Rev. bras. ortop. vol.52 número4

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

article

Effects

of

preoperative

walking

ability

and

patient’s

surgical

education

on

quality

of

life

and

functional

outcomes

after

total

knee

arthroplasty

夽

Sunil

K. Dash

a

_,

_Nishit

_Palo

a,b,∗

,

Geetanjali

Arora

c

,

Sidharth

S. Chandel

d

,

Mithilesh

Kumar

e

a_Hi-Tech_Medical_College,_Department_of_{Orthopaedics,}_Odisha,_India b_Care_Hospitals,_Department_of_{Orthopaedics,}_Odisha,_India c_Hi-Tech_Medical_College,_Department_of_Anatomy,_Odisha,_India d_Jaypee_Hospital,_Department_of_{Orthopaedics,}_Noida,_Índia e_Care_Hospitals,_Department_of_{Physiotherapy,}_Odisha,_India

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r

t

i

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e

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n

f

o

Articlehistory: Received15May2016 Accepted20June2016

Availableonline30December2016

Keywords:

Arthroplasty,replacement,knee Biomechanicalphenomena Kneejoint

Qualityoflife Treatmentoutcome

a

b

s

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t

Objective:Prospectivelyanalyzetheeffectofpreoperativewalkingstatusandthepatient’s surgicaleducationonfunctionaloutcomesandthethreedimensionsofqualityoflife(QoL) (pain,physicalfunction,andmentalhealth)afterelectivetotalkneearthroplasty(TKA). Methods:AcomparativeanalysisontheQoLandfunctionaloutcomesinpatientswho under-wenttotalkneearthroplastybetweenJanuary2014andJune2015.Tocompareeffectsofthe patient’swalkingstatusandknowledgeofthesurgicalprocedureonQoLandfunctional out-comesfollowingTKAbymeansofSF-36questionnaire,CESD10,VAS,KSS,KSFS,WOMAC, aswellasFriedmannandWymanscores,10MWT,and30-secondtimedchairtest,assessed beforetheoperationandone,three,andsixmonthsaftertheoperation.

Results:Therewere168kneesin154patients:46.75%menand53.24%women.52.38%of kneeshadgrade-IIIOAand40.47%ofkneeshadgrade-IVOA.Preoperatively,SF-36PCS was33.2andMCSwas35.4.MeanKSSandKSFSinfemaleswas37.3(16.2)and31.5(13.8); inmalesitwas49.2(18.4)and42.5(15.7),respectively.MeanWOMACscoreswere64.2in femalesand56.5inmales.MeanVASandCESD10scoreswere8.8and8.2infemales,and6.9 and6.4inmales,respectively.Postoperativelyatthefirst,third,andsixthmonth,significant improvementsinQoLandmeanSF-36,CESD10,VAS,KSS,KSFS,WOMAC,andFriedmann andWymanscoreswereobserved,aswellasinthe10MWTand30stimedchairtestscores. PatientswithbetterpreoperativefunctionalactivityandsatisfactoryunderstandingofTKA presentedabetterfunctionalperformanceandachievedagoodqualitylife(p<0.01). Discussion: SurgeonseducateTKAcandidatesregardingthesurgicalprocedure,thenature ofimplants,andhowtheprocedurewouldaffecttheirlifestyleandwhattheirexpectations fromTKAshouldbe.Thesecrucialconsiderationsshouldboosttheirconfidence,enhancing theirinvolvementandcooperationinpost-surgicalrehabilitation,therebyimprovingtheir QoL,functionalresults,andpostTKAexperience.

夽_Work_performed_in_the_centers_in_Bhubaneswar,_Odisha,_India.

∗ _{Corresponding}_author_.

E-mail:[email protected](S.K.Dash). http://dx.doi.org/10.1016/j.rboe.2016.12.011

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Conclusion: TKAcandidateswithgoodpreoperativewalkingabilityandunderstandingof kneearthroplastyhavebetterQoLinearlyandlatepost-surgeryperiods.Patient’slifestyle andunderstandingsignificantlyenhancesthepostoperativefunctionalability.

