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Function and employment after total hip replacement in older adults: A narrative review

  • Elena Zaballa
    Correspondence
    Corresponding author at: Medical Research Council - Lifecourse Epidemiology Centre, Southampton General Hospital, Tremona Road, Southampton SO16 6YDT, UK.
    Affiliations
    MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK

    MRC Versus Arthritis Centre for Musculoskeletal Health and Work, University of Southampton, Southampton, UK
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  • Elaine Dennison
    Affiliations
    MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
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  • Karen Walker-Bone
    Affiliations
    MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK

    MRC Versus Arthritis Centre for Musculoskeletal Health and Work, University of Southampton, Southampton, UK

    Monash Centre for Occupational and Environmental Health, Monash University, Melbourne, Australia
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Open AccessPublished:September 13, 2022DOI:https://doi.org/10.1016/j.maturitas.2022.09.005

      Highlights

      • The lifetime risk of hip replacement varies from 9 % to 16 % in women and from 6 % to 9 % in men.
      • Some hip arthroplasty recipients experience poor functional outcomes.
      • It is important to identify people at risk of poor outcomes preoperatively.
      • Patients feel that they lack guidance from clinicians about returning to work after hip replacement.

      Abstract

      The burden of osteoarthritis (OA) has increased steadily due to an aging population, increasing life expectancy, obesity and lifestyle factors. Total hip replacement has become one of the most prevalent and successful operations globally and it is projected that demand will continue to grow as the incidence of OA continues to increase. Patients undergoing the operation expect much-improved function and pain relief but also increasingly need to return to work postoperatively, especially given the growing demand for the procedure and the encouragement of older people to continue working by most governments in the developed world. This review provides an overview of function and employment outcomes after hip arthroplasty. Despite the generally good success rate, some patients do not attain good functional outcomes and it is important that we develop ways to identify these patients preoperatively. We describe the effect of demographic, clinical and other factors on functional outcomes, as well as trajectories of physical function and pain recovery beyond the first few weeks after total hip replacement. Regarding employment outcomes, many people in work preoperatively are likely to resume to work after recovery; however, patients feel that they lack guidance from clinicians about returning to work postoperatively. Our review encompasses factors associated with return to work, timing of return to work, and potential temporary or permanent limitations that people might experience at work depending on type of employment.

      Keywords

      1. Introduction

      Osteoarthritis (OA) is the most common form of arthritis worldwide [
      • James S.L.
      • Abate D.
      • Abate K.H.
      • Abay S.M.
      • Abbafati C.
      • Abbasi N.
      • et al.
      Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the global burden of disease study 2017.
      ], causing joint pain, stiffness, and functional disability. The burden of disability caused by OA has been growing steadily over the last three decades [
      • Collaborators GDaI
      Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019.
      ] due to increasing life expectancy, rising prevalence of obesity and lifestyle factors. According to the Global Burden of Disease study, which described changes in morbidity and mortality levels between 1990 and 2019 for 369 conditions (diseases and injuries) across 204 countries, among people aged 50–74 years, OA went from the 24th most disabling condition in 1990 to the 18th in 2019. Indeed, the burden caused specifically by hip OA specifically increased during this period, mainly among people early in their seventh decade of life (60 to 64 years old) [
      • Fu M.
      • Zhou H.
      • Li Y.
      • Jin H.
      • Liu X.
      Global, regional, and national burdens of hip osteoarthritis from 1990 to 2019: estimates from the 2019 global burden of disease study.
      ].
      In the event of joint failure, and after trials of conservative therapies, total hip replacement (THR) may be offered. THR has been one of the most effective orthopaedic operations developed during the 20th century [
      • Ferguson R.J.
      • Palmer A.J.
      • Taylor A.
      • Porter M.L.
      • Malchau H.
      • Glyn-Jones S.
      Hip replacement.
      ]. Estimates of the lifetime risk of undergoing THR have been found to vary by country, with rates ranging from 8.7 % to 15.9 % in women and 6.3 % to 8.6 % in men [
      • Ackerman I.N.
      • Bohensky M.A.
      • de Steiger R.
      • Brand C.A.
      • Eskelinen A.
      • Fenstad A.M.
      • et al.
      Lifetime risk of primary total hip replacement surgery for osteoarthritis from 2003 to 2013: a multinational analysis using National Registry Data.
      ,
      • Culliford D.J.
      • Maskell J.
      • Kiran A.
      • Judge A.
      • Javaid M.K.
      • Cooper C.
      • et al.
      The lifetime risk of total hip and knee arthroplasty: results from the UK general practice research database.
      ]. Since the earliest THRs, there have been improvements in implant-materials, surgical techniques and biomechanics which have produced very significant reductions in the failure of primary THRs (reducing the need for revision THR). Currently, the rate of revision of THR is estimated to be <1 % at one year follow-up. When failures occur, the three main causes are: aseptic loosening (42.3 %), pain (15.4 %); and dislocation/subluxation (14.7 %) [
      • Ben-Shlomo Y.
      • Blom A.
      • Boulton C.
      • Brittain R.
      • Clark E.
      • Dawson-Bowling S.
      National Joint Registry Annual Reports. The National Joint Registry 18th Annual Report 2021.
      ]. Longer term, a meta-analysis pooling data from 44 case series and Finnish and Australian orthopaedic registries over 25-years of follow-up reported a survival rate of 58 % (95 % CI 57 %–59 %) and if data were limited to those from case series, the survival rate was 77 % (95 % CI 76 %–79 %) [
      • Evans J.T.
      • Evans J.P.
      • Walker R.W.
      • Blom A.W.
      • Whitehouse M.R.
      • Sayers A.
      How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up.
      ].
      National and regional orthopaedic registries were introduced at the beginning of this century in response to concerns about long-term outcomes in relation to cemented arthroplasty survival [
      • Porter M.
      • Armstrong R.
      • Howard P.
      • Porteous M.
      • Wilkinson J.M.
      Orthopaedic registries - the UK view (National Joint Registry): impact on practice.
      ]. More recently, many registries have also introduced collection of other types of outcomes than revision, particularly patient-reported outcome measures (PROMs) including pain and function [
      • Wilson I.
      • Bohm E.
      • Lübbeke A.
      • Lyman S.
      • Overgaard S.
      • Rolfson O.
      • et al.
      Orthopaedic registries with patient-reported outcome measures.
      ].
      This review focuses on employment and functional outcomes after THR in middle-aged people and does not consider short-term (peri-operative) outcomes. These are important given the aging population, the growing requirement for THR among people aged <65 years [
      • Pabinger C.
      • Geissler A.
      Utilization rates of hip arthroplasty in OECD countries.
      ] and the fact that many countries have been introducing financial incentives and/or legislation to encourage workers to work beyond traditional state pension age.

      2. Methods

      Our focus was on mid- to longer-term outcomes after THR and therefore we did not consider papers published in the immediate peri-operative period. We identified studies published in the English Language from searches of the PubMed database from its inception until March 2022. The keywords used to run the search were combinations of “total hip replacement”, “total hip arthroplasty”, “return to work”, “employment”, “function”, “pain”, “trajectory” “mid-term” and “long-term”. Included papers were systematic reviews; meta-analyses; case-control studies; observational studies (prospective and/or retrospective); or randomized control trials. Where available, we focused on the findings from systematic reviews or meta-analyses. Relevant studies published since the most recent systematic review were also included.

