Factors influencing return to work after hip and knee replacement: a

systematic review of qualitative and quantitative literature

Abstract

Background: Return to employment is one of the key goals of joint replacement

surgery in the working-age population. There is limited quantitative and qualitative

research focusing on return to work after hip and knee replacement. It remains

unclear why certain groups of patients are not able to achieve sufficient functional

improvement to allow productive return to work whilst others can. Very little is known

about the individual patient and employer perspectives in this regard. Current

evidence for the factors influencing employment outcomes in patients undergoing hip

and knee replacement is the subject of this review.

Methods: Original articles and reviews in Medline, Embase and Psychoinfo from

1987 to 2013 were included in the analysis.

Results: Age, patient motivation, employment before surgery and type of job are

important factors in determining return to work following hip and knee replacement.

Conclusion: There is a need for further qualitative work on how and why these

factors influence employment outcomes.

Key words: arthritis, occupational rehabilitation, qualitative

Introduction

Hip and knee arthritis causes significant problems in the working-age population and

can lead to a reduced quality of life, change in employment or unemployment. The

10th National Joint Registry reports that 18-20% of patients undergoing hip and knee

replacement in England and Wales are under the age of 60 years. Joint replacement

may enable patients to continue working, which may be more cost-effective in the

long term as patients remain economically productive members of the society.

Heavy lifting and bending have been reported as important factors in the

development and progression of arthritis. The effect of arthritis on employment

depends on the type of work usually performed, with manual or lifting jobs

associated with increased levels of unemployment due to arthritis. In addition to a

loss of employment, arthritis has also been associated with a prolonged sickness

absence or a change in the type of work performed. In patients with rheumatoid

arthritis, the common factors that influence work disability include employment

factors (nature of job, physical activity, degree of autonomy at work, work

environment and transport to work), employee factors (age of onset of disease,

education, motivation and marital status), disease factors (time since onset, level of

disability and flare ups), and other factors, such as time taken for healthcare, in-

patient care, and/or rehabilitation.

Previous studies have quantitatively assessed the role of surgery in returning the

patient to work after joint replacement . In a systematic review, Kuijer et al concluded

that the literature was sparse regarding factors affecting return to work after knee or

hip replacement. While quantitative studies can identify the extent to which surgery

helps in return to work, these methodologies do not examine the perspectives of

patient or employer which would be better determined by qualitative studies.

Qualitative research aims to develop theory on individual decision making or

behaviour by gathering in-depth interview data prioritising the views of a small

number of patients or groups. In addition, qualitative approaches can develop

understanding of the experience of arthritis and its treatment, and highlight the

particular significance it may have for different categories of patient at different

stages of treatment. Since there is an emergent body of qualitative literature on

arthritis and joint replacement, this article aims to review this literature to establish

whether and how qualitative research has informed findings from the quantitative

literature on joint replacement and return to work among those of working age.

This review of qualitative and quantitative literature aims to address the following

questions:

1. What are the employed patient’s expectations from a joint replacement before

and after surgery?

2. Who is most at risk of not returning to work after joint replacement surgery?

3. What external factors are important to help patients return to work?

4. Does age of the patient determine their ability/motivation to return to work?

5. Are patients able to return to work at the same level?

Methods

A systematic literature review was conducted of the databases Medline, Embase and

PsychInfo for peer reviewed articles on humans using the search terms ‘qualitative’

and each of ‘joint replacement’ (66 citations returned), ‘knee replacement’ (90

citations returned) and ‘hip replacement’ (68 citations returned), limited to papers

from 1987 to 2013. Papers were excluded if they concerned: operations other than

hip or knee replacement; living with osteoarthritis (OA) without consideration of total

joint replacement (TJR); experience in primary care only; or questionnaire

development. Study protocols for randomised controlled trials (RCTs), quantitative or

biological studies using the word ‘qualitative’ were excluded. 47 articles were

identified, of which 3 were review articles. A second literature search was carried out

for quantitative research using keywords ‘employ$’ or ‘work’ AND each of ‘joint

replacement’, ‘knee replacement’ and ‘hip replacement’, limited to papers from 1987

to 2013. Further papers from reference lists of the remaining articles were also

followed up.

Results

Summary of qualitative literature (Table 1)

Expectations and patient decision processes prior to hip and knee replacement

There is an emerging body of qualitative studies of OA patients’ experiences and

views on TJR prior to surgery, in particular considering how these may impact on the

decision whether or not to undergo surgery. A meta-synthesis of qualitative research

exploring reasons for unmet need for total knee replacement (TKR) identified 10

studies, including four from the UK; the majority included the views of patients

awaiting either hip or knee replacement. Most studies conducted in-depth or semi-

structured interviews with samples of 17-27, though Figaro et al had a sample of 94.

