Abstract
Background
Psychological distress has been associated with inferior scores for pain after total knee arthroplasty (TKA). However, its relationships with scores and arthrofibrosis after TKA remain unclear.
Question/purposes
The objectives of this study were (1) to assess patient-reported outcomes (PROs), including Knee Society (KS) scores, of those patients who developed arthrofibrosis and underwent manipulation and compare them with a control group; and (2) in patients with arthrofibrosis who underwent manipulation, to determine PROs and KS scores of those with psychological distress and those without it.
Methods
During a 17-year period (August 1992 to October 2009), a total of 1952 TKAs were performed and included in our prospectively collected joint registry database; 1248 procedures had a postoperative followup of at least 2 years (mean, 5 years; range, 2–16 years). Among them, 57 knees (53 patients) developed arthrofibrosis and underwent manipulation under anesthesia after the index procedure. This group was compared with a matched group (by age, sex, race, and ethnicity) of 63 knees (58 patients) without arthrofibrosis. Demographics, preoperative and postoperative Quality of Well-Being scale (QWB-7), SF-36, WOMAC, and The KS knee and function scores were prospectively collected and retrospectively analyzed. Patients with < 52 points on the SF-36 Mental Component Summary subscale were considered in psychological distress for all comparisons. Active knee flexion and KS range of motion (ROM) were used as objective motion measures. Minimum followup was 2 years (mean, 5 years; range, 2–16 years).
Results
Patients who developed arthrofibrosis had worse KS function scores before TKA than did patients in the nonarthrofibrosis control group (mean 27, SD 20.5 versus 37, SD 19.3; p = 0.006). Patients with arthrofibrosis and psychological distress, before TKA and when compared with patients with arthrofibrosis but without distress, had worse QWB-7 (0.490 versus 0.547; p < 0.001) and worse WOMAC stiffness (4.92, versus 3.22; p = 0.005), respectively. Postoperatively, patients with arthrofibrosis and distress also had worse QWB-7 (0.537 versus 0.627; p = 0.002).
Conclusions
Patients with arthrofibrosis and psychological distress perceived themselves preoperatively as having worse knee and overall health status than those with arthrofibrosis but without distress. In view of this, expectations after TKA should be particularly addressed in those patients with poor function and psychological distress. Further investigations, making use of tools specifically designed to ascertain depression, are warranted.
Level of Evidence
Level III, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.
Introduction
Psychological distress has been associated in many studies with inferior scores for pain and function after TKA [6, 7, 9, 16, 18, 20]. Understanding what factors contribute to poor results after TKA is particularly useful for surgeons and healthcare providers [15]. The presence of psychological distress has been found to be associated with an increased risk of symptomatic knee osteoarthritis [14]. In one study [3], preoperative psychological distress was observed in 32% of patients undergoing primary hip and knee arthroplasty (32 of 100). Worse preoperative and postoperative scores have been found in patients undergoing TKA with psychological distress (particularly depression) [18].
Although small numbers of patients have persistent postoperative knee dysfunction after surgery as a result of limited ROM, and arthrofibrosis after TKA is associated with lower knee scores and patient dissatisfaction [17, 18, 21], little is known regarding the possible associations between the presence of preoperative psychological distress and the development of arthrofibrosis after TKA. The relationships of patient-reported outcomes (PROs) in those patients with both arthrofibrosis and psychological distress to our knowledge have not been defined.
The objectives of this study were (1) to assess patient-reported outcomes, including Knee Society (KS) scores, of those patients who developed arthrofibrosis and underwent manipulation and compare them with a control group; and (2) in patients with arthrofibrosis who underwent manipulation, to determine PROs and KS scores of those with psychological distress and those without it.
Patients and Methods
Over a period of 17 years (August 1992 to October 2009), a total of 1952 TKAs were performed and included in our prospectively collected joint registry database; 1248 procedures had a postoperative followup of at least 2 years (mean, 5 years; range, 2–16 years). Among them, 57 knees (53 patients) developed arthrofibrosis and underwent manipulation under anesthesia (MUA) after the TKA. During the period in question, the indications for MUA remained relatively constant; in general, MUA was recommended to patients who did not achieve at least 90° of flexion within 30 days, and we recommend the procedure be done within 6 weeks after the index surgery; MUAs in this series were performed following these indications and recommendations.