      3. Functional outcomes

      Functional improvement post-THR can be assessed objectively using performance-based tests, or subjectively using disease-specific patient reported outcome measures (PROMs). These are validated and self-administered scoring tools developed to assess the impact of the operation from the patient's perspective by measuring changes in function and/or pain pre- and post-surgery. A meta-analysis exploring mid-term outcomes after THR found that whether measured using the total Harris Hip Score (HHS) [
      • Harris W.H.
      Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation.
      ], combined pain and physical function from the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) [
      • Bellamy N.
      • Buchanan W.W.
      • Goldsmith C.H.
      • Campbell J.
      • Stitt L.W.
      Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee.
      ] and HHS, or other measures of health-related quality of life, patients were significantly better off in terms of pain and physical function, 3.6 to 7 years post-operatively than they were pre-operatively [
      • Shan L.
      • Shan B.
      • Graham D.
      • Saxena A.
      Total hip replacement: a systematic review and meta-analysis on mid-term quality of life.
      ]. Despite this, a literature review [
      • Beswick A.D.
      • Wylde V.
      • Gooberman-Hill R.
      • Blom A.
      • Dieppe P.
      What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients.
      ] estimated that the proportion of patients who continued to experience long-term pain post-THR (6 months to a median of 43 months follow-up) ranged between 7 % and 23 %. Consistent with this were findings from another study which assessed whether patients had achieved normal function post-operatively using the Outcome Measures in Rheumatology – Osteoarthritis Research Society International (OMERACT-OARSI) criteria [
      • Pham T.
      • van der Heijde D.
      • Altman R.D.
      • Anderson J.J.
      • Bellamy N.
      • Hochberg M.
      • et al.
      OMERACT-OARSI initiative: osteoarthritis research society international set of responder criteria for osteoarthritis clinical trials revisited.
      ]. They studied 908 THR recipients and assessed change using WOMAC [
      • Judge A.
      • Cooper C.
      • Williams S.
      • Dreinhoefer K.
      • Dieppe P.
      Patient-reported outcomes one year after primary hip replacement in a european collaborative cohort.
      ], and found that, although there was overall pain relief and function disability improvement, between 14 % - 36 % of recipients experienced either little or no improvement at follow-up after one year [
      • Judge A.
      • Cooper C.
      • Williams S.
      • Dreinhoefer K.
      • Dieppe P.
      Patient-reported outcomes one year after primary hip replacement in a european collaborative cohort.
      ]. In a subsequent study following patients 5 years post-operatively, Judge et al. [
      • Judge A.
      • Arden N.K.
      • Batra R.N.
      • Thomas G.
      • Beard D.
      • Javaid M.K.
      • et al.
      The association of patient characteristics and surgical variables on symptoms of pain and function over 5 years following primary hip-replacement surgery: a prospective cohort study.
      ] reported that 2.3 % of participants had worse function by one year and 1.2 % did not show improvement by 5 years. Importantly, patients with worse functional pre-operative scores (Oxford Hip Score (OHS) < 5) showed the greatest improvement with a mean change score of OHS score of 28 points. Given that it appears a small proportion of people do not attain good outcomes after THR, it is important to be able to identify this group pre-operatively if possible.

      3.1 Trajectories of function recovery

      Many, but not all, THR recipients experience a steady recovery post-operatively followed by either a plateau or decline in function over time [
      • Galea V.P.
      • Rojanasopondist P.
      • Ingelsrud L.H.
      • Rubash H.E.
      • Bragdon C.
      • Huddleston Iii J.I.
      • et al.
      Longitudinal changes in patient-reported outcome measures following total hip arthroplasty and predictors of deterioration during follow-up: a seven-year prospective international multicentre study.
      ]. However, there is some variation in the time taken to reach best function post-THR (Table 1). Two studies with 12-months of follow-up [
      • Lenguerrand E.
      • Wylde V.
      • Gooberman-Hill R.
      • Sayers A.
      • Brunton L.
      • Beswick A.D.
      • et al.
      Trajectories of pain and function after primary hip and knee arthroplasty: the ADAPT cohort study.
      ,
      • Hesseling B.
      • Mathijssen N.M.C.
      • van Steenbergen L.N.
      • Melles M.
      • Vehmeijer S.B.W.
      • Porsius J.T.
      Fast starters, slow starters, and late dippers: trajectories of patient-reported outcomes after Total hip arthroplasty: results from a dutch Nationwide database.
      ], reported that patients experienced a steep functional improvement within the first three months, at which point they reached the best functional scores. The first of these studies, by Lenguerrand et al. [
      • Lenguerrand E.
      • Wylde V.
      • Gooberman-Hill R.
      • Sayers A.
      • Brunton L.
      • Beswick A.D.
      • et al.
      Trajectories of pain and function after primary hip and knee arthroplasty: the ADAPT cohort study.
      ] investigated recovery of physical function separately from symptoms of pain. Participants were categorised according to their pre-operative symptoms (more severe symptoms at baseline versus less severe symptoms at baseline) and their trajectories compared post-surgery. At 3 months post-surgery, both groups reported a similar level of pain relief and level of physical function, suggesting that arthroplasty had been more beneficial for people who were more limited pre-operatively. Furthermore, no further changes in pain or function were observed between 3 and 12 months post-operatively [
      • Lenguerrand E.
      • Wylde V.
      • Gooberman-Hill R.
      • Sayers A.
      • Brunton L.
      • Beswick A.D.
      • et al.
      Trajectories of pain and function after primary hip and knee arthroplasty: the ADAPT cohort study.
      ]. The second study [
      • Hesseling B.
      • Mathijssen N.M.C.
      • van Steenbergen L.N.
      • Melles M.
      • Vehmeijer S.B.W.
      • Porsius J.T.
      Fast starters, slow starters, and late dippers: trajectories of patient-reported outcomes after Total hip arthroplasty: results from a dutch Nationwide database.
      ] identified three different trajectories of recovery using the OHS in a sample of 6030 THA recipients. In the first and most common trajectory (87.7 % of participants) overall function improved quickly by 3 months post-THR, not showing any further improvement afterwards. In a second trajectory, (7.7 % of participants) there was a more gradual recovery in the first 3 months followed by a slight decline in function around 12-months post-operatively. Factors associated with this trajectory were older age (>75 years) or being less fit (ASA score III-IV) at the time of operation, obesity, smoking, direct lateral surgical approach, hybrid fixation, and poorer pre-operative perceived health. A third trajectory (4.6 % of participants) had no functional improvement at 3 months however function improved at 1-year post-THR. Factors associated with this third trajectory were female sex, BMI ≥ 30 kg/m2 and cigarette smoking, however operation through an anterior approach incision had a protective effect.
      Table 1Characteristics of studies that described trajectories of functional outcomes after total hip replacement.
      Author, country, yearType of studySample studiedData collection – length of follow-upPatient- reported outcome measures collectedPredictors of trajectories assessed
      Lenguerrand et al., United Kingdom, 2016
      • Lenguerrand E.
      • Wylde V.
      • Gooberman-Hill R.
      • Sayers A.
      • Brunton L.
      • Beswick A.D.
      • et al.
      Trajectories of pain and function after primary hip and knee arthroplasty: the ADAPT cohort study.
      Prospective80 participants from the ADAPT cohort study who underwent THR mainly due to hip OA (92.5 %). Surgeries were performed between February 2010 and November 2011 at a mean age of 65 years (SD ± 11)Pre-THR: at a mean 19 days before surgery

      Post-THR: at 3- and 12-months follow-up
      WOMAC index. Analysis performed separately for pain and function subscalesPain and function pre-arthroplasty
      Hesseling et al., Netherlands, 2019
      • Hesseling B.
      • Mathijssen N.M.C.
      • van Steenbergen L.N.
      • Melles M.
      • Vehmeijer S.B.W.
      • Porsius J.T.
      Fast starters, slow starters, and late dippers: trajectories of patient-reported outcomes after Total hip arthroplasty: results from a dutch Nationwide database.
      Retrospective6030 patients from the Dutch Arthroplasty Register who underwent primary THR due to primary OA between January 2014 and December 2016Preoperatively (maximum 182 days pre-arthroplasty), at 3 months post-THR (63 to 110 days), and at 12 months post-THR (323 to 407 days)OHSAge, sex, smoking, ASA grade, Charnley class, BMI, previous surgical procedure on the involved hip, preoperative EQ-5D items and EQ-5D VAS scores (except for EQ5D Mobility)
      Repky et al., Germany, 2020
      • Repky S.
      • Büchele G.
      • Günther K.P.
      • Huch K.
      • Brenner H.
      • Stürmer T.
      • et al.
      Five years' trajectories of functionality and pain in patients after hip or knee replacement and association with long-term patient survival.
      Prospective420 unilateral THRs carried out between January 1995 and December 1996 due to primary OA

      Operations performed in 199 males at a median age of 59 years (IQR: 54–66), and in 221 females at a median age of 64 years (IQR: 56–70)
      Preoperatively, at 6- and 12-months post-operationFFbH

      Visual Analogue Scales

      WOMAC-physical function subscale

      WOMAC-pain subscale
      Dainty et al., United Kingdom, 2021
      • Dainty J.R.
      • Smith T.O.
      • Clark E.M.
      • Whitehouse M.R.
      • Price A.J.
      • MacGregor A.J.
      Trajectories of pain and function in the first five years after total hip and knee arthroplasty : an analysis of patient reported outcome data from the National Joint Registry.
      ProspectivePatients from the NJR who returned OHS questionnaire at 6- and 12-months post-THR between 2009 and 2010

      After exclusions 14,335 people were eligible to study pain trajectory and 14,366 to study function trajectory post-operatively
      Preoperatively, at 6 months, one, three, and five years postoperativelyOHS function domain

      OHS pain domain
      Pre-operative characteristics: age, BMI, sex, social deprivation, ethnicity, rural/urban location, and ASA grade.

