What do patients want out of their Total Knee Arthroplasty?: An Indian perspective

Abstract

Introduction and aim

Total Knee Arthroplasty surgery is one of the most successful operations in orthopaedics. Still a sizable percentage of patients remain dissatisfied. Various studies have been conducted to analyse the red flags associated with poor outcome. In this study we tried to have insight on actual requirements of Indian patients from TKA operation.

Material & methods

300 patients undergoing TKA were studied by way of patient expectation feedback form. The form had various patient related capture points. It had a leading question: What are your expectations from TKA? They were asked to rank the 5 most important options in the order of importance. The patient expectation form was distributed and collected by an independent observer.

Results

70% of patients ranked relief of pain as the most important expectation. 20% reported improvement in walking as the number one expectation. Nearly equal number listed improvement in walking and ease of doing day-to-day activities as the second most important expectation. This was followed by improvement in climbing the stairs and improvement in quality of life. Correction of deformity and no pain while squatting and getting up from sitting position ranked at the bottom.

Conclusion

Our study shows that the primary expectations of Indian population from their TKA are relief from pain and improvement in walking. Secondary expectations include ease of doing day-to-day activities and improvement in quality of life.

1. Introduction

Total Knee Arthoplasty (TKA) for osteoarthritis of the knee is quickly gaining popularity in India. The joint registry maintained by Indian Society of Hip and Knee Surgeons indicates that approximately 70,000 joint replacement surgeries were performed in India in the year 2011.¹ The demand for joint replacement surgery has risen exponentially over the past decade. According to Frost and Sullivan research, the arthroplasty market is expected to grow at a compound annual growth rate of 26.7%.¹

Despite being one of the most successful operations in orthopaedics, a sizeable percentage of patients of TKA remained dissatisfied with the outcome of the operation. Various studies have been conducted to analyse the red flags associated with poor outcome. Various studies claim that up to 14% of patients undergoing TKA surgery are not satisfied with the outcome post-operatively.² It is also well documented that satisfaction with total knee replacement is primarily determined by patient's expectations and not their absolute level of function. Satisfactory outcome post-TKA surgery should not only address residual pain and stiffness of the knee, but it should also coincide with the patient's expectations of the outcome of surgery^2,3 Hence, there is a pressing need for evaluation and documentation of the needs and expectations of Indian patients undergoing total knee replacement surgery. The current study tries to have an insight into the Indian TKA patient's expectations. The aim of the current study was to carry out an in depth assessment of patient expectations prior to TKA surgery in a representative sample of the Indian population undergoing primary TKA.

2. Materials and methods

This was a prospective cohort study which was approved by the Research Ethics Committee of the institutions where patients were admitted for surgery. All patients who had their operations under the care of two consultant orthopaedic surgeons from January 2016 to March 2018 were approached for inclusion into the study at their pre-assessment outpatient department (OPD) based consultation. 300 patients undergoing unilateral primary TKA surgery were selected for the study. The inclusion criterion was patients having a primary TKA and being able to give informed consent. Patients were excluded if they declined to take part in the study or were unable to give informed consent. Patients were provided with contact details of the concerned consultant orthopaedic surgeon in order to resolve any doubts the patient may have regarding the study being conducted. Informed written consent in a language understood by the patient was taken on their admission to the hospital for participating in the study. All patients were admitted under and operated by two consultant orthopaedic surgeons working with the same surgical team and following similar techniques of surgery, pre-operative and post-operative protocols.

On the day of admission, patients were given a structured questionnaire (Fig. 1) to fill up. Language translations were provided to ensure maximum understanding by patient while answering the questionnaire. The questionnaire included various patient related capture points along with general demographic and socio-economic data. The questionnaire also included one leading question asking the patient regarding “Their expectation from TKA surgery”. Various answer options were provided and the patients were asked to rank each option in order of importance from 1 to 5 (with 1 being the most important expectation and 5 being the least important expectation for the patient). Expectations were ranked by the proportion of patients who gave a higher importance to any one expectation over another. Patients were asked to give a score of 5 for expectations not applicable to them or unimportant to them. Any options left blank by the patients were automatically awarded a score of 5. Before receiving these questionnaires, all patients had received standard preoperative preparation including consultation with the surgeon. Baseline demographic details of the patients undergoing TKA (age, gender, weight, height) were collected. The patient's pre-operative visual analog scale (VAS) and pre-operative knee deformity

Fig. 1.

Patient expectation questionnaire.

(varus/valgus/flexion) was also recorded by an independent observer. The patient expectation form was distributed and collected by the same independent observer.