This group of patients was compared on the outcomes of interest with a control group of patients who were identified at random after matching for age, sex, race, and ethnicity; this group included 58 patients (63 knees) who did not develop arthrofibrosis after primary TKA. There were no differences on baseline patient demographics between the arthrofibrosis and the control groups (Table 1), which confirmed the efficacy of the matching procedure.
Table 1.
Demographics and body mass index of the arthrofibrosis group and the group without arthrofibrosis (control)
| Characteristic | Group | ||
|---|---|---|---|
| Arthrofibrosis | Control | p value | |
| Age (years) | 66 | 64 | 0.2 |
| Sex | |||
| Women | 73% | 81% | 0.3 |
| Men | 27% | 19% | |
| Race | |||
| Black | 11% | 6% | 0.4 |
| White | 89% | 94% | |
| Ethnicity | |||
| Hispanic | 81% | 81% | 1.0 |
| Non-Hispanic | 19% | 19% | |
| Body mass index (kg/m2; mean) | 31 | 30 | 0.3 |
Outcomes of interest included demographics and the following preoperative and postoperative PROs: Quality of Well-Being scale (QWB-7) [13], SF-36 [2], and the WOMAC [4]. Clinical scores included the KS knee and function scores [12]. In addition, active knee flexion and the KS ROM were included. All data were prospectively collected in the joint registry database but they were retrospectively analyzed. To quantify psychological distress, most investigators have used a surrogate measure of general distress, either the Mental Health score or the Mental Component Summary (MCS) score of the SF-36 [16]. Patients with < 52 points on the SF-36 MCS were considered to be in psychological distress in this investigation. Those patients with arthrofibrosis and preoperative psychological distress (as measured by the SF-36 MCS) were compared on the preoperative and postoperative outcomes of interest with those patients with arthrofibrosis but without psychological distress.
Most patients were discharged to home within 3 to 4 days in the absence of complications. Patients were then seen by the senior author (CJL) during the second and sixth postoperative weeks for staple removal and clinical evaluation. Outcomes of interest were assessed preoperatively and postoperatively at 3 months, 6 months, 1 year, and annually thereafter. All patients provided informed consent for this institutional review board-approved study. The minimum followup was 2 years (mean, 5 years; range, 2–16 years). Mean age was 65 years (range, 32–94 years).
Statistical Analysis
We determined differences between the arthrofibrosis and control groups in the QWB-7, WOMAC, KS knee and function scores, active knee flexion, and KS ROM before and after surgery using independent t-tests. Within the arthrofibrosis group, independent t-tests were used to determine if there were differences between psychologically distressed individuals and nondistressed individuals on PROs, knee scores, and objective motion measures. All statistical analyses were performed using the SPSS Software (Version 16.0; IBM Corp, Armonk, NY, USA). A p value < 0.01 was considered significant.
Results
Preoperatively and before the index surgery, patients who developed arthrofibrosis who underwent MUA had worse KS function scores than did patients in the nonarthrofibrosis control group (mean 27, SD 20.5 versus 37, SD 19.3; 95% confidence interval, −17.4 to −3.0; p = 0.006). Postoperatively and after MUA, in the same comparison, there were no differences between the groups (Table 2).
Table 2.
