Patient Satisfaction After Total Knee Replacement: A Systematic Review

Background:

The quality and state of satisfaction reporting after total knee replacement (TKR) is variable.

Questions/Purposes:

The purposes of this systematic review were (1) to examine the available literature on patient satisfaction after TKR, (2) to evaluate the quality of available evidence, and (3) to identify predictors of patient satisfaction after TKR.

Methods:

A systematic review of the MEDLINE database was performed. The initial search yielded 1219 studies. The inclusion criteria were English language, clinical outcome study with primary outcome related to TKR for osteoarthritis, and patient-reported satisfaction included as an outcome measure. Studies were assessed for demographics, methodology for reporting satisfaction, and factors influencing satisfaction.

Results:

Two hundred eight studies, including 95,560 patients who had undergone TKR, met all inclusion and exclusion criteria; 112 (53.8%) of these studies were published in the past 3 years. Satisfaction was most commonly measured using an ordinal scale. Twenty-seven studies (13%) used a validated satisfaction survey. Eighty-three percent of studies reported more than 80% satisfaction. The most commonly reported predictor of satisfaction was post-operative patient-reported functional outcome. Pre-operative anxiety/depression was the most common pre-operative predictor of dissatisfaction.

Conclusion:

There are numerous studies reporting patient satisfaction after TKR, and publication on the topic has been increasing over the past decade. However, the majority of studies represent lower levels of evidence and use heterogeneous methods for measuring satisfaction, and few studies use validated satisfaction instruments. In general, the majority of studies report satisfaction rates ranging from 80 to 100%, with post-operative functional outcome and relief of pain being paramount determinants for achieving satisfaction.

     

History of Breast Cancer Increases 90-Day Pulmonary Embolism Rates and Reimbursements After Total Hip Arthroplasty: A National Matched-Pair Analysis

Background

Rates of total hip arthroplasty (THA) are projected to increase in the coming decades. Multiple studies have focused on identifying risk factors for adverse events after joint arthroplasty, and recent attention has been directed toward cancer. Very limited data have been published examining the effects of history of malignancy on outcomes after THA. With a concomitant increase in breast cancer diagnosis and treatments in recent years, it is expected that orthopedic surgeons will likely see more breast cancer survivors in clinic. The purpose of this study is to examine the effects of a personal history of breast cancer on 90-day outcomes after THA.

Effects of Dietary Acid Load on Exercise Metabolism and Anaerobic Exercise Performance

Dietary acid load, quantified as the potential renal acid load (PRAL) of the diet, affects systemic pH and acid-base regulation. In a previous cross-sectional study, we reported that a low dietary PRAL (i.e. alkaline promoting diet) is associated with higher respiratory exchange ratio (RER) values during maximal exercise. The purpose of the present study was to confirm the previous findings with a short-term dietary intervention study. Additionally, we sought to determine if changes in PRAL affects submaximal exercise RER (as a reflection of substrate utilization) and anaerobic exercise performance. Subjects underwent a graded treadmill exercise test (GXT) to exhaustion and an anaerobic exercise performance test on two occasions, once after following a low-PRAL diet and on a separate occasion, after a high-PRAL diet. The diets were continued as long as needed to achieve an alkaline or acid fasted morning urine pH, respectively, with all being 4-9 days in duration. RER was measured during the GXT with indirect calorimetry. The anaerobic performance test was a running time-to-exhaustion test lasting 1-4 min. Maximal exercise RER was lower in the low-PRAL trial compared to the high-PRAL trial (1.10 ± 0.02 vs. 1.20 ± 0.05, p = 0.037). The low-PRAL diet also resulted in a 21% greater time to exhaustion during anaerobic exercise (2.56 ± 0.36 vs. 2.11 ± 0.31 sec, p = 0.044) and a strong tendency for lower RER values during submaximal exercise at 70% VO₂max (0.88 ± 0.02 vs. 0.96 ± 0.04, p = 0.060). Contrary to our expectations, a short-term low-PRAL (alkaline promoting) diet resulted in lower RER values during maximal-intensity exercise. However, the low-PRAL diet also increased anaerobic exercise time to exhaustion and appears to have shifted submaximal exercise substrate utilization to favor lipid oxidation and spare carbohydrate, both of which would be considered favorable effects in the context of exercise performance.

Key points

• Short-term (4-9 days) changes in the acid or alkaline promoting qualities of the diet, quantified as potential renal acid load (PRAL), alter systemic pH, as evidenced in the present study by changes in fasted morning urine pH. Low-PRAL (alkaline promoting) diets are characterized by high intakes of vegetables and fruits with limited consumption of meats, cheeses, and grains while high-PRAL diets are characterized by the opposite dietary pattern.
• An alkaline promoting (low-PRAL) diet increases anaerobic exercise performance, as evidenced by greater time-to-exhaustion during high-intensity treadmill running.
• Preliminary evidence suggests that an alkaline promoting (low-PRAL) diet increases lipid oxidation and may have a carbohydrate-sparing effect during submaximal endurance exercise, although further studies are needed.
• In contrast to what has been observed in response to habitual/long-term dietary patterns, a short-term low-PRAL diet does not increase maximal exercise respiratory exchange ratio and even appears to lower it. This suggests that short-term and long-term alterations in PRAL have different physiologic effects on this parameter.

Key words: Renal acid load, alkaline diet, substrate oxidation, respiratory exchange ratio