[The relationship of mental health providers with health insurers; an exploration]. / De ggz in relatie tot zorgverzekeraars; een verkenning.

BACKGROUND: In 2020, Zorgverzekeraars Nederland (ZN), the umbrella organization of nine health insurers in The Netherlands. presented a vision of the future of mental health care in the Netherlands in ‘De GGZ in 2025. Vergezicht op de geestelijke gezondheidszorg’ (‘Outlook on mental health care’). This document can be seen as marking the fact that key stakeholders share a common vision on the future of the GGZ in the Netherlands. Contracting care is often difficult. The tension between providing quality and sufficient care and available funding leads to friction. Congruence in vision, goals and practices are important conditions for adequate relationship building. Does the vision document contribute to this? AIM: To discuss the experiences of mental health care administrators and health insurers in contracting and collaboration. METHOD: Conducting interviews with both directors of mental health institutions and the strategic (policy) advisors of health insurers. In the approach we used the salience model. RESULTS: The relationship between mental health care administrators and health insurers is perceived to be distrustful and complex, and has deteriorated slightly in 2021 compared to 2019. Perceived power, legitimacy and urgency affect the relationship. Almost all health insurers are characterized as dominant stakeholders based on the salience model. Both parties are open to improving the relationship, which requires more transparency and mutual understanding. CONCLUSION: With the supported content of the vision document, there is to some extent shared governance. The change steps (shared innovation) considered desirable will be promoted by partly granting the intended benefits to each other (shared savings).

Health care reform and financial crisis in the Netherlands: consequences for the financial arena of health care organizations.

Over the past decade, many health care systems across the Global North have implemented elements of market mechanisms while also dealing with the consequences of the financial crisis. Although effects of these two developments have been researched separately, their combined impact on the governance of health care organizations has received less attention. The aim of this study is to understand how health care reforms and the financial crisis together shaped new roles and interactions within health care. The Netherlands - where dynamics between health care organizations and their financial stakeholders (i.e., banks and health insurers) were particularly impacted - provides an illustrative case. Through semi-structured interviews, additional document analysis and insights from institutional change theory, we show how banks intensified relationship management, increased demands on loan applications and shifted financial risks onto health care organizations, while health insurers tightened up their monitoring and accountability practices towards health care organizations. In return, health care organizations were urged to rearrange their operations and become more risk-minded. They became increasingly dependent on banks and health insurers for their existence. Moreover, with this study, we show how institutional arenas come about through both the long-term efforts of institutional agents and unpredictable implications of economic and societal crises.

A tailored intervention does not reduce low value MRI's and arthroscopies in degenerative knee disease when the secular time trend is taken into account: a difference-in-difference analysis.

PURPOSE: To evaluate the effectiveness of a tailored intervention to reduce low value MRIs and arthroscopies among patients ≥ 50 years with degenerative knee disease in 13 Dutch orthopaedic centers (intervention group) compared with all other Dutch orthopaedic centers (control group). METHODS: All patients with degenerative knee disease ≥ 50 years admitted to Dutch orthopaedic centers from January 2016 to December 2018 were included. The tailored intervention included participation of clinical champions, education on the Dutch Choosing Wisely recommendation for MRI's and arthroscopies in degenerative knee disease, training of orthopaedic surgeons to manage patient expectations, performance feedback, and provision of a patient brochure. A difference-in-difference analysis was used to compare the time trend before (admitted January 2016-June 2017) and after introduction of the intervention (July 2017-December 2018) between intervention and control hospitals. Primary outcome was the monthly percentage of patients receiving a MRI or knee arthroscopy, weighted by type of hospital. RESULTS: 136,446 patients were included, of whom 32,163 were treated in the intervention hospitals. The weighted percentage of patients receiving a MRI on average declined by 0.15% per month (ß = - 0.15, P < 0.001) and by 0.19% per month for arthroscopy (ß = - 0.19, P < 0.001). However, these changes over time did not differ between intervention and control hospitals, neither for MRI (ß = - 0.74, P = 0.228) nor arthroscopy (ß = 0.13, P = 0.688). CONCLUSIONS: The extent to which patients ≥ 50 years with degenerative knee disease received a MRI or arthroscopy declined significantly over time, but could not be attributed to the tailored intervention. This secular downward time trend may reflect anoverall focus of reducing low value care in The Netherlands. LEVEL OF EVIDENCE: III.

Performing a knee arthroscopy among patients with degenerative knee disease: one-third is potentially low value care.

