Abstract
Background
In the military, return-to-duty status has commonly been used as a functional outcome measure after orthopaedic surgery. This is sometimes regarded similarly to return to sports or as an indicator of return to full function. However, there is variability in how return-to-duty data are reported in clinical research studies, and it is unclear whether return-to-duty status alone can be used as a surrogate for return to sport or whether it is a useful marker for return to full function.
Questions/purposes
(1) What proportion of military patients who reported return to duty also returned to athletic participation as defined by self-reported level of physical activity? (2) What proportion of military patients who reported return to duty reported other indicators of decreased function (such as nondeployability, change in work type or level, or medical evaluation board)?
Methods
Preoperative and postoperative self-reported physical profile status (mandated physical limitation), physical activity status, work status, deployment status, military occupation specialty changes, and medical evaluation board status were retrospectively reviewed for all active-duty soldiers who underwent orthopaedic surgery at Madigan Army Medical Center, Joint Base Lewis-McChord from February 2017 to October 2018. Survey data were collected on patients preoperatively and 6, 12, and 24 months postoperatively in all subspecialty and general orthopaedic clinics. Patients were considered potentially eligible if they were on active-duty status at the time of their surgery and consented to the survey (1319 patients). A total of 89% (1175) were excluded since they did not have survey data at the 1 year mark. Of the remaining 144 patients, 9% (13) were excluded due to the same patient having undergone multiple procedures, and 2% (3) were excluded for incomplete data. This left 10% (128) of the original group available for analysis. Ninety-eight patients reported not having a physical profile at their latest postoperative visit; however, 14 of these patients also stated they were retired from the military, leaving 84 patients in the return-to-duty group. Self-reported “full-time duty with no restrictions” was originally used as the indicator for return to duty; however, the authors felt this to be too vague and instead used soldiers’ self-reported profile status as a more specific indicator of return to duty. Mean length of follow-up was 13 ± 3 months. Eighty-three percent (70 of 84) of patients were men. Mean age at the preoperative visit was 35 ± 8 years. The most common surgery types were sports shoulder (n = 22) and sports knee (n = 14). The subgroups were too small to analyze by orthopaedic procedure. Based on active-duty status and requirements of the military profession, all patients were considered physically active before their injury or surgery. Return to sport was determined by asking patients how their level of physical activity compared with their level before their injury (higher, same, or lower). We identified the number of other indicators that may suggest decreased function by investigating change in work type/level, self-reported nondeployability, or medical evaluation board. This was performed with a simple survey.
Results
Of the 84 patients reporting return to duty at the final follow-up, 67% (56) reported an overall lower level of physical activity. Twenty-seven percent (23) reported not returning to the same work level, 32% (27) reported being nondeployable, 23% (19) reported undergoing a medical evaluation board (evaluation for medical separation from the military), and 11% (9) reported a change in military occupation specialty (change of job description).
Conclusion
Return to duty is commonly reported in military orthopaedics to describe postoperative functional outcome. Although self-reported return to duty may have value for military study populations, based on the findings of this investigation, surgeons should not consider return to duty a marker of return to sport or return to full function. However, further investigation is required to see to what degree this general conclusion applies to the various orthopaedic subspecialties and to ascertain how self-reported return to duty compares with specific outcome measures used for particular procedures and subspecialties.
Level of Evidence
Level IV, therapeutic study.
Introduction
Evaluating the proportion of patients who return to full function (that is, to preinjury levels of physical activity) and the timing at which that occurs are important indicators of the success of orthopaedic procedures. This knowledge is especially important when counseling patients about expectations after surgery. In athletes, this may be further specified in terms of the likelihood and timing of return to sport. In the military, a commonly used metric of functional outcome after orthopaedic surgery is return to duty [2-4, 7, 11, 15, 19-24, 26, 29-32, 34-36, 38]. Return to duty is an easily collectable data point for military patients, as soldiers who are unable to return to their physical duties are placed on a trackable mandated activity restriction, called a physical profile, which prevents them from participating fully in fitness requirements (such as group physical training, group sports, and the twice-yearly graded physical fitness test). Because soldiers who return to duty are assumed capable of completing all such physical requirements, return to duty has historically been used as an indicator of return to full function, or even as a surrogate for return to sport [5, 7-9, 13-18, 22, 23, 26, 27, 29, 33]. As such, return to duty is commonly included as an outcome measure in both military research and civilian research that utilizes military populations.
