Total knee arthroplasty (TKA) results in a high degree of patient satisfaction, as it provides patients with considerable medium- and long-term benefits in terms of quality of life, pain relief and function. Nevertheless, the literature reports that up to 30% of patients are dissatisfied. This dissatisfaction is directly related to the patients' quality of life, which they deem insufficient. Their quality of life depends on many physical, behavioural, social and psychological factors that are not taken into account by functional outcome scores. After describing the principles of quality of life evaluation after TKA, we will assess the effects of patient-related factors, the surgical technique and postoperative program through an exhaustive review of the literature. Patient expectations after TKA will then be outlined, particularly return to work and return to sports.

Quality of life after total knee arthroplasty.

Patient-reported outcomes (PROs) are measures of how patients feel or what they are able to do in the context of their health status; PROs are reports, usually on questionnaires, about a patient's health conditions, health behaviors, or experiences with health care that individuals report directly, without modification of responses by clinicians or others; thus, they directly reflect the voice of the patient. PROs cover domains such as physical health, mental and emotional health, functioning, symptoms and symptom burden, and health behaviors. They are relevant for many activities: helping patients and their clinicians make informed decisions about health care, monitoring the progress of care, setting policies for coverage and reimbursement of health services, improving the quality of health care services, and tracking or reporting on the performance of health care delivery organizations. We address the major methodological issues related to choosing, administering, and using PROs for these purposes, particularly in clinical practice settings. We include a framework for best practices in selecting PROs, focusing on choosing appropriate methods and modes for administering PRO measures to accommodate patients with diverse linguistic, cultural, educational, and functional skills, understanding measures developed through both classic and modern test theory, and addressing complex issues relating to scoring and analyzing PRO data.

/pdf/patient-reported-outcomes-in-performance-measurement-56hso61gns.pdf

Patient-Reported Outcomes in Performance Measurement

Background Despite improvements in surgical technique and implant longevity, some patients continue to report dissatisfaction after total joint arthroplasty (TJA). As patient satisfaction is increasingly used as a quality metric, the objective of this study was to gain better understanding of satisfaction with total joint arthroplasty from the patient perspective. Methods Five hundred fifty-one primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) with a minimum of 1-year follow-up and were responsive to a satisfaction survey were analyzed. The incidence, predictive factors, and subjective reasoning for patient dissatisfaction were assessed. Univariate and multivariate logistic regression analyses were performed. Results Patient satisfaction was 89% for THA and 88% for TKA. Hispanic race was the most significant predictor of dissatisfaction (P = .037). The most common reasons for dissatisfaction after THA were persistent pain (N = 14/34, 41%), functional limitation (N = 12/34, 35%), surgical complication and reoperation (N = 4/34, 12%), staff or quality of care issues (N = 2/34, 6%), and slow recovery (N = 2/34, 6%). The most common reasons for dissatisfaction after TKA were persistent pain (N = 19/46, 41%), functional limitation (N = 12/46, 26%), surgical complication and reoperation (N = 8/46, 17%), staff or quality of care issues (N = 5/46, 11%), and unmet expectations (N = 2/46, 4%). Conclusion While persistent pain and functional limitation are the 2 leading reasons for dissatisfaction in both TKA and THA, a subset of patients view satisfaction as an evaluation of the process by which care is delivered. Patient satisfaction is not solely a reflection of surgical outcome and should be interpreted with caution. Potential for incomplete pain relief or full functional recovery should be discussed during preoperative counseling. Empathic care is also important and should be encouraged to enhance the overall patient experience.

Patient Dissatisfaction After Primary Total Joint Arthroplasty: The Patient Perspective.