PURPOSE: The purpose of this study was to assess in which proportion of patients with degenerative knee disease aged 50+ in whom a knee arthroscopy is performed, no valid surgical indication is reported in medical records, and to explore possible explanatory factors. METHODS: A retrospective study was conducted using administrative data from January to December 2016 in 13 orthopedic centers in the Netherlands. Medical records were selected from a random sample of 538 patients aged 50+ with degenerative knee disease in whom arthroscopy was performed, and reviewed on reported indications for the performed knee arthroscopy. Valid surgical indications were predefined based on clinical national guidelines and expert opinion (e.g., truly locked knee). A knee arthroscopy without a reported valid indication was considered potentially low value care. Multivariate logistic regression analysis was performed to assess whether age, diagnosis ("Arthrosis" versus "Meniscal lesion"), and type of care trajectory (initial or follow-up) were associated with performing a potentially low value knee arthroscopy. RESULTS: Of 26,991 patients with degenerative knee disease, 2556 (9.5%) underwent an arthroscopy in one of the participating orthopedic centers. Of 538 patients in whom an arthroscopy was performed, 65.1% had a valid indication reported in the medical record and 34.9% without a reported valid indication. From the patients without a valid indication, a joint patient-provider decision or patient request was reported as the main reason. Neither age [OR 1.013 (95% CI 0.984-1.043)], diagnosis [OR 0.998 (95% CI 0.886-1.124)] or type of care trajectory [OR 0.989 (95% CI 0.948-1.032)] were significantly associated with performing a potentially low value knee arthroscopy. CONCLUSIONS: In a random sample of knee arthroscopies performed in 13 orthopedic centers in 2016, 65% had valid indications reported in the medical records but 35% were performed without a reported valid indication and, therefore, potentially low value care. Patient and/or surgeons preference may play a large role in the decision to perform an arthroscopy without a valid indication. Therefore, interventions should be developed to increase adherence to clinical guidelines by surgeons that target invalid indications for a knee arthroscopy to improve care. LEVEL OF EVIDENCE: IV.

Local variations in mechanical properties of human hamstring tendon autografts for anterior cruciate ligament reconstruction do not translate to a mechanically inferior strand.

A ruptured anterior cruciate ligament (ACL) is often reconstructed with a multiple-strand autograft of a semitendinosus tendon alone or combined with a gracilis tendon. Up to 10% of patients experience graft rupture. This potentially results from excessive local tissue strains under physiological loading which could either result in direct mechanical failure of the graft or induce mechanobiological weakening. Since the original location in the hamstring tendon cannot be traced back from an autograft rupture site, this study explored whether clinical outcome could be further improved by avoiding specific locations or regions of human semitendinosus and/or gracilis tendons in ACL grafts due to potential mechanical or biochemical inferiority. Additionally, it examined numerically which clinically relevant graft configurations experience the lowest strains - and therefore the lowest rupture risk - when loaded with equal force. Remnant full-length gracilis tendons from human ACL reconstructions and full-length semitendinosus- and ipsilateral gracilis tendons of human cadaveric specimens were subjected to a stress-relaxation test. Locations at high risk of mechanical failure were identified using particle tracking to calculate local axial strains. As biochemical properties, the water-, collagen-, glycosaminoglycan- and DNA content per tissue region (representing graft strands) were determined. A viscoelastic lumped parameter model per tendon region was calculated. These models were applied in clinically relevant virtual graft configurations, which were exposed to physiological loading. Configurations that provided lower stiffness - i.e., experiencing higher strains under equal force - were assumed to be at higher risk of failure. Suitability of the gracilis tendon proper to replace semitendinosus muscle-tendon junction strands was examined. Deviations in local axial strains from the globally applied strain were of similar magnitude as the applied strain. Locations of maximum strains were uniformly distributed over tendon lengths. Biochemical compositions varied between tissue regions, but no trends were detected. Viscoelastic parameters were not significantly different between regions within a tendon, although semitendinosus tendons were stiffer than gracilis tendons. Virtual grafts with a full-length semitendinosus tendon alone or combined with a gracilis tendon displayed the lowest strains, whereas strains increased when gracilis tendon strands were tested for their suitability to replace semitendinosus muscle-tendon junction strands. Locations experiencing high local axial strains - which could increase risk of rupture - were present, but no specific region within any of the investigated graft configurations was found to be mechanically or biochemically deviant. Consequently, no specific tendon region could be indicated to provide a higher risk of rupture for mechanical or biochemical reasons. The semitendinosus tendon provided superior stiffness to a graft compared to the gracilis tendon. Therefore, based on our results it would be recommended to use the semitendinosus tendon, and use the gracilis tendon in cases where further reinforcement of the graft is needed to attain the desired length and cross-sectional area. All these data support current clinical standards.

