Effects of improved visual appearance on clinical outcomes after total knee arthroplasty: a randomized controlled trial

Abstract

Background

Despite advancements in total knee arthroplasty (TKA), some patients remain dissatisfied postoperatively, potentially due to subjective perceptions of knee appearance. This study investigated whether visual feedback on improved knee alignment and appearance after TKA influences pain perception and patient-reported outcomes.

Methods

In this prospective, double-blind, randomized controlled trial, 60 patients undergoing primary TKA were randomized into intervention or control groups (n = 30 each). Pre- and postoperative radiographs, photographs, and gait videos were collected. Patient-reported outcomes were measured using the Visual Analogue Scale (VAS), Oxford Knee Score (OKS), and SF-36 survey. Three months postoperatively, the intervention group received visual feedback via their pre/post images and gait videos, while the control group received routine follow-up only.

Results

Forty-nine patients were included in the final analysis. Baseline characteristics were similar. After the intervention, the VAS score was significantly lower in the intervention group than in the control group [1.00 (1.00, 2.00) vs. 2.00 (1.25, 3.00), P < 0.05], and SF-36 physical health scores improved significantly. Within-group analysis showed significant improvements in VAS, OKS, and SF-36 in the intervention group, while only OKS improved in the control group. Change-score analysis revealed a significantly greater reduction in pain in the intervention group [ΔVAS 1.00 (1.00, 2.00) vs. 0.00 (0.00, 0.00), P < 0.01].

Conclusions

Visual feedback on postoperative knee alignment may improve pain perception and patient satisfaction after TKA. Incorporating standardized image and gait documentation into follow-up recovery may enhance patient satisfaction and perceived outcomes.

Trial registration

chictr.org.cn, ChiCTR2300076318, Registration date: 01 October 2023.

Background

Total knee arthroplasty (TKA) is a widely performed surgical procedure for end-stage knee arthritis (mainly including osteoarthritis (OA) and rheumatoid arthritis (RA)), offering substantial improvements in pain, alignment, and mobility. While clinical outcomes and patient-reported outcome measures (PROMs) are typically influenced by pain relief and functional recovery, recent attention has turned to the potential role of visual appearance in shaping patient satisfaction.

In deformity-related surgeries, including spinal correction and hallux valgus and wrist deformity, studies have demonstrated that improved visual appearance following surgery enhances both clinical outcomes and patient satisfaction [1–6]. However, these findings are mostly derived from younger or female populations with high cosmetic expectations. In contrast, TKA is predominantly performed in elderly patients (aged 65 and above) [7, 8], and whether visual improvement—particularly the correction of obvious deformities such as varus/valgus—continues to influence outcomes in this demographic remains unclear.This highlights the need for further investigation into the psychological and clinical implications of visual appearance feedback after TKA.

Cosmetic assessment in TKA has generally focused on surgical wound appearance. Researchers have compared various suture materials [9] and closure techniques [10, 11], often discussing aesthetic outcomes. Other studies explored less invasive approaches like the mini-midvastus approach, which has shown cosmetic advantages despite similar clinical outcomes [12]. Nepal et al. [10] reported a mild but statistically significant correlation between wound appearance and patient satisfaction, though factors such as age, pain, psychological health, and joint function may play a more critical role. Menkowitz et al. argued that surgical scars can have lasting psychological effects on patients and influence satisfaction levels [13]. In contrast to the above studies that primarily focus on wound cosmesis, the visual appearance improvement in our study refers specifically to the correction of knee alignment or deformities, such as varus, valgus, or flexion contracture. Misir et al. in 2019 first reported that showing patients before-and-after photos of standing posture improvements following TKA could positively influence satisfaction and quality of life [14].