Various analytic approaches are adopted: thematic, grounded theory, framework,

phenomenological or content. Participants’ ages typically ranged from early 50s to

early 80s, although Woolhead et al included participants as young as 40. Where

mean ages of participants were given, these ranged from 64-76, suggesting that

those of working age are not broadly represented in this research.

These studies highlight the complexity of the decision-making process for patients,

with socio-cultural categories of aging and the role of the health care professional

being central to forming patient’s expectations around surgery. A fluid risk/benefit

threshold and culturally specific factors are likely to argue against deciding upon

surgery. The meta-synthesis concluded that coping strategies and life context were

likely to be influential on outcomes of the operation; one study found that the

indeterminacy, pain and disability experienced while on waiting lists resulted in a

sense of disenfranchisement, and a sense of lack of presence in one’s own life.

These factors also boost hopes among patients for the potential of the joint

replacement operation to transform their situation. In this context, Woolhead et al

found that waiting patients’ expectations for the impact of surgery were not clearly

formed. They could express ideal or pragmatic hopes, but indicated that they did not

understand procedures clearly enough to say whether they expected a particular

outcome. This literature was also reviewed in 2009 to illustrate the potential of

qualitative approaches.

Since O’Neill et al’s meta-synthesis a number of studies have explored this area

further with broadly similar theoretical approaches and samples. For instance, one

Swedish study interviewing 10 patients (mean age 65) awaiting hip replacement

found their outlook characterised by endurance or resignation in the face of impaired

mobility and great pain in their daily routine. Some studies have employed focus

group interviews rather than individual interviews. Patient interviews have also been

complemented with clinician interviews and observations. Findings, however, are in

general consistent with the earlier studies, with perhaps more consideration of, or

emphasis on, the specific education needs of patients awaiting or considering TJR.

Two studies note that some patients interviewed individually or in focus groups

identified barriers to employment (difficulty walking to sites and with sitting or

standing in offices for long periods) as part of the ‘final straw’ prompting their choice

to undergo total hip replacement (THR). Heaton et al note that in making this choice,

patients may have developed heightened expectations of the likely impact of THR on

their ability to work. In general, however, this literature offers no specific comment

on working lives of individuals awaiting joint replacement.

Expectations before compared with experience after hip and knee replacement

There have been fewer qualitative investigations of patient perspectives following

TJR. Although O’Neill et al’s meta-synthesis focused on the preoperative decision

process, three of the included studies also gathered data on patients’ views in the

wake of surgery. One study reported on a focus group of five patients who had

received hip or knee arthroplasty. The authors identified difficulties applying learned

skills and coping with pain in the post-operative period, and concluded that better

education before surgery on best and worst outcomes could reduce distress arising

from a mismatch between patient expectations and experience. A grounded theory

study from New Zealand of nine patients interviewed about pre- and post-operative

experience recommends support to help patients maintain their optimism throughout

the perioperative period. Woolhead et al also followed up post-operatively ten of the

patients they had interviewed prior to TJR surgery. They found that those patients

moved in their interviews from an initial assertion that their operation had left them

with few symptoms or none, to stating that they still suffered pain and disability. It

was found that they struggled to make sense of their experience and outcomes,

some blaming themselves for pain or disability for instance because they had been

‘overdoing it’. These findings are also summarised by Dieppe et al.

A meta-synthesis of 16 studies of older patients being discharged from hospital

following either hip or knee replacement identified common constructs across studies

of loss of independence, functional and activity limitations and coping with pain, all of

which bore a crucial relationship to mental outlook. Content analysis of short

interviews with 30 UK inpatients in the six weeks following a knee replacement

operation identified concerns at this stage with a wide range of aspects of life. In

France a substantial qualitative dataset, covering all stages of OA and treatments,

was gathered through interviews with 81 primary care patients with OA and 29

consultants. Patients receiving knee replacement indicated dissatisfaction with

outcomes of the surgery, and reported they were still suffering more pain than they

had expected in follow-up interviews. Patients interviewed in Sweden have also

emphasised their experience of overwhelming pain while in hospital following hip

replacement.

However, in a UK study following up hip replacement patients aged 44-83 at one to

two years, patients said they had learned to emphasise positive outcomes and

alleviate the harmful effects of pain and physical limitations by reinterpreting the

meaning of their lives allowing them to cope with their post-operative pain and

discomfort. In Sweden Gustafsson et al interviewed joint replacement patients aged

65 or above, longitudinally, in five sequential interviews over the two-year period

from joining the waiting list to cessation of post-operative care. Their analysis

highlights the ‘dream’ of becoming able-bodied and escaping bodily confinement and

pain as central to patients throughout the process, but they found that patients’ lack

of knowledge about surgical procedure had not prepared them for the transitional

changes (rethinking their beliefs and perception regarding their bodies) that were

required following their surgery. Other interview and focus group studies in the UK

and USA have also found that unrealistic expectations in patients led to them feeling

frustrated, less confident and independent than they had anticipated, and less able

to participate in activities in the months following surgery. Heaton et al note that the

nine of their 52 interviewees who described dissatisfaction with their hip replacement

after four months had suffered complications or problems with their operations, and

were frustrated that the slow rate of their recovery was preventing them returning to

work.