      OHS score pre-surgery, and at 6-month and 1-year post-THR
      ASA; American Society of Anesthesiologists, BMI; body mass index, EQ-5D; EuroQol-5 dimension, FFbH; Hannover Functionality Status Questionnaire, NJR; The National Joint Registry from England, Wales, Northern Island and Isle of Wright, OA; osteoarthritis, OHS; Oxford Hip Score, THR; total hip replacement, VAS; Visual Analogue Scale, WOMAC; Western Ontario and McMaster Universities Osteoarthritis Index.
      Two further studies [
      • Repky S.
      • Büchele G.
      • Günther K.P.
      • Huch K.
      • Brenner H.
      • Stürmer T.
      • et al.
      Five years' trajectories of functionality and pain in patients after hip or knee replacement and association with long-term patient survival.
      ,
      • Dainty J.R.
      • Smith T.O.
      • Clark E.M.
      • Whitehouse M.R.
      • Price A.J.
      • MacGregor A.J.
      Trajectories of pain and function in the first five years after total hip and knee arthroplasty : an analysis of patient reported outcome data from the National Joint Registry.
      ], followed patients for 5 years post-operatively but captured functional limitation and degree of pain at different follow-up times than the two previous studies which had only 1-year follow-up data. The authors reported that recovery of physical function and pain relief was experienced by most patients within the first 6 months post-surgery [
      • Repky S.
      • Büchele G.
      • Günther K.P.
      • Huch K.
      • Brenner H.
      • Stürmer T.
      • et al.
      Five years' trajectories of functionality and pain in patients after hip or knee replacement and association with long-term patient survival.
      ,
      • Dainty J.R.
      • Smith T.O.
      • Clark E.M.
      • Whitehouse M.R.
      • Price A.J.
      • MacGregor A.J.
      Trajectories of pain and function in the first five years after total hip and knee arthroplasty : an analysis of patient reported outcome data from the National Joint Registry.
      ] but that the best function was achieved at one year and sustained over 5 years [
      • Dainty J.R.
      • Smith T.O.
      • Clark E.M.
      • Whitehouse M.R.
      • Price A.J.
      • MacGregor A.J.
      Trajectories of pain and function in the first five years after total hip and knee arthroplasty : an analysis of patient reported outcome data from the National Joint Registry.
      ]. Analysis from the UK's National Joint Registry and including knee and hip patients identified two different trajectories over the first 5 years post-operatively. The first trajectory (70 % of patients) experienced marked improvement in pain/function which was sustained over 5 years. The other trajectory saw sustained improvement but at a more modest level. People with most pre-operative pain and worst pre-operative function were more likely to experience the second trajectory [
      • Dainty J.R.
      • Smith T.O.
      • Clark E.M.
      • Whitehouse M.R.
      • Price A.J.
      • MacGregor A.J.
      Trajectories of pain and function in the first five years after total hip and knee arthroplasty : an analysis of patient reported outcome data from the National Joint Registry.
      ]. Additionally, it was possible to predict which trajectory an individual would follow based on their scores for pain and function at 6 months post-operatively.

      3.2 Predictors of physical function

      Given that some patients obtain better results from surgery than others, it is important to understand what factors might affect functional improvement or contribute towards function decline after THR. Predictors of function post-arthroplasty have been examined, with some studies focusing exclusively on pain or physical function domains as an outcome, whilst other studies have focused on overall function (Table 2). There have been three systematic reviews [
      • Hofstede S.N.
      • Gademan M.G.
      • Vliet Vlieland T.P.
      • Nelissen R.G.
      • Marang-van de Mheen P.J.
      Preoperative predictors for outcomes after total hip replacement in patients with osteoarthritis: a systematic review.
      ,
      • Lungu E.
      • Maftoon S.
      • Vendittoli P.A.
      • Desmeules F.
      A systematic review of preoperative determinants of patient-reported pain and physical function up to 2 years following primary unilateral total hip arthroplasty.
      ,
      • Buirs L.D.
      • Van Beers L.W.
      • Scholtes V.A.
      • Pastoors T.
      • Sprague S.
      • Poolman R.W.
      Predictors of physical functioning after total hip arthroplasty: a systematic review.
      ] which have examined predictors of functional outcomes following THR. However, although published around the same time, they differed in: inclusion criteria; the length of follow-up required in included studies; the proportion of missing data which was deemed acceptable; and whether or not the indication for THR was confined to primary OA only.
      Table 2Characteristics of systematic reviews that reported functional outcomes after total hip replacement.
      Author, country, yearType of studies identified in the systematic reviewsEligibility criteriaOutcomeFollow-upPatient- reported outcome measures collected used in the studies retrievedPrognostic factors examined
      Vincent et al., United States, 2012
      • Vincent H.K.
      • Horodyski M.
      • Gearen P.
      • Vlasak R.
      • Seay A.N.
      • Conrad B.P.
      • et al.
      Obesity and long term functional outcomes following elective total hip replacement.
      23 studies (5 retrospective,18 prospective) published between 1965 and January 2011

      Studies retrieved were conducted in the United States, Europe, Canada and Australia
      Studies that examined the relationships between obesity or BMI and physical function post-THR.

      Physical function measurement collected a minimum of 6 months post-surgery

      Estimates of obesity reported either as BMI, body fat percentage or fat mass

      Full text published in English
      Functional outcomes in obese (BMI ≥ 30 kg/m2) and non-obese (BMI < 30 kg/m2) patients1 to 20 yearsHHS, OHS, WOMAC score or other survey-based tools of physical functionBMI
      Buirs et al., Netherlands, 2016
      • Buirs L.D.
      • Van Beers L.W.
      • Scholtes V.A.
      • Pastoors T.
      • Sprague S.
      • Poolman R.W.
      Predictors of physical functioning after total hip arthroplasty: a systematic review.
      33 observational studies retrieved until June 2015Studies written in English that assessed physical function among THR patients

      At least one variable examined as predictor of physical function

      No restriction in length of follow-up
      Function including physical function sub-domain and general functionFrom 3 to 72 months with an average of 18 monthsHHS, LEFS, OHS, SF-36 (PF), TUG test and WOMAC score.Age, gender, BMI, comorbidities, pre-operative physical function, and other predictors
      Hofstede et al., Netherlands, 2016
      • Hofstede S.N.
      • Gademan M.G.
      • Vliet Vlieland T.P.
      • Nelissen R.G.
      • Marang-van de Mheen P.J.
      Preoperative predictors for outcomes after total hip replacement in patients with osteoarthritis: a systematic review.
      35 prospective studies searched up to August 2014Prospective studies comprising patients who underwent THR due primary hip OA, with functional or clinical outcomes collected pre- and post-arthroplasty and a minimum of 1-year follow-up

      Studies were not eligible if they included metal on metal implants; osteotomies prior to THR; were exclusively focused on bilateral THR; and the prevalence of secondary OA was >5 %
      Functional or clinical outcomes post-THRBetween 1 and 12 yearsSF-36, SF-36 domains (PF, RP, BP, GH, VT, SF, RE, MH), change in SF-36 (correlated physical summary score (PCS)), SF-12 PCS, HHS, WOMAC score, WOMAC (physical function and pain) EQ-5D, EQ VAS, OHS, OHS (pain/function), HHS, HOOS (subscales pain, ADL, sports, QOL), EQ-5D index, EQ VAS, Pain VAS, Satisfaction VASAge gender, BMI, socio-economic status/education, comorbidities, function, radiological OA severity, expectations, pain, health related quality of life, and mental well-being
      Lungu et al., Canada, 2016
      • Lungu E.
      • Maftoon S.
      • Vendittoli P.A.
      • Desmeules F.
      A systematic review of preoperative determinants of patient-reported pain and physical function up to 2 years following primary unilateral total hip arthroplasty.
      22 studies identified from database inception to April 2015.