This prospective randomized controlled trial aimed to evaluate whether visual appearance improvement—defined as the correction of preoperative knee deformities such as varus, valgus, or flexion contracture—affects postoperative pain, functional outcomes, and patient satisfaction. In addition, we planned to explore whether this effect is influenced by patient-related factors including etiology (osteoarthritis or rheumatoid arthritis), gender, age, BMI, and the degree of preoperative deformity through subgroup analyses. We hypothesized that by presenting patients in the intervention group with pre- and postoperative images and gait videos at the three-month follow up after the operation, enhanced visual perception of improvement would correlate with better clinical outcomes and satisfaction.

Methods

This study was a prospective, double-blind, randomized controlled clinical trial approved by the Ethics Committee of Tianjin Medical University General Hospital (IRB2023-YX-191-01). Written informed consent was obtained from all participants prior to enrollment. The trial was registered in the Chinese Clinical Trial Registry (ChiCTR2300076318).

Participants and randomization

Sample Size Calculation: A 1:1 allocation ratio was used for the intervention and control groups. The primary outcome measures included pain, knee joint function, and quality of life. Based on previously published data [5], the mean Visual Analogue Scale (VAS) pain score was 1.8 in the control group and 0.4 in the intervention group, with standard deviations of 1.6 and 0.8, respectively. Assuming a two-sided alpha of 0.05 and a statistical power of 90% (β = 0.10), the required sample size was calculated using the power analysis module in SPSS. The results indicated that a minimum of 19 participants per group (total n = 38) would be necessary to detect a statistically significant difference between the two groups. To account for a potential 10% lost to follow-up rate and ensure sufficient power, we initially enrolled 60 patients. This sample size was considered adequate to maintain statistical validity even after accounting for potential attrition during the follow-up period.

Patients who underwent unilateral primary TKA for osteoarthritis or rheumatoid arthritis at Tianjin Medical University General Hospital between February and June 2022 were eligible. Inclusion criteria: (1) diagnosis of knee osteoarthritis or rheumatoid arthritis; (2) primary TKA. Exclusion criteria: (1) cognitive impairment (assessed using the Mini-Mental State Examination); (2) history of fracture or surgery on the affected knee; (3) severe osteoporosis (DXA T-score ≤ −2.5 plus fragility fracture); (4) active infection, coagulopathy, or unstable vital signs; (5) uncontrolled chronic diseases (e.g., diabetes, hypertension, acute rheumatoid or gout attacks); (6) adverse events during observation period (e.g., pulmonary embolism, myocardial infarction, deep vein thrombosis).

Participants were assigned numbers in the order of surgery and randomized into experimental and control groups in a 1:1 ratio using a computer-generated random number list created with SPSS software (version 27; IBM Corp., Armonk, NY). Randomization results were sealed in opaque envelopes by a research coordinator (KZ), who was not involved in patient assessment or intervention delivery.

This study was designed as a double-blind randomized controlled trial. Patients were blinded to group allocation and were not informed of the existence of different follow-up strategies; all participants were told that postoperative assessments were part of routine follow-up care. Outcome assessors (RP) and surgeons were fully blinded to group allocation throughout the study. At the 3-month postoperative follow-up, the researcher responsible for intervention delivery (KW) opened the sealed envelopes and provided structured visual feedback—including pre- and postoperative radiographs, gross images, and gait videos—to patients in the intervention group, while the control group received standard follow-up only. The interventionist was not involved in outcome assessment or data analysis. Statistical analysis was conducted by the second author (HY), who remained blinded to group allocation.

Surgical procedure and rehabilitation

All patients underwent unilateral primary TKA under general anesthesia, performed by the same senior surgeon. Surgical procedures, including the use of posterior-stabilized cemented prostheses without patellar resurfacing, as well as analgesic protocols, suture techniques, and perioperative management, were standardized. Pre- and postoperative rehabilitation followed national expert consensus on enhanced recovery after arthroplasty, with hospital stays of 3–4 days.

