Patient Reviews Six Months Post Op Knee Replacement
Knee Surg Relat Res. 2016 Mar; 28(1): 1–15.
Patient Satisfaction after Total Knee Arthroplasty
Immature-Joon Choi
Department of Orthopedic Surgery, Gangneung Asan Hospital, Ulsan University Higher of Medicine, Gangneung, Korea.
Ho Jong Ra
Department of Orthopedic Surgery, Gangneung Asan Hospital, Ulsan Academy College of Medicine, Gangneung, Korea.
Received 2015 Apr 16; Revised 2015 Aug 12; Accepted 2015 Sep 12.
Abstract
Full human knee arthroplasty (TKA) is ane of the virtually successful and effective surgical options to reduce pain and restore function for patients with severe osteoarthritis. The purpose of this article was to review and summarize the contempo literatures regarding patient satisfaction afterwards TKA and to clarify the various factors associated with patient dissatisfaction after TKA. Patient satisfaction is one of the many patient-reported outcome measures (PROMs). Patient satisfaction can be evaluated from ii categories, determinants of satisfaction and components of satisfaction. The former have been described as all of the patient-related factors including age, gender, personality, patient expectations, medical and psychiatric comorbidity, patient'south diagnosis leading to TKA and severity of arthropathy. The latter are all of the processes and technical aspects of TKA, ranging from the anesthetic and surgical factors, type of implants and postoperative rehabilitations. The surgeon- and patient-reported outcomes have been shown to exist disparate occasionally. Among various factors that contribute to patient satisfaction, some factors can be managed past the surgeon, which should be improved through continuous research. Furthermore, extensive discussion and explanation before surgery will reduce patient dissatisfaction after TKA.
Keywords: Knee, Osteoarthritis, Arthroplasty, Satisfaction
Introduction
Total knee arthroplasty (TKA) is one of the most constructive surgical interventions for pain relief and functional recovery in patients with advanced degenerative arthritis or rheumatoid arthritis1). Aging of the gild has led to increases in the prevalence of arthritis and the incidence of TKA for end-stage arthritis. Accordingly, the outcomes of TKA accept been reported in a multitude of studies, most of which being centered on the outcomes measured from the surgeon's perspective, such as the implant survivorship, postoperative range of move (ROM), and radiographic improvement However, it is not uncommon to run into a situation where a treatment rated successful from the surgeon's perspective fails to deliver patient satisfaction. In general, patients tend to be less satisfied with treatment outcomes than does the surgeon2,3). Harris et al.4) reported there was a discordance between patient satisfaction and surgeon satisfaction (90.3% vs. 94.v%) in 331 TKA patients at 12 months after surgery.
They attributed this mainly to the preoperative level of patient expectation and development of complications. In an endeavour to overcome the discrepancy in patient-surgeon satisfaction, patient-reported outcome measures (PROMs) designed for the objective assessment of patient satisfaction with a treatment have been devised2,5,half-dozen).
In this review article, nosotros will summarize recent literatures regarding patient satisfaction after TKA, depict currently available PROMs, and investigate various causes and predictors of patient dissatisfaction afterward TKA.
1. Patient Satisfaction
The concept of patient satisfaction was first defined past Ware et al.7) in 1873. Patient satisfaction later on TKA tin can be associated with patients' expectations, pain relief, and functional improvement. Lau et al.two) suggested that following two perspectives, internal determinants and external components, should exist considered in the evaluation of patient satisfaction. The former refers to patient-dependent factors, such as age and expectations, whereas the latter indicates patient-contained factors, such as hospital surroundings and surgical technique. Patient satisfaction after TKA has been described as ranging from 75% to 92%. Based on a review of the Swedish Knee joint Arthroplasty Registry, Dunbar et al.8) reported that 17% of the patients were non satisfied with the outcome of TKA. Schulze and Scharf9) conducted a systematic review of studies on patient satisfaction after TKA assessed between 1990–1999 and 2000–2012, which showed patient satisfaction increased from 81.2% in the erstwhile decade to 85% in the latter thirteen years. Baker et al.10) reviewed the data from the National Articulation Registry for England and Wales: 71% of the patients perceived improvement of knee symptoms, but simply 22% rated the results every bit 'first-class'. Kim et al.11) reported that in spite of the clear testify of improvement subsequently TKA in terms of restoration of daily living activities and hurting relief, patient satisfaction level was moderate.