Preoperative and postoperative comparisons between the group with arthrofibrosis and the group without arthrofibrosis (control) on patient-reported outcomes, knee scores, and ROM measures
| Dependent variable | Preoperative | Postoperative | ||||||
|---|---|---|---|---|---|---|---|---|
| Arthrofibrosis, mean (SD) | Control, mean (SD) | p value | 95% CI | Arthrofibrosis, mean (SD) | Control, mean (SD) | p value | 95% CI | |
| QWB-7 total | 0.522 (0.05) | 0.530 (0.06) | 0.4 | −0.02 to 0.01 | 0.587 (0.10) | 0.609 (0.13) | 0.3 | −0.06 to 0.02 |
| KS knee score | 42.59 (22.9) | 43.27 (23.7) | 0.8 | −9.2 to 7.8 | 81.18 (22.9) | 86.58 (22.7) | 0.2 | −14.0 to 3.2 |
| KS function score | 26.84 (20.5) | 37.06 (19.3) | 0.006* | −17.4 to −3.0 | 51.30 (22.1) | 59.76 (21.4) | 0.04 | −16.6 to −0.2 |
| WOMAC stiffness | 3.96 (2.3) | 3.61 (2.2) | 0.4 | −0.4 to 1.1 | 1.23 (2.2) | 0.56 (1.2) | 0.04 | 0.01–1.3 |
| WOMAC total | 61.16 (18.2) | 57.06 (15.8) | 0.19 | −2.1 to 10.3 | 17.00 (26.2) | 7.22 (13.6) | 0.01 | 2.0–17.4 |
| Knee active flexion | 102.39 (19.1) | 102.44 (21.2) | 0.9 | −7.3 to 7.2 | 96.71 (17.3) | 104.19 (16.1) | 0.018 | −13.6 to −1.2 |
| KS ROM | 103.07 (18.7) | 104.92 (22.0) | 0.6 | −9.2 to 5.5 | 101.63 (21.5) | 109.76 (17.0) | 0.026 | −15.2 to −0.9 |
* p value < 0.01 independent t-tests; CI = confidence interval; QWB-7 = Quality of Well-Being Index; KS = The Knee Society.
Regarding comparisons between the arthrofibrosis group with psychological distress and the group with arthrofibrosis but without psychological distress, preoperatively and before the index surgery, patients with arthrofibrosis and psychological distress had worse QWB-7 scores (mean 0.490, SD 0.04 versus 0.547, SD 0.05; 95% confidence interval, −0.08 to −0.03; p < 0.001) and worse WOMAC stiffness scores (mean 4.92, SD 2.1 versus 3.22, SD 2.1; 95% confidence interval, 0.53–2.8; p = 0.005), respectively. Postoperatively and after the MUA, patients with arthrofibrosis and psychological distress had significantly worse QWB-7 than those patients with arthrofibrosis but without psychological distress (mean 0.537, SD 0.09 versus 0.627, SD 0.10; 95% confidence interval, −0.14 to −0.03; p = 0.002, respectively) (Table 3).
Table 3.
Preoperative and postoperative comparisons between patients with arthrofibrosis and psychological distress and those patients with arthrofibrosis but without psychological distress (distressed versus nondistressed)
| Dependent variable | Preoperative | Postoperative | ||||||
|---|---|---|---|---|---|---|---|---|
| Distressed, mean (SD) | Nondistressed, mean (SD) | p value | 95% CI | Distressed, mean (SD) | Nondistressed, mean (SD) | p value | 95% CI | |
| QWB-7 total | 0.490 (0.04) | 0.547 (0.05) | < 0.001* | −0.08 to −0.03 | 0.537 (0.09) | 0.627 (0.10) | 0.002* | −0.14 to −0.03 |
| KS knee score | 41.00 (22.7) | 43.78 (23.4) | 0.6 | −15.3 to 9.7 | 80.32 (22.3) | 81.86 (23.8) | 0.8 | −14.8 to 11.7 |
| KS function score | 19.40 (18.5) | 32.66 (20.3) | 0.014 | −23.7 to −2.7 | 50.00 (24.4) | 52.32 (20.6) | 0.7 | −15.1 to 10.5 |
| WOMAC stiffness | 4.92 (2.1) | 3.22 (2.1) | 0.005* | 0.53–2.8 | 1.52 (2.2) | 1.0 (2.1) | 0.3 | −0.66 to 1.7 |
| WOMAC total | 66.96 (17.0) | 56.81 (18.0) | 0.038 | 0.59–19.6 | 20.64 (27.5) | 14.16 (25.2) | 0.3 | −7.5 to 20.5 |
| Knee active flexion | 102.68 (16.4) | 102.16 (21.3) | 0.9 | −9.8 to 10.8 | 96.23 (18.4) | 97.07 (16.8) | 0.8 | −10.7 to −10.9 |
| KS ROM | 105.40 (15.6) | 101.25 (21.0) | 0.4 | −5.9 to 14.2 | 102.73 (21.0) | 100.83 (22.2) | 0.7 | −10.3 to 14.1 |
* p value < 0.01 independent t-tests; CI = confidence interval; QWB-7 = Quality of Well-Being Index; KS = The Knee Society.