Follow-up procedure

The visual feedback intervention was delivered according to a standardized protocol to ensure consistency and reproducibility. Due to the COVID-19 pandemic, the 3-month follow-up and visual feedback were conducted online via a secure WeChat. Images were presented in a fixed predefined order: pre- and postoperative anteroposterior and lateral knee radiographs, full-length weight-bearing lower limb radiographs, pre- and postoperative gross clinical photographs, and finally pre- and postoperative gait videos, consistent with the sequence illustrated in Fig. 3. The same digital materials were used for all participants and shared on screen during the video call. Each intervention session lasted approximately 10 min. Verbal explanations were standardized and limited to neutral descriptions of alignment correction and observable postoperative changes, without additional motivational or psychological guidance.

Fig. 3.

Preoperative and postoperative imaging/gross photo comparison of a certain patient. (a) Anteroposterior (AP) knee radiograph; (b) Lateral radiographic projection of the knee joint; (c) Full-length weight-bearing radiography of bilateral lower extremities; (d) A Full length of both lower limbs (in supine position); (e) Knee joint flexion (in supine position); (f) Knee joint lateral position (in supine position); (g) Full length of both lower limbs (in standing position)

Outcomes

Baseline characteristics included age, sex, height, weight, chief complaint, physical examination, medical history, surgery date, operative side, prosthesis type, and history of contralateral knee replacement. Radiological parameters included hip-knee-ankle (HKA) angle, mechanical medial proximal tibial angle (mMPTA), and mechanical lateral distal femoral angle (mLDFA), measured both pre- and postoperatively.

Primary outcome measures included pain, knee function, and quality of life. Pain was assessed using the Visual Analog Scale (VAS). Knee function was evaluated by the Hospital for Special Surgery (HSS) knee score (clinician-assessed) and Oxford Knee Score (OKS) (patient-reported or with family assistance) [15, 16]. Quality of life was measured by the 36-Item Short Form Health Survey (SF-36), which reflected patient satisfaction.

Radiographic and photo acquisition

Standard radiographs included weight-bearing anteroposterior and lateral knee views, and full-length standing lower limb alignment films, performed according to established protocols by certified radiology technicians. Radiographic parameters of the knee were measured according to standard procedures. Specifically, in this study, a postoperative HKA angle approaching 180° was considered indicative of corrected lower limb alignment, reflecting a straighter knee in visual appearance.

For gross photo documentation, smartphone cameras with grid-line guides were used. The knee joint was centered in the frame, and the photo included the full lower limb (hip to ankle). Photos were taken in a 4:3 aspect ratio (3:4 for standing positions). The standardized position is shown in Fig. 1. Pre- and postoperative photos followed the same standards.

Fig. 1.

Illustrative example of preoperative gross photo for knee joint. (a) A Full length of both lower limbs (in supine position); (b) Knee joint flexion (in supine position); (c) Knee joint extended position (in supine position); (d) Knee joint lateral position (in supine position); (e)Full length of both lower limbs (in standing position)

Gait videos were recorded in a 9:16 aspect ratio using grid-line guidance to keep the knee centered (Fig. 2). Patients were instructed to walk forward and return, ensuring stability of the camera view. All images and videos were captured by the same resident (RP).

Fig. 2.

Illustration of preoperative video-based gait analysis

At the 3-month postoperative follow-up, the research coordinator (KW) provided patients in the intervention group with pre- and postoperative radiographic comparisons, gross photos, and gait videos in a standardized sequence to visually demonstrate the improvements (Fig. 3).

Statistical analysis

Data were analyzed with SPSS 27.0 (IBM, Armonk, NY). Normality was tested using the Shapiro–Wilk test. Normally distributed variables were expressed as mean ± SD and compared with independent t-tests; non-normal data were presented as median (IQR) and analyzed with Mann–Whitney U or Wilcoxon signed-rank tests. Categorical data were expressed as frequencies (%) and compared using chi-square tests. Statistical significance was set at P < 0.05.