two. Patient Satisfaction Measurement Tools
The Knee Gild Clinical Rating Organization (Appendix 1) has been widely used since 1989 as a relatively objective scoring system for the assessment of TKA outcomes in spite of deficiencies in the items for patient satisfaction cess. The new Human knee Lodge Knee Scoring Arrangement was introduced in 2011 to incorporate patient-reported outcome assessment scales (satisfaction, expectations, and concrete activities) in the rating system12) (Appendix two). Other popular PROMs include the 36-item Brusque Form Wellness Survey (SF-36)13), the 12-particular Short Grade Health Survey (SF-12), the Western Ontario and McMaster Universities Arthritis Index (WOMAC)14), the Knee joint injury and Osteoarthritis Outcome Score (KOOS)15), and the Oxford human knee score (OKS)16) (Appendix 3,4,5,6,7). The SF-36 is a mensurate of general health country including emotional and mental health. The WOMAC is widely used as a disease-specific mensurate in patients with osteoarthritis to evaluate the efficacy of surgical and not-surgical interventions. The KOOS is a cocky-administered questionnaire designed to assess the outcome of handling of inductive cruciate ligament injuries and meniscus injuries. The OKS has been recognized as 1 of the most constructive affliction-specific measures for patients with degenerative arthritis, which correlates strongly with hurting but less with postoperative functioning17). Amid the items that are included in these PROMs, pain, mobility, physical function, and mental health are known equally principal factors influencing patient satisfaction.
3. Patient Dissatisfaction: Causes and Types
The well-nigh mutual causes of patient dissatisfaction include balance pain and limited function; notwithstanding, pain relief and functional recovery accept demonstrated no pregnant correlation in many studies. Judge et al.18) reported that postoperative hurting was associated with the preoperative diagnosis, such as rheumatoid arthritis, and patient's mental status, such every bit anxiety and depression, whereas functional recovery was afflicted past age and gender. Scott et al.19) noted that a loftier percent of patients were non satisfied with their ability to kneel, squat, and climb stairs subsequently TKA. Co-ordinate to Ghomrawi et al.20), patients with expectations of loftier-level activities and extreme ROM reported dissatisfaction after TKA. In a report by Parvizi et al.21), 89% of the patients were satisfied with their power to perform daily living activities and 91% were satisfied in terms of pain relief. In the study, notwithstanding, merely 66% reported their knees felt normal, 33% had lingering pain, 41% suffered from stiffness, 33% complained of bothering racket, swelling, or tightness, and difficulty in getting in and out of a car, getting up and down from a chair, and climbing up and down stairs were reported in 38%, 31%, and 54%, respectively.
iv. Internal Determinants of Patient Satisfaction
The possible internal determinants of patient satisfaction include age, gender, patient'due south personality, patient'southward expectations, physical and psychological comorbidities, diagnosis for TKA, and the severity of arthropathy.
i) Historic period
There is still no consensus on the influence of age on patient satisfaction. Patients were more satisfied with the outcome of TKA when they were 60 years or younger in a study by Noble et al.22). According to Scott et al.19), younger patients tended to report their expectations were met subsequently surgery, and thus obtained greater satisfaction with the treatment outcomes. On the other mitt, Williams et al.23) reported that patient satisfaction was significantly low among patients less than 55 years of age. Parvizi et al.21) described that remainder symptoms and functional deficits were more prevalent in younger patients. Von Keudell et al.24) documented that satisfaction with postoperative hurting, ROM, and kneeling was college afterward unicompartmental knee arthroplasty in patients less than 55 years of age, whereas TKA provided greater satisfaction in patients more than 65 years of age. Therefore, it is hard to determine whether age is predictive of the consequence of TKA. Information technology appears that biological historic period, rather than chronological age, has a greater role in functional recovery after TKA.
2) Gender
Residual hurting and stiffness are likely to be more prevalent in female TKA patients25,26). However, it has not been sufficiently established as to whether gender is a predictive gene of patient satisfaction.
3) Patient's personality
Gong and Dong27) retrospectively investigated the relationship betwixt the outcomes of TKA and patient'south personality classified into 4 types: patients with extroverted personality were more satisfied than those with introverted or anxious personality later on TKA. In our opinion, however, the influence of personality on the outcome of TKA is non straightforward to make up one's mind due to the difficulty of categorizing diverse homo personalities.
