Several patient-reported outcome measures (PROMs) have been used to assess improvement in the quality of life following total knee arthroplasty (TKA). However, there is paucity of studies evaluating the sleep quality and knee function following TKA. The primary aim of our study was to evaluate the sleep quality and knee function in primary TKA patients using the Pittsburgh Sleep Quality Index (PSQI) and Knee Society Score (KSS), respectively. The secondary aim was to assess the correlation between the two outcome measures over the course of first post-operative year following TKA. One hundred sixty-eight patients (female-140/male-28) with mean age of 64.63 years (± 7.50) who underwent 168 primary unilateral TKA using a cemented posterior-stabilised implant without patella resurfacing between June 2018 and October 2018 were included in the study. Global PSQI and KSS were recorded pre-operatively and post-operatively weekly up to six weeks and at one year. Body mass index (BMI) and Charlson comorbidity index (CCI) were recorded during pre-operative assessment. Mean(± SD) BMI and CCI were 28.45(± 4.64) and 2.48(± 0.93), respectively. Pre-operative global PSQI of 1.98(± 0.97) increased to 13.48(± 3.36) in the first post-operative week (p < 0.001) and remained high during all the six weeks following TKA (p < 0.001), whereas at the first post-operative year, it reduced to 2.10(± 1.15) (p = 0.15). Pre-operative KSS of 52.00(± 9.98) increased to 71.67(± 6.58) and 85.49(± 4.67) at 6 weeks and the first post-operative year respectively (p < 0.001). Pre-operative global PSQI had moderate correlation with pre-operative KSS (r = 0.39) (p < 0.001). Strong correlation was noted between pre-operative global PSQI and six week post-operative KSS (r = 0.47) (p < 0.001). Low correlation was noted between pre-operative global PSQI and KSS at the first post-operative year (r = 0.10, p = 0.19) following TKA. Multiple regression analysis revealed age, CCI, and pre-operative range of motion as independent predictors of global PSQI. Patients undergoing TKA experience changes in sleep quality but report an overall improvement in knee function during the first post-operative year. Sleep quality has moderate to strong correlation with knee function in the early post-operative period beyond which there is a low correlation with knee function thereby suggesting a transient phenomenon. Hence patients undergoing TKA can be appropriately counselled regarding the variation in sleep quality in the post-operative period and reassured accordingly.

Temporal changes in sleep quality and knee function following primary total knee arthroplasty: a prospective study.

There is increasing evidence that patient-reported outcomes following total knee arthroplasty (TKA) are associated with psychosocial factors and pain catastrophizing. Sleep disturbance, pain, and mental health have a complex interaction, which, if unrecognized, can be associated with impaired patient-reported outcomes and dissatisfaction following TKA.The gold standard of objective sleep assessment is polysomnography, which is not feasible to use routinely for TKA patients. Wearable devices are a validated and less costly alternative.Subjective sleep measures, such as the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, or Patient-Reported Outcomes Measurement Information System (PROMIS) computerized adaptive test sleep domains, are simple to administer and provide additional insight into sleep disturbance. Although objective and subjective measures do not correlate precisely, they can be informative together.Sleep disturbances in the elderly population are common and multifactorial in etiology, stemming from the interplay of sleep disorders, medication side effects, and pain. Commonly prescribed medications following TKA as well as postoperative pain can exacerbate underlying sleep disturbances.Obstructive sleep apnea (OSA) is prevalent in patients seeking TKA. In the setting of OSA, postoperative opioids can cause respiratory depression, resulting in consequences as severe as death. A standardized multimodal pain protocol including anti-inflammatories and gamma-aminobutyric acid (GABA) analogues may allow for decreased reliance on opioids for pain control.Surgeons should reassure patients that postoperative sleep disturbance is common and transient, collaborate with the patient's primary care doctor to address sleep disturbance, and avoid prescription of pharmaceutical sleep aids. 

Sleep Disturbances and Disorders in Patients with Knee Osteoarthritis and Total Knee Arthroplasty

Background Disruptions in sleep and pain are frequent complaints following total knee arthroplasty (TKA). Perioperative sleep disturbances may lead to decreased pain tolerance as well as other consequences. The purpose of this study is to evaluate the effectiveness of self-guided meditation for improving sleep quality following TKA. Methods TKA patients, at a single institution, between August 2019 and March 2020 were exposed to a self-guided meditation video during the perioperative period via an online, digital platform. Patients were given an institutionally designed questionnaire to assess sleep quality in the perioperative period. Knee injury and Osteoarthritis Outcome Score-Joint Replacement form, Veterans RAND 12-item Health Survey, and satisfaction scores were also collected. Results were compared between those who reported utilizing the video and those who did not. Results A total of 380 patients were evaluated. One hundred eighty-nine patients reported utilizing the video, while 191 did not. No significant differences were found among baseline age, gender, or preoperative outcome variables between groups. Postoperatively, the video group’s reported time spent actually sleeping improved an average of 52 minutes more than the nonvideo group (95% confidence interval 49.8-52.8 minutes, P Conclusions Sleep quality is an important component of TKA recovery. These findings provide evidence that nonpharmacologic interventions, such as self-guided meditation, may help improve sleep quality in the perioperative period. Future studies are warranted to further investigate their potential benefits.

Michael S. Cremins

Papers

Evaluating the Success of Perioperative Self-Guided Meditation in Reducing Sleep Disturbance After Total Knee Arthroplasty.