Patient Satisfaction After Total Knee Replacement: A Systematic Review

Implication of Changes in the Imaging Measurements after Mechanically Aligned Total Knee Arthroplasty

OBJECTIVE

Imaging measurements allow assessment of the mechanical alignment before and after total knee arthroplasty (TKA). The changes in radiographic parameters in each period of time within 1 year after TKA has been poorly understood. The purpose of this study was to examine the timing and causes of imaging changes in lower extremity force lines after total knee arthroplasty with mechanical alignment.

METHODS

A total of 93 mechanically-aligned TKA were radiographically examined before, 3 days, 3 months, and 1 year after surgery. Radiographic parameters included hip-knee angle (HKA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), knee joint line orientation (KJLO), ankle joint line orientation (AJLO), the knee joint line relative to ankle joint line angle (KJLTA) and midpoints of the ankle distance (MAD). Paired t-test were used to analyze the changes of these imaging parameters, By establishing a simple tibial model, the time points of changes in the imaging parameters after TKA was determined, with an attempt to understand the post-TKA changes in these imaging parameters.

RESULTS

Statistically significant differences were found between the preoperative data and the data measured 3 days after surgery in HKA, LDFA, MPTA, MAD, KJLTA, AJLO (P < 0.05) while KJLO exhibited no significant difference (P = 0.089). There existed significant differences between the data measured 3 days and the measurements taken 3 months after operation in HKA, MPTA, KJLTA, KJLO, AJLO (P < 0.05), whereas LDFA and MAD showed no significant difference (P > 0.05). Significant differences were revealed between the data measured 3 months and those collected 1 year after surgery in LDFA, MPTA, AJLO, KJLTA (P < 0.05) but HKA, KJLO, AJLO showed no significant differences (P > 0.05). The tibial model was made to look into the changes in postoperative imaging parameters. ΔMAD and postoperative AJLO were calculated to verify the model and hypothesis.

CONCLUSIONS

Postoperative changes in radiographic parameters and tibial models showed that the lower extremities were in an unnatural state within 1 year after TKA. The changes in the lower extremities force line were the results of the gradual adaptation of the lower extremities to TKA and the lateral swing of the extremities (3°) after surgery. Imaging data 1 year after surgery should be taken into account in the explanation of post-TKA changes in lower limb force lines.

Is it prime time for robotic-assisted TKAs? A systematic review of current studies

Introduction

Less-than-optimum positioning of femoral and tibial components and improper soft tissue tension, with abnormal loads and reduced range of motion, may cause lower patient satisfaction rates. To reduce surgeon-related variables during TKA, technology-assisted TKA was introduced, including computer navigation and robotic-assisted surgery (RATKA). Although several studies show promising short- and long-term functional and radiological outcomes of RATKA, there are still concerns related to its absolute superiority over conventional TKA.

Methods

This review aims to provide an updated insight into the most recent articles reporting on outcomes (functional, radiological, and complications) of RATKA through a systematic search of major databases. A comprehensive English literature search was performed by both authors through four databases (Embase, PubMed, Web of Science, and Scopus). The full text of the final eligible studies was evaluated for inclusion, resulting in 13 studies that are included in this review.

Results

There were 2112 knees in the 13 studies, with a follow-up ranging from three months to 13 years; only three were randomized controlled trials (RCTs), and nine directly compared the results of RATKA with CTKA technique. Seven studies reported the operative time ranging from 76.8 to 156 min; six reported a longer operative time with RATKA. Length of hospital stay (LOS) was reported in six studies which ranged from 0.48 to 2.1 days; in four studies the LOS was shorter with RATKA. In seven of the nine studies comparing RATKA with CTKA, no difference in functional outcomes was found. Four out of six studies reported that the overall alignment had mechanical alignment within ±3° of neutral alignment in all RATKA patients with an HKA ranging from -0.3 to 1.8°. Only one study reported better radiological outcomes in the RATKA group. In six comparative studies, no difference was found in the incidence of complications between RATKA and CTKA.

Conclusion

Although robotic-assisted total knee arthroplasty is a promising technology that provides better component alignment and superior early functional outcomes, the justification for its widespread adoption needs more robust evidence through well-designed and better long-term studies demonstrating superior, predictable, and durable clinical results compared to conventional total knee arthroplasty techniques.

The indication for aseptic revision TKA does not influence 1-year outcomes: an analysis of 178 full TKA revisions from a prospective institutional registry

BACKGROUND AND PURPOSE

Outcomes following revision total knee arthroplasty (TKA) may depend on the indication for revision surgery. We compared pain, patient-reported outcome measures (PROMs), and patient satisfaction among different indications for an aseptic TKA revision.

PATIENTS AND METHODS

This was a retrospective study of prospective data from an institutional registry of 178 primary TKAs revised between 2012 and 2020. Patients were grouped by the main reason for their revision: loosening, malposition, instability, or stiffness. Pain during mobilization and at rest (NRS 0-10), physical function (KOOS-PS and KSS), and quality of life (EQ-5D) were surveyed preoperatively and at 2 months and 1 year postoperatively. Patient satisfaction was evaluated through questions related to knee function and their willingness to undergo the same surgery again at 1-year follow-up.

RESULTS

Pain and PROMs improved in all groups and did not differ statistically significantly between the 4 groups at 1-year follow-up, but equivalence for pain was not confirmed between groups. Overall, pain during mobilization improved by 2.4 (95% CI 1.9-3.0) at 1-year follow-up, which was both clinically and statistically significant. Improvements were seen within 2 months of surgery, with no further improvements seen 1 year postoperatively. Approximately 2/3 of patients reported that their knee function had improved and would undergo the same surgery again, at 1-year follow-up.

CONCLUSION

Statistically significant and clinically relevant improvements in pain and PROMs were seen in all 4 revision groups 1 year after revision TKA. These results may assist clinicians and patients during preoperative counselling.

Odds-ratio network for postoperative factors revealing differences in the 2-year longitudinal pattern of satisfaction between women and men after total knee arthroplasty

Timely and accurate assessments of the factors influencing satisfaction, a key indicator of success in primary total knee arthroplasty (TKA), may help improve TKA outcomes. Here we performed the longitudinal trend analysis of relation between satisfaction and 12 postoperative factors, which positively or negatively influence the patient satisfaction 2 years after TKA. In a real-world registry cohort (women/men: 1121/650), we showed similarities and differences between women and men in the contribution of postoperative factors to satisfaction 2 years after TKA as assessed by odds-ratio-similarity network. In men, the strongest negative factors were pain and complications, followed by mechanical problems. In women, the strongest negative factors were the pain and knee instability, followed by other mechanical problems, complications and low levels of sports activity. In both sexes, physical activity and the Knee Society Score (general and functional) influenced positively satisfaction; long-distance walking was associated with satisfaction only in women. A trend analysis revealed a reduction in the strength of satisfaction-related factors over 2 years of check-ups, particularly in women. Our study demonstrates that the key check-up for assessing the evolution of satisfaction in the 2 years after TKA was at 3 months in both sexes.

Association between VTE and antibiotic prophylaxis guideline compliance and patient-reported outcomes after total hip and knee arthroplasty: an observational study

BACKGROUND

Surgical site infection (SSI) and venous thromboembolism (VTE) are associated with high burden and cost and are considered largely preventable following total knee or hip arthroplasty (TKA, THA). The risk of developing VTE and SSI is reduced when prophylaxis is compliant with evidence-based clinical guidelines. However, the association between VTE and antibiotic prophylaxis clinical guideline compliance and patient-reported outcome measures (PROMs) after THA/TKA is unknown. This study aims to explore whether care that is non-compliant with VTE and antibiotic guideline recommendations is associated with PROMs (Oxford Hip/Knee Score and EQ-5D Index scores) at 90- and 365-days after surgery.

METHODS

This prospective observational study included high-volume arthroplasty public and private sites and consenting eligible participants undergoing elective primary THA/TKA. We conducted multiple linear regression and linear mixed-effects modelling to explore the associations between non-compliance with VTE and antibiotic guidelines, and PROMs.

RESULTS

The sample included 1838 participants. Compliance with VTE and antibiotic guidelines was 35% and 13.2% respectively. In adjusted modelling, non-compliance with VTE guidelines was not associated with 90-day Oxford score (β = - 0.54, standard error [SE] = 0.34, p = 0.112) but was significantly associated with lower (worse) 365-day Oxford score (β = - 0.76, SE = 0.29, p = 0.009), lower EQ-5D Index scores at 90- (β = - 0.02 SE = 0.008, p = 0.011) and 365-days (β = - 0.03, SE = 0.008, p = 0.002).. The changes in Oxford and EQ-5D Index scores were not clinically important. Noncompliance with antibiotic guidelines was not associated with either PROM at 90- (Oxford: β = - 0.45, standard error [SE] = 0.47, p = 0.341; EQ-5D: β = - 0.001, SE = 0.011, p = 0.891) or 365-days (Oxford score: β = - 0.06, SE = 0.41, p = 0.880 EQ-5D: β = - 0.010, SE = 0.012, p = 0.383). Results were consistent when complications were included in the model and in linear mixed-effects modelling with the insurance sector as a random effect.

CONCLUSIONS

Non-compliance with VTE prophylaxis guidelines, but not antibiotic guidelines, is associated with statistically significant but not clinically meaningful differences in Oxford scores and EQ-5D Index scores at 365 days.

What matters to patients following total knee arthroplasty? A grounded theory of adapting to a knee replacement

Background

Globally the volume of total knee arthroplasty (TKA) is on the rise, reflecting aging populations, an associated increase in treatment of osteoarthritis, and a desire for improved quality of life. There is evidence that as high as 15 to 20% of patients are not satisfied with their TKA results and efforts need to be made to improve these rates. This study set out to identify what patients consider important when reflecting on TKA satisfaction, to pave the way to identifying service transformation opportunities that will enhance patient-centred care and satisfaction with this procedure.