4) Patient'south expectations
The degree to which patients' expectations are met can be an important predictor of patient satisfaction. Bourne et al.28) reported that unmet expectations were the strongest predictor of dissatisfaction later TKA. Scott et al.29) likewise showed a close correlation between patients' expectations and their satisfaction. Nevertheless, patient's expectations tend to exist higher than the surgeon's4,twenty). Initially later TKA, patients are mostly concerned with pain relief. In the long-term, however, they expect to recover symptomfree functions for activities that personally matter to themselves. While surgeons relate to the patients' long-term goals, they are well aware that such expectations may not be fulfilled30). Therefore, information technology is an important role of the surgeon to inform the patient of the possibility of unmet expectations. Opposite to these results, recent systemic reviews past Haanstra et al.31) and Culliton et al.32) have shown that there is no notable association betwixt patient's expectations and postoperative satisfaction, suggesting the need for more objective measures of assessment.
5) Comorbidities
Comorbidities have been established as a predictor of patient dissatisfaction afterward TKA33) in a multitude of studies. Scott et al.29) demonstrated that preoperative dorsum pain or hurting in the other joints was significantly associated with postoperative dissatisfaction. Singh and Lewallen34) reported that postoperative pain was severer in patients with medical or psychological comorbidities. Clement and Burnett35) showed generic physical health was related to patient satisfaction. Vissers et al.36) observed patients with low preoperative mental wellness based on the SF-12 and SF-36 scores obtained poor outcomes in terms of pain relief and functional improvement. Wylde et al.37) reported that patients with medical comorbidities were more likely to feel pain or functional disability later on TKA. Fisher et al.26) noted a college incidence of express mobility afterward TKA in patients with diabetes or pulmonary affliction. Although the prevalence of anxiety and depressive symptoms that are high in patients scheduled for TKA decreases significantly later surgery38), these patients tend to have lower satisfaction afterward surgery than those without preoperative comorbidities18,37,38). On the other manus, some studies have shown that preoperative low does not bear upon postoperative function36). Rather, patients with preoperative depression appear to obtain higher level of satisfaction afterward TKA than those without39).
6) Diagnosis for TKA
Rheumatoid arthritis patients have been reported to have greater satisfaction than patients with other indications for surgery18). This tin can be attributed either to 1) the fact that the about of import expectation amid rheumatoid arthritis patients is pain relief, whereas patients with other diseases are more concerned with functional improvement40) or to two) the relatively depression expectation among patients with rheumatoid arthritis41).
7) Severity of arthropathy
Bourne et al.28) reported the postoperative satisfaction was low amongst patients who complained of astringent pain while resting, lying in a bed, or sitting on a chair before surgery. On the other paw, Maratt et al.42) described that patients with severe pain or dysfunction before surgery were more likely to be satisfied after surgery equally long every bit the preoperative symptoms did not cause astringent disruption in health-related quality of life. Kim et al.43) reported patient'south dissatisfaction with TKA was associated with poor preoperative WOMAC score, indicating that terminate-phase arthritis patients are likely to have a low level of satisfaction. However, Schnurr et al.44) have recently shown that patients with mild or moderate osteoarthritis are at an elevated risk for dissatisfaction afterward TKA. In a study past Polkowski et al.45), the incidence of unexplained pain after TKA was higher in patients with early on-stage osteoarthritis before surgery.
viii) Other factors
Fisher et al.26) reported high torso mass index, previous history of human knee surgery, and disabilities as patient factors that could contribute to poor satisfaction subsequently TKA. Other factors that can be associated with postoperative dissatisfaction include low social support and poverty18,37), living alone28), and postoperative varus knee joint alignment3). Isle of mann et al.46) observed improvements in outcome scores after revision TKA when it was performed past a different surgeon from the primary TKA that was considered as failure; therefore, they concluded that dissatisfaction with a previous TKA does not predispose to continued dissatisfaction later revision.
5. External Components of Patient Satisfaction
External components that tin can be associated with patient satisfaction include anesthesia, postoperative hurting management, surgical technique, implant type, and postoperative rehabilitation.
1) Anesthesia and postoperative hurting management
Some studies take associated anesthesia and postoperative hurting management with patient satisfaction. In full general, TKA is performed under regional or full general anesthesia. According to a literature review by Fischer et al.47), regional anesthesia appears to result in greater patient satisfaction after TKA. Withal, in a study past Harsten et al.48) where the results of TKA were compared among patients randomly allocated to receive either general anesthesia or spinal anesthesia during surgery, the general anesthesia group obtained more favorable results than the spinal anesthesia grouping in terms of early recovery, pain relief, dizziness or nausea, and early ambulation. A multifariousness of attempts have been fabricated for initial pain relief afterward TKA and ultimately for improved patient satisfaction. In the past, narcotic analgesics were prescribed for pain control after TKA; withal, information technology is used less frequently these days due to the risk of complications49). According to Andersen and Kehlet50), intraoperative periarticular injections may contribute to pain relief and reduced use of narcotic analgesics. Femoral nervus blocks that are effective for postoperative hurting management may likewise decrease the need for narcotic analgesics51). However, consensus on the efficacy of sciatic nervus occludent still remains elusive52,53).
