the swing of driving. (P1107 – female, THA, 53 years, public sector worker)

or decided themselves when the prescribed return time might be as they felt confident in their own recovery. Others asked for advice but were not given any prescribed time of abstinence so made their own decisions.

.they said that if I felt well enough then to do it, and if I was capable of doing it then that was fine. I did have somebody with me to start with just to get my confidence back. (P2004 – female, TKA, 68 years, private sector worker)

Advice from the GP

The GP appeared to have a peripheral role in providing direction on driving, with very few participants referring to advice given by their family doctor. Only one reported that their GP carried out any form of testing of their recovery, although in this particular case he was a volunteer driver and had not been given any advice by his hospital consultant surgeon.

I thought I’d go and see my GP and explain the situation and she was actually quite thorough. She wanted to see my leg and check my range of movement and she said I don’t see any reason why. There are people out there who are disabled who drive with no legs, just hand control. I said yeah, but I’m driving for the NHS. (P2315 – male, TKA, 64 years, voluntary sector worker)

Advice from the hospital

The majority of interviewees who had received post-surgical advice on driving received this at their hospital follow-up appointment. In most cases this was verbal advice from their consultant orthopaedic surgeon.

I think the appointment came through, it was about eight weeks after my op so I phoned up and said could I possibly, is there any possibility this appointment could be rescheduled because this has taken me two weeks over my six weeks and I would like to think that I will be given approval to drive….So I went and saw my consultant. It was actually one day before my six weeks. He actually said to me, are you driving? I’m like well, no, because I was told I had to get clearance from you to allow me to drive. He said well, look at you, you’re doing remarkably well, I’m delighted with your progress, you could have been driving. I said well, I just did as I was instructed – and waited to get clarification from him and that’s what I did. (P1105 – female, THA, 56 years, private sector worker)

Advice was generally sought or given at the hospital follow-up appointment which was usually, but not always, at six weeks after surgery. In one case the hospital consultant surgeon had cited vehicle insurance being invalidated unless a minimum of six weeks had elapsed since surgery. In other cases, the surgeon placed the onus back onto the patient to make the decision about their return to driving. One participant actively pursued obtaining advice as they needed to be able to drive in order to work, and their hospital consultant surgeon advised them to abstain for a period of six weeks. Another interviewee, who was a volunteer driver, sought advice from the surgeon regarding when he would be safe to drive. However, the surgeon did not see this as his role, so the participant consulted his GP who advised accordingly.

I just said I did voluntary work for the ambulance and I said I’m still able to drive the automatic car because obviously the left leg is redundant as it were, but I said how long? I want to know about the process. Do I need to come back and get a letter off you? He just said no, you need about six weeks, you’re feeling you can do an emergency stop to see if you feel safe when you’re driving. That was all that was said about it really. I said do I get a letter off you? They said we don’t do letters for that. (P2315 – male, TKA, 64 years, voluntary sector worker)

Some participants received advice from an allied health professional (AHP).

.well a few people told me that but the occupational therapist as well when I saw them on the, I think they call it hip school ….they said if you’ve got a manual car you can’t drive for six weeks, but if you’ve got an automatic, well depending on which hip it is of course, then you can perhaps drive after three weeks. (P1003 – female, THA, 61 years, public sector worker)

One interviewee reported making the decision themselves, but sought further confirmation from an AHP, who felt able to provide this reassurance.

Written information

A number of participants took their advice on driving after surgery from written information they had received prior to surgery. This advice generally advised 6 weeks abstinence. Although some took their advice from the written information provided, many also sought confirmation from their consultant surgeon prior to driving.

I got literature to say that usually it’s round about the six-week mark. And they then said well you’ve got to, if you feel comfortable to drive, basically if you can do an emergency stop etc., then you can try it. And then I saw the consultant, it would be round about the eight-week mark, and I’d said to him that I was going to drive and he just said fine. (P1229 – female, THA, 61 years, public sector worker)

This was particularly when the painkillers prescribed contraindicated driving.

They don’t advise you driving. Plus, the fact whilst you were recuperating, you’re on various tablets and there was one particular one it was kind of making me a little bit dizzy and therefore you couldn’t afford to drive really…. If you read all the literature on the painkillers as well, it gives you all the side effects. (P2103 – male, TKA, 73 years, private sector worker)

Peer support

One participant referred to the knowledge gained from others who had undergone joint replacement surgery. He used this knowledge to make the decision for himself on when to return to driving.

I had two friends who had the same operation …So therefore I was aware not to drive because of insurance, of restriction from insurer that you’re not able. So therefore, that is what I said then to my employer. (P1106 – female, THA, 66 years, public sector worker)

Time taken to return to driving

The length of time that participants reported refraining from driving post-surgery varied from two to ten weeks. Most of the written information provided specifies a 6 weeks period of abstinence. However, some participants who drove automatic cars returned to driving less than four weeks post-surgery.