This randomized controlled trial is reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) guidelines.

Results

General Characteristics

A total of 60 patients were initially enrolled. After excluding 3 lost to follow-up, 6 with missing data, and 2 with significant bias, 49 patients were finally included (25 in the intervention group and 24 in the control group (Fig. 4). No significant differences were found between the two groups in terms of baseline demographics or radiological parameters (Tables 1 and 2). Postoperatively, the HKA angle significantly improved from 173.5 ± 7.68 to 178.2 ± 1.65 (P < 0.01), indicating corrected lower limb alignment and improved visual appearance.

Fig. 4.

Flow diagram demonstrating the flow of patients through the randomized clinical study

Table 1.

Participant demographics

Baseline Characteristics	Total(n = 49)	Control group(n = 24)	Intervention group(n = 25)	P
Gender(male(%))	12 (24.5)	8 (33.3)	4 (16.0)	0.281
Operated side(left(%))	25 (51.0)	14 (58.3)	11 (44.0)	0.473
Age (year)	67.76 ± 5.10	67.21 (5.29)	68.28 (4.95)	0.468
Height(cm)	161.98 ± 5.79	162.67 (6.20)	161.32 (5.41)	0.421
Weight(kg)	68.80 ± 10.02	70.29 ± 9.67	67.36 ± 10.34	0.311
BMI (kg/m2)	26.19 ± 3.46	26.55 ± 3.28	25.85 ± 3.67	0.484
Contralateral TKA (%)	4 (8.2)	2 (8.3)	2 (8.0)	1

Gender, operated side, and Contralateral TKA are expressed in terms of the number of cases and percentage (%); Age, height, weight and BMI were expressed as mean ± standard deviation (mean ± SD); Contralateral TKA: indicates whether the patient had undergone total knee arthroplasty on the contralateral side prior to the study

Abbreviation: BMI Body Mass Index

Table 2.

Comparison of radiological parameters within and between groups

Radiological parameters	Time	Total	Control group	Intervention group	P
HKA (°) mean ± SD	Preoperative	173.53 (7.68)	172.08 (7.26)	174.92 (7.96)	0.199
	Postoperative	178.18 (1.65)	178.12 (1.45)	178.24 (1.85)	0.811
	P	< 0.001	< 0.001	< 0.001
mMPTA(°) mean ± SD	Preoperative	86.12 (2.92)	86.12 (3.23)	86.12 (2.65)	0.995
	Postoperative	88.65 (1.54)	88.46 (1.44)	88.84 (1.62)	0.390
	P	< 0.001	< 0.001	< 0.001
mLDFA (°) mean ± SD	Preoperative	90.18 (3.21)	90.79 (2.75)	89.60 (3.56)	0.197
	Postoperative	90.12 (1.15)	89.88 (1.23)	90.36 (1.04)	0.141
	P	> 0.05	> 0.05	> 0.05

Abbreviation: HKA hip-knee-ankle angle, mMPTA Mechanical medial proximal tibial angle, mLDFA Mechanical lateral distal femoral angle

Comparison of preoperative and pre-intervention outcome measures

There were no significant differences in baseline scores between the two groups prior to surgery, indicating good comparability. Before the intervention, there was a significant difference in SF-36 physical health (PH) scores between groups (intervention group: 239.00 [194.00, 295.00] vs. control group: 304.50 [237.00, 357.00]), but no differences in other outcome measures. Within both groups, pain, knee function, and quality of life significantly improved from preoperative to pre-intervention assessments, indicating good surgical outcomes (Table 3).

Table 3.