Discussion
Psychological disorders are fairly prevalent worldwide (5%–25%) with up to 6.6% of the population in the United States experiencing a major depressive disorder in any given year [11]. It has been shown that up to one-third of the patients who undergo an elective TKA are under psychological distress [3, 11, 16, 19]. Psychological distress (in particular depression) among patients who undergo TKA seems to lead to poorer preoperative and postoperative scores [18]. The literature is scarce regarding the possible associations between the presence of preoperative psychological distress and the development of arthrofibrosis after TKA and it is not conclusive concerning the PROs in this particular subgroup of patients [18]. As a consequence, the purposes of this investigation were (1) to assess PROs (including knee scores) of those patients who developed arthrofibrosis and underwent manipulation and compare them with a control group without arthrofibrosis; and (2) among patients with arthrofibrosis who underwent manipulation, to determine the PROs/knee scores of those with psychological distress and those without it.
Our results should be interpreted in light of several limitations. First, we evaluated a sample that underwent surgery in a specific Hispanic-predominated population in south Florida, USA; for this reason, results might not be generalizable to other populations. In addition, some of the results found in our study might have been subjected to sampling error as a result of the relatively small numbers of knees. Second, in an effort to adjust for as many confounding factors as possible, we compared the arthrofibrosis group with a control group matched by age, sex, race, and ethnicity. However, we did not adjust for other factors such as quadriceps strength, level of education, socioeconomic status, or medical comorbidities [9–11, 14]. Third, the KS score is not an independent endpoint from ROM, because that score does include a component related to ROM. However, that is a small part of the overall score, and we believe this issue does not preclude its use, because the KS score measures numerous items apart from ROM. Finally, we were not able to ascertain the exact number of patients to whom MUA was recommended although we think this number is very low, if any. However, because psychological distress might have influenced the decision to undergo manipulation, this circumstance represents another limitation. Again, we do not think that a substantial number of patients declined MUA as a result of their psychological distress, because this is not a frequent occurrence in this practice. Consequently, we do not think that this limitation was likely to have materially influenced the results.
We found that the arthrofibrosis group had a worse mean preoperative (before the index surgery) KS function score than did the group without arthrofibrosis (control). This is consistent with previous reports of patients’ preoperative scores serving as predictors of knee stiffness after TKA [1, 17]. Postoperatively and after manipulation, we found that patients with arthrofibrosis did not have significant differences in the same comparison, a result that is not in agreement with previous investigations [10, 21].
Preoperatively and before the index surgery, patients with arthrofibrosis and psychological distress had lower QWB-7 and WOMAC stiffness than did patients with arthrofibrosis but without psychological distress. This finding was sustained postoperatively and after manipulation for the QWB-7. Similar results have been reported by others, in that patients with poor mental health usually perceive themselves as having a worse clinical state [15, 18, 19]. In our study population, it occurred that patients with arthrofibrosis and psychological distress had similar KS scores and active knee flexion and ROM when compared with patients with arthrofibrosis but without psychological distress; however, these distressed patients perceived themselves in a worse clinical state. This highlights the complexity behind these sorts of outcomes after TKA, because the clinician might perceive that the patient had a satisfactory outcome when the patient in fact perceives his or her results as not being satisfactory. It has been proposed that the perception of pain in knee osteoarthritis is influenced by factors that go beyond the severity of anatomic osteoarthritic changes [8, 14]. This same principle has been proposed in TKA, in which psychological distress (including depression) has been associated with worse preoperative and postoperative PROs [15, 18]. Notwithstanding, it is worth mentioning that in a delta change done between the preoperative and postoperative SF-36 MCS scores, patients classified preoperatively as being psychologically distressed had a substantial improvement (14.24 and 12.59, respectively), whereas patients who were psychologically nondistressed had a slight loss (−2.25 and −4.94, respectively). Several authors [5, 7, 16, 18] have noted an improvement in the mental health of patients undergoing TKA hypothesizing that pain before surgery might lead to depression and thus undergoing knee arthroplasty would improve depression and pain. However, further studies are warranted to support such a hypothesis.