      Studies were conducted in Europe, the United States, Canada and Australia
      Studies that comprised primary unilateral THRs due to hip OA in which patients were followed between 3 and 24 months post-THR. Additionally, studies were eligible if function and/or pain was measured through a disease specific validated PROM, multivariate analyses were used to identify determinants of pain and disability, and full text was published in English or FrenchPain and/or physical functionBetween 3 and 24 monthsHHS

      HOOS

      LEFS

      OHS

      WOMAC score
      Age, gender, living arrangements, level of education, socioeconomic status, psychosocial determinants, general health, severity of radiographic OA, BMI, pre-operative pain and function, other clinical variables and waiting times for arthroplasty
      Ponnusany et al., Canada, 2019
      • Ponnusamy K.E.
      • Somerville L.
      • McCalden R.W.
      • Marsh J.
      • Vasarhelyi E.M.
      Revision rates and functional outcome scores for severely, morbidly, and super-obese patients undergoing primary Total hip arthroplasty: a systematic review and meta-analysis.
      Meta-analysis including 33 studies identified from databases inception to August 2016Studies that examined primary THR outcomes by BMI used as a categorical variable, with BMI ≥ 35 kg/m2 as the highest BMI category usedChange in pre/post-operation functional score, reoperation, and revision rates in non-obese (BMI < 30 kg/m2) and obese patients (BMI ≥ 30 kg/m2)Not specified. Some studies with short-term follow-up (<1 year), and other studies with longer follow-up (≥1 year)HHS, OHS EQ-5D, WOMAC scoreBMI
      Wylde et al., United Kingdom, 2019
      • Wylde V.
      • Kunutsor S.K.
      • Lenguerrand E.
      • Jackson J.
      • Blom A.W.
      • Beswick A.D.
      Is social support associated with patient-reported outcomes after joint replacement? A systematic review and meta-analysis.
      56 studies retrieved from database inception to April 2019 of which 13 were included in meta-analysis and 43 in a narrative synthesisStudies on adults undergoing primary THR, TKR or other type of procedures if results for THR and TKR were provided separately

      The outcome had to assess pain, function, satisfaction, or general health using PROMs at 3 months or longer post-operatively, and assessment of social support was performed pre-operatively or within the first 6 weeks of surgery

      Studies that used surgeon administered tools were excluded
      PROMs that evaluated pain, function, satisfaction, or general healthSF-36 or SF-12 total or subscale scores, Functional Independence Measure, OHS, OKS, Yale Physical Activity Scale, IRES questionnaire, HOOS/KOOS, Nottingham Health Profile, EQ-5D, EQ-5D VAS, Instrumental Activity of Daily Living, pain VAS, satisfaction VAS, WHOQOL-100, and WOMAC scoreSocial support
      Lemos et al., United States, 2021
      • Lemos J.L.
      • Welch J.M.
      • Xiao M.
      • Shapiro L.M.
      • Adeli E.
      • Kamal R.N.
      Is frailty associated with adverse outcomes after orthopaedic Surgery?: a systematic review and assessment of definitions.
      82 studies of which 18 examined associations between frailty and post-operative outcomes.

      The search was performed up to December 2020
      Studies that reported orthopaedic surgical outcomes in patients characterised as frail using any tool to measure frailty

      A minimum level of evidence of Level IV (per the Oxford Centre for Evidence-Based Medicine)

      Full text published in English
      2/18 studies assessed function post-arthroplastyWOMAC score, HOOSFrailty
      BMI; body mass index, EQ-5D; EuroQol-5 dimension, HHS; Harris Hip Score, HOOS; hip disability and osteoarthritis outcome score, IRES; Indicators of the Rehabilitation Status questionnaire, KOOS; knee injury and osteoarthritis outcome score, LEFS; lower extremity functional scale, OHS; Oxford Hip Score, PROM; patient-reported outcome measure, SF-12; The 12-item Short Form Health Survey; SF-36: The 36-item Short Form Health Survey; PF: physical functioning; RP: physical role; BP: bodily pain; GH; general health; VT: vitality; SF: social functioning; RE: role-emotional; MH: mental health; MCS: mental component, TUG test; Timed Up and Go, THR; total hip replacement, TKR; total knee replacement, VAS: the Visual Analogue Scale, WOMAC; Western Ontario and McMaster Universities Osteoarthritis Index, WHOQOL-100; World Health Organization Quality of Life-100.

      3.2.1 Demographic variables

      Based on the results of the three systematic reviews, age may or may not predict outcomes after THR. In the review by Buirs et al. [
      • Buirs L.D.
      • Van Beers L.W.
      • Scholtes V.A.
      • Pastoors T.
      • Sprague S.
      • Poolman R.W.
      Predictors of physical functioning after total hip arthroplasty: a systematic review.
      ] 10 out of the 15 included studies found that undergoing THR at a younger age was associated with better functional outcomes post-operatively. Consistent with this, another review [
      • Lungu E.
      • Maftoon S.
      • Vendittoli P.A.
      • Desmeules F.
      A systematic review of preoperative determinants of patient-reported pain and physical function up to 2 years following primary unilateral total hip arthroplasty.
      ] reported that in 4 out of the 11 studies retrieved it was older THR recipients who had poorer functional outcomes or pain. However, a third review [
      • Hofstede S.N.
      • Gademan M.G.
      • Vliet Vlieland T.P.
      • Nelissen R.G.
      • Marang-van de Mheen P.J.
      Preoperative predictors for outcomes after total hip replacement in patients with osteoarthritis: a systematic review.
      ] found no conclusive evidence that age affected function post-arthroplasty. Regarding gender, one systematic review [
      • Buirs L.D.
      • Van Beers L.W.
      • Scholtes V.A.
      • Pastoors T.
      • Sprague S.
      • Poolman R.W.
      Predictors of physical functioning after total hip arthroplasty: a systematic review.
      ] found that in some studies male gender was a predictor of better function, whereas in other studies it was female gender. A second systematic review concluded that gender did not affect functional outcomes after THR [
      • Lungu E.
      • Maftoon S.
      • Vendittoli P.A.
      • Desmeules F.
      A systematic review of preoperative determinants of patient-reported pain and physical function up to 2 years following primary unilateral total hip arthroplasty.
      ].

