Early postoperative predictors of satisfaction following total knee arthroplasty

BackgroundDespite the excellent total knee arthroplasty (TKA) results reported using traditional outcome measures, dissatisfaction rates of up to 30% are reported following surgery. Although several preoperative factors have been identified as possible predictors of satisfaction, there is conflicting evidence. Identification of dissatisfaction in the early postoperative assessment may therefore be an alternative consideration.MethodsWe examined the relationship between 12-month satisfaction, and early post-operative outcomes in a cohort of 486 TKA patients. Preoperative, and postoperative outcome measures at 3- and 12-months (Oxford knee score, pain score, SF12, and knee motion), were analysed and compared between patients who were satisfied and dissatisfied at 12-months following TKA. Mean scores, and postoperative change in scores were calculated. Postoperative outcomes were examined for correlation with satisfaction, and multivariate logistic regression models used to identify potential predictors of dissatisfaction.ResultsOverall satisfaction was 77.0%. No preoperative differences were observed between groups. Dissatisfaction was associated with worse postoperative status across all outcome measures (p < 0.001), except the 3-month SF12-physical component (p = 0.052). Dissatisfied patients demonstrated minimal further improvement or even worsening of outcome scores between 3- and 12-months postoperatively (p < 0.02). Both the 3-month OKS (OR = 1.15, p < 0.001), and knee flexion (OR = 1.03, p = 0.009) were significant predictors of subsequent 12-month satisfaction.ConclusionsDissatisfaction following TKA is associated with worse outcomes as early as 3 months following surgery, with minimal further improvement subsequently achieved at 12-months. Early postoperative assessment following TKA should therefore be considered, including clinical assessment, to identify those patients at risk of dissatisfaction.     

Diabetes does not influence the early outcome of total knee replacement: A prospective study assessing the Oxford knee score,short form 12, and patient satisfaction

BackgroundThere is conflicting evidence as to whether diabetes mellitus influences the functional outcome and patient satisfaction after a total knee replacement (TKR). The aim of this study was to assess the effect of diabetes upon the Oxford knee score (OKS), short form (SF)-12, and patient satisfaction after TKR.MethodsProspective pre- and post-operative (one year) OKS and SF-12 scores for 2389 patients undergoing primary TKR were compiled, of which 275 (12%) patients suffered with diabetes. Patient satisfaction was assessed at one year.ResultsPatients with diabetes were more likely to have a greater level of comorbidity (p < 0.001), and a worse pre-operative OKS and SF-12 score (p < 0.02), compared to those patients without diabetes. Diabetes was not a significant (p > 0.41) independent predictor of post-operative OKS or the SF-12 physical score on multivariable analysis. Although, factors more prevalent within the diabetic cohort (heart disease, vascular disease, liver disease, anaemia, depression, back pain, worse pre-operative OKS and SF-12 score) were found to be independent predictors of post-operative OKS and SF-12 physical score. Interestingly, diabetes was associated with a significantly greater improvement in mental wellbeing (SF-12 mental component), which was confirmed on multivariable analysis. Patient satisfaction was not influenced by a concomitant diagnosis of diabetes (p = 0.57).ConclusionThe outcome of TKR as assessed by the OKS, SF-12, and overall patient satisfaction rates are not influenced by diabetes per se, although factors more prevalent within this population result in a worse post-operative outcome.Level of evidence: prospective cohort study, level III.     

Does preoperative anxiety and depression predict satisfaction after total knee replacement?

Background and purposeApproximately one fifth of patients are not satisfied with the outcome of total knee arthroplasty (TKA). Preoperative variables associated with poorer outcomes are severity and chronicity of pain, psychological disease, poor coping strategies and pain catastrophisation. Psychological disease may be expressed as anxiety and depression. It is unclear whether anxiety and depression before TKA are constitutional or result from knee pain. The aim of this study was to explore the association of anxiety and depression with knee pain and function using specific outcome measures.MethodsForty consecutive patients undergoing TKA completed Hospital Anxiety and Depression Scale (HAD) and Oxford Knee Scores (OKS) preoperatively and at 3 and 6 months postoperatively.ResultsThe HAD and OKS significantly improved post-operatively (p < 0.001). There was a greater change between the preoperative and postoperative scores in the OKS than the HAD. The severity of preoperative anxiety and depression was associated with higher levels of knee disability (coefficient ? 0.409, p = 0.009). Postoperatively reduction in anxiety and depression was associated with improvement in knee disability after 3 (coefficient ? 0.459, p = 0.003) and 6 months (coefficient ? 0.428, p = 0.006).InterpretationThe difficulty in interpreting preoperative anxiety and depression and the outcome of TKA is establishing whether they are the cause or effect of pain in the knee. As anxiety and depression improve with knee pain and function, this study suggests that knee pain contributes to the psychological symptoms and that a successful TKA offers an excellent chance of improving both.     