The importance of supportive care from health care professionals throughout the

perioperative period in order to facilitate joint replacement patients’ transition is

stressed by all authors. Four studies have noted that the accounts of their release

from hospital suggest paternalistic relationships with, or orientation towards, health

care providers, although studies interviewing patients in Finland and Sweden

following hip arthroplasty find strong post-operative satisfaction with health care

providers. Family support may be crucial to successful rehabilitation following

release from hospital. In Canada, the increasing numbers of TJRs performed and the

changing profile of those receiving the operations towards younger age groups have

increased the need for rehabilitation services. A study from New Zealand concluded

that prehabilitation, postoperative nursing care and discharge planning can help in

patients’ optimism and motivation to self-help and patient teaching should reflect

realistic recovery process.

Summary of quantitative research on employment outcome after hip and knee

replacement (Table 1)

Our search did not reveal any qualitative study looking at employment outcome after

total hip and knee replacement. Quantitative analyses have however been

performed.

Who is most at risk of not returning to work after joint replacement surgery?

Lyall et al, in a study on employment outcome after total knee replacement showed

that 40 out of 41 patients (97.5%) who were working pre-operatively went back to

work within six months.. Patients were often back at work in six weeks and 35

patients (85%) were pleased with the result of the operation. In their study,

individuals not working pre-operatively did not resume working postoperatively. The

mean period of unemployment in their group before operation was 35 months

(range, 21–58 months). Their results show 80% of patients in the unemployed group

prior to total knee replacement had previously performed manual jobs, involving

prolonged periods of standing, lifting and bending down and 20% were performing

non-manual jobs. Overall, eight patients (53%) were pleased with the results of the

operation. This study indicates that patients working pre-operatively are highly likely

to continue working after total knee replacement. However, total knee replacement is

unlikely to facilitate return to work for the already unemployed.

Jorn et al concluded that the patients who were on sick leave for less than 180 days

preoperatively had better health profile (Nottingham Health Profile – in terms of

emotion, energy, pain, physical mobility, sleep and social isolation) than those who

were off for more than 180 days and were more likely to return to work

postoperatively.

Mobasheri et al examined the effect of total hip replacement on employment status

in patients under 60 years of age. They found 49 out of 51 patients returned to work

after total hip replacement if they had been working pre-operatively, a return to work

rate of 96%. Half of patients off work pre-operatively returned to work after hip

replacement. They concluded if a patient was off work due to hip pain then total hip

replacement would facilitate a return to work. However, Mobasheri et al also reported

a reduced rate of re-employment in patients who had been unemployed for more

than one year before operation. Malek et al noted that at ten years after hip

resurfacing 90% of patients were in the same employment after surgery, with no or

minimal restriction.

What external factors are important to help patients return to work?

Kuijer et al in their systematic review, where they only found three studies suitable to

be included, reported that surgical approach and type of operation may have an

influence on return to work; restrictions on patient movements have a negative

influence; discharge guidelines have no effect and the percentage of patients

returning to work and time to return to work varies. The timing of discharge from

hospital does not influence the number returning to work. This review clearly

highlights the limitations of available literature to draw relevant and meaningful

conclusions and the need to perform more robust studies.

Styron et al explored the preoperative predictors of returning to work after primary

total knee replacement and concluded that although the physical demands of a

patient's job have a moderate influence on the patient's ability to return to work

following a primary total knee arthroplasty, the patient's characteristics, particularly

motivation, play a more important role. They concluded that the median time to

return to work after knee replacement was 8.9 weeks, with patients who had a sense

of urgency to return to work taking half the time of the other group.

Foote et al found that the type of procedure may influence employability, with

patients undergoing total knee replacement and unicondylar knee replacements

having better return to employment as compared with patellofemoral replacement,

while the physical intensity of the work remained the same.

Does age of the patient determine their ability/motivation to return to work?

Bohm et al in a review of 60 patients who had undergone total hip replacement

concluded that the patients who returned to work were younger (mean age 49.9

years versus 60.3 years), less likely to be collecting disability insurance, had better

physical function and Oxford-12 hip score, less functional limitation from medical

conditions and conversely, poorer job satisfaction before surgery. They did not find

any difference in the groups in terms of physical demands at job or workforce

flexibility. Patients reported an increase in income, decrease in number of hours per

week of work, increased productivity and increased ability to cope with physical

demands of workplace. They concluded that surgery should be undertaken before

the patient’s hip dysfunction forces them off work.