Background The relationship between patient expectations, patient-reported outcomes (PROs), and satisfaction in total knee arthroplasty (TKA) patients is not well understood. Methods We prospectively evaluated patients who underwent primary TKA at 4 institutions. Demographics were collected. Preoperatively, patients completed the Hospital for Special Surgery Knee Replacement Expectations Survey (HSS-KRES), SF-12, UCLA activity, and Knee Disability and Osteoarthritis Score. At 6 months and 1 year postoperatively, patients completed the Hospital for Special Surgery Knee Replacement Fulfillment of Expectations Survey (HSS-KRFES), a satisfaction survey, and PROs. Step-wise multivariate regression models were created. Results Eighty-three patients were enrolled. At 6 months and 1 year postoperatively, the follow-up rate was 84.3% and 92.7%, respectively. No demographics or preoperative PROs were predictive of HSS-KRES. Preoperative HSS-KRES did not predict postoperative satisfaction, but higher HSS-KRES predicted higher HSS-KRFES at 1 year, greater improvement in UCLA activity at 6 months and 1 year, and SF-12 Physical Composite Scale and Knee Disability and Osteoarthritis Score at 6 months. Higher HSS-KRFES predicted higher satisfaction at 6 months and 1 year. Conclusion In TKA patients, preoperative expectations are not influenced by patient demographics or preoperative function. Higher preoperative expectations predict greater postoperative improvement in PROs and fulfillment of expectations. These findings highlight the importance of preoperative patient expectations on postoperative outcome.

Higher Patient Expectations Predict Higher Patient-Reported Outcomes, But Not Satisfaction, in Total Knee Arthroplasty Patients: A Prospective Multicenter Study

Patient-specific orthopaedic implants are emerging as a clinically promising treatment option for a growing number of conditions to better match an individual's anatomy. Patient-specific implant (PSI) technology aims to reduce overall procedural costs, minimize surgical time, and maximize patient outcomes by achieving better biomechanical implant fit. With this commercially-available technology, computed tomography or magnetic resonance images can be used in conjunction with specialized computer programs to create preoperative patient-specific surgical plans and to develop custom cutting guides from 3-D reconstructed images of patient anatomy. Surgeons can then place these temporary guides or "jigs" during the procedure, allowing them to better recreate the exact resections of the computer-generated surgical plan. Over the past decade, patient-specific implants have seen increased use in orthopaedics and they have been widely indicated in total knee arthroplasty, total hip arthroplasty, and corrective osteotomies. Patient-specific implants have also been explored for use in total shoulder arthroplasty and spinal surgery. Despite their increasing popularity, significant support for PSI use in orthopaedics has been lacking in the literature and it is currently uncertain whether the theoretical biomechanical advantages of patient-specific orthopaedic implants carry true advantages in surgical outcomes when compared to standard procedures. The purpose of this review was to assess the current status of patient-specific orthopaedic implants, to explore their future direction, and to summarize any comparative published studies that measure definitive surgical characteristics of patient-specific orthopaedic implant use such as patient outcomes, biomechanical implant alignment, surgical cost, patient blood loss, or patient recovery.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/os.12282

Patient-Specific Orthopaedic Implants

Total knee arthroplasty (TKA) is one of the most 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 recent literatures regarding patient satisfaction after TKA and to analyze 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 two 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's 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 be disparate occasionally. Among various factors that contribute to patient satisfaction, some factors can be managed by the surgeon, which should be improved through continuous research. Furthermore, extensive discussion and explanation before surgery will reduce patient dissatisfaction after TKA.

Patient Satisfaction after Total Knee Arthroplasty

Purpose
To evaluate the survival rate and long term clinical outcomes of hybrid total knee arthroplasty (TKA).

Long-term Results of Hybrid Total Knee Arthroplasty: Minimum 10-years Follow-up.