The incidence and impact of arthroscopy in the year prior to total knee arthroplasty

Background

Prior knee surgery and arthroscopy is known to increase complications and re-operations in subsequent total knee arthroplasty (TKA). We set out to examine the time dependant effect of arthroscopy on Patient Reported Outcome Measures following subsequent TKA.

Inflammatory predictors of ongoing pain 2 years following knee replacement surgery

IntroductionThe prevalence of unrelieved pain following total knee arthroplasty (TKA) is substantial.ObjectiveWe asked if cytokine markers of inflammation in preoperative serum or knee synovial fluid (SF) would predict pain 2 years following TKA.MethodsDemographic data and functional outcomes were recorded at baseline and 2 years with the WOMAC index. Serum and SF tissue samples were collected at the time of surgery. Linear regression modeling was used to determine the relationship between SF/serum inflammatory markers and a lesser improvement in self reported pain at two years follow-up.ResultsOf our 28 patient cohort, significant correlations between serum and SF levels were found for IL-1β (p < 0.002), MIP-1β (p < 0.001), adiponectin (p < 0.001) and leptin (p < 0.001). Adjusted analysis showed that greater SF concentrations of TNF-α, MMP-13 and IL-6 were independent predictors of less pain improvement at two years follow-up (p < 0.05).ConclusionsThose patients, having ongoing pain despite no clinical or radiological cause, may have an inflammatory profile characterizing a predisposition to ongoing pain after TKA.Level of EvidencePrognosis study, Level 2.     

Comparison of peripheral nerve block with periarticular injection analgesia after total knee arthroplasty: A randomized,controlled study

BackgroundPain after total knee arthroplasty (TKA) is usually severe. Recently, the usefulness of local periarticular injection analgesia (PAI) and peripheral nerve block (PNB) has been reported. We report a prospective blinded randomized trial of PAI versus PNB in patients undergoing primary TKA, in accordance with the CONSORT statement 2010.MethodsA total of 210 patients undergoing TKA under spinal anesthesia were randomized to receive PNB group or PAI group. In the PNB group, femoral nerve block and sciatic nerve block were performed. In the PAI group, a special mixture containing ropivacaine, saline, epinephrine, morphine hydrochloride, and dexamethasone was injected into the periarticular soft tissue. Pain intensity at rest was assessed using a numerical rating scale (NRS: 0–10) after surgery. Use of a diclofenac sodium suppository (25 mg) was allowed for all patients at any time after surgery, and the diclofenac sodium suppository usage was assessed. The NRS for patient satisfaction at 48 hours after surgery was examined.ResultsThe average NRS for pain at rest up to 48 hours after surgery was low in both groups. Within 48 hours after surgery, the diclofenac sodium suppository usage was similar in both groups. There were no significant differences in the NRS for patient satisfaction in both groups.ConclusionsThe analgesic effects of PAI and PNB are similar. PAI may be considered superior to PNB because it is easier to perform.Level of EvidenceTherapeutic Level 1.     

Patient satisfaction after primary total and unicompartmental knee arthroplasty: An age-dependent analysis

BackgroundPatient-related outcomes have become the focus of increased attention when assessing knee arthroplasty.MethodsWe retrieved questionnaires from 485 (584 knees) patients at a minimum of 3 years after undergoing primary knee arthroplasty. We excluded bilateral knee arthroplasty, leaving 141 UKA and 245 TKA who rated their satisfaction and expectation regarding pain, range of motion (ROM), daily living function (DLF), return to recreational activity (RRA) and ability to kneel (ATK) on a scale of 0 (worst) to 10 (best). We further collected data on pain level and the modified Cincinnati rating scale. Range of motion was documented pre- and postoperatively at a minimum of six months. The cohort was subdivided into three age groups and compared with each other (Group 1: < 55, n = 113; Group 2: 55–64, n = 117; Group 3: 65 +, n = 155).ResultsAverage satisfaction with pain, ROM and ATK for patients under 55 was higher for UKA than for TKA. Patients > 65 with TKA were on average more satisfied than patients with UKA in these three items. However, patients under 55 with UKA were up to 2.9 times more likely to have their expectations met when compared to patients receiving TKA. Patients with UKA under 55 rated their joint as good/excellent in 96.0% versus patients in the same age group with TKA in 81.0%.ConclusionsWe found that overall, younger patients who were treated with UKA demonstrated higher satisfaction scores in most subsets when compared with the patients of the same age group who received TKA.     