Power, legitimacy and urgency: Unravelling the relationship between Dutch healthcare organisations and their financial stakeholders.

Healthcare organisations rely on their financial stakeholders for capital to invest in state-of-the-art buildings, equipment, innovation and the delivery of healthcare services. Nevertheless, relations between healthcare organisations and their financial stakeholders have not been well studied. Here, we studied the relations between Dutch healthcare organisations and two of their main financial stakeholders (banks and health insurers) against the backdrop of system reforms and the financial crisis. We conducted a survey of healthcare executives to evaluate their relations with banks and health insurers in terms of power, legitimacy and urgency. These three attributes are based on the salience model of Mitchel, Agle and Wood (1997). We further tested for differences in power, legitimacy and urgency across organisational sector and size. The results showed that healthcare organisations value banks as legitimate stakeholders with a well-demarcated influence and a clear-cut function. The relationship with health insurers is more complex. Healthcare organisations experience considerable influence from health insurers but question the legitimacy of their claims. Since health insurers play a crucial role in the Dutch healthcare system, these findings question the workability of the relationship between healthcare organisations and health insurers and the position of health insurers in the overall healthcare sector. Our results are relevant to countries with public-private health systems and contribute to the development of the salience model by showing the individual value of stakeholder attributes and the relevance of context.

Spectroscopic photoacoustic imaging of cartilage damage.

OBJECTIVE: Osteoarthritis (OA) is a chronic joint disease characterized by progressive degradation of cartilage. It affects more than 10% of the people aged over 60 years-old worldwide with a rising prevalence due to the increasingly aging population. OA is a major source of pain, disability, and socioeconomic cost. Currently, the lack of effective diagnosis and affordable imaging options for early detection and monitoring of OA presents the clinic with many challenges. Spectroscopic Photoacoustic (sPA) imaging has the potential to reveal changes in cartilage composition with different degrees of damage, based on optical absorption contrast. DESIGN: In this study, the capabilities of sPA imaging and its potential to characterize cartilage damage were explored. To this end, 15 pieces of cartilage samples from patients undergoing a total joint replacement were collected and were imaged ex vivo with sPA imaging at a wide optical spectral range (between 500 nm and 1,300 nm) to investigate the photoacoustic properties of cartilage tissue. All the PA spectra of the cartilage samples were analyzed and compared to the corresponding histological results. RESULTS: The collagen related PA spectral changes were clearly visible in our imaging data and were related to different degrees of cartilage damage. The results are in good agreement with histology and the current gold standard, i.e., the Mankin score. CONCLUSIONS: This study demonstrates the potential and possible clinical application of sPA imaging in OA.

[Rheumatoid arthritis: more than a joint disease]. / Reumatoïde artritis: meer dan een gewrichtsziekte.

Rheumatoid arthritis (RA), one of the most common autoimmune disorders, mostly manifests itself as polyarthritis. However, extra-articular organ manifestations can also occur, even though their incidence has decreased substantially due to effective treatment with disease-modifying anti-rheumatic drugs. In this article we describe three patient cases of extra-articular manifestations in RA in the absence of prominent arthritis. The diversity of symptoms in RA can be of interest to different medical specialties who will occasionally encounter them in daily practice.

Preferences and beliefs of Dutch orthopaedic surgeons and patients reduce the implementation of "Choosing Wisely" recommendations in degenerative knee disease.

