Abstract
Introduction:
Total knee arthroplasty (TKA) is an increasingly used treatment option for younger patients with osteoarthritis. Previous research has found only 66% patients <60 years who underwent TKA postoperatively reported that their knees felt normal. However, the prior studies did not compare underlying causes for dissatisfaction based on age. This study compared the satisfaction and residual symptom rates between patients ages <60 and ≥60 years and identified specific reasons for their dissatisfaction between the age groups.
Methods:
Patients who underwent unilateral TKA for osteoarthritis from 2014 to 2016 were electronically sent a 15-question survey pertaining to surgery satisfaction. Following patient identification and survey completion, patient demographics, medical history, surgical time, and length of stay were collected through manual review of medical records. Patients who completed surveys were grouped by age (<60 years or ≥60 years) for analysis.
Results:
In total, 1189 ≥ 60-year-old patients and 388 < 60-year-old patients were included. Most patients in both cohorts reported satisfaction with overall knee function (<60: 68.6%; ≥60: 71.8%; P = 0.175). Fewer <60-year patients reported normal knee function (66.5% vs. 75.2%; P < 0.001). The most common residual symptom in both cohorts was continued pain.
Conclusion:
Patients younger than 60 years reported less satisfaction with performing normal activities and decreased normal knee function postoperatively. The <60 cohort reported requiring more readmissions for TKA concerns; however, no difference was observed in the rate of revision TKA between the cohorts. This information may be beneficial to clinicians and younger patients when discussing postoperative outcomes and functional expectations following TKA.
Total knee arthroplasty (TKA) is a common orthopaedic procedure for the treatment of osteoarthritis, and it is performed more than 600,000 times per year in the United States.1 It is increasingly common for younger patients to undergo TKA, and both the overall number of TKAs and those completed in the younger patients is projected to continue to increase.2,3
Previous research has suggested that younger patients have comparable or inferior outcomes compared with older patients following TKA.4-7 In addition, many studies have not detected differences in clinical outcomes and satisfaction for younger patients following TKA. However, multiple systematic reviews have demonstrated that younger patients improve in pain, function, and quality of life following TKA, and satisfaction scores have been reported to exceed 85% without notable differences between younger and older groups.7-9 A survey study conducted by Parvizi et al10 also showed that patients younger than 60 years undergoing TKA reported an overall satisfaction rate of 90% following surgery, although only 66% of patients indicated that their knees felt normal. However, the authors did not compare the most common reasons for patient dissatisfaction between older and younger patients undergoing TKA.
The purpose of this study was to determine the satisfaction rate and residual symptom rate between young (<60 years) and older (≥60 years) adult patients. In addition, this study identified the main reasons for patient dissatisfaction and if satisfaction/residual symptom rates differ from those of the study of Parvizi et al in patients following TKA for osteoarthritis. We hypothesize that younger patients may have higher rates of dissatisfaction and residual symptoms. Younger patients may have improved satisfaction in our cohort than those in the cohort of Parvizi et al due to changes in practice and changes in expectation management in younger patients undergoing TKA.
Methods
This was a retrospective cohort study conducted at a single academic tertiary care center. Following institutional review board approval, adult patients who underwent unilateral TKA for osteoarthritis from 2014 to 2016 were identified using a structured language query (SQL) with the common procedural code (CPT) 27447. Manual review of medical records was then done to confirm indication for surgery and laterality of surgery.
Following identification, patients were electronically sent a 15-question survey pertaining to TKA surgery satisfaction (Figure 1) in 2022. The electronic survey was adopted from Parvizi et al10 and modified to include three additional questions 1b, 14, and 15. The survey was sent in 2022 to allow for the evaluation of satisfaction and outcomes at time interval of at least five years postoperatively for all patients. Patients were excluded if they underwent bilateral TKA, revision surgery, primary TKA for an indication other than osteoarthritis, had incomplete medical records, were younger than 18 years at the time of surgery, or did not fully complete the 15-question survey.
Figure 1.
Image showing full electronic survey.
Following patient identification, patient demographics, medical history, surgical time, and length of stay was collected through manual review of medical records. Demographic information collected included sex, body mass index (BMI), surgical laterality, history of diabetes mellitus, alcohol use, and smoking status.