In conclusion, patients who developed arthrofibrosis had worse preoperative KS function than patients without postoperative arthrofibrosis. Compared with patients with arthrofibrosis but without psychological distress, those patients with arthrofibrosis and psychological distress perceived themselves as having worse quality of well-being and more stiffness before the surgical intervention and their worse quality of well-being perception was sustained after surgery. Expectations after TKA should be particularly addressed in those patients with poor function and psychological distress. Further investigations, making use of tools specifically designed to ascertain depression, are warranted.
Acknowledgments
We thank Mark D. Rossi PhD, PT, for his statistical and technical support.
Footnotes
One of the authors (CJL) is a consultant and receives royalties from Mako Surgical Corp (Fort Lauderdale, FL, USA); he also owns stock in Johnson & Johnson (New Brunswick, NJ, USA), Zimmer (Warsaw, IN, USA), Stryker (Mahwah, NJ, USA), Wright Technologies, Inc (Arlington, TN, USA), and Symmetry Medical (Warsaw, IN, USA). One of the authors (CJL) certifies that he has or may receive payments or benefits, in any one year, an amount in excess of USD 10,000 from Mako Surgical Corp, Johnson & Johnson, Zimmer, Stryker, Wright Technologies, Inc, and Symmetry Medical.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.
Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
This work was performed at the Center for Advanced Orthopedics at Larkin, South Miami, FL, USA.
References
- 1.Anouchi YS, McShane M, Kelly F, Jr, Elting J, Stiehl J. Range of motion in total knee replacement. Clin Orthop Relat Res. 1996;331:87–92. doi: 10.1097/00003086-199610000-00012. [DOI] [PubMed] [Google Scholar]
- 2.Arocho R, McMillan CA, Sutton-Wallace P. Construct validation of the USA-Spanish version of the SF-36 health survey in a Cuban-American population with benign prostatic hyperplasia. Qual Life Res. 1998;7:121–126. doi: 10.1023/A:1008801308886. [DOI] [PubMed] [Google Scholar]
- 3.Ayers DC, Franklin PD, Trief PM, Ploutz-Snyder R, Freund D. Psychological attributes of preoperative total joint replacement patients: implications for optimal physical outcome. J Arthroplasty. 2004;19:125–130. doi: 10.1016/j.arth.2004.06.019. [DOI] [PubMed] [Google Scholar]
- 4.Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15:1833–1840. [PubMed] [Google Scholar]
- 5.Blackburn J, Qureshi A, Amirfeyz R, Bannister G. Does preoperative anxiety and depression predict satisfaction after total knee replacement? Knee. 2012;19:522–524. doi: 10.1016/j.knee.2011.07.008. [DOI] [PubMed] [Google Scholar]
- 6.Brander V, Gondek S, Martin E, Stulberg SD. Pain and depression influence outcome 5 years after knee replacement surgery. Clin Orthop Relat Res. 2007;464:21–26. doi: 10.1097/BLO.0b013e318126c032. [DOI] [PubMed] [Google Scholar]
- 7.Clement ND, MacDonald D, Burnett R. Primary total knee replacement in patients with mental disability improves their mental health and knee function: a prospective study. Bone Joint J. 2013;95:360–366. doi: 10.1302/0301-620X.95B3.29563. [DOI] [PubMed] [Google Scholar]