PURPOSE: The purpose of this study was to assess which factors were associated with the implementation of "Choosing Wisely" recommendations to refrain from routine MRI and arthroscopy use in degenerative knee disease. METHODS: Cross-sectional surveys were sent to 123 patients (response rate 95%) and 413 orthopaedic surgeons (response rate 62%) fulfilling the inclusion criteria. Univariate and multivariate logistic regression analyses were used to identify factors associated with implementation of "Choosing Wisely" recommendations. RESULTS: Factors reducing implementation of the MRI recommendation among patients included explanation of added value by an orthopaedic surgeon [OR 0.18 (95% CI 0.07-0.47)] and patient preference for MRI [OR 0.27 (95% CI 0.08-0.92)]. Factors reducing implementation among orthopaedic surgeons were higher valuation of own MRI experience than existing evidence [OR 0.41 (95% CI 0.19-0.88)] and higher estimated patients' knowledge to participate in shared decision-making [OR 0.38 (95% CI 0.17-0.88)]. Factors reducing implementation of the arthroscopy recommendation among patients were orthopaedic surgeons' preferences for an arthroscopy [OR 0.03 (95% CI 0.00-0.22)] and positive experiences with arthroscopy of friends/family [OR 0.03 (95% CI 0.00-0.39)]. Factors reducing implementation among orthopaedic surgeons were higher valuation of own arthroscopy experience than existing evidence [OR 0.17 (95% CI 0.07-0.46)] and belief in the added value [OR 0.28 (95% CI 0.10-0.81)]. CONCLUSIONS: Implementation of "Choosing Wisely" recommendations in degenerative knee disease can be improved by strategies to change clinician beliefs about the added value of MRIs and arthroscopies, and by patient-directed strategies addressing patient preferences and underlying beliefs for added value of MRI and arthroscopies resulting from experiences of people in their environment. LEVEL OF EVIDENCE: IV.

Timing of anterior cruciate ligament reconstruction and preoperative pain are important predictors for postoperative kinesiophobia.

PURPOSE: Fear of movement (kinesiophobia) is a major limiting factor in the return to pre-injury sport level after anterior cruciate ligament reconstruction (ACLR). The aim of this study was to gain insight into the prevalence of kinesiophobia pre-ACLR, 3 months post-ACLR and 12 months post-ACLR. Furthermore, the preoperative predictability of kinesiophobia at 3 months post-ACLR was addressed. METHODS: A retrospective study with data, which were prospectively collected as part of standard care, was conducted to evaluate patients who underwent ACLR between January 2017 and December 2018 in an orthopaedic outpatient clinic. Patient characteristics (age, sex, body mass index), injury-to-surgery time, preoperative pain level (KOOS pain subscale) and preoperative knee function (IKDC-2000) were used as potential predictor variables for kinesiophobia (TSK-17) at 3 months post-ACLR in linear regression analysis. RESULTS: The number of patients with a high level of kinesiophobia (TSK > 37) reduced from 92 patients (69.2%) preoperatively to 44 patients (43.1%) 3 months postoperatively and 36 patients (30.8%) 12 months postoperatively. The prediction model, based on a multivariable regression analysis, showed a positive correlation between four predictor variables (prolonged injury-to-surgery time, high preoperative pain level, male sex and low body mass index) and a high level of kinesiophobia at 3 months postoperatively (R2 = 0.384, p = 0.02). CONCLUSION: The prevalence of kinesiophobia decreases during postoperative rehabilitation, but high kinesiophobia is still present in a large portion of the patients after ACLR. Timing of reconstruction seems to be the strongest predictor for high kinesiophobia 3 months post-ACLR. This study is the first step in the development of a screening tool to detect patients with kinesiophobia after ACLR. Identifying patients preoperatively opens the possibility to treat patients and thereby potentially increase the return to pre-injury sport level rate after ACLR. LEVEL OF EVIDENCE: III.

Photon-Momentum-Induced Molecular Dynamics in Photoionization of N_{2} at hν=40 keV.

We investigate K-shell ionization of N_{2} at 40 keV photon energy. Using a cold target recoil ion momentum spectroscopy reaction microscope, we determine the vector momenta of the photoelectron, the Auger electron, and both N^{+} fragments. These fully differential data show that the dissociation process of the N_{2}^{2+} ion is significantly modified not only by the recoil momentum of the photoelectron but also by the photon momentum and the momentum of the emitted Auger electron. We find that the recoil energy introduced by the photon and the photoelectron momentum is partitioned with a ratio of approximately 30∶70 between the Auger electron and fragment ion kinetic energies, respectively. We also observe that the photon momentum induces an additional rotation of the molecular ion.

[Regional healthcare labels: differences in care needs and psychosocial functioning]. / Regionale zorgvignetten: verschillen in zorgbehoeften en psychosociaal functioneren.

