[Social and professional effects of hip prosthetic replacment on people under 50 years of age].
Although total hip prosthetic replacement is a common surgical procedure, it is not without social and professional consequences. In a certain number of cases, return to occupational activities is not possible. In others, it is difficult. Long-term work break repercussions can be major as they often go together with financial difficulties. The medical counsultant and the occupational doctor will have an important role to play at the time of the return to occupational activities or to determine the conditions of workplace adaptation or a vocational training program.Functional recovery after insertion of total hip prosthesis observes precise rules of articular mobilization, weight bearing and muscular strengthening.In the young patient, before 50 years old, objectives will be more accurate and progress not only will concern recovery of daily living, walking and do-it-yourself activities but also return to sports, play and occupational activities. Not only will reactivation be physical, muscular and articular but also behavioral and psychological.Disease and its consequences, surgery in particular, cause a psychological and a physical aggression which modifies the patient's self-concept. • Vulnerability and plastic wrong (limping, modifications of gesture and sports performanee as well as modifications of the living conditions). The patient unconsciously translates this physical affection into: * loneliness (taking away or exclusion from the usual surroundings of those who are in good health) * "blues" * lack of dynamism * uselessness, feeling of being incompetent "in those conditions, what's the use of fighting?" ٜ At the same time - loss of social status: "Colleagues get up to go to work, children go to school, all the others are productive, I'm good at nothing." - impression of uselessness, dependence; reinforcement of turning in on the self. •The undertaking by a surgeon and his team (anaesthetist, nurse, physiotherapist) which implies constraints, orders, assessments, exercices turns the patient into an "under ling" and makes him lose his independence. Patient's self-concept is modified by the disease and its treatment. Modification of his role in the family and in the society leads him to behave as a man of leisure as an assisted person (3rd age concept).Return to work: If it is desirable, it is not always possible, 3 cases may occur: 1 - occupational activity is incompatible 2 - occupational activity is compatible if the workplace is adapted 3 - occupational activity is compatible. Occupational activity is incompatible. It only involves patients with demanding occupational activities with prolonged upright stance and load carrying or working at a height. Craftsmen and farmers adjust their activity and return to their former work.Associated lesions are often responsable for the absence of return to work. * If the patient had an occupational accident: at the time of finalisation, he will be proposed a permanent partial disablement pension. His rate is determined by the medical consultant. * If the patient is under a sick leave scheme, he can benefit from daily compensation for a maximum of three years. Nonetheless, if his state is stabilized before the end of this period, the medical consultant can set a date of return to occupational activities. If the patient has an employer, he can have a pre-return to work examination by the occupational doctor who will determine a temporary incapacity which may turn into definitive incapacity. The attending physician can then apply for a disablement pension and the medical consultant will be required to determine the level of incapacity exhibited by the patient. For a patient to benefit from a disablement pension, his capacity to work will have to be reduced by two thirds by the disabling affection. Several elements have to be taken into account: - the pathological state itself - the particular elements of the individual considered, these elements can increase or decrease the after-effect of the psychological factors. It involves the general state of health, the age, the physical and mental abilities, and those of vocational training and of the job carried out. - social elements have to be taken into account, what are the actual possibilities for the salaried employee to find a job according to the labour market context of the region he lives in. Occupational activities possible subject to: - workplace adjustment - vocational training. If the patient has no employer, he will be examined by the doctor responsable for the re-employment who will assess with him the characteristics of the workplace wanted.If the patient has an employer, a workplace which physical constraints will be compatible with the handicap of the patient will be searched for in collaboration with the occupational doctor.If no workplace adaptation is possible, vocational training will be considered. It observes relatively strict rules and will only be proposed to the youngest patients. This vocational training session will prolong the work break to a year. This will only be possible with the agreement of the COTOREP (vocational guidance and professional rehabilitation technical commission) and from the patient it needs strong motivation, a certain academic level and a match between the patients' desire, their human qualities and their intellectual abilities is essential. It is a real strategy which is implemented to lead a patient to register at a vocational training centre (there are 100 of them in France).Vocational orientation and problem assessment must be undertaken early enough so that they can repress the psychological inhibitions and take advantage of the functional rehabilitation time to determine the academic level and improve it if necessary. - Motivation: The patient must be personally motivated to undertake a vocational training program which will last for a long time and will keep him far away from his family and his emotional environment. The vocational training program thus cannot be undertaken following the set, the employer or right-thinking people entreaties. Sometimes secondary advantages can favour or oppose a vocational training assessment and this must be taken into account. - Academic level: The level of vocational training will be proportional to the academic level at that time. It will thus be assessed and remedial teaching will be planned early to reinforce academic knowledge which has been acquired but not used so may have been forgotten. A certain number of means will be implemented: - Potentialities: Even if a patient has a low academic level, he may have intellectual faculties of conceptualization of practical turn of mind, of memory which will allow him to rapidly acquire a good level of knowledge. The patients will be offerred information on the subject of carreers, pathways and academic level required. It is advisable that they should be accompanied in this step by competent librarians. Compatible occupational activity: Functional rehabilitation will be completed by retraining aiming at recovering stamina and at intensifying physical activities level essentially by play or sports activities. In some cases, retraining in a specialized centre can be considered.


CONCLUSIONS
Social and professional difficulties which go together with resettlement of patients with total hip prostheses justify the therapeutic team involvment completed by the presence of the medical consultant, the occupational doctor and social organisations particularly the COTOREP. The medical consultant will be required for the pre-return examination, will determine whether a return to work is possible, the temporary incapacity, the definitive incapacity and will start the presentation before the COTOREP to obtain the recognition of disabled worker and undertake a vocational training program. He is in charge of the worker's follow-up after his return to occupational activities.The medical consultant will decide on the return to occupational activities as soon as the medical state is stabilized and before the 3rd year, the deadline of the work break duration. He may in case of definitive incapacity apply for a fast-track disablement file. He will determine the disability rate for workers under sick leave scheme and will determine the definitive partial disability rate for patients with occupational accidents.
Institut Régional de Réadaptation, 35, rue Lionnois, F-54000, Nancy, France.
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Hip arthroplasty; Professional; Psychology; Social