3. Statistical analysis

The primary outcome for the study was the proportion of patients having the expectations listed on the study questionnaire. To identify these proportions to within a margin of error of 5%, the 95% confidence intervals for any proportion needed to be ±15.5%. This required 278 patients. Assuming a declination by 5% of the patients, gave the number as 292 patients. Therefore sample size of 300 patients was calculated for the study. Expectations were ranked by the proportion of patients who gave a higher importance to any one expectation over another. Patients were asked to give a score of 5 for expectations not applicable to them or unimportant to them. Any options left blank by the patients were automatically awarded a score of 5.

Multiple studies have tried using a multivariate model with all demographic variables (age, gender, and geographic location) and preoperative characteristics (body mass index and the presence of comorbidity) showing significance in the univariate models to identify independent predictors of expectations. However, this statistical methodology was not included in our study since no single variable was found to be a significant predictor by other studies.⁴

4. Results

The study was conducted over a period from January 2016 to March 2018. A total of 326 primary TKA total knee replacement surgeries were performed by our surgical team during this period. Out of which 300 patients who consented to participate in the study were recruited for this study. No patients were lost to follow-up and expectation questionnaire responses were collected from each patient for analysis.

Out of the 300 patients recruited for the study, 82% patients were female. Mean age of patients was 68.54 years (range 60–84 years). 54% were right sided TKA and 46% were left sided TKA (Table 1). 92% patients were operated for primary osteoarthritis and remaining 8% were operated for inflammatory arthritis.

Table 1.

Patient Demographics, Sample size n = 300.

Gender	Sample Size	Average Age	Right TKA	Left TKA	Total
Female	246	68	133 (54.07%)	113(45.93%)	246
Male	54	71	29 (53.70%)	25(46.30%)	54
Total:	300	68.54	162 (54%)	138 (46%)	300 (100%)

Based on the responses to the expectation questionnaires, 70% of the patients marked “relief from pain” as the most important outcome expected from their TKA surgery (Marked by patients as Rank 1). Further, 20% patients chose “improvement in walking” as their primary expectation from TKA surgery (Fig. 2).

Fig. 2.

Most important expectation (Rank 1).

Nearly equal proportion of patients listed “improvement in walking” and “ease of doing day-to-day activities” as the second most important expectation (Rank 2) (Fig. 3). 60% of the sample size chose “improvement in climbing stairs” and 30% chose “improvement in quality of life” as the third most important expectation (Rank 3) (Fig. 4). “Correction of deformity” and “no pain while getting up from seated position” was ranked at the bottom of the list almost universally by all patients. We have correlated the patients expectations out of their TKA with respect to their pre-operative VAS score and degree of deformity of the knee (flexion/varus/valgus). The patients with preoperative VAS score of more than 7 have predominantly listed relief of pain as their main expectation out of their TKA as against patients with preoperative VAS score ≤7 (p value < 0.001) (Table 2). There was no statistically significant difference in the expectations between patients with deformity <5° and patients with deformity> 5° (p value 0.8261). (Table 3).

Fig. 3.

Second most important Expectation (Rank 2).

Fig. 4.

Third most important expectation (Rank 3).

Table 2.

Comparison according to pre operative VAS score with p values.

	Patient's with VAS ≤7	Patient's with VAS >7	p value
Total no. of patients	62	238
Relief of pain main expectation	28(45.16%)	182(76.47%)	<0.0001

Table 3.

Comparison according to pre-operative degree of deformity with p values.

	Patient's with deformity ≤5	Patient's with deformity >5	p value
Total no. of patients	144	156
Expectation of correction of deformity	11(7.64%)	13(8.33%)	0.8261

5. Discussion

Despite far-reaching advances in technology and surgical technique associated with TKA, there are still a large proportion of post-TKA patients who are not satisfied with the outcome of the surgery. Noble PC et al., in 2006 noted that 75% of post-TKA patients are either “satisfied” or “very satisfied” with their knee replacement, while 14% were “dissatisfied” or “very dissatisfied.” They further noted that satisfaction with TKA is primarily determined by patient's level of expectation and not their absolute function. They recommended that 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 this procedure.²

A study conducted by Liebermann JR et al., in 1996 highlighted a discrepancy between patient's and physician's evaluations of the results of total hip arthroplasty. This discrepancy increased when the patient was not satisfied with the outcome. They recommended that the use of patient's self-administered questionnaires as well as traditional physician-generated assessments may provide a more complete evaluation of the results of total hip arthroplasty.⁵

Similarly, Wylde V et al., noted in 2007 that a significant proportion of patients experience chronic knee pain, functional disability, a poor quality of life and dissatisfaction after TKA. Although some poor outcomes after TKA are due to surgical technique and implant factors, much of the pain and disability after surgery is medically unexplained. Various red flags like older age, female gender, low socioeconomic status, depression, and high patient's expectations are identified as poor prognostic factors. Hence there is a need to develop a preoperative screening protocol to identify the at risk dissatisfied patients.⁶