      3.2.2 Body mass index (BMI)

      There is not a clear and consistent message from the literature about the effect of BMI on functional outcomes. Two systematic reviews [
      • Lungu E.
      • Maftoon S.
      • Vendittoli P.A.
      • Desmeules F.
      A systematic review of preoperative determinants of patient-reported pain and physical function up to 2 years following primary unilateral total hip arthroplasty.
      ,
      • Buirs L.D.
      • Van Beers L.W.
      • Scholtes V.A.
      • Pastoors T.
      • Sprague S.
      • Poolman R.W.
      Predictors of physical functioning after total hip arthroplasty: a systematic review.
      ] reported an association between higher BMI and worse post-operative functional or pain outcomes. Specifically, Vincent and colleagues [
      • Vincent H.K.
      • Horodyski M.
      • Gearen P.
      • Vlasak R.
      • Seay A.N.
      • Conrad B.P.
      • et al.
      Obesity and long term functional outcomes following elective total hip replacement.
      ] reported that obese patients (BMI ≥ 30 kg/m2) at the time of THR had worse functional performance post-operatively, suggesting that although these patients benefitted from the surgery their physical function improvement might be poorer than that achieved by non-obese patients. However, a more recent meta-analysis revealed no differences in changes in functional scores when the authors compared non-obese (BMI < 25 kg/m2) people with: severely obese (BMI > 35 kg/m2) patients (0.04: 95 % CI 20.02–0.10), morbidly obese (BMI > 40 kg/m2) patients (0.19 95 % CI, 20.08–0.46), and severely obese (BMI > 50 kg/m2) patients (20.12 95 % CI 20.57–0.33) [
      • Ponnusamy K.E.
      • Somerville L.
      • McCalden R.W.
      • Marsh J.
      • Vasarhelyi E.M.
      Revision rates and functional outcome scores for severely, morbidly, and super-obese patients undergoing primary Total hip arthroplasty: a systematic review and meta-analysis.
      ]. Likewise, in a cohort of 191 THR recipients, obesity was not related with hip function or pain at 10 years post-operatively [
      • Haebich S.J.
      • Mark P.
      • Khan R.J.K.
      • Fick D.P.
      • Brownlie C.
      • Wimhurst J.A.
      The influence of obesity on hip pain, function, and satisfaction 10 years following Total hip arthroplasty.
      ].

      3.2.3 Comorbidities

      Evidence was consistent showing that preoperative comorbid conditions measured as number of comorbidities or specific medical conditions were associated with poorer outcomes post-operatively including overall function [
      • Lungu E.
      • Maftoon S.
      • Vendittoli P.A.
      • Desmeules F.
      A systematic review of preoperative determinants of patient-reported pain and physical function up to 2 years following primary unilateral total hip arthroplasty.
      ,
      • Buirs L.D.
      • Van Beers L.W.
      • Scholtes V.A.
      • Pastoors T.
      • Sprague S.
      • Poolman R.W.
      Predictors of physical functioning after total hip arthroplasty: a systematic review.
      ], pain and physical function [
      • Lungu E.
      • Maftoon S.
      • Vendittoli P.A.
      • Desmeules F.
      A systematic review of preoperative determinants of patient-reported pain and physical function up to 2 years following primary unilateral total hip arthroplasty.
      ].

      3.2.4 Pre-operative function (physical function and pain)

      Level of function deterioration before THR is a moderate to strong predictor of functional outcomes post-arthroplasty. Patients with more severe pain/function before surgery are more likely to achieve worse pain/function outcomes post-operatively [
      • Judge A.
      • Arden N.K.
      • Batra R.N.
      • Thomas G.
      • Beard D.
      • Javaid M.K.
      • et al.
      The association of patient characteristics and surgical variables on symptoms of pain and function over 5 years following primary hip-replacement surgery: a prospective cohort study.
      ,
      • Lungu E.
      • Maftoon S.
      • Vendittoli P.A.
      • Desmeules F.
      A systematic review of preoperative determinants of patient-reported pain and physical function up to 2 years following primary unilateral total hip arthroplasty.
      ], similarly people with better preoperative physical function are more likely to reach better physical functional performance after replacement [
      • Buirs L.D.
      • Van Beers L.W.
      • Scholtes V.A.
      • Pastoors T.
      • Sprague S.
      • Poolman R.W.
      Predictors of physical functioning after total hip arthroplasty: a systematic review.
      ]. Additionally, studies reporting changes in pre- and post-surgical function scores have consistently suggested that patients with better pre-operative function, and less severe radiological OA benefit from less changes in pre- and post-operative function, however these patients obtained better functional scores post-arthroplasty [
      • Hofstede S.N.
      • Gademan M.G.
      • Vliet Vlieland T.P.
      • Nelissen R.G.
      • Marang-van de Mheen P.J.
      Preoperative predictors for outcomes after total hip replacement in patients with osteoarthritis: a systematic review.
      ,
      • Lungu E.
      • Maftoon S.
      • Vendittoli P.A.
      • Desmeules F.
      A systematic review of preoperative determinants of patient-reported pain and physical function up to 2 years following primary unilateral total hip arthroplasty.
      ].

      3.2.5 General health and mental health

      The review by Lungu and colleagues [
      • Lungu E.
      • Maftoon S.
      • Vendittoli P.A.
      • Desmeules F.
      A systematic review of preoperative determinants of patient-reported pain and physical function up to 2 years following primary unilateral total hip arthroplasty.
      ] found that poor THR outcomes in terms of function, pain or a combination of function and pain were associated with worse reported general health in 4 out of 4 studies. In one study, people with good mental health reached better physical function post-THR after follow-up over 72 months [
      • Buirs L.D.
      • Van Beers L.W.
      • Scholtes V.A.
      • Pastoors T.
      • Sprague S.
      • Poolman R.W.
      Predictors of physical functioning after total hip arthroplasty: a systematic review.
      ]. However, Geeske et al. [
      • Peeters G.M.E.E.
      • Rainbird S.
      • Lorimer M.
      • Dobson A.J.
      • Mishra G.D.
      • Graves S.E.
      Improvements in physical function and pain sustained for up to 10 years after knee or hip arthroplasty irrespective of mental health status before surgery.
      ] collected mental health status in a cohort of middle-aged women in the 13 years prior to surgery to assess the impact of mental health on physical function and pain post-arthroplasty. The authors concluded that both women with poor and good mental health obtained similar benefit from the surgery up to 10 years post-THR.

      3.2.6 Social support

      Pooled data from two studies comprising 2022 lower limb arthroplasty recipients suggested that patients who had social support at one-year post-THR benefitted in terms of their function measured as WOMAC score [
      • Wylde V.
      • Kunutsor S.K.
      • Lenguerrand E.
      • Jackson J.
      • Blom A.W.
      • Beswick A.D.
      Is social support associated with patient-reported outcomes after joint replacement? A systematic review and meta-analysis.
      ].

      3.2.7 Other predictors

      Other factors have been less well studied. Buirs et al. [
      • Buirs L.D.
      • Van Beers L.W.
      • Scholtes V.A.
      • Pastoors T.
      • Sprague S.
      • Poolman R.W.
      Predictors of physical functioning after total hip arthroplasty: a systematic review.
      ] concluded that there was weak evidence for a role of level of education and pre-operative quadriceps strength and very limited evidence regarding any effect of alcohol intake, vitamin D insufficiency and allergies on THR functional outcomes. On the other hand, 3 studies from the review performed by Lungu et al. found that lower level of education was associated with worse pain and or function at 3 to 24 months post-operatively [
      • Lungu E.
      • Maftoon S.
      • Vendittoli P.A.
      • Desmeules F.
      A systematic review of preoperative determinants of patient-reported pain and physical function up to 2 years following primary unilateral total hip arthroplasty.
      ]. One study by Vergara et al. [
      • Vincent H.K.
      • Horodyski M.
      • Gearen P.
      • Vlasak R.
      • Seay A.N.
      • Conrad B.P.
      • et al.
      Obesity and long term functional outcomes following elective total hip replacement.
      ] found that patients waiting longer than 6 months for their THR experienced less improvement in function 1 year post-operatively, when compared with the benefits experienced by those who had waited for <3 months. A systematic review [
      • Lemos J.L.
      • Welch J.M.
      • Xiao M.
      • Shapiro L.M.
      • Adeli E.
      • Kamal R.N.
      Is frailty associated with adverse outcomes after orthopaedic Surgery?: a systematic review and assessment of definitions.
      ] reported a relationship between frailty and poorer functional outcomes at 3 year follow-up post-THR (1 out of 2 studies).