BACKGROUND: Severe mental illnesses (SMI) are associated with high mental healthcare and other healthcare costs. In 2012, mental healthcare labels were developed to create more transparency between insurance companies, municipalities, and mental healthcare. The labels are based on care intensity, and should provide a regional overview of the present groups of patients with SMI.
AIM: Explore the functionality and validity of the used labels in relation to needs for care and psychosocial functioning.
METHOD: The ROM data (needs for care, functioning) from 706 patients were tested per label by Chi-square tests and ANOVAs. For two high complex labels (alarming care avoiders and persons with safety risks), repeated measures ANOVAs and McNemar tests were used to analyse changes in functioning and needs over time.
RESULTS: To a limited extent, the labels were distinctive in care needs and functioning. The most restrictions in functioning and (unfulfilled) needs were present in the labels 'alarming care avoiders' and 'avoiding danger'. These findings were stable over time.
CONCLUSION: The labels are not sufficiently distinctive. To enhance regional care planning, it is desirable to combine existing information on healthcare labels with information on care needs and functioning. KEY WORDS functioning, mental healthcare labels, needs for care, routine outcome monitoring, severe mental illness.

The OARSI core set of performance-based measures for knee osteoarthritis is reliable but not valid and responsive.

PURPOSE: The Osteoarthritis Research Society International has identified a core set of performance-based tests of physical function for use in people with knee osteoarthritis (OA). The core set consists of the 30-second chair stand test (30-s CST), 4 × 10 m fast-paced walk test (40 m FPWT) and a stair climb test. The aim of this study was to evaluate the reliability, validity and responsiveness of these performance-based measures to assess the ability to measure physical function in knee OA patients. METHODS: A prospective cohort study of 85 knee OA patients indicated for total knee arthroplasty (TKA) was performed. Construct validity and responsiveness were assessed by testing of predefined hypotheses. A subgroup (n = 30) underwent test-retest measurements for reliability analysis. The Oxford Knee Score, Knee injury and Osteoarthritis Outcome Score-Physical Function Short Form, pain during activity score and knee extensor strength were used as comparator instruments. Measurements were obtained at baseline and 12 months after TKA. RESULTS: Appropriate test-retest reliability was found for all three tests. Intraclass correlation coefficient (ICC) for the 30-s CST was 0.90 (95% CI 0.68; 0.96), 40 m FPWT 0.93 (0.85; 0.96) and for the 10-step stair climb test (10-step SCT) 0.94 (0.89; 0.97). Adequate construct validity could not be confirmed for the three tests. For the 30-s CST, 42% of the predefined hypotheses were confirmed; for the 40 m FPWT, 27% and for the 10-step SCT 36% were confirmed. The 40 m FPWT was found to be responsive with 75% of predefined hypothesis confirmed, whereas the responsiveness for the other tests could not be confirmed. For the 30 s CST and 10-step SCT, only 50% of hypotheses were confirmed. CONCLUSIONS: The three performance-based tests had good reliability, but poor construct validity and responsiveness in the assessment of function for the domains sit-to-stand movement, walking short distances and stair negotiation. The findings of the present study do not justify their use for clinical practice. LEVEL OF EVIDENCE: Level 1. Diagnostic study.

PROMs in paediatric knee ligament injury: use the Pedi-IKDC and avoid using adult PROMs.

PURPOSE: The aim of this systematic review was to present an evidence-based overview of psychometric properties of patient-reported outcome measures (PROMs) for children with knee ligament injury. METHODS: A systematic search of literature was performed in PubMed, EMBASE and Cochrane databases. The inclusion criteria were diagnostic studies evaluating psychometric properties (validity, reliability, responsiveness) and comprehensibility of PROMs as well as studies including children (age < 18 years) with knee ligament injury. The systematic review was performed following the PRISMA statement. RESULTS: Ten studies were included. Eight studies evaluated psychometric properties of PROMs, and two studies analysed comprehensibility of PROMs. The Pedi-IKDC has been evaluated in four studies and has acceptable psychometric properties. The KOOS-Child is evaluated in one study and has acceptable psychometric properties. The use of adult PROMs in children causes problems in comprehensibility. CONCLUSION: The Pedi-IKDC is an adequate PROM for children with knee ligament injuries. It is valid, reliable and responsive. The KOOS-Child might be an alternative PROM for the Pedi-IKDC, but has only been evaluated in one study. The clinical relevance of the present systematic review is that adult versions of PROMs are not recommended in children and adolescents. LEVEL OF EVIDENCE: III.

Recoil-Induced Asymmetry of Nondipole Molecular Frame Photoelectron Angular Distributions in the Hard X-ray Regime.