Although many studies have investigated the relationship between preoperative expectations and postoperative outcomes and/or satisfaction,⁷ relatively few have attempted to quantify exactly what patients' expectations are and to rank them in order of importance to patients.^3,8,9 To the best of our knowledge, this is the first study performed on an Indian population which provides evidence of the levels of expectations that patients have of their TKA. Our results showed that 70% of patients considered pain relief and 20% considered the ability to walk as the single most important expectation from their TKA surgery. Ease of day-today activities and improved quality of life are the second most important expectations by Indian population following their TKA surgery. Despite speculation that the demand for high-flexion activities like squatting and cross-legged sitting would be an important factor in the expectations of Indian TKA patients, the demands of Indian patients are focused on relief of pain and improvement in walking. Similar results were found in studies conducted on Anglo-Saxon population.^{4,8, 9, 10, 11}

Studies performed on different cohorts based on countries of residence (United States of America, United Kingdom, Australia and Scotland) agree with our findings that pain relief and ability to walk are the most important expectations of patients.¹⁰

Very few, if any patients raised queries regarding expectations of high-intensity activities like gym activities and marathon running. However, these queries were raised during the pre-counselling and consultation period and not at the time of data collection, one day prior to surgery. In this regard, our study concurs more with the study performed in Scotland⁴ where patient expectations were recorded post-counselling and education rather than studies where patient expectations were collected and recorded pre-counselling.^{8,12, 13, 14, 15} Understanding the pre TKA procedure patient expectations is extremely important as it will help in appropriate pre-operative patient counselling there by improving the post TKA patient satisfaction. In our study we have demonstrated that pre-operative, peri-operative and post-operative counselling imparted by a trained counselor to the TKA patient has favorable impact on the patient satisfaction after TKA.¹⁶

The average Indian patient undergoing TKA surgery has primary concerns related to relief of pain, increased comfort during walking and ease of doing day-to-day activities.

6. Strengths and limitations of the study

Strengths.

• 1.We believe this is the first study performed on an Indian population which tries to assess the needs and expectations of Indian population from their TKA surgery. This study will help us further counsel and educate the patients, manage their expectations and contribute to patient satisfaction in future.
• 2.Patients were asked to fill the Expectation Response Questionnaire after the counselling and education process, this ensured that unrealistic expectations of patients regarding the outcome of their TKA were weeded out during the counselling phase and the expectations marked by the patients would be correlated better with their post-operative satisfaction parameters.

Weaknesses.

• 1.The first limitation of the study is patients undergoing bilateral TKA surgery were not included in this study. Further study and research is required to assess the needs and expectations of patients undergoing bilateral TKA surgery and their satisfaction with the surgery.
• 2.The second limitation of the study is 82% of our study population is female. However, this bias could not be avoided as it is well established that women suffer from osteoarthritis of knees far more commonly than males in the Indian population and consequently, far more female patients undergo TKA surgery than male patients. We do accept that the male study population may give more importance to activity level (being more active outdoors than females) as against the female population.
• 3.The third limitation of the study is that patients with preoperative high VAS score are likely to list relief of the pain as their main expectation out of their TKA.
• 4.The fourth limitation of our study is that our questionnaire is not validated. We do recognize that a recognized validated and non-modifiable questionnaire should be used to assess patient expectations. Hospital for Special Surgery (HSS) patient expectation survey is the best instrument available. Unfortunately no Indian version of HSS is available nor is it validated. Also HSS patient expectation survey has about 17 questions. As it was our first effort to understand the patient's expectations we kept the questionnaire simple and very easy to complete.

7. Conclusion

Our study shows that the primary expectations of Indian population from their TKA are relief from pain and improvement in walking. Secondary expectations include ease of day-to-day activities and improvement in quality of life. The rate of dissatisfaction among TKA patients post-operatively remains as high as 14%, understanding the expectations of the patients pre-operatively may help to reduce this figure in future and achieve higher patient satisfaction. Importance of thorough pre-operative counselling and education regarding realistic patient expectation cannot be over-emphasised in achieving a satisfied and happy post-TKA patient.

Funding

The research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.

Ethics approval

Local ethics committee approval was obtained before the study. Also, all patients consented to participate.

Consent for publication

We hereby give our consent for publication.

Authors' contributions

All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Previous presentation

This data (part of it) was presented as an abstract oral presentation at the 62nd Annual conference of the Indian Orthopaedic Association, Indore 26–31st December 2017.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Declaration of competing interest

The authors declare there are no financial conflicts of interest to disclose.

Abbreviations

Total Knee Arthroplasty

TKA

Out Patient Department

OPD

Osteoarthritis

OA

Visual Analog Scale

(VAS)