Comparison of outcomes measures between preoperative and pre-intervention

	Group	preoperative	Pre-intervention	P
VAS	Control	4.00(2.00,4.00)	2.00(2.00,3.00)	0.000
	Intervention	4.00(2.00,5.50)	2.00(2.00,3.50)	0.010
	P	0.949	0.211
HSS	Control	55.75 ± 11.40	85.96 ± 7.39	0.000
	Intervention	52.80 ± 14.46	85.00 ± 7.51	0.000
	P	0.433	0.655
OKS	Control	37.50 ± 7.17	26.17 ± 7.38	0.000
	Intervention	40.72 ± 8.65	28.64 ± 7.95	0.000
	P	0.164	0.265
SF-36 PH	Control	175.00(113.00,237.75)	304.5(237.00, 357.00)	0.000
	Intervention	116.00(94.5,194.5)	239.00(194.00, 295.00)	0.000
	P	0.183	0.010
SF-36 MH	Control	241.78(181.42,340.08)	354.78(283.78,378.61)	0.002
	Intervention	242.78(172.61,292.83)	345.56(311.11,369.00)	0.000
	P	0.624	0.764

HSS and OKS are expressed as mean ± standard deviation (mean ± SD); VAS and SF-36 were expressed as quartiles for median (IQR) because they did not conform to the normal distribution

Abbreviation: VAS Visual analogue score, HSS score Hospital for Special Surgery score, OKS Oxford knee score, SF-36, The 36-Item Short Form Health Survey

Comparison of outcome measures before and after intervention

Table 4 shows comparisons of main clinical outcome measures before and after the intervention. After the intervention, VAS scores significantly decreased in the intervention group and were significantly lower than those in the control group (1.00 [1.00, 2.00] vs. 2.00 [1.25, 3.00], p = 0.048). The median between-group difference was 1.0 (95% CI: 0.00–1.00; Z = − 1.979), corresponding to a small-to-moderate effect size (r = 0.28). OKS scores improved significantly within both groups after the intervention; however, no significant difference was observed between the groups. In the intervention group, the mean OKS score decreased from 28.64 ± 7.95 to 25.12 ± 5.45 (p = 0.001). Similarly, in the control group, the score decreased from 26.17 ± 7.38 to 23.75 ± 6.00 (p = 0.003). These findings suggest that regular follow-up improved subjective knee joint function in both groups, but the visual feedback intervention did not result in a significantly greater improvement in OKS compared to standard follow-up alone. SF-36 physical health (PH) scores increased significantly in the intervention group, from a median of 239.00 (IQR: 194.00–295.00) to 261.00 (IQR: 196.50–324.00) (p = 0.028), while no significant within-group change was observed in the control group, whose scores rose from 304.50 (IQR: 237.00–357.00) to 319.00 (IQR: 267.50–352.75) (p = 0.135). Notably, SF-36 PH scores were significantly higher in the control group at both time points (p < 0.05). Mental health (SF-36 MH) scores showed no significant change within or between groups. Table 5 further demonstrates that among the outcome measures, only the change in VAS scores (ΔVAS) differed significantly between groups, with a median reduction of 1.00 (IQR: 1.00–2.00) in the intervention group versus 0.00 (IQR: 0.00–0.00) in the control group (P < 0.01), confirming the pain-relieving effect of the visual intervention.

Table 4.

Comparison of outcomes measures between pre-intervention and post-intervention

	Group	Pre-intervention	Post-intervention	P
VAS	Control	2.00(2.00,3.00)	2.00(1.25,3.00)	0.083
	Intervention	2.00(2.00,3.50)	1.00(1.00,2.00)	0.000
	P	0.211	0.048
OKS	Control	26.17 ± 7.38	23.75 ± 6.00	0.003
	Intervention	28.64 ± 7.95	25.12 ± 5.45	0.001
	P	0.265	0.407
SF-36 PH	Control	304.5(237.00, 357.00)	319.00(267.50, 352.75)	0.135
	Intervention	239.00(194.00, 295.00)	261.00(196.50,324.00)	0.028
	P	0.010	0.018
SF-36 MH	Control	354.78(283.78,378.61)	362.94(270.00,378.69)	0.061
	Intervention	345.56(311.11,369.00)	355.00(316.67,373.00)	0.481
	P	0.764	0.667

OKS is expressed as mean ± standard deviation (mean ± SD); VAS and SF-36 were expressed as quartiles for median (IQR) because they did not conform to the normal distribution. For the post-intervention comparison of VAS scores between groups, the Hodges–Lehmann estimator was used to estimate the median difference with a 95% confidence interval. Effect size (r) was calculated as Z/√N based on the Mann–Whitney U test

Table 5.