      4. Work outcomes

      Approximately 20 % of THRs are performed on people below of 60 years of age [
      • Registry. TNJ
      Patient characteristics for primary hip replacement procedures.
      ], therefore for these younger patients it is important to have information about the effect of arthroplasty on employment. Work-related outcomes are not routinely collected by clinicians, however some surgeons as part of the decision to perform the arthroplasty may ask patients about their occupation [
      • Coole C.
      • Nouri F.
      • Narayanasamy M.
      • Baker P.
      • Drummond A.
      Total hip and knee replacement and return to work: clinicians' perspectives.
      ]. Most patients who are working pre-operatively will intend to return to work (RTW) post-operatively [
      • Baker P.
      • Coole C.
      • Drummond A.
      • Khan S.
      • McDaid C.
      • Hewitt C.
      • et al.
      Occupational advice to help people return to work following lower limb arthroplasty: the OPAL intervention mapping study.
      ] and will need advice about when they can expect to RTW. Patients may also need advice regarding specific demands of their job e.g., physically demanding activities and/or loading or driving. Unfortunately, guidelines for clinicians are lacking. Qualitative research with patients has suggested that when occupational advice is offered to patients this generally relates to time needed off work rather than strategies to facilitate RTW effectively [
      • Nouri F.
      • Coole C.
      • Baker P.
      • Drummond A.
      Return to work advice after total hip and knee replacement.
      ] and sustain employment post-operatively. In the absence of current guidance this section describes relevant epidemiological evidence focused on employment outcomes after hip replacement. The main characteristics of the studies discussed hereafter are shown in Table 3.
      Table 3Characteristics of studies that evaluated return to work after total hip replacement.
      Author, country, yearType of studySample studiedEligibility criteriaFollow-upOutcomePrognostic factors assessed in relation to employment outcomes
      Mobasheri et al., United Kingdom, 2006
      • Mobasheri R.
      • Gidwani S.
      • Rosson J.W.
      The effect of total hip replacement on the employment status of patients under the age of 60 years.
      Retrospective101 primary THRs in

      86 patients who were 51.4 years (range, 29–60 years) at the time of the operation

      The main indication for surgery was primary OA (67 %)
      Primary THRs carried out between 1993 and 2003 in patients below 60 years of age by a surgical team in the UK6 months - 10 years post-THR

      Mean: time: 3 years
      RTWBearing surface and size of femur head
      Kuijer et al., Netherlands, 2009
      • Kuijer P.P.
      • de Beer M.J.
      • Houdijk J.H.
      • Frings-Dresen M.H.
      Beneficial and limiting factors affecting return to work after total knee and hip arthroplasty: a systematic review.
      Systematic review3 studies: 2 prospective, and 1 matched case-control studyStudies published from March 1998 to 2008 on primary THR/TKR or revision of THR/TKR that a) described RTW after surgery or employment status, and factors that affected RTW, and b) were written in English, French, German or Dutch languageMinimum: 150 days after hospital admission Maximum: 20.2 months (13–36) post-surgeryFactors that affected RTWSurgical approach: two-incision versus mini-posterior approach

      Movement restrictions post-operation
      Nunley et al., United States, 2011
      • Nunley R.M.
      • Ruh E.L.
      • Zhang Q.
      • Della Valle C.J.
      • Engh Jr., C.A.
      • Berend M.E.
      • et al.
      Do patients return to work after hip arthroplasty surgery.
      Retrospective806 people (682 THRs, 124 SAs) of whom 65.9 % were male (431 THRs, 100 SAs), and 34.1 % female (251 THRs, 24 SAs)

      Mean age at the time of surgery was 49.5 years (±7.21), with OA (88.6 %) as the main indication to have hip surgery
      Consecutive THRs or surface arthroplasties carried out in 5 centres between January 2005 and June 2007

      Patients were eligible if: a) they had pre-symptomatic UCLA score ≥ 6, b) age at operation was 18–60 years in males and 18–55 in females, c) indication for surgery was OA, posttraumatic arthritis, avascular necrosis, or hip dysplasia, and d) bearing surfacing was: highly cross-linked polyethylene against metal, ceramic, or oxinium/ceramic on ceramic; or metal on metal

      People were excluded if post-operative complications occurred (e.g., revision surgery), one of the implant components was cemented or patients had comorbidities that limited their level of activity (i.e., inflammatory arthritis, sickle cell)
      2.3 years post-surgeryRTW, time to RTW, number of hours worked post-operativelyNone
      Cowie et al., United Kingdom, 2013
      • Cowie J.G.
      • Turnbull G.S.
      • Ker A.M.
      • Breusch S.J.
      Return to work and sports after total hip replacement.
      Retrospective259 cemented THRs (239 people) and 26 hip resurfacings in patients operated at an average age of 55.2 years (SD ±7.2)

      155 participants were female (64.8 %) and primary OA was the main indication for surgery in the majority of THR recipients (91 %)
      THRs performed in a university teaching hospital between September 2005 and September 2009 among patients who were <65 years of age at the time of the arthroplasty

      Bilateral procedures included only if there was at least 6 months between consecutive operations

      Simultaneous THR procedures were excluded
      3.1 years post-THR (SD ± 0.97), range (0.58–5.42)Rate of RTW and RTS post-THRNone
      Sankar et al., Canada, 2013
      • Sankar A.
      • Davis A.M.
      • Palaganas M.P.
      • Beaton D.E.
      • Badley E.M.
      • Gignac M.A.
      Return to work and workplace activity limitations following total hip or knee replacement.
      Prospective190/437 people who underwent THR and completed a questionnaire pre-surgery and additionally chose to participate in the workforce post-surgery

      Mean age at the time of THR: 56.1 years (SD ± 9.9)
      Patients from a cohort of primary THR/TKR recipients due to OA, who were recruited between 2005 and 2008 across four tertiary-care centres in Canada

      Eligible participants were 18 to 65 years of age at the time of the operation, with English proficiency to be able to complete the consent form and the questionnaires

      People were excluded if they had a revision or hemiarthroplasty procedure, or the indication for arthroplasty was trauma or malignancy. Participants were also excluded if they were retired, unemployed, did not participate in the workforce, or had a long-term disability pre-operatively
      2 weeks pre-surgery and at 1-, 3-, 6- and 12- months post-operativelyRTW (full time or part-time), and the Workplace Activity Limitations scale post-surgeryNone
      Malviya et al., United Kingdom, 2014
      • Malviya A.
      • Wilson G.
      • Kleim B.
      • Kurtz S.M.
      • Deehan D.
      Factors influencing return to work after hip and knee replacement.
      Systematic review57 qualitative and quantitative studies published from 1987 to 2013Not clearly reported. THR and TKR studies that detailed employment outcomesNot specifiedRTW in relation to factors influencing on resuming workAge, comorbidities, motivation, nature of job, employment pre- and post-arthroplasty, and expectations from the operation
      Tilbury et al., Netherlands, 2014
      • Tilbury C.
      • Schaasberg W.
      • Plevier J.W.
      • Fiocco M.
      • Nelissen R.G.
      • Vliet Vlieland T.P.
      Return to work after total hip and knee arthroplasty: a systematic review.
      Systematic review19 studies published between 1984 and April 2013: 14 on THR (3872 patients of whom 2055 were males), 4 on TKR, and 1 paper on TKR and THR

      Average age of THR patients ranged from 46.9 to 69.7 years
      Studies that examined THR or TKR in relation to employment outcomes (RTW, work capacity, work ability, sick leave, or productivity), and were published in English, French, German or Dutch languageMinimum 6–7 weeks and maximum 4.2 years post-surgeryRate and timing to RTW, and predictors of returning to workFactors related to work status after THR and TKR included sociodemographic, health and job characteristics.
      Hoorntje et al., Netherlands, 2018
      • Hoorntje A.
      • Janssen K.Y.
      • Bolder S.B.T.
      • Koenraadt K.L.M.
      • Daams J.G.
      • Blankevoort L.
      • et al.
      The effect of Total hip arthroplasty on sports and work participation: a systematic review and meta-analysis.
      Systematic review37 studies (23 on RTW and 14 on RTS) published between 1965 and 2016: 3 case–control studies, 1 cross sectional study, 6 prospective, 24 retrospective, 2 non-randomized controlled studies, and 1 randomized prospective studyObservation or intervention studies focused on THR patients due to hip OA, who engaged in sports or work prior arthroplasty and had the intention to resume sport or work after surgery

      No restrictions in terms of year or language of publication were used
      3.8 years, range (0.25–11)Rate of RTS and/or RTW, and the timing of RTS/RTW.