I was driving after three weeks and the thing that made me say I could drive if I have an automatic car. (P2206 – male, TKA, 75 years, public sector worker)

A number of those interviewed made the decision to return to driving before the six week point because they felt confident in their abilities to control the car. One was advised to leave driving for four weeks but returned at two and a half weeks after surgery as he felt confident to do so. The most commonly reported time post-surgery when driving was resumed was six weeks – the time point most commonly advocated in advisory information. However, some participants waited considerably longer.

But after 10 weeks or so I was, I seemed very capable to just do. We’ve got an automatic car……. (P2313 – male, TKA, 76 years, self employed)

One of those interviewed reported a return to driving at the prescribed six weeks post-surgery but waited a further six weeks before resuming his volunteer driving role.

What I did, for myself, it was six weeks for driving around but I waited about 12 weeks before I went back for the ambulance (P2315 – male, TKA, 64 years, voluntary sector worker)

Vehicle design

Participants reported finding a higher car easier to get in and out of as it did not involve so much bending – which was problematic for many after surgery.

I could get in and out my van without much difficulty. If it had been a lower car, if it had been like a sports car or something then I may have been a bit wary because of obviously the 90 degree angle between the torso and the leg. But the van, I could step up into it. I could walk up and downstairs unaided, so the leg felt strong enough to drive. (P1011 – male, THA, 53 years, private sector worker)

Those people who had vehicles which were lower to the ground reported problems with bending their leg to access the car. Others had problems due to the size of the car, making their seating position problematic after their surgery. Those who reported that they had a vehicle with automatic transmission appeared to return to driving sooner with fewer problems than those with a car with manual transmission. This was particularly pertinent when it was their left side which was affected by the surgery.

It was my left leg and my vehicle's automatic, automatic transmission, so you never use your left leg. Anyway, they actually said well look, if you feel comfortable really, it wasn’t a problem. (P2201 – male, TKA, 51 years, self employed)

Some of those interviewed had a choice of vehicle so were able to drive their automatic car until their problems had resolved. One however opted not to return to driving until ten weeks after surgery, even though he had an automatic car, and it was twelve weeks until he returned to driving a manually operated van.

I probably left it about ten weeks before I drove the car, which is automatic and then about another two more weeks before I started driving the van, which is a normal van, manual van. (P2227 – female, THA, 65 years, private sector worker)

Problems with driving post-surgery

The majority of driving problems experienced post-surgery related to aching and stiffness in the affected limb. However, this was relatively short lived with participants feeling that they were “back to normal.”

I did still get a little bit of pain, but obviously using the clutch you’re not on that constantly. It might be the accelerator or you know what I mean, it’s just now and again. So I did feel a little bit of discomfort at the beginning, but that was just getting seated properly I think in the car. I drive a little 500 so they’re not the comfortablist of seats to sit in but I sat on a cushion so that helped. (P1307 – female, THA, 65 years, private sector)

Other people reported fewer problems with the actually driving the vehicle. Instead their problems were around access to the car due to the seating position or height of the vehicle.

Some interviewees cited their use of analgesia as being a major influence on when they returned to driving.

I was just about off my pain relief tablets. The one that worried me most of all was, certainly for the first fortnight, I was on morphine and then I knocked that on the head after a fortnight and then I was just on paracetamol, but instead of having them four times a day, I think it was I was taking them for the first fortnight, I was down to just taking them on a morning and evening, cut them down in half and, when I was able to do that, I thought I’ll give driving a go. (P2206 – male, TKA, 75 years, public sector)

Return to work and driving

A number of those interviewed reported that they needed to drive for their work. One interviewee was particularly proactive in his approach to his return, making sure that he had full medical and occupational health approval. Most interviewees reported that they used their car for getting to and from work. The RTW was, as a consequence, dependent on their ability to drive or use public transport.

…he said you can’t drive for six weeks. And he said, and in the beginning there you get specific advice that there are certain things you can’t do. So he would advise not to work for six weeks, which was for me clear because at my work I need the car. So if I can’t drive I can’t work. (P1106 – female, THA, 66 years, public sector worker)

Some participants who relied on their ability to drive in order to access their place of work, either worked from home or had colleagues pick them up from home during their period of recovery.

One interviewee understood that driving a vehicle with an automatic transmission would make it easier for her to drive and regain her independence. She opted to hire an automatic vehicle until the advised length of time of abstinence from driving had elapsed. She was therefore able to RTW more promptly.

Well after my operation I was doing fine, so I hired an automatic. And it was my left hip, so I got an automatic car and that was wonderful because I got my independence back then…….it cost me a fair bit of money as you can imagine, but I wasn’t having to rely on my husband to take me everywhere because I’m out and about a lot. (P1003 – female, THR, 62 years, public sector worker)

Discussion

The original study aim was to recruit a purposive sample of approximately 10–15 patients in each of three OPAL centres (or a maximum of 45 patients from all centres). The main issue for recruitment was driving- some patients had never driven or had given up driving because of their previous ongoing hip or knee problems. Nevertheless, this was a large qualitative study with thirty- eight patients being interviewed and, to our knowledge, is the largest study conducted in this area to date.

