To Drive or Not to Drive?

Commentary “When can I drive?” This common question from patients involves multiple patient, surgeon, societal, and medicolegal considerations1. Limited evidence on the safety of driving after shoulder surgery and a lack of formal guidelines further complicate the surgeon’s role in advising patients. We commend Badger et al. on their efforts to study driving fitness after rotator cuff repair. Using thorough subjective and objective serial assessments of real-world driving, they provide empirical evidence that routine driving performance in a sling is adequate as soon as 2 weeks after rotator cuff repair. Not only was driving performance noninferior to baseline on all parameters at all time points, but the patients also exhibited less aggressive braking and more stable steering by 2 weeks after the surgical procedure. The findings strongly suggest that patients are more cautious while driving after rotator cuff repair and can effectively compensate for the limitations of the operatively treated extremity for routine driving. Patients were more self-critical of their ability to parallel park than the on-board safety monitor. The study by Badger et al. is an important step forward in helping surgeons to advise patients on their return to driving after rotator cuff repair, but it raises questions about safety both on and off the road. Rehabilitation protocols after rotator cuff repair vary widely, with some advocating early active motion over sling immobilization2. Grubhofer et al. recently showed that patients with <60% sling compliance had a 13-fold higher rate of rotator cuff repair failure at a 1-year follow-up, indicating that sling immobilization has important implications regarding healing in the early postoperative period3. Badger et al. showed that patients, despite wearing a sling at the 2-week postoperative test, had the hand ipsilateral to the operatively treated extremity on the upper portion of the steering wheel 6% to 11% of the time and on the lower steering wheel 25% to 26% of the time. It is unclear if patients used the operatively treated extremity to execute essential aspects of driving and to what extent such maneuvers exceeded postoperative motion restrictions. Although Badger et al. showed no decreases in PROMIS v2.0UE7ASF (Patient-Reported Outcomes Measurement Information System version 2.0 Upper Extremity 7A-item Short Form) scores postoperatively, the lack of postoperative imaging and of longer follow-up limited conclusions regarding the risks of early driving with respect to rotator cuff repair failure. The findings of Badger et al. corroborate those of Hasan et al.4, who studied simulated automatic transmission driving in normal subjects with a sling on the dominant driving arm. Hasan et al. found that there was no adverse effect of sling immobilization for routine driving; however, there were significantly more collisions in hazardous conditions requiring an evasive maneuver when the subjects were wearing a sling4. A follow-up simulator study observed an increase in collisions at 2 weeks after total shoulder arthroplasty, with a return to baseline by 6 weeks and improvement at 12 weeks5. Although hazardous conditions that lead to collisions are much rarer in the real world, they are potentially catastrophic, particularly at high speed. Badger et al. did not assess hazardous conditions in their study for obvious safety reasons, but simulator studies have demonstrated that there is an increased risk of collisions and potential catastrophe in hazardous conditions. The risk of an impaired response to hazardous driving conditions must be considered when counseling patients and determining the safety of returning to driving. Consequently, we believe that patients who undergo rotator cuff repair should continue to be advised not to drive as long as a sling is required postoperatively. If patients choose to drive despite this advice, then they should limit it to routine, low-speed driving.