Methods

Twenty-seven TKA recipients were recruited in the province of British Columbia, Canada. Semi-structured interviews were conducted about participants’ experience and satisfaction with TKA, three to four years post-surgery. Grounded theory was employed to analyze participants’ stories about what was front of mind when they reflected on satisfaction with their new knee.

Results

Participants described their post-TKA knee in terms its adequacy: how it felt and worked, and how it matched their pre-surgical expectations. The central element of their stories was the process of adapting, which gave rise to their perceptions of adequacy. Adapting comprises the patient experience of physically integrating and cognitively accepting their new knee. Patterns of adapting reflect the level of the new knee’s achieved adequacy and the straightforwardness of the adapting process.

Discussion

The conceptualization of adequacy and the process of adapting allow a patient-centred understanding of what patients experience following TKA. For participants who did not readily achieve the adequacy they had anticipated, the challenges they experienced during adapting dominated their stories. Participants’ adapting stories afford key insights into how the health care system could adjust to better support TKA patients, and improve rates of satisfaction with this procedure.

Conclusions

The process of adapting lends itself to system intervention in support of enhanced post-TKA outcomes and satisfaction. These interventions could include the development of a care model including long-term clinical support for patients whose knees do not achieve desired results on schedule, and collaborating with patients to set and manage reasonable expectations about how their post-TKA knee will feel and function.

Inaccuracy of the intramedullary femoral guide: traditional instrumentation lacks precision and accuracy

PURPOSE

The purpose of the study was to utilize a large-scale biomorphometric computer tomography (CT) database to determine the desirable starting point and angle for placement of the femoral intramedullary rod in the sagittal plane.

METHODS

A CT-based modeling and analytics system (SOMA, Stryker, Mahwah, NJ) was used to evaluate 1029 entire-femur CT scans. From this, 19,464 simulations were run to test whether a 20 cm intramedullary rod, with a radius of 4 mm, would successfully pass through the femoral canal before contacting cortical bone. First, modelling included varying angles from 0-6 degrees in the sagittal plane, at 1-degree intervals. Next, the start point was adjusted with an assumed 3 degrees of induced flexion in comparison to the mechanical axis.

RESULTS

A total of 5012 simulations were able to place the femoral intramedullary rod 20 cm into the canal. The angle of the rod that created the highest proportion of successful jig placement was at a 3-degree angle of induced flexion to the orthogonal plane of the transepicondylar axis (TEA), with 33.7% successful jig placements. The starting point for the greatest proportion of successful guide placements was 48.5% along the distance between the sTEA, slightly closer to the lateral side. In the AP plane, the average distance to the ideal start point was 12.1 mm anterior to the PCL.

CONCLUSION

By examining over a thousand femoral CT scans, an angle of 3 degrees of induced flexion was identified in the sagittal plane with the highest proportion of successful placement of an intramedullary rod before cortical contact. It is important to note the high rate of failure in completely inserting the 20 mm rod.

LEVEL OF EVIDENCE

This is a prospective computer based model.

Intraoperative midflexion medial laxity using navigation affects patient expectations following posterior stabilized total knee arthroplasty

BACKGROUND

Patient satisfaction and expectations are now recognized as an outcome measure for successful total knee arthroplasty (TKA). The purpose of this study was to determine which factors including soft tissue balance during surgery affect patient satisfaction and expectations after TKA.

METHODS

A total of 135 patients (157 knees) with knee osteoarthritis who underwent primary TKA with a posterior stabilized design were studied. After implantation of all components, varus/valgus laxity of the knee was measured intraoperatively with the knee at 0°, 30°, 60°, 90°, and 120° guided by an image-free navigation system. Factors that affected patient satisfaction and expectations, including lateral and medial laxities, were evaluated using the 2011 Knee Society score.

RESULTS

The mean intraoperative lateral laxity was 1.1°, 1.6°, 0.9°, 1.3°, and 1.7° with the knee at 0°, 30°, 60°, 90°, and 120°, respectively. The mean intraoperative medial laxity was 1.1°, 1.4°, 1.1°, 1.1°, and 1.7° with the knee at 0°, 30°, 60°, 90°, and 120°, respectively. Patient satisfaction after TKA correlated positively with symptom (R = 0.61, p < 0.01) and functional activity (R = 0.47, p < 0.01) scores. Patient expectations after TKA weakly positively correlated with symptom (R = 0.29, p < 0.01) and functional activity (R = 0.20, p = 0.01) scores, and weakly negatively with medial laxity at 30° (R = -0.21, p < 0.01).

CONCLUSION

Midflexion medial laxity was associated with worse patient expectations after TKA. Avoiding medial laxity could be one of the important techniques during TKA.

Use of intraoperative technology in total knee arthroplasty is not associated with reductions in postoperative pain

PURPOSE

Our systematic review and meta-analysis sought to assess how technology-assistance impacts (1) post-operative pain and (2) opioid use in patients undergoing primary total knee arthroplasty (TKA).

METHODS

Four online databases were queried for studies published up to October 2021 that reported on pain and opioid usage between technology-assisted and manual TKA (mTKA) patients. Mantel-Haenszel (M-H) models were utilized to calculate pooled mean difference (MDs) and 95% confidence interval (CIs). Subgroup analyses were conducted to isolate robotic-arm assisted (RAA) and computed-assisted navigation (CAN) cohorts. Risk of bias was assessed for all included non-randomized studies with the Methodological Index for Non-Randomized Studies (MINORS) tool. For the randomized control trials included in our study, the Detsky scale was applied.

RESULTS

Our analysis included 31 studies, reporting on a total of 761,300 TKAs (mTKA: n = 753,554; Computer-Assisted Navigation (CAN): n = 1,309; Robotic-Arm Assisted (RAA): n = 6437). No differences were demonstrated when evaluating WOMAC (MD: 0.00, 95% CI - 0.69 to 0.69; p = 1.00), KSS (MD: 0.01, 95% CI - 1.46 to 1.49; p = 0.99), KOOS (MD - 2.91, 95% CI - 6.17 to 0.34; p = 0.08), and VAS (MD - 0.54, 95% CI - 1.01 to - 0.007; p = 0.02) pain scores between cohorts. There was mixed evidence regarding how opioid consumption differed between TKA techniques.

CONCLUSION

The present analysis demonstrated no difference in terms of pain across a variety of utilized patient-reported pain measurements. However, there were mixed results regarding how opioid consumption varied between manual and technology-assisted cohorts, particularly in the immediate post-operative period.

LEVEL OF EVIDENCE

III.

Robot-assisted knee arthroplasty improves component positioning and alignment, but results are inconclusive on whether it improves clinical scores or reduces complications and revisions: a systematic overview of meta-analyses

PURPOSE

The purpose of this systematic overview was to identify, synthesise and critically appraise findings of meta-analyses on robot-assisted versus conventional unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). The hypothesis was that robotic assistance would reduce complications and revision rates, yield better clinical scores, and improve component positioning and alignment.

METHODS

Two researchers independently conducted a literature search using Embase^®, MEDLINE^®, Web of Science, Allied and Complementary Medicine™ and Cochrane Database of Systematic Reviews on 2 November 2020 for meta-analyses (Level I-IV) on robotic assistance in UKA and/or TKA. Outcomes were tabulated and reported as weighted mean difference (WMD), risk ratio (RR) or weighted odds ratio (WOR), and were considered statistically significant when p < 0.05.

RESULTS

A total of ten meta-analyses were identified; four on robot-assisted UKA (n, 1880 robot-assisted vs. 2352 conventional UKA; follow-up, 0 to 60 months), seven on robot-assisted TKA (n, 4567 robot-assisted vs. 5966 conventional TKA; follow-up, 0 to 132 months). Of the meta-analyses on UKA, one found that robotic assistance reduced complication rates (relative risk (RR), 0.62), one found that it improved clinical scores (weighted mean difference (WMD), 19.67), three found that it extended operation times (WMD, 15.7 to 17.1 min), and three found that it improved component positioning and alignment (WMD, - 1.30 to - 3.02 degrees). Of the meta-analyses on TKA, two found that robotic assistance improved clinical scores (WMD, 1.62-1.71), two found that that it extended surgery times (WMD, 21.5-24.26 min), and five found that it improved component positioning and alignment (WMD, - 0.50 to - 10.07 degrees). None of the meta-analyses reported differences in survivorship between robot-assisted versus conventional knee arthroplasty.

CONCLUSION

Robot-assisted knee arthroplasty enabled more accurate component positioning and placement within target zones, but extended operation time considerably. Although robotic assistance improved component positioning, its benefits regarding clinical scores, patient satisfaction and implant survivorship remains to be confirmed. Finally, this overview revealed that six of the ten meta-analyses were of 'critically low quality', calling for caution when interpreting results.

LEVEL OF EVIDENCE

IV.

A single type of varus knee does not exist: morphotyping and gap analysis in varus OA

PURPOSE

To achieve a higher level of satisfaction in patients having undergone Total Knee Arthroplasty (TKA), a more personalized approach has been discussed recently. It can be assumed that a more profound knowledge of bony morphology and ligamentous situation would be beneficial. While CT/MRI can give 3D information on bone morphology, the understanding of the ligamentous situation in different flexion angles is still incomplete. In this study, the dynamic gap widths of a large number of varus knees were assessed in various flexion angles, to find out whether all varus knees behave similar or have more individual soft tissue patterns. Additionally, it was investigated whether the amount of varus deformity or other patient factors have an effect on joint gap widths.