Because the military is an influential producer of orthopaedic and sports-related research, and since military studies are often included in systematic reviews or meta-analyses that combine both military and civilian populations, readers are put to the task of deciding how to use return to duty as an outcome metric [22]. However, there is inconsistency in how return-to-duty data are reported, making it potentially challenging to interpret outcomes of not only military-specific studies but also larger studies that use military populations. Inconsistencies typically revolve around lack of or variability in reporting of other indicators, such as returning to duty but with limitations, change in job description, or anticipated retirement. Because of this, some have raised concerns regarding the applicability of return to duty as a measure of return to full function or return to sport [6].
We therefore asked, (1) What proportion of military patients who reported return to duty also returned to athletic participation as defined by self-reported level of physical activity? (2) What proportion of military patients who reported return to duty reported other indicators of decreased function (such as nondeployability, change in work type or level, or medical evaluation board)?
Patients and Methods
Study Design and Setting
We performed a retrospective study of survey data collected from active-duty military service members who underwent orthopaedic surgery at Madigan Army Medical Center, Joint Base Lewis-McChord from February 2017 to October 2018. This is a large, combined Army and Air Force base comprising multiple combat and support units, as well a Special Forces group and Ranger battalion. As such, active-duty soldiers seen in the Madigan orthopaedic clinic are diverse in their job descriptions, ranging from highly specialized and elite combat personnel to more sedentary fields of support and logistics. Survey data were collected on patients preoperatively and 6, 12, and 24 months postoperatively in all subspecialty (sports, arthroplasty, shoulder, elbow and hand, spine, foot and ankle) and general orthopaedic clinics via an online questionnaire. This questionnaire was initially employed with a simple online survey for the purposes of quality improvement and internal tracking of clinical outcomes and was not created for the purpose of this study. Therefore, all data analysis was retrospective. We felt this had adequate face validity based on review of the survey by multiple parties who deemed the survey to be free of leading or confusing questions. This included review of the survey by the hospital’s Department of Clinical Investigation, who approved the survey for use. The questions used for the purpose of this study were considered straightforward with a low likelihood of misinterpretation.
Participants
Patients were considered potentially eligible if they were on active-duty status at the time of their surgery and consented to the survey (1319 patients). Eighty-nine percent (1175) were excluded because survey data from the 1-year mark were not available, leaving 144 patients. One-year follow-up was chosen because in patients who still have limitations at 1 year, a medical evaluation board evaluation is typically initiated, meaning that the patient would become eligible for medical discharge from the military because of a persistent physical limitation. Of the 144, 9% (13) were excluded because the same patient underwent multiple procedures (and thus the same patient completed surveys in multiple clinics), and 2% (3) were excluded for incomplete data, leaving 128 patients for analysis.
Ninety-eight patients reported not having a physical profile at their latest postoperative visit, and thus were deemed to have returned to full duty. However, 14 patients reported in their job description that they were retired from the military, which disqualified them from the return-to-duty group, leaving a total of 84 patients. Self-reported “full-time duty with no restrictions” was originally used as the indicator for return to duty; however, authors felt this to be too vague and instead used soldiers’ self-reported profile status as a more specific indicator of return to duty. The mean length of follow-up of these patients was 12.9 ± 3.10 months. Eighty-three percent (70 of 84) of patients were male. The mean age at the preoperative visit was 35.4 ± 7.76 years. Patients were predominantly enlisted soldiers rather than officers (87% [73 of 84]).