- 8.Dieppe PA, Lohmander LS. Pathogenesis and management of pain in osteoarthritis. Lancet. 2005;365:965–973. doi: 10.1016/S0140-6736(05)71086-2. [DOI] [PubMed] [Google Scholar]
- 9.Ellis HB, Howard KJ, Khaleel MA, Bucholz R. Effect of psychopathology on patient-perceived outcomes of total knee arthroplasty within an indigent population. J Bone Joint Surg Am. 2012;94:e84. doi: 10.2106/JBJS.K.00888. [DOI] [PubMed] [Google Scholar]
- 10.Fisher DA, Dierckman B, Watts MR, Davis K. Looks good but feels bad: factors that contribute to poor results after total knee arthroplasty. J Arthroplasty. 2007;22:39–42. doi: 10.1016/j.arth.2007.04.011. [DOI] [PubMed] [Google Scholar]
- 11.Howard KJ, Ellis HB, Khaleel MA, Gatchel RJ, Bucholz R. Psychosocial profiles of indigent patients with severe osteoarthritis requiring arthroplasty. J Arthroplasty. 2011;26:244–249. doi: 10.1016/j.arth.2010.03.002. [DOI] [PubMed] [Google Scholar]
- 12.Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;248:13–14. [PubMed] [Google Scholar]
- 13.Kaplan RM, Anderson JP, Wu AW, Mathews WC, Kozin F, Orenstein D. The Quality of Well-being Scale. Applications in AIDS, cystic fibrosis, and arthritis. Med Care. 1989;27:S27–43. doi: 10.1097/00005650-198903001-00003. [DOI] [PubMed] [Google Scholar]
- 14.Kim KW, Han JW, Cho HJ, Chang CB, Park JH, Lee JJ, Lee SB, Seong SC, Kim TK. Association between comorbid depression and osteoarthritis symptom severity in patients with knee osteoarthritis. J Bone Joint Surg Am. 2011;93:556–563. doi: 10.2106/JBJS.I.01344. [DOI] [PubMed] [Google Scholar]
- 15.Lingard EA, Katz JN, Wright EA, Sledge CB. Predicting the outcome of total knee arthroplasty. J Bone Joint Surg Am. 2004;86:2179–2186. doi: 10.2106/00004623-200410000-00008. [DOI] [PubMed] [Google Scholar]
- 16.Lingard EA, Riddle DL. Impact of psychological distress on pain and function following knee arthroplasty. J Bone Joint Surg Am. 2007;89:1161–1169. doi: 10.2106/JBJS.F.00914. [DOI] [PubMed] [Google Scholar]
- 17.Pereira GC, Walsh M, Wasserman B, Banks S, Jaffe WL, Di Cesare PE. Kinematics of the stiff total knee arthroplasty. J Arthroplasty. 2008;23:894–901. doi: 10.1016/j.arth.2007.07.015. [DOI] [PubMed] [Google Scholar]
- 18.Perez-Prieto D, Gil-Gonzalez S, Pelfort X, Leal-Blanquet J, Puig-Verdie L, Hinarejos P. Influence of depression on total knee arthroplasty outcomes. J Arthroplasty. 2013;29:44–47. doi: 10.1016/j.arth.2013.04.030. [DOI] [PubMed] [Google Scholar]
- 19.Riddle DL, Wade JB, Jiranek WA. Major depression, generalized anxiety disorder, and panic disorder in patients scheduled for knee arthroplasty. J Arthroplasty. 2010;25:581–588. doi: 10.1016/j.arth.2009.04.002. [DOI] [PubMed] [Google Scholar]
- 20.Rosenberger PH, Jokl P, Ickovics J. Psychosocial factors and surgical outcomes: an evidence-based literature review. J Am Acad Orthop Surg. 2006;14:397–405. doi: 10.5435/00124635-200607000-00002. [DOI] [PubMed] [Google Scholar]
- 21.Seyler TM, Marker DR, Bhave A, Plate JF, Marulanda GA, Bonutti PM, Delanois RE, Mont MA. Functional problems and arthrofibrosis following total knee arthroplasty. J Bone Joint Surg Am. 2007;89(Suppl 3):59–69. doi: 10.2106/JBJS.G.00457. [DOI] [PubMed] [Google Scholar]