Patients who completed surveys were grouped by age at the time of TKA (<60 years or ≥60 years) for analysis. T-tests or Mann-Whitney U tests were used to compare continuous data, and Chi-squared or Fisher exact were used to compare categorical data. All data analyses were completed using R studio (version 4.1.2, Vienna, Austria) and a P value of <0.05 was considered statistically significant.
Results
In total, 10,443 patients were sent an electronic survey at least five years after unilateral TKA. Of those, 1577 TKA patients who completed the electronic survey were included in this study. The average follow-up time from surgery to survey completion was 6.98 years (range: 5.60, 8.60 years). Of those who completed the survey, 1189 patients were ≥60 years, whereas 388 were <60 years at the time of surgery. Patients younger than 60 years demonstrated a higher BMI but decreased smoking use (nonsmoker: 74.2% vs. 71.7%; P = 0.020) and length of stay (1.52 ± 0.74 vs. 1.66 ± 1.03; P = 0.029). No other differences were found regarding sex (P = 0.347), surgical laterality (P = 0.322), history of diabetes (P = 0.723), alcohol use (P = 0.983), or surgical time (P = 0.282) between the patient cohorts (Table 1).
Table 1.
Demographics
| ≥60 Years | <60 Years | P | |
| N = 1189 | N = 388 | ||
| Sex | 0.347 | ||
| Women | 655 (55.1%) | 225 (58.0%) | |
| Men | 534 (44.9%) | 163 (42.0%) | |
| BMI | 30.6 (5.36) | 31.8 (5.57) | <0.001a |
| Laterality | 0.322 | ||
| Left | 545 (45.8%) | 166 (42.8%) | |
| Right | 644 (54.2%) | 222 (57.2%) | |
| Diabetes | 126 (10.6%) | 38 (9.79%) | 0.723 |
| Alcohol use | 631 (53.1%) | 205 (52.8%) | 0.983 |
| Smoking | 0.020a | ||
| No | 852 (71.7%) | 288 (74.2%) | |
| Current | 36 (3.03%) | 21 (5.41%) | |
| Former | 301 (25.3%) | 79 (20.4%) | |
| OR time | 78.1 (25.9) | 81.2 (26.9) | 0.282 |
| LOS | 1.66 (1.03) | 1.52 (0.74) | 0.029a |
Statistical significance at P < 0.05. Data presented as mean (standard deviation) and n (%).
BMI, body mass index; OR, operating room; LOS, length of stay.
Regarding electronic survey responses, most patients in both cohorts reported to be satisfied with overall function in their knee postoperatively (<60: 68.6%; ≥60: 71.8%). However, no differences were found in the rate of knee function or dissatisfaction between the <60 and ≥60 cohorts (13.7% vs. 10.3%; P = 0.175). Patients in both cohorts who reported dissatisfaction or in between satisfaction/dissatisfaction stated that their main concern with their knee was continued pain. More patients in ≥60 cohort reported satisfaction with the ability to perform normal activities when compared with <60 cohort (84.5% vs. 79.6%; P = 0.031). Both cohorts reported a similar frequency of problems with getting out of a car (P = 0.079), getting out of a chair (P = 0.283), or difficulty going up the stairs (P = 0.069) (Table 2).
Table 2.