The most common surgery type was sports/arthroscopic shoulder procedures (22 of 84) and sports/arthroscopic knee procedures (14 of 84). Other surgery types included elbow and hand (n = 11), spine (n = 14), sports/arthroscopic hip (n = 12), foot and ankle (n = 5), hip arthroplasty (n = 3), general orthopaedic surgery (n = 2), and knee arthroplasty (n = 1). The subgroups were too small to analyze by orthopaedic procedure; however, we felt this was acceptable as we were investigating self-reported return to duty in orthopaedics as a whole. Based on active-duty status and requirements of the military profession, all patients were considered physically active before their injury or surgery.
Description of Experiment
Patient demographic information included age, gender, and preoperative military rank were retrospectively collected from compiled survey data after inclusion and exclusion criteria were met as described above. Outcome measures from the most recent follow-up visit included level of physical activity, deployability, medical evaluation board status, and changes in military occupation specialty (that is, any changes in work type)
Primary and Secondary Study Outcomes
Our primary study goal was to assess what proportion of military patients who reported return to duty also returned to athletic participation as defined by self-reported level of physical activity. Return to duty was determined by asking patients about their profile status; specifically, “What is your current profile status? (on temporary profile for this injury or body part, on permanent profile for this injury or body part, on temporary profile for a different injury/body system, on permanent profile for a different injury/body part).” In civilian workplaces, some patients have physical restrictions after surgical interventions; for example, the patients could be restricted to light duty after spine surgery for a period of time or perhaps even permanently. In the military, the analog of this is called a physical profile. If a military service member cannot return to full duty after injury or surgery, but he or she still has enough physical function to remain in the service, that service member is given a “physical profile” that describes which duties he or she can and cannot perform. Just like physical restrictions in the civilian workplace, physical profiles may be temporary or permanent, with the intention of allowing service members to heal while continuing on active duty. Physical profiles limit a service member’s physical activity, often reducing requirements for the physical fitness test or restricting their involvement in unit-level physical training. If a service member requires a temporary profile for an extended amount of time, or if they have a medical condition that will likely not resolve, they may be transitioned to a permanent profile. Patients who did not select a profile option in the survey were deemed to have returned to duty without restrictions.
Return to athletic participation, or return to sport, was determined by asking patients, “What is your level of physical activity compared to before your injury? (higher, same or lower).” Active-duty military patients commonly engage in mandated sport-related activities with their units on a daily basis, which would be encompassed in this broader question regarding physical activity.
Our secondary study goal was to assess what proportion of military patients who reported return to duty reported other indicators of decreased function (such as nondeployability, change in work type/level, or medical evaluation board). We evaluated the deployability of patients because this is an important metric when characterizing return to duty. A patient may return to duty but not be considered deployable by their units, indicating a potential persistent functional deficit and diminished capability. On the contrary, it is also possible for patients to deploy despite the injury or condition if they can meet specific minimum tasks as determined by their military branch. To assess for deployability, patients were asked, “Are you currently considered deployable? (yes/no).”
Medical evaluation board status was also evaluated. Rather than having a service member continue on active duty with a permanent profile, a service member might be referred to a medical evaluation board to undergo medical discharge from the military. This is typically initiated when a patient sustains an injury or has a medical condition that is not expected to improve enough for the patient to return to full duty within 1 year. The medical evaluation board process can be prolonged, at times taking 6 to 12 months. During this time, service members often return to work, albeit with few or no physical activity requirements. A military patient who reports full return to duty (no profile), but also reports undergoing a medical evaluation board, might indicate a failure to return to full function. Medical evaluation board status was measured by asking patients, “Are you facing or have you gone through a medical evaluation board? (yes/no).”