Influence of low back pain on total knee arthroplasty outcome

BackgroundPreoperative pain and functional status are strong determinants of postsurgical success in total knee arthroplasty. Patients suffering chronic pain from other coexistent musculoskeletal problems may respond differently postoperatively, with potentially poorer outcomes after surgery. The aim of the study was to determine the influence of low back pain on the outcome of total knee replacement surgery.MethodsAll patients completed Oxford Knee Scores (OKS), American Knee Society Scores (AKSS) and SF-12 (both physical and mental components). Patients were divided into those with (n = 40) and without a documented history of low back pain (n = 305).ResultsOKS, AKSS and SF-12 physical scores were significantly worse for patients with low back pain at 24 months following surgery. The mental component of the SF-12 measure demonstrated a significant improvement in median mental health post-operatively for patients with no current history of low back pain. In contrast the group with low back pain showed no improvement in mental health scores post-operatively.ConclusionThis study demonstrates that symptomatic low back pain influences functional outcome after total knee arthroplasty surgery and that patients with low back pain show limited or no improvement in mental health post-operatively.Level of evidence II.     

Baseline varus deformity is associated with increased joint loading and pain of non-operated knee two years after unilateral total knee arthroplasty

Background

The goals of this study were (1) to document the gait pattern of patients with unilateral knee osteoarthritis (OA), (2) to determine the knee adduction moment (KAM) changes in the non-operated knee, and (3) to identify the predictors of change in KAM in the non-operated knee.

Aseptic versus septic revision total knee arthroplasty: Patient satisfaction,outcome and quality of life improvement

We prospectively compared the clinical outcomes and patient satisfaction rates of aseptic (n = 30) versus septic revision TKA (n = 15) at a mean follow-up of 40 months. We hypothesized that the clinical results of septic revision TKA would be inferior to aseptic revision TKA. The indication for revision in aseptic group was stiffness in 11 patients, aseptic loosening in 13, patellar loosening or maltracking in 6 patients. Patients operated for infection had better post-operative Knee Society Scores (KSS), Function Scores and SF-36 Mental Scores than aseptic group but there were no significant differences in the satisfaction rates. Patients operated for infection had more improvement in their KSS (p = 0.004) and Function Scores (p = 0.02) than patients revised for stiffness. Moreover, patients operated on for patellar problems had higher satisfaction rates than patients revised for stiffness (p = 0.01) or aseptic loosening (p = 0.01). Thus, patients undergoing septic revision TKA had better outcomes compared to those with aseptic revision TKA. However, in the aseptic group, revision TKA for stiffness was associated with the poorest outcomes. The indication for aseptic revision is an important variable when discussing treatment and outcome with patients.     

Predicting patient reported outcome in total knee arthroplasty using body mass index and limb measurements

Background

Body mass index (BMI) has not been shown to correlate with Patient Reported Outcome Measures (PROMs) following total knee arthroplasty (TKA). We investigated the relationship between weight, BMI, limb morphology, and Oxford Knee Score (OKS). Furthermore, the utility of a novel radiological measurement, the Knee Mass Index (KMI), was investigated.

Time between the first and second operations for staged total knee arthroplasties when the interval is determined by the patient

BackgroundThe purpose of this study was to evaluate the interval between the first and second operations for staged total knee arthroplasties (TKAs) in patients with bilateral knee osteoarthritis. Depending on satisfactory preoperative health status, the patients determined the timing of the second operation. We also analysed correlations between the interval and patient characteristics.MethodsEighty-six patients with bilateral knee osteoarthritis were analysed. The mean follow-up time from the first TKA was 96 months. The side of the first TKA was chosen by the patients. The timing of the second TKA was determined by the patients, depending on their perceived ability to tolerate the additional pain and limitations to activities of daily living.ResultsThe median interval between the first and second operations was 12.5 months, with a range of 2 to 113 months. In 43 (50%) patients, the interval was < 12 months. There was no difference in the interval between females and males (p = 0.861), and no correlation between the interval and body mass index or age. There was weak correlation between the year of the first TKA and the interval (R = − 0.251, p = 0.020), with the interval getting significantly shorter as the years progressed (p = 0.032).ConclusionsThe median interval between the first and second operations in patients who underwent staged TKAs for bilateral knee osteoarthritis was about 1 year. The results of the current study may help patients and physicians to plan effective treatment strategies for staged TKAs.Levels of evidenceLevel II.     