Satisfaction Survey Responses and Surgical Outcomes
| ≥60 Years | <60 Years | P | |
| Overall knee function satisfaction | 0.175 | ||
| Satisfied | 854 (71.8%) | 266 (68.6%) | |
| In between | 213 (17.9%) | 69 (17.8%) | |
| Dissatisfied | 122 (10.3%) | 53 (13.7%) | |
| Main concern with knee | 0.558 | ||
| Pain | 93 (44.1%) | 33 (41.8%) | |
| Function | 19 (9.00%) | 9 (11.4%) | |
| Not feeling normal | 28 (13.3%) | 15 (19.0%) | |
| Residual stiffness | 26 (12.3%) | 8 (10.1%) | |
| Residual grinding | 1 (0.47%) | 0 (0.00%) | |
| Residual popping | 5 (2.37%) | 0 (0.00%) | |
| Residual click | 8 (3.79%) | 1 (1.27%) | |
| Other | 20 (9.48%) | 6 (7.59%) | |
| All symptoms listed | 11 (5.21%) | 7 (8.86%) | |
| Satisfaction with ability to perform normal activities | 1005 (84.5%) | 309 (79.6%) | 0.031a |
| Satisfaction with degree of pain relief | 1026 (86.3%) | 321 (82.7%) | 0.101 |
| Problems with getting out of car | 0.079 | ||
| Never | 538 (45.2%) | 167 (43.0%) | |
| Rarely | 313 (26.3%) | 95 (24.5%) | |
| Sometimes | 233 (19.6%) | 76 (19.6%) | |
| Often | 74 (6.22%) | 29 (7.47%) | |
| Extremely Often | 31 (2.61%) | 21 (5.41%) | |
| Problems with getting out of chair | 0.283 | ||
| Never | 624 (52.5%) | 192 (49.5%) | |
| Rarely | 272 (22.9%) | 86 (22.2%) | |
| Sometimes | 195 (16.4%) | 66 (17.0%) | |
| Often | 71 (5.97%) | 28 (7.22%) | |
| Extremely often | 27 (2.27%) | 16 (4.12%) | |
| Difficulty going up and down stairs | 0.069 | ||
| No difficulty | 666 (56.0%) | 206 (53.1%) | |
| A little | 288 (24.2%) | 94 (24.2%) | |
| Somewhat | 121 (10.2%) | 34 (8.76%) | |
| Quite | 50 (4.21%) | 18 (4.64%) | |
| Very | 37 (3.11%) | 16 (4.12%) | |
| Extremely | 27 (2.27%) | 20 (5.15%) | |
| Frequency of experiencing pain in replaced knee | <0.001a | ||
| Never | 566 (47.6%) | 134 (34.5%) | |
| Rarely | 285 (24.0%) | 123 (31.7%) | |
| Sometimes | 190 (16.0%) | 58 (14.9%) | |
| Often | 98 (8.24%) | 41 (10.6%) | |
| Extremely often | 50 (4.21%) | 32 (8.25%) | |
| Frequency of experiencing swelling or tightness | <0.001a | ||
| Never | 682 (57.4%) | 167 (43.0%) | |
| Rarely | 195 (16.4%) | 81 (20.9%) | |
| Sometimes | 175 (14.7%) | 61 (15.7%) | |
| Often | 95 (7.99%) | 41 (10.6%) | |
| Extremely often | 42 (3.53%) | 38 (9.79%) | |
| Frequency of experiencing stiffness | <0.001a | ||
| Never | 501 (42.1%) | 135 (34.8%) | |
| Rarely | 301 (25.3%) | 90 (23.2%) | |
| Sometimes | 225 (18.9%) | 76 (19.6%) | |
| Often | 114 (9.59%) | 47 (12.1%) | |
| Extremely often | 48 (4.04%) | 40 (10.3%) | |
| Frequency of experiencing grinding, popping, or clicking | <0.001a | ||
| Never | 715 (60.1%) | 180 (46.4%) | |
| Rarely | 218 (18.3%) | 68 (17.5%) | |
| Sometimes | 153 (12.9%) | 69 (17.8%) | |
| Often | 70 (5.89%) | 36 (9.28%) | |
| Extremely often | 33 (2.78%) | 35 (9.02%) | |
| Frequency of experiencing stiffness in contralateral knee | <0.001a | ||
| Never | 482 (40.5%) | 111 (28.6%) | |
| Rarely | 280 (23.5%) | 96 (24.7%) | |
| Sometimes | 259 (21.8%) | 96 (24.7%) | |
| Often | 124 (10.4%) | 43 (11.1%) | |
| Extremely often | 44 (3.70%) | 42 (10.8%) | |
| Frequency of experiencing grinding, popping, or clicking in contralateral knee | <0.001a | ||
| Never | 715 (60.1%) | 178 (45.9%) | |
| Rarely | 224 (18.8%) | 78 (20.1%) | |
| Sometimes | 142 (11.9%) | 68 (17.5%) | |
| Often | 79 (6.64%) | 36 (9.28%) | |
| Extremely often | 29 (2.44%) | 28 (7.22%) | |
| Consider knee to feel normal | 894 (75.2%) | 258 (66.5%) | 0.001a |
| Frequency of limping while walking | <0.001a | ||
| Never | 582 (48.9%) | 147 (37.9%) | |
| Rarely | 290 (24.4%) | 99 (25.5%) | |
| Sometimes | 176 (14.8%) | 62 (16.0%) | |
| Often | 86 (7.23%) | 42 (10.8%) | |
| Extremely often | 55 (4.63%) | 38 (9.79%) | |
| Frequency of play or participation in recreational activity | 0.540 | ||
| Never | 354 (29.8%) | 106 (27.3%) | |
| Rarely | 204 (17.2%) | 67 (17.3%) | |
| Sometimes | 247 (20.8%) | 88 (22.7%) | |
| Often | 279 (23.5%) | 84 (21.6%) | |
| Extremely often | 105 (8.83%) | 43 (11.1%) | |
| Readmission for knee arthroplasty concern | 72 (6.06%) | 41 (10.6%) | 0.004a |
| Required knee revision | 96 (8.07%) | 41 (10.6%) | 0.159 |
Statistical significance at P < 0.05. Data presented as mean (SD) and n (%).