Work type and change in military occupational specialty were also evaluated as return-to-duty measures. Military occupational specialty is a code used to describe a specific job function within a military branch. Although all service members are required to meet a standard for their military branch’s physical fitness test at least once per year, there is still substantial variability in their occupational demands throughout the remainder of the year based on their specific jobs. For instance, in the Army, it is likely that units in combat-arms branches demand a higher degree of fitness than do units in service-support branches. This is evident by the intensity of unit-level training, expectations for fitness test scores, and availability of advanced schools or courses that require a high degree of fitness for attendance consideration (such as Ranger school, Airborne school, or combat engineer school). If a military patient returns to full active duty after orthopaedic surgery but undergoes a change in their occupation, this implies that they may have not returned to a preoperative level of fitness. Change in work type was measured by asking patients, “Is the type of work you do the same as before your injury or joint problem? (yes/no).” Patients were also asked the follow-up question of, “If your work status is different now, is this due to your injury or joint problem? (yes/no).” Change in military occupational specialty was measured by asking patients to report their military occupational specialty before the injury and postoperatively, and the percentage of these changes was calculated.
Ethical Approval
Ethical approval for this study was waived by Madigan Army Medical Center, Joint Base Lewis-McChord, WA, USA (reference number #220067).
Statistical Analysis
The statistical analysis was performed using Microsoft Excel (Microsoft Corp) with Data Analysis Toolpak. Descriptive data are reported as simple percentages of patients.
Results
Return to Duty and Physical Activity
Of the 84 patients reporting return to duty at the final follow-up, 67% (56) reported an overall lower level of physical activity.
Return to Duty and Full Function
Of the patients reporting return to duty, 27% (23 of 84) reported not returning to the same work level, 32% (27 of 84) reported being considered nondeployable, 23% (19 of 84) reported undergoing a medical evaluation board, and 11% (9 of 84) reported a change in military occupational specialty. However, only 4 of 9 patients who reported a change in military occupational specialty attributed it to their injury or joint problem.
Discussion
Success of an orthopaedic procedure is often dictated by the rate by which patients return to full function (such as preinjury levels of physical activity, or in the case of athletes, the rate of return to sport). In the military, return to duty is commonly reported as a way of describing a patient’s return to full function, or even equated to return to sport [2-4, 7, 11, 15, 19-24, 26, 29-32, 34-36, 38]. Because military studies often are used as a part of systematic reviews or meta-analyses that encompass both military and civilian patients, return to duty is a relevant outcome measure for civilian and military readers alike as they attempt to interpret these studies. However, there is variability in how return to duty is reported in clinical research, and it is unclear whether return to duty is an appropriate indicator of return to function or return to sport. This makes it challenging to interpret not only military studies, but also larger studies that combine both military and civilian populations. Based on our preliminary investigation, return to duty may not be an adequate indicator of return to full function or return to sport. A large proportion of military patients who reported not having a profile at their final follow-up visit, and had thus returned to duty, reported having a lower level of physical activity, as well as a number of other indicators that suggest decreased function.
Limitations
This study has many limitations. Data were pooled from multiple orthopaedic procedure types ranging from minor surgery to larger, more invasive procedures. This means that certain patients would likely have had a much easier time returning to duty than others and would have had very different postoperative courses. However, the goal of all orthopaedic procedures performed on active-duty military patients is to allow the service member to return to duty within 1 year after surgery. If this was a clearly unreasonable goal at the time of the preoperative visit, most of these patients would have been referred to a medical evaluation board rather than proceeding with surgery in the military setting. Since the aim of this study was to investigate return to duty as an outcome measure in all areas of orthopaedics rather than specific return-to-duty rates in each procedure type, we felt it was still appropriate to pool patients from dissimilar types of surgery.
