Compensation and Litigation-Related Factors as Predictors of Return to Work after Orthopaedic and Musculoskeletal Treatment: A Systematic Review

Abstract

Return to work (RTW) is an important patient-centred and socioeconomic outcome after orthopaedic injury and treatment. Compensation and litigation processes may influence occupational recovery, but their independent relationship with RTW remains uncertain.

Methods:
PubMed/MEDLINE, Scopus and the Cochrane Central Register of Controlled Trials were searched for observational studies examining compensation, insurance claims or litigation in relation to work-related outcomes after orthopaedic or musculoskeletal treatment. Two reviewers independently screened studies, extracted data and assessed methodological quality using the Newcastle-Ottawa Scale. Because of substantial clinical and methodological heterogeneity, findings were synthesised narratively.

Results:
The search identified 1,544 records, of which 10 observational studies were included; individual sample sizes ranged from 59 to 9,343 participants. Seven studies were rated as good quality and three as fair quality. Populations included hip and severe lower-limb trauma, cervical and thoracolumbar or lumbar spinal conditions, and shoulder disorders. In a direct comparison after hip fracture, compensable status was associated with lower odds of RTW at 12 months (adjusted odds ratio [aOR] 0.33, 95% confidence interval [CI] 0.16-0.70). After severe lower-extremity trauma, absence of legal involvement was associated with a higher rate of total RTW (relative rate ratio 1.61, 95% CI 1.19-2.17). Within compensation-only cohorts, early orthopaedic assessment after shoulder arthroscopy was associated with full-duty RTW of 72% compared with 35% after later assessment; late assessment was associated with RTW failure (odds ratio 4.89, 95% CI 1.60-14.90). Stable RTW after vertebroplasty was 54.3% compared with 70.8% after conservative treatment (aOR 0.46, 95% CI 0.24-0.88). However, several studies lacked non-compensated comparator groups, four publications arose from overlapping Ohio claims data, RTW definitions varied, and only one study used a validated functional measure.

Conclusion:
Available observational evidence suggests that compensation and litigation-related factors may be associated with delayed or unsuccessful RTW. However, causality and an independent prognostic effect cannot be established because of mixed traumatic and degenerative populations, heterogeneous exposure and outcome definitions, overlapping cohorts, inadequate comparator groups and limited measurement of physical function. Prospective studies using clearly defined populations, baseline exposure assessment, standardised RTW outcomes and validated functional measures are required