Purpose The purpose of this study is to evaluate the risk of sequential bilateral total knee arthroplasty (TKA) under 1 anesthesia in patients 75 years or older. Materials and methods Patients aged 75 years or older who underwent sequential bilateral TKA (bilateral group, n=159) and unilateral TKA (unilateral group, n=159) between 2002 and 2012 were selected. All patients were evaluated for underlying medical diseases, such as cardiac, pulmonary, and renal problems, and high-risk patients were recommended to postpone the surgery. We compared the underlying diseases, major postoperative complications, and the length of hospital stay between bilateral and unilateral groups. Results The prevalence of underlying diseases of the bilateral group was 74.8% and major complications occurred in 6 patients (3.8%). The prevalence of underlying diseases of the unilateral group was 52.4% and complications were observed in 4 patients (2.4%). Although the complication rate of the bilateral group was slightly higher than that of the unilateral group, the difference was not statistically meaningful (p=0.204). The length of hospital stay was 21.9 days for the bilateral group and 24.9 days for the unilateral group. Conclusions There was no significant difference in postoperative complications between groups. The result shows that bilateral TKA can be relatively safe compared with unilateral TKA in patients 75 years or older. However, careful selection of low-risk patients is advised.

Perioperative Risk Assessment in Patients Aged 75 Years or Older: Comparison between Bilateral and Unilateral Total Knee Arthroplasty

Stiff knees, like completely ankylosed or arthrodesed knees, can be painless. Total knee arthroplasty (TKA) for these painless, stiff knees is technically demanding. However, it can correct the alignment and advance the range of motion to improve quality of life. So, we reviewed the preoperative and postoperative results of functional and pain scores, range of motion (ROM) and complications in painless, stiff knees treated by TKA. Fifteen painless, stiff knees underwent TKA from January 1998 to January 2017. The mean follow-up period was 15.4 (2.4–22.2) years. All the knees were completely ankylosed or arthrodesed. Clinical outcome and complications were evaluated using medical record review, serial plan radiography, ROM assessment, Knee Society score (KSS), Knee Society function score (FS), and a visual analog scale for pain (VAS). All patients were satisfied with their operated knees. Mean KSS and FS scores were improved from 36 and 50.9 to 76.9 and 67.2, respectively (P < 0.001 and P = 0.01). The mean ROM increased from 0o preoperatively to 77.6o (15–130) at the final follow-up (P < 0.001). The mean VAS had worsened from 0 preoperatively to 0.2 postoperatively, however it was not significant (P = 0.1). Major postoperative complications were reported in five of the knees (33.3%). The results of TKA for painless, stiff knees were satisfactory with improved ROM and quality of life. Although some patients had mild pain and complications postoperatively, they were satisfied with the result. However, our study recommends that surgeons should consider the high rate of complications in the completely ankylosed or arthrodesed knees. A retrospective case series, Level IV.

/pdf/results-of-total-knee-arthroplasty-for-painless-stiff-knees-56l4nrlvkw.pdf

Results of total knee arthroplasty for painless, stiff knees

Here, we describe a popliteal mass that was initially misdiagnosed as a simple popliteal cyst, which finally turned out to be osteochondrolipoma. A 63-year-old housewife presented with sustained knee pain in association with a palpable mass on the popliteal fossa. The mass was in the posteromedial area and soft, non-tender, non-movable in the posteromedial area. Using plain radiography, the mass appeared as a round, soft tissue density lesion containing bony fragments. We performed an ultrasound-guided needle biopsy in conjunction with magnetic resonance imaging, followed by an open excisional biopsy. Microscopically, histological sections showed a lipoma with cartilaginous and osseous differentiation, finally diagnosed as osteochondrolipoma. In conclusion, popliteal masses are not always simple cysts, and the evaluation of masses in the popliteal fossa is always necessary.

/pdf/osteochondrolipoma-presenting-as-a-popliteal-cyst-1pji35asdg.pdf

Young Joon Choi

Papers

Patient Satisfaction after Total Knee Arthroplasty

Long-term Results of Hybrid Total Knee Arthroplasty: Minimum 10-years Follow-up.

Perioperative Risk Assessment in Patients Aged 75 Years or Older: Comparison between Bilateral and Unilateral Total Knee Arthroplasty

Results of total knee arthroplasty for painless, stiff knees

Osteochondrolipoma Presenting as a Popliteal Cyst