The oxford knee score minimal clinically important difference for revision total knee arthroplasty

BackgroundMinimal clinically important difference (MCID) is crucial for interpreting meaningful improvements in patient-reported outcome measures (PROMs). No previous study has evaluated the MCID for the Oxford Knee Score (OKS) in revision total knee arthroplasty (TKA). This study aimed to propose the OKS MCID for revision TKA.MethodsProspectively collected data from 191 patients who underwent revision TKA at a single institution was analysed. Clinical assessment was performed preoperatively and at 2 years using OKS and Short-Form 36 Physical Component Score (SF-36 PCS). MCID was evaluated with a three-pronged methodology, using (1) anchor-based method with linear regression, (2) anchor-based method with receiver operating characteristic (ROC) and area under curve (AUC), (3) distribution-based method with standard deviation (SD). The anchors used were improvement in SF-36 PCS ≥ 12, patient satisfaction, and implant survivorship following revision TKA.ResultsThe MCID determined by anchor-based linear regression method using improvements in SF-36 PCS was 4.9 points. The MCID determined by anchor-based ROC was 10.5 points for satisfaction (AUC = 74.8%) and 13.5 points for implant survivorship (AUC = 73.7%). The MCID determined by distribution-based method of 0.5 SD was 4.7.ConclusionThe proposed MCID for OKS following revision TKA is 4.9 points. Patients who achieve an improvement in OKS of at least 10.5–13.5 points by 2 years are likely to be satisfied with their surgery and not require a subsequent re-revision TKA. Patients undergoing revision TKA should aim for an improvement in OKS of at least 10.5–13.5 points as a target score.     

Annual trends in knee arthroplasty and tibial osteotomy: Analysis of a national database in Japan

Background

Various nationwide studies have reported differing annual trends in utilization of knee arthroplasty and tibial osteotomy. Using the Diagnosis Procedure Combination database in Japan, the present series examined annual trends and demographics in total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA) and tibial osteotomy.

Does intraoperative transfusion during total knee arthroplasty reduce the need for transfusion after surgery?: A preliminary retrospective cohort study

ObjectivesAfter total knee arthroplasty (TKA), many patients experience anemia due to blood loss. To prevent postoperative anemia and allogeneic blood transfusion after TKA, we used prophylactic allogeneic or autologous blood transfusion intraoperatively. This study evaluated the effects of prophylactic transfusion during TKA.Materials and methodsThis retrospective cohort study included 579 patients receiving scheduled unilateral TKA. We allocated the patients into three groups, the prophylactic allogeneic transfusion (Group AL), prophylactic autologous transfusion (Group AT), and no prophylactic transfusion with intra-articular tranexamic acid administration (Group C) groups. After propensity score matching, we compared the rate of postoperative allogeneic blood transfusions until three days after TKA, postoperative hemoglobin and hematocrit levels until four days after TKA, and the side effects in each groups.ResultsThe postoperative allogeneic blood transfusion rates were statistically higher in group AL and AT than in group C (18.2% and, 18.9% vs 2.3%, respectively; P < 0.000). The postoperative hemoglobin and hematocrit levels were statistically lower in group Auto than in group C (P < 0.0001), but the levels in group AL were not different from those of group C (P = 0.493 vs. P = 0.384 respectively). In addition, the side effects were statistically higher in group AL and AT than in group C.ConclusionProphylactic intra-operative transfusions did not reduce the rates of allogeneic transfusions and produced more side effects and hypotension after surgery than intra-articular tranexamic acid administration with no prophylactic transfusion in patients undergoing TKAs.     

Radiographic severity,extent and pattern of cartilage loss are not associated with patient reported outcomes before or after total knee arthroplasty in end-stage knee osteoarthritis

BackgroundThe aim of this study was to determine if radiographic severity, extent or pattern of knee osteoarthritis was associated with pain and function before total knee arthroplasty (TKA) or improvement therein one year after TKA.MethodsA prospective study of 259 patients undergoing unilateral TKA for Kellgren-Lawrence (KL) grade ≥ 3 knee osteoarthritis was conducted: mean age 69.8 ± 9.7 (44–91); mean BMI 31.0 ± 5.8 (17–52); 152/259 (58.7%) female. Preoperative radiographs were assessed using the KL and Ahlback systems. Preoperatively and 1 year postoperatively patients completed Oxford Knee Scores, VAS-Pain and EQ-5D scores. Full thickness cartilage loss was recorded intraoperatively.ResultsMedian radiographic severity was Ahlback 2, KL 4: 51/259 (19.7%) hypertrophic; 23/259 (8.8%) atrophic. Neither Ahlback nor Kellgren-Lawrence OA grade was associated with OKS, VAS Pain or EQ-5D prior to TKA (p > 0.05). The extent and pattern of cartilage loss did not affect preoperative PROMs. Radiographic OA severity, compartment involvement, and pattern of cartilage loss were not significantly associated with PROMs or improvements therein following TKA (p > 0.05). Hypertrophic OA was associated with less pain before TKA (difference 6.8, 0.23–13.9 95%CI, p = 0.044), and worse improvement in OKS following TKA (difference −3.41, −6.8 to −0.05 95%CI, p = 0.047). Better preoperative OKS and hypertrophic OA were independently associated with poorer improvement in OKS 1 year following TKA (R² = 0.208).ConclusionProvided at least one compartment has KL grade ≥ 3 changes, further radiographic severity, pattern or extent of cartilage loss did not affect PROMs before or after TKA: multicompartmental was no worse than unicompartmental disease.     