When compared with the ≥60 patients, <60 patients reported higher frequency of experiencing pain in their replaced knee (extremely often: 8.25% vs. 4.21%; P < 0.001), swelling or tightness (extremely often: 9.79% vs. 3.53%; P < 0.001), stiffness (extremely often: 10.3% vs. 4.04%; P < 0.001), and grinding/popping/clicking (extremely often: 9.02% vs. 2.78%; P < 0.001). In the contralateral knee, younger patients also reported higher frequency of stiffness (extremely often: 10.8% vs. 3.70%; P < 0.001) and grinding/popping/clicking compared with the older patient cohort (extremely often: 7.22% vs. 2.44%; P < 0.001) (Table 2).
Overall, fewer patients in the younger cohort considered their replaced knee to feel normal compared with the older cohort (66.5% vs. 75.2%; P < 0.001). Younger patients also reported higher frequency of limping while walking (extremely often: 9.79% vs. 4.63%; P < 0.001), but no difference in frequency of play/participation in recreational activity (extremely often: 11.1% vs. 8.83%, P = 0.540). The <60 cohort reported requiring more readmissions for knee arthroplasty concerns (10.6% vs. 6.06%; P = 0.004); however, no difference was found in the rate of revision TKA between the cohorts (10.6% vs. 8.07%; P = 0.159; Table 2).
Discussion
As more individuals now undergo TKA at younger ages, adequate satisfaction and successful postoperative outcomes continue to be large concerns for both patients and physicians.1 In this survey study, younger patients who underwent TKA were more likely to be unsatisfied with the ability to perform normal activities postoperatively in comparison to older patients. Overall, the main reason for TKA dissatisfaction was pain in both older and younger patients. In addition, younger patients experienced higher frequency of postoperative swelling, stiffness, pain, and knee grinding sensation in their replaced knee. Although younger patients had higher readmission rates for postoperative TKA concern, ultimately, no difference was observed in revision TKA rate. These results show that there are notable differences in satisfaction and residual symptoms between younger and older patients, which should be considered by surgeons when counseling younger prospective TKA patients before surgery regarding postoperative expectations.
Several studies have further evaluated the overall satisfaction rates in all patients undergoing TKA and in younger TKA patients, younger than 60 years. Historically, an estimated 20% of patients are dissatisfied following TKA; however, more recent literature determined the average rate of dissatisfaction to be 10%.11,12 Similar rates of satisfaction were reported in the <55 cohort as a systematic review of 13 studies determined patient satisfaction rate to be 85.5%.9 Most notably, a multicenter survey using a similar survey by Parvizi et al reported that 89% of patients younger than 60 years reported satisfaction to perform normal daily living activities and 66% stated that their knees felt normal. In addition, the authors stated that only a minority of patients reported some degree of pain, stiffness, and other residual symptoms.10 In comparison, our results determined that younger patients had lower satisfaction and higher incidence of residual symptoms when compared with patients of Parvizi et al. Furthermore, we determined that when directly compared with older patients, younger patients (<60 years) reported lower rate of satisfaction to perform normal daily activities and higher frequency of residual symptoms.