METHODS

A series of 1000 consecutive TKA patients, including their CAS data and patient records were analyzed. Joint gap widths in multiple flexion angles (0°, 30°, 60°, 90°) were measured in mm and differences between the joint gaps were compared. A "standard" varus knee was defined as follows: (1) Lateral extension gap greater than medial, (2) lateral flexion gap greater than medial, and (3) flexion gap greater than extension gap. The percentage of fulfillment was tested for each and all criteria. To measure the influence of varus deformity on gap width difference, three subgroups were formed based on the deformity. Data were analyzed at 0°, 30°, 60° and 90° flexion. The effect of patient factors (gender, BMI, age) on gap sizes was tested by performing subgroup analyses.

RESULTS

Only 444 of 680 (65%) patients met all three varus knee criteria. The lateral extension gap (4.1 mm) was significantly larger than the medial extension gap (0.6 mm) in 657 (97%) patients and the gap difference highly correlated with the amount of varus deformity (r² = 0.62). In all flexion positions, however, no correlation between gap differences and varus deformity existed. Women had significantly larger extension and flexion gaps. Age and BMI showed no significant effect on gap widths.

CONCLUSION

Varus knees show a large inter-individual variability regarding gap widths and gap differences. The amount of varus deformity correlates highly with the medio-lateral gap difference in extension, but not in any flexion angle. As varus knees are not all alike, a uniform surgical technique will not treat all varus knees adequately and the individual gap sizes need to be analyzed and addressed accordingly with an individualized balancing technique. Which final balancing goal should be achieved needs to be analyzed in future studies.

LEVEL OF EVIDENCE

Level III.

Factors contributing to 1-year dissatisfaction after total knee arthroplasty: a nomogram prediction model

Background

Identifying risk factors and early intervention are critical for improving the satisfaction rate of total knee arthroplasty (TKA). Our study aimed to identify patient-specific variables and establish a nomogram model to predict dissatisfaction at 1 year after TKA.

Methods

This prospective cohort study involved 208 consecutive primary TKA patients with end-stage arthritis who completed self-reported measures preoperatively and at 1 year postoperatively. All participants were randomized into a training cohort (n = 154) and validation cohort (n = 54). Multiple regression models with preoperative and postoperative factors were used to establish the nomogram model for dissatisfaction at 1 year postoperatively. The least absolute shrinkage and selection operator method was used to screen the suitable and effective risk factors (demographic variables, preoperative variables, surgical variable, and postoperative variables) collected. These variables were compared between the satisfied and dissatisfied groups in the training cohort. The receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis were used to validate the discrimination, calibration, and clinical usefulness of the model. Results were evaluated by internal validation of the validation cohort.

Results

The overall satisfaction rate 1 year after TKA was 77.8%. The nomogram prediction model included the following risk factors: gender; primary diagnosis; postoperative residual pain; poor postoperative range of motion; wound healing; and the rate of change in the degree of coronal lower limb alignment (hip–knee–ankle angle, HKA).The ROC curves of the training and validation cohorts were 0.9206 (95% confidence interval [CI], 0.8785–0.9627) and 0.9662 (0.9231, 1.0000) (95% CI, 0.9231, 1.0000), respectively. The Hosmer–Lemeshow test showed good calibration of the nomogram (training cohort, p = 0.218; validation cohort, p = 0.103).

Conclusion

This study developed a prediction nomogram model based on partially modifiable risk factors for predicting dissatisfaction 1 year after TKA. This model demonstrated good discriminative capacity for identifying those at greatest risk for dissatisfaction and may help surgeons and patients identify and evaluate the risk factors for dissatisfaction and optimize TKA outcomes.

Association of circulating gene expression signatures with stiffness following total knee arthroplasty for osteoarthritis: a pilot study

A subset of patients undergoing total knee arthroplasty (TKA) for knee osteoarthritis develop debilitating knee stiffness (reduced range of motion) for poorly understood reasons. Dysregulated inflammatory and immune responses to surgery correlate with reduced surgical outcomes, but the dysregulated gene signatures in patients with stiffness after TKA are poorly defined. As a consequence, we are limited in our ability to identify patients at risk of developing poor surgical outcomes and develop preventative approaches. In this pilot study we aimed to identify perioperative blood gene signatures in patients undergoing TKA for knee osteoarthritis and its association with early surgical outcomes, specifically knee range of motion. To do this, we integrated clinical outcomes collected at 6 weeks after surgery with transcriptomics analyses in blood samples collected immediately before surgery and at 24 h after surgery. We found that patients with stiffness at 6 weeks after surgery have a more variable and attenuated circulating gene expression response immediately after surgery. Our results suggest that patients with stiffness following TKA may have distinct gene expression signatures detectable in peripheral blood in the immediate postoperative period.

Patient Satisfaction Scores Are a Poor Metric of Orthopedic Care

Patient satisfaction scores are a popular metric used to evaluate orthopedic care. There is little consistency with how satisfaction is described in the orthopedic literature. Online physician reviews are a growing trend that directly and indirectly affect a surgeon's reputation. There is little correlation of higher satisfaction with improved surgical outcomes, so rating surgical care may be misguided and possibly dangerous. Patient satisfaction is an important part of the patient-centered care model, so rating systems should directly reflect quality. More research is needed to determine the relationship between patient satisfaction and the delivery of quality care. [Orthopedics. 2022;45(3):e127-e133.].

Ultrasound-guided intra-articular injection of expanded umbilical cord mesenchymal stem cells in knee osteoarthritis: a safety/efficacy study with MRI data

Aim: This study has the primary objective of studying the effect of Wharton jelly mesenchymal stem cells (WJMSCs) in the treatment of knee osteoarthritis. As a secondary end point, we report on the efficacy of such therapy. Patients and methods: 16 patients with advanced Kellgren stage were treated using two doses of expanded WJMSCs given 1 month apart. Patients were followed for 48 months using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and 12 months using magnetic resonance imaging (MRI). Results: Treatment was well tolerated. One patient developed moderate effusion and one superficial phlebitis. We observed functional and pain improvement at 12 and 48 months (p < 0.0001), with statistically significant improvement on MRI scans at 12 months in cartilage loss, osteophytes, bone marrow lesions, effusion and synovitis (p < 0.01), and highly significant improvement in subchondral sclerosis (p < 0.0001). Conclusion: WJMSCs are safe and potentially effective in producing significant improvement in KOOS and MRI scores when administered intra-articularly in knee osteoarthritis cases under ultrasound guidance.

Italian Translation, Adaptation, and Validation of the Novel Satisfaction Measure Assessment after Primary Total Joint Arthroplasty: The Goodman Score Questionnaire

Patient satisfaction after total joint arthroplasties (TJA) represents a key element for the evaluation of surgery success in relation to subjects' needs and expectations. The assessment tools are applied inconsistently throughout the literature, and thus, it is difficult to compare results among different studies. Goodman et al. proposed a standardized questionnaire with strong psychometric properties for the assessment of satisfaction. The present study aims to translate, adapt, and validate the Goodman questionnaire for the Italian population. After translation and back translation, the questionnaire was administrated to 50 patients. Internal consistency, test-retest reliability, floor and ceiling effects, and construct validity were evaluated (correlation with KOOS/HOOS, SF-12 PCS/MCS, EQ-5D). Responsiveness was evaluated with respect to SF-12 PCS improvements. The Italian version of the Goodman score questionnaire demonstrated psychometric properties similar to those of the original version. The translated questionnaire showed good internal consistency (Cronbach's alpha = 0.836) and test-retest reliability (ICC: 0.507). Moderate/strong correlations were observed between the Italian version of the Goodman score and other scores. The score significantly discriminated patients who improved from those who did not improve in SF-12 PCS after treatment. This study provides an adapted and validated Italian version of the Goodman score questionnaire, with psychometric properties similar to those of its original counterpart.

Length of Hospital Stay after Total Knee Arthroplasty: A Correlation Study on 1200 Patients

In countries with a high average population age, total knee arthroplasty is still carried out in an inpatient setting. The roadmap to performing major surgery on an outpatient basis passes through the understanding of those perioperative features that correlate with higher lengths of hospital stay (LOS). A retrospective database of 1200 patients was reviewed for retrieving preoperative and perioperative factors including anthropometric and demographic data, comorbidities, preoperative laboratory assessment, and surgical time. Considering the LOS as a discrete series, data were analyzed by means of logistic regression with multiple univariate and multivariate models. The results showed a median length of hospital stay of 3 (IQR 3, 4) days. According to multiple univariate analysis, arterial hypertension (p = 0.008), diabetes mellitus (p = 0.028), CCI score (p < 0.001), ASA score (p = 0.006), surgical time (p < 0.001) and intraoperative blood loss (p < 0.001) were significantly associated with the duration of hospital stay in days. Moreover, preoperative hemoglobin value was inversely correlated to the LOS (p = 0.008). Multivariate analysis showed a significant correlation between LOS and surgical time and intraoperative blood loss. Many factors influence the permanence of the inpatient and acting on those variables, by stabilizing comorbidities and optimizing laboratory values, may reduce the overall healthcare burden.

Comparison of Biomechanical Gait Parameters and Patient-Reported Outcome in Patients After Total Knee Arthroplasty With the Use of Fixed-Bearing Medial Pivot and Multi-radius Design Implants—Retrospective Matched-Cohort Study

Background

Total knee arthroplasty (TKA) is considered to be highly successful in treatment of end-stage osteoarthritis. There are multiple implant designs available on the market, and it is difficult to point which one is the best. The aim of this study was to compare the clinical and functional outcomes and gait pattern after TKA with the use of fixed-bearing medial pivot (K-Mod) vs multi-radius design (NexGen) implants and to compare them to norms for healthy patients with no osteoarthritis or arthroplasty procedure in anamnesis.