Radiographic assessment of knee–ankle alignment after total knee arthroplasty for varus and valgus knee osteoarthritis

Background

There are unanswered questions about knee–ankle alignment after total knee arthroplasty (TKA) for varus and valgus osteoarthritis (OA) of the knee. The aim of this retrospective study was to assess knee–ankle alignment after TKA.

Visual knee-kinetic biofeedback technique normalizes gait abnormalities during high-demand mobility after total knee arthroplasty

Background

Abnormal knee mechanics frequently follow total knee arthroplasty (TKA) surgery with these deficits amplifying as task demands increase. Knee-kinetic biofeedback could provide a means of attenuating gait abnormalities. The purposes of this study were as follows: (1) to describe the gait characteristic differences between patients with TKA and non-TKA adults during level (low-demand) and decline (high-demand) walking; and (2) where differences existed, to determine the impact of knee-kinetic biofeedback on normalizing these abnormalities.

A comparison of alignment using patient specific guides,computer navigation and conventional instrumentation in total knee arthroplasty

BackgroundPatient specific guides (PSG) have been introduced as a tool in total knee arthroplasty (TKA) in an attempt to improve limb alignment and reduce operative time compared to other established surgical techniques. The purpose of this study was to compare the post-operative radiographic alignment and operative time in patients who underwent TKA surgery with PSG, conventional instrumentation or computer-assisted navigation surgery using fully cemented components.MethodsA cohort of 260 patients who underwent TKA surgery using PSG (PSG group, n = 115) was compared to patients who underwent TKA using either conventional instrumentation (CON group, n = 92) or computer-assisted navigation (CAS group, n = 53). Post-operative CT imaging using the Perth CT protocol was used to compare alignment between the three groups.ResultsIn the PSG and CAS groups, the post-operative hip–knee angle (HKA) was within 3° of neutral alignment in 91.3% and 90.7% of patients, respectively. This compared to 80.4% of patients in the CON group (p = 0.02). There were no significant differences with respect to alignment when comparing individual component positioning between the PSG and CAS groups apart from tibial slope (Table 3). Total operative time was found to be significantly reduced in the PSG group (80.2 min) compared to both the CON group (86 min, p = 0.002) and the CAS group (110.2 min, p < 0.0001).ConclusionsThe use of PSG resulted in similar alignment accuracy to CAS and superior alignment to CON with significantly shorter operative times.     

Osteochondral autografting (mosaicplasty) in articular cartilage defects in the knee: Results at 5 to 9 years

We evaluated short- and medium-term results of the treatment of articular cartilage defects of the knee with autogenous cylindrical osteochondral grafts (mosaicplasty) in 69 patients (median age 33 years) with symptomatic articular cartilage defects. Data of Lysholm score and visual analogue scale (VAS) of pain (0 = no pain; 100 = worst possible pain) were collected before the surgery, at 12 months postoperatively and 5 to 9 (median 7) years after the surgery. At the last follow-up the patients were also asked to state their degree of satisfaction with the outcome on a VAS (0 = not at all satisfied; 100 = completely satisfied), and to answer if they would have undergone the surgery again if necessary (yes or no). The mean Lysholm score and VAS of pain improved from 48 and 62, respectively, at the time of surgery to 81 and 24, respectively, at the 12-months follow-up (p < 0.001 for both comparisons). From 12 months postoperatively, the Lysholm score and VAS of pain deteriorated to 68 and 32, respectively at the 5- to 9-year follow-up (p < 0.001 and p = 0.018, respectively). The mean degree of satisfaction with the outcome was 70 (SD 28), and 61 patients (88%) stated that they would have undergone the surgery again. In conclusion, the mosaicplasty leads to improvement of symptoms and function at short- and medium-term follow-up. A deterioration of the results is observed from 12 months postoperatively to 5–9 years postoperatively.