Patient Satisfaction after Total Knee Arthroplasty: Who is Satisfied and Who is Not?
TL;DR: A cross-sectional study of patient satisfaction after 1703 primary TKAs performed in the province of Ontario confirmed that approximately one in five (19%) primary TKA patients were not satisfied with the outcome.
Abstract: Despite substantial advances in primary TKA, numerous studies using historic TKA implants suggest only 82% to 89% of primary TKA patients are satisfied. We reexamined this issue to determine if contemporary TKA implants might be associated with improved patient satisfaction. We performed a cross-sectional study of patient satisfaction after 1703 primary TKAs performed in the province of Ontario. Our data confirmed that approximately one in five (19%) primary TKA patients were not satisfied with the outcome. Satisfaction with pain relief varied from 72–86% and with function from 70–84% for specific activities of daily living. The strongest predictors of patient dissatisfaction after primary TKA were expectations not met (10.7× greater risk), a low 1-year WOMAC (2.5× greater risk), preoperative pain at rest (2.4× greater risk) and a postoperative complication requiring hospital readmission (1.9× greater risk). Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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TL;DR: To review published studies in representative populations with total hip or knee replacement for the treatment of osteoarthritis reporting proportions of people by pain intensity, there is an urgent need to improve general awareness of this possibility and to address determinants of good and bad outcomes.
Abstract: Background Total hip or knee replacement is highly successful when judged by prosthesis-related outcomes. However, some people experience long-term pain. Objectives To review published studies in representative populations with total hip or knee replacement for the treatment of osteoarthritis reporting proportions of people by pain intensity. Data sources MEDLINE and EMBASE databases searched to January 2011 with no language restrictions. Citations of key articles in ISI Web of Science and reference lists were checked. Study eligibility criteria, participants and interventions Prospective studies of consecutive, unselected osteoarthritis patients representative of the primary total hip or knee replacement population, with intensities of patient-centred pain measured after 3 months to 5-year follow-up. Study appraisal and synthesis methods Two authors screened titles and abstracts. Data extracted by one author were checked independently against original articles by a second. For each study, the authors summarised the proportions of people with different severities of pain in the operated joint. Results Searches identified 1308 articles of which 115 reported patient-centred pain outcomes. Fourteen articles describing 17 cohorts (6 with hip and 11 with knee replacement) presented appropriate data on pain intensity. The proportion of people with an unfavourable long-term pain outcome in studies ranged from about 7% to 23% after hip and 10% to 34% after knee replacement. In the best quality studies, an unfavourable pain outcome was reported in 9% or more of patients after hip and about 20% of patients after knee replacement. Limitations Other studies reported mean values of pain outcomes. These and routine clinical studies are potential sources of relevant data. Conclusions and implications of key findings After hip and knee replacement, a significant proportion of people have painful joints. There is an urgent need to improve general awareness of this possibility and to address determinants of good and bad outcomes.
1,000 citations
TL;DR: The goal of the present study was to develop and validate a new score ("Forgotten Joint Score," or FJS) introducing a new aspect of patient-reported outcome: the patient's ability to forget the artificial joint in everyday life.
Abstract: With improving patient outcome after joint arthroplasty, new assessment tools with increased discriminatory power especially in well-performing patients are desirable. The goal of the present study was to develop and validate a new score ("Forgotten Joint Score," or FJS) introducing a new aspect of patient-reported outcome: the patient's ability to forget the artificial joint in everyday life. After a pilot study, the FJS was validated and showed high internal consistency (Cronbach α = .95). Ceiling effects were considerably lower for the FJS (9.2%) compared with the Western Ontario and McMaster Universities subscales (16.7%-46.7%). Known-group comparisons proved the FJS to be highly discriminative in a validation sample of 243 patients. The FJS not only reflects differences between "good" and "bad" but also between "good," "very good," and "excellent" outcomes. This concise score is appealing for its more adequate measurement range and because it measures the new, promising concept of the "forgotten joint."
488 citations
Cites result from "Patient Satisfaction after Total Kn..."
...Previous studies showed consistently better outcome after THA compared with TKA [13-17]....
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TL;DR: A systematic literature review explores key factors affecting patient dissatisfaction following total knee arthroplasty and found that patient dissatisfaction pertains to several key factors.
Abstract: Background Dissatisfaction following total knee arthroplasty (TKA) is common. Approximately 20% of patients report dissatisfaction following primary TKA. This systematic literature review explores key factors affecting patient dissatisfaction following TKA. Methods Six literature databases published between 2005 and 1 January 2016 were searched using 3 key search phrases. Papers were included if the study investigated patient dissatisfaction in primary unilateral or bilateral TKA. Information from each article was categorized to the domains of socioeconomic, preoperative, intraoperative, and postoperative factors affecting patient dissatisfaction. Results This review found that patient dissatisfaction pertains to several key factors. Patient expectations prior to surgery, the degree of improvement in knee function, and pain relief following surgery were commonly cited in the literature. Fewer associations were found in the socioeconomic and surgical domains. Conclusion Identifying who may be dissatisfied after their TKA is mystifying; however, we note several strategies that target factors whereby an association exists. Further research is needed to better quantify dissatisfaction, so that the causal links underpinning dissatisfaction can be more fully appreciated and strategies employed to target them.