Comparison of changes in each outcomes measures before and after the intervention

	Control group	Intervention group	P
ΔVAS	0.00(0.00,0.00)	1.00(1.00,2.00)	0.000
ΔOKS	1.00(0.00,2.75)	2.00(1.00,7.00)	0.103
ΔSF-PH	−5.00(−15.00,0.00)	−20.00(−41.50,2.50)	0.162
ΔSF-MH	0.00(−19.78,0.00)	0.00(−20.50,10.61)	0.700

Expressed in terms of the median and interquartile range (median (IQR))

Discussion

The key finding of this study is that patients who visually perceived improvement in knee alignment—via pre- and postoperative radiographs, gross images, and gait videos—demonstrated greater pain relief following total knee arthroplasty (TKA), compared to those receiving standard follow-up. While this study cannot establish a causal relationship, the results support a potential association between visual appearance feedback and improved pain outcomes. Although the between-group difference in VAS scores reached statistical significance, its clinical relevance should be interpreted in the context of the minimal clinically important difference (MCID). Previous studies have suggested that the MCID for VAS pain ranges from approximately 1 to 2 points [17, 18]. In the present study, the median reduction in VAS score in the intervention group approached this lower threshold, indicating a modest but potentially meaningful improvement in pain perception. Given that the intervention consisted solely of structured visual feedback without any additional medical or rehabilitative measures, this degree of pain reduction may still be clinically relevant, particularly as a low-cost, low-risk adjunct to routine postoperative follow-up.

Total knee arthroplasty (TKA) is primarily indicated for end-stage arthritis, including osteoarthritis and rheumatoid arthritis, which are often accompanied by varying degrees of varus or valgus deformity. A key surgical goal is to restore neutral limb alignment, thereby improving both function and appearance [19, 20]. While TKA generally yields significant improvements in pain and function [21, 22], studies show that patient satisfaction does not always align with clinical outcome scores [23], with dissatisfaction rates up to 19% [24]. As Gandhi et al. argued, patient expectations play a vital role in this discrepancy [25]. Patients undergoing TKA usually have high expectations for the operation. Most patients expect significant improvement in pain and fewer functional limitations [26]. This aspect is often underappreciated in outcome assessments.

In other orthopedic procedures like spine and hallux valgus surgery, cosmetic improvement following deformity correction has been associated with better satisfaction and functional recovery [3, 5, 27]. Although these conditions differ anatomically from TKA, they share the principle that visible alignment correction may positively affect patient perception and outcomes. In contrast, most expectation scales used in TKA—such as the HSS-KRES, New KSS, and various custom questionnaires [28–31]—focus on pain and function while rarely incorporating appearance-related concerns. This gap underscores the need to further explore whether visual outcomes should be considered a relevant dimension in evaluating TKA success.

Previous studies on visual feedback in TKA have primarily focused on postoperative range-of-motion photographs [27, 32], with inconsistent results: some reported no significant benefit [27], while others observed improved early knee flexion [32]. In contrast, our study adopted a more comprehensive visual intervention by presenting full-limb radiographs, gross photographs, and gait videos, allowing patients to directly perceive correction of lower-limb deformity and functional improvement. Such visual feedback may facilitate psychological reassurance and shift patients’ attention toward objective recovery progress, thereby reducing perceived pain through cognitive–emotional modulation. Similar effects of visual confirmation on pain perception and functional recovery have been reported in spine and foot surgery [3–5]. In addition, both groups showed improvement after routine follow-up, underscoring the importance of regular clinical engagement. SF-36 Physical Health scores, which are closely associated with patient satisfaction [33], improved following the intervention. However, no significant differences were observed in OKS or SF-36 Mental Health scores, possibly due to the relatively short interval between assessments [14].