Methods

A group of 30 patients who received the medial pivot (MP) TKA and 33 patients who received the posterior-stabilized (PS) TKA between May and August of 2018 were included. All surgeries were performed in the level III academic hospital by a single surgeon. Every patient was asked to fulfill the The Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire preoperatively and 2 years postoperatively. Standard X-ray, biomechanical gait analysis using a motion capture system, and statistical analysis were performed at 2 years postoperatively.

Results

A total of 28 patients from either MP cohort (93%) or PS (85%) matched-control cohort completed the whole assessment at the final follow-up. There were statistically significant differences in a few gait parameters such as shorter mean step length both in operated and healthy limb, lower mean gait velocity, and lower mean walking cadence than the norm in both MP and PS groups. As to the WOMAC score, there was statistically significant improvement in both groups comparing preoperative and postoperative outcomes. Nevertheless, in the MP group, there was a significantly higher score, indicating worse outcomes, in the stiffness part of the WOMAC score than in the PS group. No significant differences were found between groups during radiological evaluation.

Conclusions

There were satisfying and promising clinical, radiographic, and patient-reported outcomes in both MP and PS groups with very little difference in relation to norm values. However, both implants failed in fully restoring gait patterns similar to the healthy limb of the same patient.

The Use of Opioids and Pain Medications in the Management of Postoperative Pain in Total Knee Arthroplasty Patients: A Retrospective Study

Purpose

The opioid crisis amplified the concern for the appropriate use of opioids. Our study aims to investigate the pain levels and amount of opiates needed during the first three days following total knee arthroplasty (TKA), whereby Drug Enforcement Administration (DEA) Schedule II oral opiates are not available.

Methods

A year-long retrospective review of adult patients who underwent TKA was conducted. The postoperative pain scores and mean morphine equivalents (MME) were measured. These outcomes were assessed according to demographics, anesthesia, and analgesia used.

Results

For our 78 patients, there was no statistical difference for stratification by baseline characteristics except in spinal anesthesia, which decreased pain on the first day. Conversely, MME increased to its significantly highest of 14.22 ± 29.58 mg on day 3. The effect was noted for patient-controlled analgesia where patients with intravenous analgesia received less opioid than those on epidural analgesia on postoperative day one.

Conclusions

Using a similar regimen of analgesia, postoperative pain following TKA would be controlled by a relatively low amount of opioids by the third postoperative day. Spinal anesthesia and patient-controlled epidural analgesia were linked to better pain control and less opioid needed.

Multimodal prediction of pain and functional outcomes 6 months following total knee replacement: a prospective cohort study

BACKGROUND

Knee osteoarthritis (OA) is among the most common and disabling persistent pain conditions, with increasing prevalence and impact around the globe. In the U.S., the rising prevalence of knee OA has been paralleled by an increase in annual rates of total knee arthroplasty (TKA), a surgical treatment option for late-stage knee OA. While TKA outcomes are generally good, post-operative trajectories of pain and functional status vary substantially; a significant minority of patients report ongoing pain and impaired function following TKA. A number of studies have identified sets of biopsychosocial risk factors for poor post-TKA outcomes (e.g., comorbidities, negative affect, sensory sensitivity), but few prospective studies have systematically evaluated the unique and combined influence of a broad array of factors.

METHODS

This multi-site longitudinal cohort study investigated predictors of 6-month pain and functional outcomes following TKA. A wide spectrum of relevant biopsychosocial predictors was assessed preoperatively by medical history, patient-reported questionnaire, functional testing, and quantitative sensory testing in 248 patients undergoing TKA, and subsequently examined for their predictive capacity.

RESULTS

The majority of patients had mild or no pain at 6 months, and minimal pain-related impairment, but approximately 30% reported pain intensity ratings of 3/10 or higher. Reporting greater pain severity and dysfunction at 6 months post-TKA was predicted by higher preoperative levels of negative affect, prior pain history, opioid use, and disrupted sleep. Interestingly, lower levels of resilience-related "positive" psychosocial characteristics (i.e., lower agreeableness, lower social support) were among the strongest, most consistent predictors of poor outcomes in multivariable linear regression models. Maladaptive profiles of pain modulation (e.g., elevated temporal summation of pain), while not robust unique predictors, interacted with psychosocial risk factors such that the TKA patients with the most pain and dysfunction exhibited lower resilience and enhanced temporal summation of pain.

CONCLUSIONS

This study underscores the importance of considering psychosocial (particularly positively-oriented resilience variables) and sensory profiles, as well as their interaction, in understanding post-surgical pain trajectories.

Low grade of radiographic osteoarthritis predicts unsatisfactory response of the contralateral knee replacement in two-stage bilateral total knee arthroplasty

PURPOSE

It is difficult to counsel patients with bilateral osteoarthritis who are unsatisfied with their first knee replacement as to whether they are likely to have a better outcome after the contralateral knee is replaced. The purpose of this study was to determine whether predictive factors can be found to prognosticate outcome of the second-side knee replacement when a patient has an unsatisfactory response to the first, with the hypothesis that predictors, such as prosthetic factors and radiographic level of osteoarthritis, may be able to predict a satisfactory response to the contralateral knee replacement.

MATERIALS AND METHODS

An analysis of staged bilateral knee replacements performed at a tertiary arthroplasty centre from 2012 to 2018 was undertaken. A total of 550 knee replacements in 275 patients were included in this study. The primary variable measured was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Satisfactory response to surgery was defined as a WOMAC score improved by 17 points or more, and 56 or greater. Patients who did not achieve a satisfactory response with their first knee replacement were further analysed for predictive factors (age, sex, pre-operative score, mental score, socioeconomic status, type of prosthesis, use of navigation, patella resurfacing and radiographic osteoarthritis) of an unsatisfactory response for their contralateral knee replacement.

RESULTS

Overall, 44 (16%) patients failed to achieve a satisfactory response from both their first and contralateral knee replacements. The factor most predictive of an unsatisfactory response to their first knee replacement was pre-operative mental health score. However, in patients who did not achieve a satisfactory response with their first knee replacement, radiographic osteoarthritis, as measured by the Kellgren-Lawrence (KL) score was the main predictor of satisfactory response for their contralateral knee replacement. Only patients with KL grade 4 osteoarthritis were likely to have a satisfactory response with their contralateral knee replacements (KL4 versus KL3, Odds ratio 3.57 (CI 1.26-10.03) p = 0.016*). Patients with KL grade 3 osteoarthritis were unlikely to have a satisfactory response, and in this series, no patient with KL grade 2 osteoarthritis had a satisfactory response.

CONCLUSION

In a patient who has an unsatisfactory response to their first knee replacement, the best predictor of achieving a satisfactory response to his/her contralateral knee replacement is the level of radiographic osteoarthritis in that knee.

LEVEL OF EVIDENCE

IV: Retrospective Cohort study.

Satisfaction With the Process vs Outcome of Care in Total Hip and Knee Arthroplasty

BACKGROUND

Patient satisfaction, with both process of care and outcome of care, is critical for measuring the quality and value of elective procedures such as arthroplasty. The purpose of this study is to evaluate the correlation between early postoperative satisfaction with the process of care and 2-year satisfaction with the outcome of care after total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

We retrospectively analyzed data from institutional arthroplasty registries. Satisfaction with the outcome of care was measured on a scale of 0-100 by a previously validated questionnaire administered 2 years postoperatively. Patient satisfaction with the process of care was measured by the Press Ganey (PG) inpatient survey, also scored 0-100. We examined the correlation between these 2 measures of satisfaction in patients who underwent primary THA or TKA.

RESULTS

In total, 721 TKA patients and 760 THA patients underwent surgery and completed both the PG survey and 2-year satisfaction questionnaire. The mean age was 65.1 years with a mean body mass index of 28.8 and 56% were female. The mean PG survey score for the entire cohort was 95.6. The mean 2-year satisfaction score was 90.3. The Spearman correlation coefficient between the PG survey and the 2-year satisfaction survey was 0.23 for TKA patients (P < .001) and 0.13 for THA patients (P < .001).

CONCLUSION

We found a weak correlation between the measurement of satisfaction with the process of care surrounding hip and knee arthroplasty using the PG survey and measurement of satisfaction with the outcome of care after arthroplasty using a validated 2-year satisfaction instrument.

Evaluating willingness for surgery using the SMART Choice (Knee) patient prognostic tool for total knee arthroplasty: study protocol for a pragmatic randomised controlled trial

BACKGROUND

Approximately 1 in 5 patients feel unsatisfied after total knee arthroplasty (TKA). Prognostic tools may aid in the patient selection process and reduce the proportion of patients who experience unsatisfactory surgery. This study uses the prognostic tool SMART Choice (Patient Prognostic Tool for Total Knee Arthroplasty) to predict patient improvement after TKA. The tool aims to be used by the patient without clinician input and does not require clinical data such as X-ray findings or blood results. The objective of this study is to evaluate the SMART Choice tool on patient decision making, particularly willingness for surgery. We hypothesise that the use of the SMART Choice tool will influence willingness to undergo surgery, especially when used earlier in the patient TKA journey.

METHODS

This is a multicentred, pragmatic, randomised controlled trial conducted in Melbourne, Australia. Participants will be recruited from the St. Vincent's Hospital, Melbourne (SVHM) Orthopaedic Clinic, and the client base of HCF, Australia (private health insurance company). Patients over 45 years of age who have been diagnosed with knee osteoarthritis and considering TKA are eligible for participation. Participants will be randomised to either use the SMART Choice tool or treatment as usual. The SMART Choice tool provides users with a prediction for improvement or deterioration / no change after surgery based on utility score change calculated from the Veterans-RAND 12 (VR-12) survey. The primary outcome of the study is patient willingness for TKA surgery. The secondary outcomes include evaluating the optimal timing for tool use and using decision quality questionnaires to understand the patient experience when using the tool. Participants will be followed up for 6 months from the time of recruitment.