We investigate angular emission distributions of the 1s photoelectrons of N_{2} ionized by linearly polarized synchrotron radiation at hν=40 keV. As expected, nondipole contributions cause a very strong forward-backward asymmetry in the measured emission distributions. In addition, we observe an unexpected asymmetry with respect to the polarization direction, which depends on the direction of the molecular fragmentation. In particular, photoelectrons are predominantly emitted in the direction of the forward nitrogen atom. This observation cannot be explained via asymmetries introduced by the initial bound and final continuum electronic states of the oriented molecule. The present simulations assign this asymmetry to a novel nontrivial effect of the recoil imposed to the nuclei by the fast photoelectrons and high-energy photons, which results in a propensity for the ions to break up along the axis of the recoil momentum. The results are of particular importance for the interpretation of future experiments at x-ray free electron lasers operating in the few tens of keV regime, where such nondipole and recoil effects will be essential.

The Pellegrini-Stieda Lesion of the Knee: An Anatomical and Radiological Review.

The Pellegrini-Stieda lesion is a calcification on the medial side of the knee. The origin of this tissue is controversial. The purpose of our study is to investigate the origin of the Pellegrini-Stieda lesion using conventional radiography as to recreate the circumstances in which Pellegrini and Stieda had to study this pathology. Six nonpaired fresh-frozen cadaveric knees were used. A surgical approach to the medial side of the knee was performed using the layered approach. The origin of the gastrocnemius muscle (GM) (n = 3) or the superficial medial collateral ligament (sMCL) (n = 3) were marked with a radio-opaque fluid. X-ray analysis was performed by measuring the distance from the proximal part of the marking to the medial tibial plateau, multilayer views, and comparison to the original X-rays by Pellegrini-Stieda. Two out of three markings in both the GM and sMCL group were matched with the correct structure. The images were digitally processed so that the osseous structures became partly transparent. After overlaying the images, we found a random distribution of the markings. The Stieda/GM group had no overlap of the markings at all. Compared with the original images from the publications by Pellegrini and Stieda, no comparable position could be found between the original lesions and the markings in our specimens. Conventional X-ray of the knee could not reproduce a distinction between the sMCL and GM as origins for the Pellegrini-Stieda lesion as suggested by Pellegrini and Stieda.

[Assessment of ligament and tendon injuries of the elbow using magnetic resonance imaging]. / Band- und Sehnenverletzungen des Ellenbogens in der Magnetresonanztomographie.

An overview about the normal anatomy and frequent pathologies of tendons and ligaments of the elbow using MRI will be provided. The unique joint configuration and articulation, as well as passive ligamentous and active muscle structures as well as the unique configuration of the articulating components of the elbow contribute to joint stabilization. MRI is an essential imaging modality in patients with ligamentous injuries including the sequelae of joint dislocation as well as chronic pathologies such as long-standing and refractory tendinopathies. Ideally, when reporting MRI of the elbow, the joint is separated into its four compartments, anterior, posterior, medial and lateral, allowing precise, comprehensive and structured reporting.

When is it safe to resume driving after total hip and total knee arthroplasty? a meta-analysis of literature on post-operative brake reaction times.

AIMS: The aim of this study was to assess the current available evidence about when patients might resume driving after elective, primary total hip (THA) or total knee arthroplasty (TKA) undertaken for osteoarthritis (OA). MATERIALS AND METHODS: In February 2016, EMBASE, MEDLINE, Web of Science, Scopus, Cochrane, PubMed Publisher, CINAHL, EBSCO and Google Scholar were searched for clinical studies reporting on 'THA', 'TKA', 'car driving', 'reaction time' and 'brake response time'. Two researchers (CAV and JJT) independently screened the titles and abstracts for eligibility and assessed the risk of bias. Both fixed and random effects were used to pool data and calculate mean differences (MD) and 95% confidence intervals (CI) between pre- and post-operative total brake response time (TBRT). RESULTS: A total of 19 studies were included. The assessment of the risk of bias showed that one study was at high risk, six studies at moderate risk and 12 studies at low risk. Meta-analysis of TBRT showed a MD decrease of 25.54 ms (95% CI -32.02 to 83.09) two weeks after right-sided THA, and of 18.19 ms (95% CI -6.13 to 42.50) four weeks after a right-sided TKA, when compared with the pre-operative value. CONCLUSION: The TBRT returned to baseline two weeks after a right-sided THA and four weeks after a right-sided TKA. These results may serve as guidelines for orthopaedic surgeons when advising patients when to resume driving. However, the advice should be individualised. Cite this article: Bone Joint J 2017;99-B:566-76.