Another limitation of this study is substantial loss to follow-up. This study was retrospectively performed on available survey data that were initially collected as a part of quality improvement and internal tracking of clinical outcomes rather than as a part of a prospective study. Therefore, a large number of patients did not have survey data completed at the 1-year postoperative mark. This is likely due to many patients opting out of the survey at their subsequent follow-up visits. However, it is also possible, but less likely, that these patients were truly lost to follow-up. There are a variety of reasons this might be the case. Patients may have been medically discharged from the military before their follow-up at the 1-year postoperative time point, meaning there was an over-representation of patients with better outcomes in our study. However, the opposite may also be true in that the 1-year follow-up may have preferentially selected patients with poorer outcomes, as some providers might have discharged their patients from care after 3 to 6 months. This would be mean there was a selection bias for patients with more persistent limitations at the 1-year visit. Similarly, a portion of patients who were doing well may have been lost to follow-up because of changing duty stations, leading to an overrepresentation of patients undergoing medical evaluation boards because this precludes a change in duty station.
Another limitation of this study is a lack of specific outcome scores. Comparing return-to-duty rates with specific validated outcome measures for each surgery type would likely provide a much clearer picture of return to duty as a functional outcome measure and is certainly an area of future research. Additionally, we did not have specific data in our patient population on rates of return to high levels of athletic participation, which is commonly used for return to sport. Rather, we had to infer that level of physical activity in military patients, who are required to participate in sports and sport-like activities with their units, was an indicator of their ability to return to sport. Therefore, readers should interpret these findings with caution and recognize that this is only a preliminary investigation that aimed to elucidate a possible discrepancy in the way return to duty is currently being implemented versus a potentially more appropriate use.
Return to Duty and Physical Activity
Concerns regarding the use of return to duty as a surrogate for return to sport appear to be justified, based on our analysis. Return to sport is most commonly defined as a return to a high level of athletic participation, and some studies have attempted to answer how return to duty relates to return to sport. In hip arthroscopy, Yoo et al. [37] recently compared the clinical outcomes of military service members with those of active, young, nonmilitary patients after hip arthroscopy. They found that return-to-duty times were similar to return-to-sport times in the nonmilitary population (5.9 ± 4.3 months versus 6.3 ± 3.7 months). This suggests that return to duty may be a good surrogate for return to sport. However, in response to that study, Barlow [6] published an editorial commentary urging caution in interpreting these results. He discussed that there is a body of evidence in hip arthroscopy that suggests inequality between military and nonmilitary patients in terms of return to duty versus return to sport. For example, in a study of more than 400 military patients, 39% returned to full, unrestricted military service after hip arthroscopy [33]. However, in a subset analysis, in elite naval Special Forces and SEALs, return-to-duty rates were much higher (86% and 77%, respectively) and were similar to return-to-sport rates for civilian athletes (79% to 96%, respectively) [1, 25, 28]. This indicates that for the nonelite military patient, return-to-duty rates are not equivalent to return to sport in hip arthroscopy. Our study was comprised largely of nonelite military patients, as they comprise the majority of service members, in a similar way that most patients who are seen in outpatient civilian orthopaedic clinics are not professional or Division 1 collegiate athletes.
Although most patients in our investigation reported successful return to duty, they also reported a lower level of physical activity at the 1-year follow-up. This suggests that these patients are having difficulty returning to their baseline level of physical activity, which, in the military, comprises group fitness, group sports, and sport-like activities (such as combative or martial arts, buddy carries, sprint drills, ruck marching and running, and obstacle courses). If patients are unable to return to their previous level of these activities, it is unlikely that they would return to a high level of athletic participation if they were civilian athletes. Therefore, our investigation suggests that self-reported return to duty may not be an adequate surrogate for return to sport. Moving forward, readers of military studies, and studies that combine both civilian and military patients, should interpret return to duty with caution when used in the context of return to sport, as they may not be equivalent outcomes. Based on our analysis, return to duty may be a lower threshold of function when compared with return to sport. When designing studies using military patients, clinicians should avoid grouping return-to-duty with return-to-sport rates. Or, they might instead focus on other validated outcome measures specific to each subspecialty within orthopaedics.