DISCUSSION

The SMART Choice tool has the potential to improve patient decision making for TKA. Although many prognostic tools have been developed for other areas of surgery, most are confined within academic bodies of work. This study will be one of the first to evaluate the impact of a prognostic tool on patient decision making using a prospective clinical trial, an important step in transitioning the tool for use in clinical practice.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry (ANZCTR) - ACTRN12622000072718 . Prospectively registered - 21 January 2022.

Logistic Regression and Machine Learning Models Cannot Discriminate Between Satisfied and Dissatisfied Total Knee Arthroplasty Patients

BACKGROUND

Approximately 20% of total knee arthroplasty (TKA) patients are found to be dissatisfied or unsure of their satisfaction at 1-year post-surgery. This study attempted to predict 1-year post-surgery dissatisfied/unsure TKA patients with pre-surgery and surgical variables using logistic regression and machine learning methods.

METHODS

A retrospective analysis of patients who underwent primary TKA for osteoarthritis between 2012 and 2016 at a single institution was completed. Patients were split into satisfied and dissatisfied/unsure groups. Potential predictor variables included the following: demographic information, patella re-surfaced, posterior collateral ligament sacrificed, and subscales from the Knee Society Knee Scoring System, the Knee Society Clinical Rating System, the Western Ontario and McMaster Universities Osteoarthritis Index, and the 12-Item Short Form Health Survey version 2. Logistic regression and 6 different machine learning methods were used to create prediction models. Model performance was evaluated using discrimination (AUC [area under the receiver operating characteristic curve]) and calibration (Brier score, Cox intercept, and Cox slope) metrics.

RESULTS

There were 1432 eligible patients included in the analysis, 313 were considered to be dissatisfied/unsure. When evaluating discrimination, the logistic regression (AUC = 0.736) and extreme gradient boosted tree (AUC = 0.713) models performed best. When evaluating calibration, the logistic regression (Brier score = 0.141, Cox intercept = 0.241, and Cox slope = 1.31) and gradient boosted tree (Brier score = 0.149, Cox intercept = 0.054, and Cox slope = 1.158) models performed best.

CONCLUSION

The models developed in this study do not perform well enough as discriminatory tools to be used in a clinical setting. Further work needs to be done to improve the performance of pre-surgery TKA dissatisfaction prediction models.

The Impact of Medical Comorbidities on Patient Satisfaction in Chronic Rhinosinusitis

BACKGROUND

Patient satisfaction has a significant bearing on medical therapy compliance and patient outcomes. The purpose of this study was to (1) describe patient satisfaction, as characterized by the Patient Satisfaction Questionnaire-18 (PSQ-18), in the care of patients with chronic rhinosinusitis (CRS) and (2) analyze the impact of comorbidities on satisfaction using the functional comorbidity index (FCI).

METHODS

Patient demographics, disease severity measures, and PSQ-18 scores for patients with CRS presenting to a tertiary rhinology clinic between November 2019 and April 2020 were collected and analyzed. FCI was calculated retrospectively using the electronic medical record; individual comorbidities were tabulated. Spearman's correlations followed by multivariate regression was used to assess the relationship between medical comorbidities and PSQ-18.

RESULTS

Sixty-nine patients met criteria for analysis. There were no significant differences in age, gender, and Sinonasal Outcomes Test-22 scores between CRS patients with (CRSwNP) and without (CRSsNP) nasal polyps. There was no significant difference in the mean FCI for patients with CRSwNP versus CRSsNP (5.1 and 4.3, respectively) (P = .843). Similarly, there was no significant difference in the mean sum PSQ-18 score (78/100 in both) between these cohorts (P = .148). The mean sum PSQ-18 score was not significantly associated with anxiety (P = .728), depression (P = .624), or FCI (P = .282), but was significantly associated with hearing impairment (P < .001).

CONCLUSION

Patient satisfaction in the care of CRS is generally high with a diagnosis of comorbid hearing impairment demonstrating a negative association with satisfaction in this cohort.

Effectiveness of Ultrasound-Guided Canal Adductor Blockade for Chronic Pain and Functioning in Knee Osteoarthritis: A Prospective Longitudinal Observational Study

Methods

Seventy-seven patients with chronic knee osteoarthritis pain received ultrasound-guided ACB with 14 ml 0.25% levobupivacaine and 100 mcg clonidine. At baseline and 1 month after the blockade, we assessed maximal and minimal pain intensity in the knee using a numeric rating scale (NRS) and the Knee Injury and Osteoarthritis Outcome Score (KOOS). The range of motion in extension and flexion (ROMext and ROMflex) and quadriceps muscle strength of both knees (QS), Timed Up and Go Test (TUG), and 30-Second Chair Stand Test (30CST) results were determined at baseline, 1 hour, 1 week, and 1 month after the blockade.

Results

ACB with levobupivacaine and clonidine appeared to decrease pain severity (NRS_max 8.13 to 4.2, p < 0.001 and NRS_min 3.32 to 1.40, p < 0.001). Similarly, knee ROMext decreased from 3.90 preintervention to 2.89 postintervention at 1 month, p < 0.001; ROMflex decreased from 5.70 to 3.29, p < 0.001; TUG time decreased from 3.22 to 2.93, <0.001; QS increased from 18.43 to 22.77, p < 0.001; CST increased from 8.23 to 10.74, p < 0.001. The KOOS for pain (36.40 to 58.34), symptoms (52.55 to 64.32), activities of daily living functions (ADLs, 36.36 to 60.77), and quality of life (QoL, 17.87 to 30.97) also increased, all p < 0.001.

Conclusion

ACB appeared to decrease pain and increase ambulation. If our preliminary results are reproducible in a planned randomized controlled trial, ACB could be a useful adjunctive pain therapy in patients with disabling pain due to knee OA.

Substantial clinical benefit and patient acceptable symptom states of the Forgotten Joint Score 12 after primary knee arthroplasty

Background and purpose - Knowing how to interpret values obtained with patient reported outcome measures (PROMs) is essential. We estimated the substantial clinical benefit (SCB) and patient acceptable symptom state (PASS) for Forgotten Joint Score 12 (FJS) and explored differences depending on methods used for the estimates. Patients and methods - The study was based on 195 knee arthroplasties (KA) performed at a university hospital. We used 1 item from the Knee injury and Osteoarthritis Outcome Score domain quality of life and satisfaction with surgery, obtained 1-year postoperatively, to assess SCB and PASS thresholds of the FJS with anchor-based methods. We used different combinations of anchor questions for SCB and PASS (satisfied, satisfied with no or mild knee difficulties, and satisfied with no knee difficulties). A novel predictive approach and receiver-operating characteristics curve were applied for the estimates. Results - 70 and 113 KAs were available for the SCB and PASS estimates, respectively. Depending on method, SCB of the FJS (range 0-100) was 28 (95% CI 21-35) and 22 (12-45) respectively. PASS was 31 (2-39) and 20 (10-29) for satisfied patients, 40 (31-47) and 38 (32-43) for satisfied patients with no/mild difficulties, and 76 (39-80) and 64 (55-74) for satisfied patients with no difficulties. The areas under the curve ranged from 0.82 to 0.88. Interpretation - Both the SCB and PASS thresholds varied depending on methodology. This may indicate a problem using meaningful values from other studies defining outcomes after KA. This study supports the premise of the FJS as a PROM with good discriminatory ability in patients undergoing KA.

No difference in patient-reported satisfaction after 12 months between customised individually made and off-the-shelf total knee arthroplasty

PURPOSE

A subset of patients is usually not satisfied after a total knee arthroplasty (TKA). Customised individually made (CIM) TKA are deemed to overcome drawbacks of classical off-the-shelf (OTS) TKA, but evidence is still sparse. The aim of this study was to compare satisfaction of patients with CIM and OTS TKA.

METHODS

This prospective cohort study compared clinical and patient-reported outcome measures (PROM) between patients with CIM and OTS TKA. The primary outcome was patient satisfaction after 12 months. Secondary outcomes were the Knee Society Score (KSS), the Knee injury and Osteoarthritis Outcome Score (KOOS), the Forgotten Joint Score (FJS-12) and the EQ-5D-3L after 4 and 12 months.

RESULTS

Data were analysed from 74 CIM TKA and 169 OTS TKA between January 2017 and September 2020. Patients with CIM TKA were slightly younger, more often male, had a lower body mass index, a lower KSS and partially higher preoperative PROMs. Patient satisfaction after 12 months was high and comparable (CIM 87%, OTS 89%). All PROMs improved for both groups (p < 0.001) and did not differ after 12 months (p > 0.063). The majority of patients improved above the minimal important difference (range 65 to 89%) and reported a clear overall improvement (CIM 86%, OTS 87%). The postoperative KSS, notably regarding knee stability, was higher for CIM TKA (p < 0.001).

CONCLUSION

No difference was found in patient satisfaction between CIM and OTS TKA after 12 months. In both groups, patient satisfaction was high and PROMs improved considerably.

LEVEL OF EVIDENCE

II, prospective cohort study.

Central Sensitization and Postoperative Improvement of Quality of Life in Total Knee and Total Hip Arthroplasty: A Prospective Observational Study

Background:

While total knee arthroplasty (TKA) and total hip arthroplasty (THA) lead to excellent clinical outcomes, some patients experience residual surgical site pain and reduced satisfaction. This prospective observational study investigated the prevalence of preoperative and postoperative residual central sensitization (CS) after TKA and THA. The influence of residual CS on the improvement in quality of life (QOL) was also investigated.