      Level of activity measured as the UCLA and the Grimby scale
      None
      Laasik et al., Finland, 2019
      • Laasik R.
      • Lankinen P.
      • Kivimäki M.
      • Aalto V.
      • Saltychev M.
      • Mäkelä K.
      • et al.
      Return to work after primary total hip arthroplasty: a nationwide cohort study.
      Prospective408 hip replacements (73 % women) identified from The Finnish Public Sector (FPS) study

      Arthroplasties were performed at an average age of 54 years (32–67)
      The Finnish Public Sector (FPS) study is a nationwide register (n = 151,901) that covers a wide range of occupations. Participants from this study were eligible they underwent unilateral THR between 1996 and 2011 and completed a survey pre-operativelyFrom hospital discharge to either date of returning to work, perceiving a disability pension/old-age pension, died, or end of follow-up.Factors associated with RTW post-arthroplastyAge, sex, marital status, obesity, current smoking, alcohol intake, comorbidities, psychological distress, self-rated health, pre-operative occupation leisure-time physical activity, preoperative sickness and year of the surgery
      Al-Hourani et al., United Kingdom, 2021
      • Al-Hourani K.
      • MacDonald D.J.
      • Turnbull G.S.
      • Breusch S.J.
      • Scott C.E.H.
      Return to work following Total knee and hip arthroplasty: the effect of patient intent and preoperative work status.
      Prospective91 out of 195 total joint arthroplasties were THRs carried out at a median age of 59 years [IQR, 54–62] and 46.2 % of participants were maleUnilateral total joint arthroplasties undertaken in people ≤65 years of age and performed from January to November 2018 in a National Health Service institution in the UK

      People were excluded if they underwent partial knee arthroplasty, bilateral and revision procedures, or they if had retired pre-arthroplasty for other reasons than joint disability
      1-year post-THRRTW after THRAge, sex, BMI, SIMD, medical comorbidities and musculoskeletal comorbidities, employment, and PROMS (OHS, OKS, Oxford APQ, EQ-5D VAS pain, Satisfaction)
      Zaballa et al., United Kingdom, 2022
      • Zaballa E.
      • Ntani G.
      • Harris E.C.
      • Lübbeke A.
      • Arden N.K.
      • Hannouche D.
      • et al.
      Feasibility and sustainability of working in different types of jobs after total hip arthroplasty: analysis of longitudinal data from two cohorts.
      Retrospective411 participants (206 men and 205 women) who underwent THR due to primary (71 %) or secondary OA and provided detailed information on occupational history post-THR.

      Median age to have surgery: 64 years (IQR: 57–68)
      Elective unilateral THRs from the Geneva Hip Arthroplasty Register performed between December 1996–December 2012, and from the Clinical outcomes in Arthroplasty study performed between April 2010–December 2013

      Patients were included if aged 18 to 64 years at the time of primary THR, and they had been followed a minimum of 5 years since operation

      Bilateral procedures were excluded
      Median 7.5 years (IQR: 6.2–12.1)Rate of RTW and stopping work due to the hip replaced post-THRPhysically-demanding occupational activities (standing, walking, kneeling/squatting, carrying/lifting, digging, climbing ladders and climbing stairs), and leisure-time physical activities
      APQ; Activity and Participation Questionnaire, BMI; body mass index, EQ-5D; EuroQol-5 dimension, IQR; interquartile range; OHS, Oxford Hip Score; OKS, Oxford knee score, PROMs; patient-reported outcome measures, RTS; return to sport, RTW; return to work, SIMD, Scottish Index of Multiple Deprivation THR; total hip replacement, TKR; total knee replacement, VAS; Visual Analogue Scale.

      4.1 Return to work and time off paid work

      Hoorntje and colleagues [
      • Hoorntje A.
      • Janssen K.Y.
      • Bolder S.B.T.
      • Koenraadt K.L.M.
      • Daams J.G.
      • Blankevoort L.
      • et al.
      The effect of Total hip arthroplasty on sports and work participation: a systematic review and meta-analysis.
      ] systematically reviewed studies that examined rates of RTW until October 2017 and time taken off sick by THR recipients. Pooled data from 23 THR studies showed that the mean rate of RTW for people working pre-operatively was 69 %, whereas when studies rated as high quality were considered the mean rate was 83 %. Even a subsequent study based on 408 employees from the Finnish Public sector reported that 94 % THR recipients returned to work at 3 months post-operatively [
      • Laasik R.
      • Lankinen P.
      • Kivimäki M.
      • Aalto V.
      • Saltychev M.
      • Mäkelä K.
      • et al.
      Return to work after primary total hip arthroplasty: a nationwide cohort study.
      ]. Furthermore, THR can be beneficial for some people who are unable to work pre-operatively but who are fit for work post-operatively [
      • Al-Hourani K.
      • MacDonald D.J.
      • Turnbull G.S.
      • Breusch S.J.
      • Scott C.E.H.
      Return to work following Total knee and hip arthroplasty: the effect of patient intent and preoperative work status.
      ,
      • Zaballa E.
      • Ntani G.
      • Harris E.C.
      • Lübbeke A.
      • Arden N.K.
      • Hannouche D.
      • et al.
      Feasibility and sustainability of working in different types of jobs after total hip arthroplasty: analysis of longitudinal data from two cohorts.
      ,
      • Mobasheri R.
      • Gidwani S.
      • Rosson J.W.
      The effect of total hip replacement on the employment status of patients under the age of 60 years.
      ]. Most people go to back to the same type of occupation pre-operatively, however people in more physically-demanding jobs might need to change to less strenuous jobs. In the study by Cowie et al. 13/169 (7.7 %) of those who worked after arthroplasty changed to a less physical job [
      • Cowie J.G.
      • Turnbull G.S.
      • Ker A.M.
      • Breusch S.J.
      Return to work and sports after total hip replacement.
      ]. Similarly 6 out of 62 THR recipients from another study moved to jobs with lower physical demands [
      • Mobasheri R.
      • Gidwani S.
      • Rosson J.W.
      The effect of total hip replacement on the employment status of patients under the age of 60 years.
      ]. Nunley et al. reported that 42/672 people did not RTW after their THR however in 12 out of these 42 people the operated hip was mainly the reason not to RTW [
      • Nunley R.M.
      • Ruh E.L.
      • Zhang Q.
      • Della Valle C.J.
      • Engh Jr., C.A.
      • Berend M.E.
      • et al.
      Do patients return to work after hip arthroplasty surgery.
      ].
      In terms of time taken off work post-arthroplasty, there is wide variation reported with a mean duration ranging between 1 and 17 weeks (7 studies) [
      • Hoorntje A.
      • Janssen K.Y.
      • Bolder S.B.T.
      • Koenraadt K.L.M.
      • Daams J.G.
      • Blankevoort L.
      • et al.
      The effect of Total hip arthroplasty on sports and work participation: a systematic review and meta-analysis.
      ]. Pooled data from these studies estimated that the mean time off work is 8.9 weeks, or the mean is 11.4 weeks if only the results of high-quality studies are considered.