Previous studies have evaluated surgical outcomes following TKA in patients younger than 60 years; however, the literature comparing patient satisfaction in older and younger patients is still limited. In a study by Long et al,13 which evaluated long-term outcomes with a minimum follow-up of 25 years in patients younger than 65 years, survivorship was reported to be 82.5% for tibial or femoral revision and 70.1% for revision for all causes. Similarly, a longitudinal study followed 114 TKAs on patients younger than 55 years for 40 years and determined implant survivorship to range from 52.1 to 65.3% at 40 years postoperatively.14 Both studies reported that TKA performed in young patients led to excellent survivorship and therefore suggested TKA to be an appropriate option for patients with end-stage osteoarthritis. Although we did not evaluate survivorship in this study, we found that younger patients had higher readmission rates pertaining to their TKA, but no difference was found in revision surgery, which supports previous findings regarding surgical outcomes by age. The evidence suggests that younger patients experience comparable functionality with lower revision rates; however, satisfaction following TKA is still lower than in those who undergo TKA at an older age.
The mechanism for decreased satisfaction in younger patients following TKA is believed to be multifactorial. Previous studies have determined predictors such as mental health status, poor patient coping skills, postoperative complications, persistent stiffness and pain to be associated with dissatisfaction in all patients.12,15 In the studies that determined younger age to be associated with TKA satisfaction, the authors suggested that higher daily demands on the knee joint and unrealistic expectations could be possible reasons for lower satisfaction.16–18 A commentary by Vince19 suggested that knee arthroplasty may more easily meet the needs for more senior patients in terms of pain relief or function, whereas younger and healthier patients may not prefer the results of an arthroplasty to the performance of their own knee joint. We hypothesize the sizable differences in residual symptoms and normal knee function present in our study may be better explained by the previously referenced high expectations and greater daily activity in younger patients because no difference was found in revision rates. As the number of younger patients undergoing TKA continues to increase, it will be vital for surgeons to consider differences in expectations based on age when discussing an indicated TKA with prospective patients. With proper preoperative education, younger patient expectations may be modified and therefore allow for better satisfaction postoperatively.
There are several limitations. First, as an electronic survey was used to contact patients and gather postoperative satisfaction responses, there is the potential for selection bias. It is possible that there were patients who were unable to complete the survey due to limited access to an electronic device or did not list a valid electronic mail address. Second, the survey used in this study was not a previously validated survey study. However, this survey has been previously used in a multicenter study10 and includes reasons for dissatisfaction following surgery. Therefore, we believe that this survey is a valid method to determine residual symptoms and reasons for dissatisfaction in patients undergoing TKA. Third, as the survey was done more than five years postoperatively, it is possible that patients may demonstrate recall bias regarding their outcomes following TKA. However, the survey captured the rate of satisfaction at the seven-year postoperative time frame, which may better capture long-term satisfaction rates. Finally, the overall included patient cohort demonstrated at 71.0% satisfaction with their TKA surgery. As previous studies have demonstrated higher rates of satisfaction in both younger and older adult patients,10,11,20,21 we postulate that it is likely more patients that were dissatisfied with surgery were more likely to complete the electronic survey. Future prospective studies to evaluate long-term follow-up without the possibility of recall bias. In addition, it is possible that many patients did not complete one-year follow-up, as previous research has shown follow-up visit attendance after TKA decline from 95.7% at two weeks to 64.4% at one-year postoperatively.22 Therefore, further studies should evaluate the association of long-term postoperative outcomes and satisfaction with large patient cohorts.
Conclusion
This study determined that when compared with older patients, those younger than 60 years at the time of unilateral TKA reported less satisfaction with performing normal activities and more often stated that their knee did not feel normal postoperatively. Younger patients reported requiring more readmissions for knee arthroplasty concerns; however, no differences was found between the age cohorts in the rate of revision TKA. This information may be beneficial to clinicians and younger patients when discussing postoperative outcomes and functional expectations following unilateral TKA.
Footnotes
Dr. Saxena is a board or committee member of AAOS, the American Association of Hip and Knee Surgeons, and the American Board of Orthopaedic Surgery, Inc, the Eastern Orthopedic Association, the New Jersey Orthopedic Society, and the Pennsylvania Orthopaedic Society. He is a paid consultant for Corin U.S.A. He serves on the editorial or governing board of the Journal of Arthroplasty, the Journal of Bone and Joint Surgery—American, the Journal of Surgical Orthopedic Advances, and the Journal of the American Academy of Orthopedic Surgeons. He has stock or stock options with Parvizi Surgical Innovations and receives research support from United Orthopaedics. The other authors have no disclosures.
Contributor Information
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Eleanor Jenkins, Email: Eleanor.Jenkins@students.jefferson.edu.
Arjun Saxena, Email: arjun.saxena@rothmanortho.com.
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