Methods:

The participants were 40 patients who underwent TKA and 47 patients who underwent THA. CS was measured using the central sensitization inventory (CSI) questionnaire. Knee symptoms were evaluated using the Knee Injury and Osteoarthritis Outcome Scales (KOOS), and hip symptoms were evaluated using the Japanese Orthopedic Association Hip-disease Evaluation Questionnaires (JHEQ). General QOL was evaluated using EuroQOL (EQ-5D-5l). Regression analysis was performed to estimate factors related to low QOL after surgery.

Results:

Preoperatively, 47.5% of TKA patients and 66.0% of THA patients were CS positive (P=0.083), which reduced to 10.0% (P=0.042) and 25.5% (P=0.202), respectively, 3 months after surgery. Although the improvements in KOOS subscales and EQ-5D-5l scores in TKA patients with residual CS were significantly lower than in those without residual CS, residual CS status had no effect on JHEQ subscales and EQ-5D-5l scores in THA patients. Regression analysis indicated that EQ-5D-5l was negatively correlated with CSI in the TKA group (P=0.017). In contrast, CSI was not correlated with EQ-5D-5l in the THA group (P=0.206).

Conclusion:

Postoperative QOL improvement was achieved 3 months after THA regardless of residual CS status. In contrast, preoperative CS was negatively associated with the improvement in QOL after TKA.

The relationship between patient safety culture with patient satisfaction and hospital performance in Shafa Hospital of Kerman in 2020

BACKGROUND

Hospitals are a significant part of the health system, so their performance is always measured based on some factors such as patient satisfaction and their safety level.

AIM

The present study was aimed to examine the relationship between patient safety culture with patient satisfaction and hospital performance.

MATERIALS AND METHODS

This descriptive-analytical, cross-sectional study was performed on 240 patients, 240 staff and 20 hospital managers in Shafa hospital of Kerman, Iran, in 2020. To collect data, the patient safety culture, the patient satisfaction, and the hospital performance questionnaires were used. The data were analyzed by SPSS and PLS software; to measure the research model, structural equation models and confirmatory factor analysis were used.

RESULTS

The variable "patient satisfaction" and its components had a high mean, with the component "the treating physician" having the highest mean. The variables "patient safety culture and hospital performance" had a medium mean. There was a significant positive relationship between patient safety culture-hospital performance, patient safety culture-patient satisfaction, and patient satisfaction-hospital performance.

CONCLUSION

The patient satisfaction level was appropriate in the studied center, and a positive and significant relationship was found between patient safety culture and patient satisfaction and hospital performance.

Cognitive behavioral therapy cannot relieve postoperative pain and improve joint function after total knee arthroplasty in patients aged 70 years and older

PURPOSE

A randomized controlled trial was conducted to investigate whether cognitive behavioral therapy (CBT) can improve postoperative pain, knee function, and negative emotion in patients aged 70 years and older who underwent total knee arthroplasty (TKA).

METHODS

This study used randomized, parallel group, controlled trial to divide the included 90 patients into CBT group and usual care group. The primary outcome measure of the study was the Visual Analogue Scale (VAS) at activity. The secondary outcome measures included the Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), Knee Range of Motion (ROM), Oxford Knee Score (OKS), Hospital for Special Surgery Knee Rating Scale (HSS), analgesics dose, and postoperative complications.

RESULTS

83 patients who met the criteria were randomized into CBT group and usual care group. In the SAS, score of the CBT group decreased by 4.3 points at 7th day and 8.2 at 14th day after surgery with respect to preoperative SAS score, the usual care group increased by 1.5 at 7th day and decreased 1.1 at 14th day, and tended to be similar at 3rd month after surgery. There were no significant differences at 7th and 14th day in SDS, however, score of the CBT group was 5.8 and the usual care group was 1.9 at 3rd month after surgery. No statistically significant differences in VAS at activity, ROM, OKS, HSS, analgesics frequency, and postoperative complications between two groups.

CONCLUSIONS

CBT was superior to usual care group in relieving anxiety at 7th day and 14th day, and depression at 3rd month, however, CBT cannot relieve postoperative pain and improve joint function after TKA in patients aged 70 years and older.

The effect of total knee geometries on kinematics: An experimental study using a crouching machine

Obtaining anatomic knee kinematics after a total knee is likely to improve outcomes. We used a crouching machine to compare the kinematics of standard condylar designs with guided motion designs. The standard condylars included femoral sagittal radii with constant radius, J-curve and G-curve; the tibial surfaces were of low and high constraint. The guided motion designs were a medial pivot and a design with asymmetric condylar shapes and guiding surfaces. The machine had a flexion range from 0° to 125°, applied quadriceps and hamstring loading, and simulated the collateral soft tissues. The kinematics of all standard condylar knees were similar, showing only small anterior-posterior displacements and internal-external rotations. The two asymmetric designs showed posterior displacements during flexion, but less axial rotations than anatomic knees. The quadriceps forces throughout flexion were very similar between all designs, reflecting similar lever arms. It was concluded that standard condylar designs, even with variations in sagittal radii, are unlikely to reproduce anatomic kinematics. On the other hand, designs with asymmetric constraint between medial and lateral sides, and other guiding features, are likely to be the way forward. The mechanical testing method could be further improved by superimposing shear forces and torques during the flexion-extension motion, to include more stressful in vivo functional conditions.

Satisfaction with playing pre-injury sports 1 year after anterior cruciate ligament reconstruction using a hamstring autograft

BACKGROUND

Few studies have examined patient satisfaction with playing pre-injury sports after anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to investigate patient satisfaction with playing pre-injury sport and identify factors associated with satisfaction.

METHODS

A total of 97 patients underwent unilateral ACL reconstruction using a hamstring autograft and returned to pre-injury sports 1 year after surgery. Patient satisfaction with playing pre-injury sport was assessed by a visual analog scale (VAS) and an ordinal four-grade scale. Problems related to the operated knee were also assessed. Knee muscle strength, single leg hop distance, knee laxity, subjective knee pain, and fear of movement/reinjury using Tampa Scale for Kinesiophobia-11 (TSK-11) were measured. Multivariate linear regression analysis was performed to determine the factors associated with patient satisfaction with playing pre-injury sport 1 year after surgery.

RESULTS

The average VAS score for patient satisfaction with playing pre-injury sports 1 year after surgery was 77.8 ± 20.2. Of the 97 patients, 87 patients (89.7%) answered "satisfied" or "mostly satisfied", whereas 51 patients (52.6%) had one or more problems. Multivariate linear regression analysis identified that the TSK-11 score was associated with patient satisfaction with playing a pre-injury sport 1 year after surgery.

CONCLUSION

Most of the patients who returned to pre-injury sports were satisfied with their outcomes. In contrast, approximately half of the patients had one or more problems after returning to play pre-injury sports. In particular, fear of movement/reinjury was significantly associated with patient satisfaction with playing pre-injury sport 1 year after surgery.

Evaluation and Management of a Painful Knee After Total Knee Arthroplasty

Pain after total knee arthroplasty (TKA) is not infrequent and may be indicative of a broad spectrum of prosthesis-related, intra-articular, or extra-articular pathologies. To diagnose and treat the underlying cause of a painful TKA, systematic evaluation of the patient is critical to ensure that they are managed appropriately and expeditiously. This evidence-based review presents current concepts regarding the pathophysiology, etiology, and diagnosis of painful TKA and our recommended approach for management. [Orthopedics. 2021;44(6):341-352.].

What influences patient satisfaction after total knee replacement? A qualitative long-term follow-up study

OBJECTIVES

To explore whether a conceptual model of patient satisfaction previously developed 1-2 years post-total knee replacement (TKR) is still relevant 3-4 years post-TKR. Specifically, (i) what is the stability in satisfaction levels 3-4 years post-TKR? and (ii) does the existing conceptual model of patient satisfaction after TKR apply at this later follow-up?

DESIGN

A constructivist grounded theory qualitative follow-up study. The present study was theoretically governed by the findings of the initial qualitative inquiry. One-on-one semi-structured interviews were used to test the assumptions of the model developed from the findings of the previous study.

SETTING

An urban Australian public hospital PARTICIPANTS: From 40 people who participated in the original study, 11 participants were purposively sampled based on their level of satisfaction and factors driving satisfaction as reported in their first interview. There were six women and five men, the average time since TKR was 3 years and 5 months, and the average age at time of interview was 77 years.

RESULTS

Satisfaction levels were mostly stable with the exception of three participants; two transitioned in a positive direction; one in a negative direction. The meaning of satisfaction and the factors that influenced satisfaction were consistent with the original findings. However, beliefs relating to the influence of ageing on persistent knee symptoms and functional limitations were more dominant in the present study.

CONCLUSIONS

The findings provide support for patient satisfaction being a multifactorial construct that is potentially modifiable over time. Clinicians may apply the conceptual model we have described to optimise satisfaction in patients up to 3-4 years post-TKR.

Intra-Articular Corticosteroid Injection After Total Knee Replacement: Is it Safe?

Recalcitrant pain after total knee replacement (TKR) is sometimes treated with intra-articular steroid injections (IASI), with few studies reporting on the risk of subsequent periprosthetic joint infection (PJI). This is a systematic review to evaluate the incidence and risk of PJI after IASI into a total knee replacement.

We searched online databases using the keywords "total knee replacement," "total knee arthroplasty," "steroids" and "intra-articular injection." A total of 7386 articles (PubMed - 91, Embase - 70, Web of Science - 57, CINAHL - 8, and Google Scholar - 7160) were retrieved on the initial search. After applying exclusion criteria, four articles were included in this review for evaluation and statistical analysis. There were no level one or two studies.

The incidence of infection after IASI at 12 months was 138/6499 or 2.1%, while the incidence of infection rate among controls at 12 months was 158/11256 or 1.4%. A chi-square test showed that the difference in infection rate was significant (p = 0.0002424). A caveat is that simple statistical test results are virtually guaranteed to be statistically significant with large sample size.