      4.2 Predictors of resuming work

      Four reviews have summarised the evidence about factors which determine RTW after THR [
      • Hoorntje A.
      • Janssen K.Y.
      • Bolder S.B.T.
      • Koenraadt K.L.M.
      • Daams J.G.
      • Blankevoort L.
      • et al.
      The effect of Total hip arthroplasty on sports and work participation: a systematic review and meta-analysis.
      ,
      • Kuijer P.P.
      • de Beer M.J.
      • Houdijk J.H.
      • Frings-Dresen M.H.
      Beneficial and limiting factors affecting return to work after total knee and hip arthroplasty: a systematic review.
      ,
      • Malviya A.
      • Wilson G.
      • Kleim B.
      • Kurtz S.M.
      • Deehan D.
      Factors influencing return to work after hip and knee replacement.
      ,
      • Tilbury C.
      • Schaasberg W.
      • Plevier J.W.
      • Fiocco M.
      • Nelissen R.G.
      • Vliet Vlieland T.P.
      Return to work after total hip and knee arthroplasty: a systematic review.
      ]. Kuijer et al. highlighted the scarcity of literature published between 1998 and 2008 on predictors of RTW after lower limb arthroplasty. The authors found that restricting movement during the early post-operative period could limit RTW whereas following guidelines to discharge THR patients had no effect on timing to resume to work [
      • Kuijer P.P.
      • de Beer M.J.
      • Houdijk J.H.
      • Frings-Dresen M.H.
      Beneficial and limiting factors affecting return to work after total knee and hip arthroplasty: a systematic review.
      ]. Systematic reviews published subsequently have reported that age was not found associated with RTW in some studies, but that some studies found that younger patients were more likely to RTW [
      • Hoorntje A.
      • Janssen K.Y.
      • Bolder S.B.T.
      • Koenraadt K.L.M.
      • Daams J.G.
      • Blankevoort L.
      • et al.
      The effect of Total hip arthroplasty on sports and work participation: a systematic review and meta-analysis.
      ,
      • Malviya A.
      • Wilson G.
      • Kleim B.
      • Kurtz S.M.
      • Deehan D.
      Factors influencing return to work after hip and knee replacement.
      ,
      • Tilbury C.
      • Schaasberg W.
      • Plevier J.W.
      • Fiocco M.
      • Nelissen R.G.
      • Vliet Vlieland T.P.
      Return to work after total hip and knee arthroplasty: a systematic review.
      ]. Similarly, most studies have not found an association between sex and likelihood of RTW, as was reported in the review by Hoorntje and colleagues (10 out of the 12 studies) [
      • Hoorntje A.
      • Janssen K.Y.
      • Bolder S.B.T.
      • Koenraadt K.L.M.
      • Daams J.G.
      • Blankevoort L.
      • et al.
      The effect of Total hip arthroplasty on sports and work participation: a systematic review and meta-analysis.
      ]. However, THR recipients were less likely to RTW if they were on sick leave either at the time of surgery [
      • Hoorntje A.
      • Janssen K.Y.
      • Bolder S.B.T.
      • Koenraadt K.L.M.
      • Daams J.G.
      • Blankevoort L.
      • et al.
      The effect of Total hip arthroplasty on sports and work participation: a systematic review and meta-analysis.
      ,
      • Malviya A.
      • Wilson G.
      • Kleim B.
      • Kurtz S.M.
      • Deehan D.
      Factors influencing return to work after hip and knee replacement.
      ] or >30 days in the year prior to arthroplasty [
      • Laasik R.
      • Lankinen P.
      • Kivimäki M.
      • Aalto V.
      • Saltychev M.
      • Mäkelä K.
      • et al.
      Return to work after primary total hip arthroplasty: a nationwide cohort study.
      ]. There is some evidence that having attained higher levels of educational qualifications is associated with both a higher rate of RTW and less time taken to RTW [
      • Hoorntje A.
      • Janssen K.Y.
      • Bolder S.B.T.
      • Koenraadt K.L.M.
      • Daams J.G.
      • Blankevoort L.
      • et al.
      The effect of Total hip arthroplasty on sports and work participation: a systematic review and meta-analysis.
      ] but this may relate to these individuals having availability of less physically demanding and more flexible types of work. Certainly, Laasik et al. [
      • Laasik R.
      • Lankinen P.
      • Kivimäki M.
      • Aalto V.
      • Saltychev M.
      • Mäkelä K.
      • et al.
      Return to work after primary total hip arthroplasty: a nationwide cohort study.
      ] reported that people in non- physically demanding occupations (e.g. physician or teacher) were twice as likely to RTW compared with manual workers. It not surprising therefore that it takes longer to RTW for people with occupations that entail higher physical demands as compared with those in jobs with no physical demands [
      • Hoorntje A.
      • Janssen K.Y.
      • Bolder S.B.T.
      • Koenraadt K.L.M.
      • Daams J.G.
      • Blankevoort L.
      • et al.
      The effect of Total hip arthroplasty on sports and work participation: a systematic review and meta-analysis.
      ]. Other predictors that have been examined to a small extent in the literature are self-employed versus employed; availability of a disability pension; job satisfaction; and surgical approach however the existing evidence is scarce, and no conclusions can be made.

      4.3 Workability post-operatively

      Currently it is unclear whether people can sustain physically-demanding jobs or whether certain activities should be avoided post-operatively. Return to work can be part of successful rehabilitation but, in some cases, a phased RTW with modification of tasks or hours may be required [
      • Nunley R.M.
      • Ruh E.L.
      • Zhang Q.
      • Della Valle C.J.
      • Engh Jr., C.A.
      • Berend M.E.
      • et al.
      Do patients return to work after hip arthroplasty surgery.
      ]. Sankar et al. found that some occupational activities which are difficult or impossible to perform pre-operatively can become possible post-operatively but that some THR recipients continued to experience difficulties with lifting, carrying and moving objects, crouching and kneeling [
      • Sankar A.
      • Davis A.M.
      • Palaganas M.P.
      • Beaton D.E.
      • Badley E.M.
      • Gignac M.A.
      Return to work and workplace activity limitations following total hip or knee replacement.
      ]. In a more recent study [
      • Zaballa E.
      • Ntani G.
      • Harris E.C.
      • Lübbeke A.
      • Arden N.K.
      • Hannouche D.
      • et al.
      Feasibility and sustainability of working in different types of jobs after total hip arthroplasty: analysis of longitudinal data from two cohorts.
      ], 7 % of the 411 THR patients who worked post-operatively reported that they had stopped working partly or mainly due to problems with their operated hip. Standing ≥4 h, kneeling/squatting and carrying/lifting≥10 kg on an average day at work were strongly associated with having to stop work post-operatively.

      5. Conclusion

      In summary some studies have described different trajectories of physical function and pain recovery for up to 5 years post-arthroplasty, showing that most people achieve good results from surgery. Pre-operative function and severity of radiological OA may be important determinants of the risk of a poor outcome. However, the evidence about other predictors (e.g. age, gender) is conflicting and no reliable predictive model is as yet available. Among people working pre-operatively, most RTW post-THR, however being on sick leave pre-operatively can be associated with reduced odds of return to work. Conversely, it seems that attainment of a higher level of education, which obviously is not unrelated to the nature of the job to which someone needs to return, is a predictor of better chances of RTW.

      6. Clinical implications and need for research

      Although THR is a very successful procedure some recipients fail to achieve physical function improvement and pain relief. More research that might enable prediction of those likely to have poor outcomes pre-operatively is indicated. Now that PROMs are collected more regularly through arthroplasty registries [
      • Wilson I.
      • Bohm E.
      • Lübbeke A.
      • Lyman S.
      • Overgaard S.
      • Rolfson O.
      • et al.
      Orthopaedic registries with patient-reported outcome measures.
      ] (i.e. The American Joint Replacement Registry, The Australian Orthopaedic Association National Joint Replacement Registry and Swedish National Registry), more data will be available to better understand the functional outcomes after THR in the mid- to long-term (beyond 10-year follow-up) as well as which factors contribute towards a decline in function.
      Arthroplasty recipients who need to RTW post-operatively should receive occupational advice and support covering how long it might take to RTW and taking account of the nature of their job, and also the types of occupational activities involved. Future research should address whether more physically-demanding jobs may affect work sustainability, or function in the mid- to long-term post-operation.

      Contributors

      Elena Zaballa participated in the conception of the paper, performed a literature search, and drafted the manuscript.
      Elaine Dennison participated in the conception of the paper and revised the manuscript.
      Karen Walker-Bone participated in the conception of the paper, edited and revised the manuscript.
      All authors saw and approved the final version and no other person made a substantial contribution to the paper.

      Funding

      This work was supported by the MRC Versus Arthritis Centre for Musculoskeletal Health and Work [award number 22090 ].

      Provenance and peer review

      This article was commissioned and was externally peer reviewed.

      Declaration of competing interest

      The authors declare that they have no competing interest.

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