A novel contribution of our study is the standardized method for gross knee photography and gait recording. Although image-based assessment is well established for hallux valgus [34], there is no such standard for knee evaluation. Our protocol may offer a reproducible model for future studies. Validation of visual angles in gross images against radiographic data remains a topic for further research.

Although baseline characteristics (age, gender, height, weight, BMI) did not differ between groups, the absence of subgroup analyses remains a limitation. As a single-center prospective randomized trial, the study minimized institutional bias but was restricted by small sample size and short follow-up. Future multicenter studies with larger cohorts are needed to strengthen the evidence for visual feedback after TKA. Another limitation is the lack of a specific scale to assess perceptions of knee appearance. In addition, photographs were obtained immediately postoperatively with dressings in place due to COVID-19 restrictions, limiting standardized follow-up at 3 months. Nevertheless, key indicators of deformity correction (e.g., varus/valgus alignment) remained visible, though delayed photographs after swelling resolution might provide more refined cosmetic evaluation.

Conclusion

Visual feedback highlighting correction of knee alignment after total knee arthroplasty was associated with a significant reduction in patient-reported pain, as reflected by changes in VAS scores. Although improvements in physical health–related quality of life were observed, these differences were present before intervention and did not differ significantly between groups when change scores were compared. Therefore, the primary benefit of visual feedback in this study appears to be pain relief rather than broader functional or mental health improvement. Given the multifactorial nature of postoperative discomfort and patient expectations, visual feedback may serve as a supportive component of follow-up care. Further studies with larger sample sizes and longer follow-up are warranted to determine whether this approach confers sustained functional or satisfaction-related benefits before routine implementation can be recommended.

Abbreviations

VAS

The visual analogue scale

HSS

American Hospital for Special Surgery Knee Score

OKS

Oxford Knee Score

SF-36

The 36-Item Short Form Health Survey

HKA

The Hip-Knee-Ankle

mMPTA

The Mechanical Medial Proximal Tibial Angle

TKA

Total knee arthroplasty

mLDFA

The Mechanical Lateral Distal Femoral Angle

ROM

Range of motion

SD

Standard deviation

HSS-KRES

Hospital for Special Surgery Knee Replacement Expectations Survey

New-KSS

New knee society knee scoring system

BMI

Body Mass Index

Authors’ contributions

Ran Pang and Hui Yin contributed equally to this work and should be considered co-first authors. Ran Pang and Hui Yin: outcome assessor; edited the first draft of this work. Hui Yin, Yali Zhao and Xinglong Zhang : completed the statistical analysis and improved the manuscript. Kai Zhang: Clinical research coordinator. Kaixuan Wu: follow-up of patients and imposition of interventions. Hui Li, Zhijun Li and Huafeng Zhang: conceived and identified the topic of the study. All authors read and approved the final manuscript.

Funding

This work was supported by funding from Tianjin Natural Science Foundation (Grant No. 23JCYBJC00700) and Tianjin Key Medical Discipline Construction Project (Grant No.TJYXZDXK-3-005 A).

Data availability

The trial protocol, statistical analysis plan, and de-identified individual participant data are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was performed in line with the principles of the Declaration of Helsinki. This study received ethical approval from the Ethics Committee of Tianjin Medical University General Hospital (IRB2023-YX-191-01). Informed consent was obtained from all individual participants included in the study.

Consent for publication

Written informed consent for publication of personal and clinical details, including any potentially identifiable images, was obtained from all participants. Specifically, written consent was obtained for the publication of images presented in Figures 1–3.

Competing interests

The authors declare no competing interests.