2) Surgical technique
Minimally invasive TKA performed through a small incision accelerates recovery later surgery. Thus, information technology has been expected to improve patient satisfaction after TKA. Withal, Hernandez-Vaquero et al.54) reported that minimally invasive technique and the traditional surgical technique did not demonstrate meaning differences in satisfaction among TKA patients. Therefore, the influence of surgical technique on patient satisfaction should be investigated in farther research.
3) Type of implant
In spite of being established as an constructive surgical technique, TKA has evolved continuously to improve accommodate patients' desire for functional improvement. The bear upon of implant design on the upshot of TKA has been studied past many researchers, and some of which take demonstrated a relationship betwixt the type of implant and postoperative satisfaction. Hamilton et al.55) conducted a prospective, double-bullheaded randomized control trial for comparing of Kinemax TKA and Triathlon TKA, which showed that the outcome of TKA could be influenced by the prosthesis design. Bakery et al.56) carried out comparisons of half dozen different TKA implants: the NexGen implant (Zimmer, Warsaw, IN, U.s.a.) resulted in greater improvement after TKA than the other 5 implant types. Contrary to these studies, a multi-center randomized controlled trial by Wylde et al.57) showed no significant difference in patient satisfaction between the Kinemax fixed- and mobile-bearing TKA.
4) Postoperative rehabilitation
Recently, Levine et al.58) reported that rehabilitation managed by a physical therapist did non result in difference in patient satisfaction and functioning compared to neuromuscular electrical stimulation performed at home without therapist's supervision. Kim et al.59) too reported that regular passive ROM exercises did not offer boosted clinical benefits to TKA patients. Notwithstanding, we believe that systematic rehabilitation guided past a concrete therapist would be conducive to a more rapid return to normal daily activities.
Conclusions
TKA has been recognized as a successful treatment for knee arthritis that delivers relatively high satisfaction compared to the other surgical treatments from the orthopedic surgeon'south perspective. However, information technology is not uncommon to detect discrepancies in patient-surgeon satisfaction: patients are ofttimes less satisfied the outcome than the surgeons expect, suggesting the need to develop more objective patient satisfaction measures. Among various factors that contribute to patient satisfaction, some factors tin can be managed past the surgeon, which should exist improved through continuous research. One of the factors about strongly associated with postoperative satisfaction is patient's expectations: unmet expectations result in dissatisfaction. Therefore, it is important for surgeons to reach an understanding with patients on the possible benefits and risks of TKA through extensive discussion and caption before surgery in order to reduce the likelihood of patient dissatisfaction.
Appendix 1
Articulatio genus Society Score (KSS)
Appendix ii
The New Articulatio genus Order Score
Appendix iii
Short Class Health Survey (SF-36)
This survey asks for your views nearly your health. This information volition help yous go on runway of how you feel and how well you are able to practice your usual activities.
Respond every question by selecting the reply as indicated. If you are unsure virtually how to answer a question, please give the best respond you tin.
Appendix 4
Short Form Health Survey (SF-12)
This survey asks for your views about your health. This information will help yous keep track of how yous feel and how well you are able to exercise your usual activities. Respond every question by selecting the answer equally indicated. If you are unsure about how to reply a question, please give the best answer you tin.
Appendix v
The Western Ontario and McMaster Universities (WOMAC) Alphabetize of Osteoarthritis
Overview:
The WOMAC Index is used to appraise patients with osteoarthritis of the hip or knee using 24 parameters. It can exist used to monitor the course of the illness or to make up one's mind the effectiveness of anti-rheumatic medications.
While the alphabetize was beingness developed performance of social functions and the status of emotional function were also included. These were non included in the terminal musical instrument.
Appendix 6
Knee Injury and Osteoarthritis Outcome Score (KOOS)
Appendix seven
Oxford Knee Score (OKS)
Please respond the following 12 multiple choice questions (during the past 4 weeks).
Footnotes
Conflict of Interest: No potential conflict of interest relevant to this article was reported.
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Articles from Knee Surgery & Related Research are provided here courtesy of Korean Knee joint Club
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4779800/