IASI into a TKR is not a benign procedure and that may be associated with a significantly increased risk of subsequent periprosthetic joint infection. We, therefore, recommend against IASI into a TKR until better studies can be performed to determine their safety and efficacy.

A randomized controlled trial comparing functional outcomes for navigated kinematically aligned total knee arthroplasty versus navigated mechanically aligned total knee arthroplasty : the MaKKRO trial

Aims

Nearly 99,000 total knee arthroplasties (TKAs) are performed in UK annually. Despite plenty of research, the satisfaction rate of this surgery is around 80%. One of the important intraoperative factors affecting the outcome is alignment. The relationship between joint obliquity and functional outcomes is not well understood. Therefore, a study is required to investigate and compare the effects of two types of alignment (mechanical and kinematic) on functional outcomes and range of motion.

Methods

The aim of the study is to compare navigated kinematically aligned TKAs (KA TKAs) with navigated mechanically aligned TKA (MA TKA) in terms of function and ROM. We aim to recruit a total of 96 patients in the trial. The patients will be recruited from clinics of various consultants working in the trust after screening them for eligibility criteria and obtaining their informed consent to participate in this study. Randomization will be done prior to surgery by a software. The primary outcome measure will be the Knee injury and Osteoarthritis Outcome Score The secondary outcome measures include Oxford Knee Score, ROM, EuroQol five-dimension questionnaire, EuroQol visual analogue scale, 12-Item Short-Form Health Survey (SF-12), and Forgotten Joint Score. The scores will be calculated preoperatively and then at six weeks, six months, and one year after surgery. The scores will undergo a statistical analysis.

Discussion

There is no clear evidence on the best alignment for a knee arthroplasty. This randomized controlled trial will test the null hypothesis that navigated KA TKAs do not perform better than navigated MA TKAs.

Cite this article: Bone Jt Open 2021;2(11):945–950.

Does the anatomic design of total knee prosthesis allow for a better component fit than its nonanatomic predecessor? A matched cohort Study

Background

Total knee arthroplasty (TKA) is considered the most efficient treatment of end-stage osteoarthritis. There is an ongoing debate about proper implant designs and articulation types. One of the considered causes of unsatisfactory outcome and patients’ dissatisfaction is femoral or tibial component overhanging, which can lead to chronic knee pain and restricted motion. The aim of this study is to compare radiological outcomes of TKA using an anatomic PERSONA Posterior-Stabilized (PS) knee design with its nonanatomic predecessor, the NexGen LPS.

Methods

A group of 39 patients who received the PERSONA PS system and 33 patients who received the NexGen LPS was included. PERSONA patients were matched to NexGen patients using a 0.1 propensity score threshold with priority given to exact matches. Anteroposterior, lateral, and long-leg radiographs were taken preoperatively and at 6 weeks postoperatively to perform radiological and statistical analysis.

Results

The PERSONA subgroup had statistically higher posterior condylar offset. There is no statistically significant difference in posterior condylar offset ratio. There were less cases of femoral notching, femoral overhang, and placing tibial baseplate in the medial overhang in the PERSONA PS subgroup than in the NexGen subgroup (each statistically significant). Occurrence of tibial underhang was not statistically significant.

Conclusion

Radiological assessment in short-term follow-up showed excellent results for PERSONA knee design with better fit to native femur and tibia. In comparison to its predecessor, it also spares more bone tissue. As the aforementioned parameters are risk factors of lesser clinical outcomes, the PERSONA design gives high hopes for improvement of TKA satisfaction rate.

Depression and anxiety correlate differentially with dissatisfaction with healthcare services in older adults: The Yilan Study, Taiwan

BACKGROUND/PURPOSE

Previous studies have seldom investigated the psychological factors that are associated with dissatisfaction with healthcare services. We therefore examined the associations of depression and anxiety with service dissatisfaction among older adults.

METHODS

A community-based health survey was conducted from 2012 to 2016. Residents aged ≥65 years were randomly recruited from Yilan City, Taiwan. Besides overall dissatisfaction, we assessed dissatisfaction with physicians' ability, physicians' attitude, and waiting time. The Hospital Anxiety and Depression Scale was used to detect depressive and anxiety symptoms with optimal cut-off points of 3 for the anxiety subscale and 6 for the depression subscales.

RESULTS

Of the 3480 residents included in this study, the overall dissatisfaction rate was 7.9%. After controlling for covariates, depressive and anxiety symptoms were consistently correlated with the various dimensions of dissatisfaction. More specifically, depressive symptoms were associated with overall dissatisfaction and dissatisfaction with physicians' ability and attitude. Conversely, anxiety was uniquely associated with dissatisfaction with waiting time.

CONCLUSION

Psychological symptoms were consistent correlates of dissatisfaction with healthcare services among older adults, although the specific symptoms had different associations with the various dimensions of dissatisfaction.

Factors Influencing Patient Satisfaction With Care and Surgical Outcomes for Total Hip and Knee Replacement

INTRODUCTION

Although patient satisfaction with total joint arthroplasty has been a well-measured outcome, little is known about how preadmission and post-discharge care experiences affect patients' rating of satisfaction.

OBJECTIVE

This work aimed to identify actionable factors associated with better ratings of overall care and surgical results.

METHODS

A 36-item survey assessing care in the preoperative, perioperative, and post-discharge phases of care and across all phases was mailed to 7,031 patients who underwent primary unilateral elective total hip arthroplasty and total knee arthroplasty in 2018. Exploratory factor analysis identified 7 actionable domains. Stepwise logistic regression models identified domains associated with ratings of overall care and satisfaction with surgical outcome.

RESULTS

Of the 3,026 (43%) patients who returned the survey; 2,814 (93%) rated their overall experience of care as very good or excellent and satisfaction with surgical results as ≥ 7 on a 10-point scale. In exploratory factor analysis, four factors predicted higher ratings of both overall care and surgical outcome: knowing what to do with symptoms and pain during recovery (factor 1), self-reported health (factor 3), knowing what to expect before surgery (factor 4), and shared decision making (factor 6). Coordinated information among providers (factor 2), home health experience (factor 5), and patient-provider relationships (factor 7) also predicted overall care ratings.

CONCLUSION

Patient-centered quality improvement in total joint replacement care requires thinking of care across the entire episode, including before and after the hospital stay for surgery, in addition to perioperative care. The actionable factors identified from this study can be incorporated into total joint replacement care to improve patients' satisfaction with overall care and surgical results.

Preoperative and intraoperative factors contributing to patient satisfaction after bi-cruciate stabilized total knee arthroplasty

BACKGROUND

One of the causes of dissatisfaction following total knee arthroplasty (TKA) is abnormal knee kinematics. A newly designed bi-cruciate stabilized (BCS) TKA system has been developed to produce close-to-normal kinematics because of its anatomic tibiofemoral articular geometry and cam-post mechanism. Although BCS TKA is expected to improve patient satisfaction, no reports have described the appropriate technique or soft tissue handling required to achieve excellent satisfaction with BCS TKA. This study is to identify preoperative and intraoperative predictors of patient satisfaction after BCS TKA.

METHODS

Altogether, we studied 113 knees with primary varus knee osteoarthritis that underwent BCS TKA with a navigation system. Preoperative parameters including Knee Society Score and patient-reported scores [the Knee injury and Osteoarthritis Outcome Score (KOOS)] and intraoperative parameters including coronal, sagittal and axial alignment and joint laxity in each compartment that affected patient satisfaction was evaluated. Satisfaction score was evaluated with use of the 2011 Knee Society Scoring system. The multivariate regression analysis included age and preoperative and intraoperative parameters that correlated with satisfaction scores in the univariate analysis (P < 0.05).

RESULTS

The mean satisfaction score was 28.2 ± 6.1. Multivariate regression analysis showed that the predictors of patient satisfaction were a preoperative high KOOS score for activities of daily living (P < 0.001), male sex (P = 0.005), older age (P = 0.027), and minimal medial joint laxity during flexion (P = 0.031).

CONCLUSION

When performing BCS TKA, surgeons should pay attention to maintaining proper stability of the medial compartment, especially during flexion.

[Short-term effectiveness of novel computer navigation system assisted total knee arthroplasty]

Objective

To investigate the short-term effectiveness of novel computer navigation system (Knee 3 software; Brainlab, Germany) assisted total knee arthroplasty (TKA).

Methods

Between July 2020 and December 2020, 19 patients underwent unilateral TKA assisted with Knee 3 software. There were 4 males and 15 females. The mean age was 66.3 years (range, 52-79 years). Eighteen patients were diagnosed with osteoarthritis and 1 patient with rheumatoid arthritis. Sixteen patients had varus knees and 3 patients had valgus knees. Preoperative Western Ontario and McMaster University Osteoarthritis Index (WOMAC) pain, stiffness, function, and total scores were 12.4±3.4, 2 (1, 4), 22 (18, 29), and 37 (29, 43), respectively. Intraoperatively, the medial and lateral gaps in knee extension and in 90° of knee flexion were recorded. The operation time, intraoperative blood loss, blood transfusion, and complications were recorded. The hip-knee-ankle angle (HKA), lateral distal femoral angle, and medial proximal tibial angle were measured to evaluate lower limb alignment and prostheses's alignment using X-ray films at 6 weeks after operation. Patient's satisfaction rate and WOMAC pain, stiffness, function, and total scores were investigated.