396 citations
TL;DR: ConclusionsKinematically aligned TKA restores function without catastrophic failure regardless of the alignment category, and the concern that kinematic alignment compromises function and places the components at a high risk for catastrophic failure is unfounded.
Abstract: Background
Kinematically aligned TKA restores function by aligning the femoral and tibial components to the normal or prearthritic joint lines of the knee. However, aligning the components to the joint lines of the normal knee also aligns the tibial component in varus, creating concern that varus alignment might result in poor function and early catastrophic failure.
345 citations
Cites background or result from "Patient Satisfaction after Total Kn..."
...Although establishing neutral mechanical alignment has been considered a cornerstone for a successful and durable TKA, patients report a high incidence of dissatisfaction with this alignment technique [1, 4, 21]....
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...Similarly, the mean WOMAC score of 92 ± 12 for all our kinematically aligned TKAs is comparable to if not higher than the mean WOMAC score of 85 ± 13 for a subset of satisfied patients comprising 76% of mechanically aligned TKAs reported in the Ontario (Canada) province registry [4]....
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...Although a mechanically aligned TKA improves the patient’s function, arthroplasty registries have shown that 20% to 25% of patients remain dissatisfied [1, 4, 26]....
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TL;DR: High fulfilments of expectation in both THR and TKR was significantly predicted by young age, greater improvements in Oxford score and high pre-operative mental health scores, and the fulfilment of expectations was highly correlated with satisfaction.
Abstract: Patient expectations and their fulfilment are an important factor in determining patient-reported outcome and satisfaction of hip (THR) and knee replacement (TKR). The aim of this prospective cohort study was to examine the expectations of patients undergoing THR and TKR, and to identify differences in expectations, predictors of high expectations and the relationship between the fulfilment of expectations and patient-reported outcome measures. During the study period, patients who underwent 346 THRs and 323 TKRs completed an expectation questionnaire, Oxford score and Short-Form 12 (SF-12) score pre-operatively. At one year post-operatively, the Oxford score, SF-12, patient satisfaction and expectation fulfilment were assessed. Univariable and multivariable analysis were performed. Improvements in mobility and daytime pain were the most important expectations in both groups. Expectation level did not differ between THR and TKR. Poor Oxford score, younger age and male gender significantly predicted high pre-operative expectations (p < 0.001). The level of pre-operative expectation was not significantly associated with the fulfilment of expectations or outcome. THR better met the expectations identified as important by patients. TKR failed to meet expectations of kneeling, squatting and stair climbing. High fulfilment of expectation in both THR and TKR was significantly predicted by young age, greater improvements in Oxford score and high pre-operative mental health scores. The fulfilment of expectations was highly correlated with satisfaction.
315 citations
References
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TL;DR: For diagnostic systems used to distinguish between two classes of events, analysis in terms of the "relative operating characteristic" of signal detection theory provides a precise and valid measure of diagnostic accuracy.
Abstract: Diagnostic systems of several kinds are used to distinguish between two classes of events, essentially "signals" and "noise". For them, analysis in terms of the "relative operating characteristic" of signal detection theory provides a precise and valid measure of diagnostic accuracy. It is the only measure available that is uninfluenced by decision biases and prior probabilities, and it places the performances of diverse systems on a common, easily interpreted scale. Representative values of this measure are reported here for systems in medical imaging, materials testing, weather forecasting, information retrieval, polygraph lie detection, and aptitude testing. Though the measure itself is sound, the values obtained from tests of diagnostic systems often require qualification because the test data on which they are based are of unsure quality. A common set of problems in testing is faced in all fields. How well these problems are handled, or can be handled in a given field, determines the degree of confidence that can be placed in a measured value of accuracy. Some fields fare much better than others.
8,569 citations
"Patient Satisfaction after Total Kn..." refers background in this paper
...Preoperative, intraoperative and postoperative variables were explored between the satisfied and dissatisfied total knee replacement groups to determine where statistical differences may exist [24]....
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Journal Article•
TL;DR: WOMAC is a disease-specific purpose built high performance instrument for evaluative research in osteoarthritis clinical trials and fulfil conventional criteria for face, content and construct validity, reliability, responsiveness and relative efficiency.
Abstract: Within the context of a double blind randomized controlled parallel trial of 2 nonsteroidal antiinflammatory drugs, we validated WOMAC, a new multidimensional, self-administered health status instrument for patients with osteoarthritis of the hip or knee. The pain, stiffness and physical function subscales fulfil conventional criteria for face, content and construct validity, reliability, responsiveness and relative efficiency. WOMAC is a disease-specific purpose built high performance instrument for evaluative research in osteoarthritis clinical trials.
7,147 citations
TL;DR: Real improvements in the outcome of TKA must address prevention of residual pain, stiffness and swelling, and each patient's preoperative concept of the likely outcome of these procedures.