Return to Duty and Full Function
If return to duty appears to not be an appropriate correlate to return to sport, the question remains whether it is an appropriate indicator of returning to function. For the purposes of this study, return to full function would indicate a return to preinjury levels of physical activity. The aforementioned finding that most patients reported lower levels of physical activity would suggest that return to duty may also not be an appropriate indicator of return to full function. Additionally, numerous patients reported not returning to the same work level and being considered nondeployable. These two metrics suggest that return to duty may not demonstrate a return to full function if service members have not returned to their baseline level of work and are deemed not safe for deployment. It is possible that their deployment status may have been unrelated to a physical limitation but rather because of administrative causes. However, approximately 50% of soldiers report being nondeployable because of profile or physical incapability [12]. Some authors have suggested that return to duty should even encompasses a service member’s deployability. For instance, Cole et al. [10] evaluated the use of return to duty in concussion research, concluding that a better definition is needed to increase specificity. They recommended that researchers use Department of Defense definitions of individual medical readiness and deployment-limiting conditions, and defined return to duty as “return to deployment readiness.”
Finally, our study found service members who reported full return to duty frequently were undergoing or had undergone a medical evaluation board. This is another potential indicator of not returning to full function because this is most commonly the result of a prolonged physical limitation that has been deemed irresolvable. Therefore, in addition to interpreting return to duty with caution in regard to return to sport, readers should similarly avoid viewing return to duty as synonymous with return to full function. Return to duty may still be an important indicator of success of orthopaedic procedures specifically in military populations, as the goal of military orthopaedic surgeons is to return service members to their duty obligations. Return to duty may also be relevant in discussions with patients regarding their likelihood or timing of returning to work, as this may be a more appropriate parallel. However, clinicians should recognize that return to duty may not indicate a full return to function when counseling their patients using military studies. Additionally, researchers hoping to include military studies in systematic reviews or meta-analyses that also include civilian populations may want to consider separate outcome metrics when combining populations. For military clinicians, it is similarly important to include other outcome measures so that the data may have more applicability outside the military. With return-to-duty rates, it may also be helpful to closely evaluate other potential indicators of decreased function, such as deployability, medical evaluation boards, or changes in work level or type.
Conclusion
Return-to-duty status is commonly reported in military orthopaedics as a way of describing postoperative functional outcome. Our preliminarily investigation suggests self-reported full return to duty may not be an appropriate indicator of return to full function, nor an adequate surrogate for return to sport. We concede that this is a preliminary investigation and not specific enough to apply to particular subspecialties of orthopaedics, although it certainly is hypothesis-generating with respect to potential future studies in individual orthopaedic subspecialties. However, it does seem to suggest that readers of military studies and larger studies that combine military and civilian populations should use caution when comparisons are made between return to duty and return to sport. Additionally, clinicians using these studies to counsel their patients, civilian or military, on expectations after surgery should recognize that return-to-duty rates or timing or return to duty may not parallel their timing or rate of return to sport or return to full function. Further studies using validated outcome measures are needed to accurately delve into return to duty as a functional outcome measure in each subspecialty of orthopaedics. This would include prospective or retrospective studies specifically investigating how other outcome measures, collected on military patients, correlate with their return to duty, and how these outcome measures compare with return to sport or return to full function in civilian populations for the same procedures.
Acknowledgment
We thank Debra K Hood BSN for all of her organizational assistance with survey data collection/compilation.
Footnotes
Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
Ethical approval for this study was waived by Madigan Army Medical Center, Joint Base Lewis-McChord, WA, USA (reference number 220067).
This work was performed at Madigan Army Medical Center, Joint Base Lewis-McChord, WA, USA.
Contributor Information
Nicholas J. Drayer, Email: nidrayer7@gmail.com.
Matthew J. Nowak, Email: matthewjnowak@gmail.com.
Kyle S. Ardavanis, Email: kyleardavanis@gmail.com.
Franklin J. Powlan, Email: franklin.powlan@cuanschutz.edu.
Brendan D. Masini, Email: brendan.d.masini.mil@mail.mil.
Daniel G. Kang, Email: daniel.g.kang.mil@mail.mil.
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