Results

Eighteen patients (94.7%) had medial- lateral gap balancing in knee extension, 18 patients (94.7%) had medial-lateral gap balancing in 90° of knee flexion, 19 patients (100%) had medial gap balancing between knee extension and 90° of knee flexion, and 18 patients (94.7%) had lateral gap balancing between knee extension and 90° of knee flexion. The mean operation time was 126 minutes (range, 100-200 minutes). The mean intraoperative blood loss was 205 mL (range, 100-400 mL). Patients were followed up 4-8 months, with an average of 6.2 months. Postoperative complications included 1 deep vein thrombosis of lower extremities and 1 cerebral infarction. X-ray films showed that the mean HKA, lateral distal femoral angle, and medial proximal tibial angle were 179.8° (range, 178°-182°), 83.5° (range, 80°-87°), and 89.5° (range, 87°-93°), respectively. At last follow-up, WOMAC pain, stiffness, function, and total scores were 3.6±1.9, 0 (0, 2), 4 (2, 6), and 9 (5, 10), respectively, which improved when compared with preoperative scores ( P<0.05). Twelve patients were very satisfied with the operation results and 7 patients were satisfied with the operation results. The overall satisfaction rate was 100%.

Conclusion

Knee 3 software can help to obtain good gap balancing and optimal lower limb alignment, with high patient's satisfaction and good short-term effecectiveness.

Factors Affecting the Satisfaction Levels of Patients who Underwent Orthopedic Knee Surgery in the Early Postoperative Period

The aim of this study was to investigate the effects of biopsychosocial parameters in the early postoperative period on the satisfaction of patients. Seventy-seven patients (female/male: 61/16, age: 40.28 ± 17.67 years) who underwent arthroscopic meniscectomy (n = 43), anterior cruciate ligament reconstruction (n = 25) and total knee arthroplasty (n = 9) were included in this study. The satisfaction levelwas evaluated using the Orthopedics Service Inpatient Satisfaction Survey (OTISS). In addition, the pain intensity, anxiety, depression, and independence level in daily living activities of the patients were evaluated. There was a very weak negative correlation between the anxiety and the satisfaction level with the physiotherapist and secretary (r: -0.274, p: 0.016; r:-0.265, p: 0.020). A very weak negative correlation was found between the pain intensity at activity and satisfaction with the nurse (r: -0.227, p: 0.048). There were very weak correlations between feeding and satisfaction with the physiotherapist (r: 0.292, p: 0.010), secretary (r: 0.285, p: 0.012), doctor (r: -0.269, p: 0.018), nurse (r: 0.300, p: 0.008) general satisfaction (r: 0.251, p: 0.028) and OTISS total score (r: -0.305, p: 0.007). In conclusion, the pain intensity, anxiety, and independence level in the early postoperative period were related to the satisfaction levels of patients who have undergone orthopedic knee surgery.

Navigation und Robotik in der Knieendoprothetik

Hintergrund

Die Langlebigkeit einer Knieprothese hängt von der korrekten Ausrichtung der Prothesenkomponenten und der mechanischen Achse des Beins sowie einer optimalen Weichteilbalancierung ab. Um dieses Ziel präziser und sicherer zu erreichen, wurde die computerassistierte Chirurgie entwickelt. Ziel dieses Artikels ist es, die Navigation und Robotik zu bewerten und die aktuellen Ergebnisse zu diskutieren.

Methode

Umfassende Literaturrecherche in der Datenbank PubMed und dem Suchdienst Google Scholar.

Ergebnisse

Die computerassistierte Chirurgie führt zu einer präziseren Ausrichtung der mechanischen Beinachse und der Positionierung der Prothesenkomponenten. Trotzdem sind die klinischen Ergebnisse zur Kniefunktion und die Resultate der patientenbezogenen Fragebögen (PROMs) kontrovers. Sie zeigen, wie für die Überlebensrate, keinen signifikanten Unterschied zur konventionellen Technik. Hohe Anschaffungs- und Unterhaltskosten limitieren zudem die Verbreitung dieser Systeme.

Schlussfolgerung

Momentan bietet die bildgestützte Navigation dem Chirurgen bei gewissen Operationsschritten eine wertvolle Unterstützung für ein präziseres und sichereres Arbeiten. Trotzdem sind Langzeitstudien zur Kniefunktion, zu den PROMs, zur Überlebensrate dringend erforderlich. In der Robotik zeigen nur kurzfristige Ergebnisse ähnliche Trends wie bei der Navigation. Die Robotiksysteme müssen und werden sich weiterentwickeln, um den Anforderungen der Nutzer und Patienten zu entsprechen (Kosten, Größe, Programmierung).

Validation of the Spanish version of the Goodman score in total hip arthroplasty

PURPOSE

Currently, patient-reported outcome measures (PROMs) are the standard instruments used to compare arthroplasty results. Goodman et al. recently published a well-constructed scale with excellent psychometric properties that can be quickly administered. The main objective of our study was to translate, culturally adapt, and validate a Spanish version of the Goodman questionnaire in patients who underwent total hip arthroplasty (THA).

METHODS

The original Goodman scale was translated into Spanish and cross-culturally adapted. Then, the data from this version were tested for psychometric quality. We designed a cross-sectional study for data collection. This study enrolled 2 institutions. Patients who underwent hip replacement due to primary osteoarthritis secondary to dysplasia between 1 January 2018 and 31 December 2019 were included. A total of 153 patients were contacted twice to record the Goodman and Oxford hip scales (OHS) to assess the validity of the questionnaire. Reliability was tested using the Cronbach's alpha, Concordance using 3 test: intraclass correlation coefficient (ICC), Lin's concordance correlation coefficient (CCC), and the Bradley-Blackwood F test. The spearman correlation was used to asses correlation between the OHS and the Spanish-adapted Goodman scale.

RESULTS

The overall satisfaction after THA was reported to be "very satisfied" by 137 patients (75%), and only 14 patients reported some degree of dissatisfaction (6%). The improvement in quality of life was reported to be "more than I ever dreamed possible" by 41% patients. Cronbach's alpha was acceptable, reaching a coefficient of 0.95 (95% confidence interval, 0.82-1). No statistical difference (t test, p = 0.55) was found in the original version, with great internal validity. Test re-test concordance was optimal among the 3 tests used. A moderate correlation was found between the OHS and the Spanish-adapted Goodman scale.

CONCLUSION

The Spanish version of the Goodman questionnaire in THA is a reliable, consistent, and feasible scale to evaluate patient satisfaction and improvement in the quality of life in Spanish speakers.

Patients With High Chronic Postoperative Knee Pain 5 Years After Total Knee Replacement Demonstrate Low-grad Inflammation, Impairment of Function, and High Levels of Pain Catastrophizing

OBJECTIVES

Total knee replacement (TKR) normally provides improvements of physical function and reduces pain. However, ∼20% of the patients report chronic postoperative knee pain. The aims of the present study were to assess the pain, physical function, and physiological characteristics 5 years after TKR surgery.

MATERIALS AND METHODS

Eighty patients were recruited 5 years after TKR and divided into 2 groups based on their average 24-hour knee pain intensity assessed on a visual analog scale (VAS 0 to 10) ("high pain group": VAS≥3; "low pain group": VAS<3). The patients completed the PainDETECT Questionnaire (PDQ), Oxford Knee Score (OKS), Pain Catastrophizing Scale, and Forgotten Joint Score-12. Furthermore, the patients underwent a clinical examination of the knees and high-sensitivity serum C-reactive protein was measured as an inflammatory marker.

RESULTS

A total of 53% of the patients in the high pain group were not satisfied with the outcome, while only 11% of the patients in the low pain group was not satisfied, and the pain intensities in the 2 groups were 5.1 (4.6 to 5 to 6) and 1.1 (0.6 to 1.5) (P<0.001), respectively. Furthermore, the high pain group demonstrates worse scores in: Forgotten Joint Score-12 (P=0.001), OKS function (P<0.001), OKS pain (P<0.001), and Pain Catastrophizing Scale (P<0.001).The high pain group demonstrated increased level of high-sensitivity serum C-reactive protein (4.3 mg/L [3.2 to 5.5] vs. 1.7 mg/L [1.2 to 2.2], P<0.001), and decreased range of motion in the knee (110 vs. 119-degree range of motion, P=0.013).

DISCUSSION

Patients with high chronic postoperative knee pain 5 years after TKR demonstrate decreased physical function, higher levels of catastrophizing thoughts, and increased levels of inflammation.

Utilisation of outpatient physiotherapy in patients following total knee arthroplasty - a systematic review

OBJECTIVE

Data on the utilisation of outpatient physiotherapy (PT) in patients following total knee arthroplasty (TKA) are scarce, and available studies have not been systematically synthesised. This study aims to summarise the existing literature on outpatient PT following TKA as well as to identify factors associated with its use.

METHODS

A systematic literature search in MEDLINE (via PubMed), CINAHL, Scopus and PEDro was conducted in July 2020 without language restrictions. Two authors independently selected studies, extracted data and assessed study quality. The primary outcome was the proportion being treated with at least one session of outpatient PT (land- or water-based treatments supervised/provided by a qualified physiotherapist) during any defined period within 12 months following TKA. Furthermore, predictors for the use of PT were assessed. Studies including only revision surgeries or bilateral TKA were excluded.

RESULTS

After screening 1934 titles/abstracts and 56 full text articles, 5 studies were included. Proportions of PT utilisation ranged from 16.7 to 84.5%. There were large variations in the time periods after hospital discharge (4 weeks to 12 months) and in the reporting of PT definitions. Female sex was associated with higher PT utilisation, and compared to patients after total hip arthroplasty, utilisation was higher among those following TKA.

CONCLUSION

Despite using a broad search strategy, we found only 5 studies assessing the utilisation of PT after hospital discharge in patients with TKA. These studies showed large heterogeneity in PT utilisation, assessed time periods and PT definitions. Clearly, more studies from different countries with uniform PT definitions are needed to address this relevant public health question.