Participants reported considerable variations in the advice they were given on when they could safely return to driving after surgery, which supports the findings of others [9–11]. It also mirrors the inconsistency in national and expert guidelines: while the RCS patient guidance suggests six weeks abstinence from driving after hip surgery and eight weeks after knee surgery [7,8], Versus Arthritis stipulate six weeks for both THA and TKA [7,8] and the NHS information website prescribes four to six weeks driving abstinence for both THA and TKA [6].

A recent systematic review and meta-analysis of return to driving after THA [21] found that the actual mean recommended return time was 4.5 weeks. Patient self-reporting identified safely returning to driving after approximately 6 weeks. These findings also reiterate the findings of an earlier systematic review examining the clinical considerations for returning to driving after both THA and TKA [22] which found that return time was around 4 weeks, with a range of 2–8 weeks. In their study of predictors of return to driving after total joint arthroplasty, Rondon et al. [23] found that 98% of patients surveyed returned to driving within 12 weeks of surgery. Their premise, that identification of predictors for a safe return to driving would inform advice from clinicians, would appear to have some merit when these inconsistencies are considered.

Driving is a necessity for many people to enable them to access work, leisure and other activities. Interestingly, overall, there was little difference between the advice given to those who had undergone THA with those who had had a TKA. The participants in our study reported that their ability to resume driving impacted significantly on their RTW. This echoed the findings of McGonagle et al. [16] who cited the lack of permission to drive as a direct impediment to return to work. This suggests that this is also an issue which requires further attention: if patients were able to return to driving sooner, this may result in them having less time off work which is particularly important for those who are self-employed or do not receive “sick pay.” However, this would need to be a discussion that the patient has with a relevant healthcare professional and at present it is not obvious who this might be.

The important and long running issue is the debate over who is responsible for determining fitness to drive. There is not enough evidence to support the determination of fitness to drive after lower limb arthroplasty as the responsibility of any particular UK authoritative body [11]. Traditionally the role has fallen to the medical profession, but GPs and hospital doctors have been shown to give incomplete driving advice, with hospital doctors and medical students showing poor awareness of DVLA guidelines [24]. As a possible way forward, in the Department of Health (DoH) guidelines for commissioners, it is suggested that driving assessment could fit within the remit of the occupational therapist (OT) as it is an activity of daily living for many [25]. Hitherto, our findings suggest that this is not yet happening in practice.

This was a relatively large interview study of patients post THA and TKA which generated important findings. There were common themes around the inconsistency of advice given and the need to self-manage. Yet there were limitations. All of those interviewed were employed and wished to go back to work, making the issue of driving even more critical for them. It must also be acknowledged that those interviewed were those who had the time to take part in the study, perhaps suggesting that they were more likely to still be off work.

Our findings suggest that return to safe driving after THA and TKA is both under researched and under reported. There is inconsistency in both the content and the delivery of driving advice, including around who has the responsibility for the provision of this advice. Patients consequently appear to make their own decisions on when to resume driving, and develop their own strategies to accelerate this process. As driving now plays a pivotal role in the maintenance of independence and access to work and usual activities, there needs to be greater importance placed on the provision of explicit advice and support to those undergoing orthopaedic surgery. This is particularly so given that more, younger, working people require THA and TKA [3] and as people potentially remain in work for longer [26]. There must be greater clarity from healthcare professionals when advising patients about their legal responsibilities in informing the DVLA and insurance companies about their surgery.

Ethical approval

Occupational advice for Patients undergoing Arthroplasty of the Lower limb study (OPAL study) was approved by the Health Research Authority’s East Midlands – Derby Research Ethics Committee (Reference 16/EM/0341; Date of approval 18 August 2016). The OPAL study was adopted on to the NIHR Portfolio on 16 December 2016 (CPMS identifier: 32609). The study was sponsored by the South Tees Hospitals NHS Foundation Trust.

Department of health disclaimer

This report presents independent research commissioned by the National Institute for Health Research (NIHR). The views and opinions expressed by the authors in this publication are those of the authors and do not necessarily reflect those of the National Health Service, the National Institute for Health Research, Medical Research Council, Central Commissioning Facility, NIHR Evaluations, Trials and Studies Coordinating Centre, the Health Technology Assessment programme or the Department of Health.

Acknowledgements

The authors would like to thank the study participants.

We are also grateful to all the members of the wider OPAL study group who contributed to the concept, design, delivery and analysis of the study: Sayeed Khan (Make UK, the Manufacturers Organisation), Louise Thomson (Faculty of Medicine and Health Sciences, University of Nottingham), Catherine Hewitt and Catriona McDaid (York Trials Unit, University of York), Iain McNamara (Norfolk and Norwich University Hospital NHS Foundation Trust), David McDonald (University of Stirling), Judith Fitch (British Orthopaedic Association Patient Liaison Group), and Gerry Richardson (Centre for Health Economics, University of York).

Finally, we thank Dr Jo Ablewhite for comments on earlier draft papers.

The funding body have not been involved in the design of the study, data collection, data analysis and data interpretation. They have not been involved in the writing of this manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This project was funded by the National Institute for Health Research Health Technology Assessment (HTA) programme [project number 15/28/02]. Further information available at https://www.journalslibrary.nihr.ac.uk/programmes/hta/152802/#/