Are patients able to return to work at the same level?

Mariconda et al found that 82% of patients after total hip replacement were able to

return to the same physical demands after surgery while about 14% had to take a

more sedentary role.

Styron et al reported that patients with less pain preoperatively, more physically

demanding job and receiving workman’s compensation (sickness benefit) returned to

work slower. Jorn et al concluded that patients with a light workload preoperatively

returned to work sooner.

Discussion

Patient views and experience leading up to surgery are quite well covered in the

literature. with relative similarity of findings and conclusions in studies from different

countries using varied methods. However, there is scope for considerably more work

exploring patients experience after surgery, with only a handful of studies gathering

such data. Neither pre- nor post-operative studies have touched to any great extent

on joint replacement in middle age. Gignac et al note the importance of remaining

independent and employed to younger patients with OA, and that the focus in

qualitative literature on functional limitations has not been matched by examination

of impacts on such wider social roles. Since average age in the samples from

studies reviewed above is more than 62 years the majority of participants followed

up after surgery have been retired. As such, this body of work does not substantially

consider the particular impact of joint replacement surgery on OA sufferers’ working

lives. Although an impact on working life has been noted as an issue for younger OA

patients in one focus group study, qualitative studies have not looked in detail at how

barriers to work are experienced by these patients in day-to-day working life and the

patient or the employers’ perspective. Some qualitative research has been

performed to look at expectations and outcomes of knee or hip replacement, in terms

of patient experience. However, we could find no qualitative study that has explored

the employment outcome after joint replacement in the young working-age

population (under 60 years). Qualitative studies have not looked in detail at how

barriers to work are experienced by these patients in day-to-day working life and the

patient or the employers’ perspective. It has repeatedly been found that, prior to

operations, patients in this age group have general and not very clearly formed

visions of post-operative outcomes, and therefore no clear expectations for their

employment.

One of the limitations of our study is the inability to provide evidence for qualitative

work on employment outcome, as there is a lack of studies looking into this aspect of

joint replacement. The studies that have been included suffer from an element of

selection bias, which would be inherent to this type of work.

Qualitative studies would have the scope to identify the barriers that young working-

age patients undergoing joint replacement might face at work before and after

surgery, which cannot be detected by simple quantitative outcome measures. They

would also fulfil arthritis patients’ wishes for richer interaction with researchers in the

gathering of data in this area. It would be interesting to know if there are surgically

modifiable factors, in terms of implant or procedure choice, which may have

implications on this. Indeed there is a possibility that if the patient and employer

expectations are tailored to setting realistic goals, the outcome may be different.

Clearly a qualitative study of the younger working-age population has the potential to

identify factors that might help achieve these goals.

Table 1 summarises the answers to the key questions raised in the review. During

the consenting process patients’ expectations should be explored and addressed as

unrealistic expectations may actually lead to poorer recovery. Surgeons need to be

aware that patients who have been unable to work before surgery and those who

have been on unemployment benefit are unlikely to return to work after their hip or

knee replacement. Younger patients with fewer co-morbidities were more likely to

return to work. Creating a supportive environment at home and work can help

facilitate this. Although majority of the patients can return to the same level, those

involved in heavy manual labour will take longer time.

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Table 1

Answers to key questions

(* to ***) - RCGP 3 star grading of evidence

What are the patient’s expectations from a joint replacement?

Barriers to employment are important factors driving the patients to proceed with

joint replacement surgery(***). Patients have high expectations of the impact of joint

replacement surgery on their ability to work(***). Unrealistic expectations leads to

heightened frustration and slower rate of recovery preventing them from returning to

work.

Who is most at risk of not returning to work after joint replacement surgery?

Patients who were unemployed before surgery are less likely to obtain gainful

employment after surgery and patients who have been off-sick longer preoperatively

were less likely to return to work(***). Motivation is the key factor in early return to

work(**).

What external factors are important to help patients return to work?

Supportive care from healthcare providers and family support after surgery are

helpful in facilitating successful rehabilitation and satisfaction(**). Patients on

benefits are less likely to return to work while self-employed return to work

sooner(***). Patients who are have no restriction on activity following joint

replacement surgery return to work sooner(***).

Do age and co-morbidities of the patient determine their ability/motivation to return to work?

Younger patients and those with less co-morbidities were more likely to return to

work(**).

Are patients able to return to work at the same level?

Majority of the patients are able to return to work at the same level, although patients

involved in heavy manual labour return to work slower, while those with light work

load returned sooner(***).