Abstract: Satisfaction with the outcome of total knee arthroplasty is highly variable, with a small but significant percentage of patients reporting dissatisfaction with the procedure. The purpose of this study was to determine which factors contribute to patient satisfaction with total knee replacement (TKR)
963 citations
"Patient Satisfaction after Total Kn..." refers background in this paper
...Despite substantial advances in primary TKA patient selection, surgical technique, and implant design, numerous studies indicate only 82% to 89% of patients were satisfied with their primary total knee arthroplasty [2, 9, 11, 12, 14, 22, 23, 26]....
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...We have confirmed that meeting patient expectations is of the utmost importance in achieving patient satisfaction after primary TKA [9, 14, 15, 20, 22]....
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...Increasing evidence is emerging that patients and doctors do not always agree on quality-of-life improvements after therapeutic interventions [9, 15, 21, 22]....
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...Numerous reports have noted that not all patients are satisfied after their primary total knee replacement with only 82–89% expressing satisfaction [2, 9, 11, 12, 14, 22, 23, 26]....
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...[22] that patient satisfaction decreases with advancing age, residual symptoms, expectations not met and less functional improvement....
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TL;DR: The findings of the present study suggest that age and obesity do not have a negative impact on patient-relevant outcomes (pain and physical function) and have the potential to increase appropriate referrals for knee replacement and thereby reduce the pain and functional disability due to osteoarthrosis of the knee.
Abstract: A cross-sectional, community-based survey of a random sample of 1750 of 242,311 Medicare recipients was performed. The patients were at least sixty-five years old and had had a primary or revision knee replacement (either unilaterally or bilaterally) between 1985 and 1989. Three samples were surveyed separately: a national sample (to reflect the United States as a whole) and samples from Indiana and the western part of Pennsylvania (sites chosen for convenience to assess the validity of the findings for the national sample on a regional level). Each sample was stratified by race, age, residence (urban or rural), and the year of the procedure. Valid and reliable questionnaires were used to elicit the participants' assessments of pain, physical function, and satisfaction two to seven years after the knee replacement. Of the 1486 patients who were eligible for inclusion in the survey, 1193 (80.3 per cent) responded. The mean age of the respondents was 72.6 years. Eight hundred and forty-nine respondents (71.2 per cent) were white, and 849 (71.2 per cent) were women. The participants reported that they had little or no pain in the knee at the time of the survey, regardless of the age at the time of the knee replacement, the body-mass index, or the length of time since the knee replacement. After adjustment for potential confounding variables, predictors of better physical function after the replacement were an absence of problems with the contralateral knee, primary knee replacement (rather than revision) (Indiana sample only), and a lower body-mass index (Indiana and western Pennsylvania samples). Four hundred and fifteen (85.2 per cent) of the 487 patients in the national sample were satisfied with the result of the knee replacement. In what we believe to be the first community-based study of the outcome of knee replacement, patients reported having significant (p = 0.0001) and persistent relief of pain, improved physical function, and satisfaction with the result two to seven years postoperatively. The findings of the present study suggest that age and obesity do not have a negative impact on patient-relevant outcomes (pain and physical function). Dissemination of these findings has the potential to increase appropriate referrals for knee replacement and thereby reduce the pain and functional disability due to osteoarthrosis of the knee.
641 citations
"Patient Satisfaction after Total Kn..." refers background in this paper
...Despite substantial advances in primary TKA patient selection, surgical technique, and implant design, numerous studies indicate only 82% to 89% of patients were satisfied with their primary total knee arthroplasty [2, 9, 11, 12, 14, 22, 23, 26]....
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...Numerous reports have noted that not all patients are satisfied after their primary total knee replacement with only 82–89% expressing satisfaction [2, 9, 11, 12, 14, 22, 23, 26]....
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TL;DR: It is concluded that satisfaction after knee arthroplasty is stable and long-lasting in unrevised cases and that even after revision most patients are satisfied.
Abstract: During a validation process of the Swedish Knee Arthroplasty Register (SKAR), living registered patients were sent a questionnaire to ask if they had been reoperated on. This gave an opportunity to pose a simple four-point question with respect to patient satisfaction which 95% of patients answered. We analyzed the answers of patients operated on between 1981 and 1995 and found that only 8% of the patients were dissatisfied regarding their knee arthroplasty 2-17 years postoperatively. The satisfaction rate was constant, regardless of when the operation had been performed during the 15-year period. The proportion of satisfied patients was affected by the preoperative diagnosis, patients operated on for a long-standing disease more often being satisfied than those with a short disease-duration. There was no difference in proportions of satisfied patients, whether they had primarily been operated on with a total knee arthroplasty (TKA) or a medial unicompartmental arthroplasty (UKA). For TKAs performed with primary patellar resurfacing, there was a higher ratio of satisfied patients than for TKAs not resurfaced, but this increased ratio diminished with time passed since the primary operation. Unrevised knees had a higher proportion of satisfied patients than knees that had been subject to revision, and among patients revised for medial UKA, the proportion of satisfied patients was higher than among patients revised for TKA. We conclude that satisfaction after knee arthroplasty is stable and long-lasting in unrevised cases and that even after revision most patients are satisfied.
638 citations