Efeitos

da

habilidade

ambulatória

pré-operatória

e

da

educac¸ão

cirúrgica

do

paciente

sobre

a

qualidade

de

vida

e

os

resultados

funcionais

após

artroplastia

total

do

joelho

Palavras-chave:

Artroplastia,substituic¸ão,joelho Fenômenosbiomecânicos Articulac¸ãodojoelho Qualidadedevida Resultadodotratamento

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o

Objetivo: Analisarprospectivamenteoefeitodoestadoambulatóriopré-operatórioeda educac¸ãocirúrgicadopacientesobreos resultadosfuncionaisedastrêsdimensõesda qualidadedevida(QV;dor,func¸ãofísicaesaúdemental)apósaartroplastiatotaldojoelho (ATJ).

Métodos: AnálisecomparativadaQVedosresultadosfuncionaisempacientessubmetidos aartroplastiatotaldejoelhoentrejaneirode2014ejunhode2015.Paracompararosefeitos doestadoambulatóriodopacienteeoconhecimentosobreoprocedimentocirúrgicona qualidadedevidaenosresultadosfuncionaisapósATJ,osquestionáriosSF-36,CESD10, EVA,KSS,KSFSeWOMACforamusados,bemcomo osescoresdeFriedmaneWyman, 10MWTeotestedecadeirade30segundos,nopré-operatórioeum,trêseseismesesapós acirurgia.

Resultados:Oestudoincluiu168joelhosde154pacientes:46.75%homense53.24%mulheres. 52,38%dosjoelhosapresentaramOAdegrauIIIe40,47%dosjoelhos,OAdegrauIV.No períodopré-operatório,oSF-36PCSfoi33,2eoMCSfoi35,4.AmédiadoKSSedoKSFS emmulheresfoi37,3(16,2)e31,5(13,8),respectivamente;noshomens,foi49,2(18,4)e42,5 (15,7),respectivamente.OsescoresmédiosdoWOMACforam64,2paraasmulherese56,5 paraoshomens.OsescoresmédiosdaEVAeCESD10foram8,8e8,2nasmulherese6,9e6,4 noshomens,respectivamente.Noprimeiro,terceiroesextomesespós-operatórios,foram observadasmelhoriassignificativasnaQVenamédiadosescoresSF-36,CESD10,EVA,KSS, KSFS,WOMACeFriedmanneWyman,bemcomono10MWTenotestedecadeirade30 segundos.Pacientescommelhoratividadefuncionalpré-operatóriaecomcompreensão satisfatóriasobreaATJobtiveramresultadosfuncionaismelhoresealcanc¸aramumaboa qualidadedevida(p<0,01).

Discussão: CirurgiõesexplicamaospacientescandidatosaATJoprocedimentocirúrgico,a naturezadosimplantes,comooprocedimentoafetariaoestilodevidaequaisdevemseras expectativasemrelaçãoaoresultadodaATJ.Estasconsideraçõescruciaisdevemaumentar aconfiançadopaciente,aumentandooseuenvolvimentoecooperaçãonoprocessode reabilitaçãopós-cirúrgica,melhorandoassimsuaqualidadedevida,resultadosfuncionais eexperiênciaapósaATJ.

Conclusão:CandidatosàATJcomboacapacidadeambulatóriapré-operatóriaecompreensão dacirurgiaapresentammelhorqualidadedevidanoperíodopós-operatórioinicialede longoprazo.Oestilodevidaeograudecompreensãodopacienteemrelac¸ãoàcirurgia aumentamsignificativamenteacapacidadefuncionalpós-operatória.

Introduction

Osteoarthritisespeciallyofthehipandkneenotonlyaffects thequalityoflifeoftheindividualnotonlyphysicallybutalso emotionallyandsocially,limitingactivitiessuchaswalking, climbingstairs,andself-care.1

Total knee arthroplasty has become a common procedure2,3 _in _treatment _of _advanced _knee _{osteoarthritis.}

TKAisthemosteffectivesurgicalprocedureforreducingpain andincreasingfunctionalcapacity,correctthedeformityand improvethepatient’squalityoflife(QoL)4–8_when

conserva-tivetreatmentfails9_with_greatest_improvements_in_pain_and

functionoccurduringthefirst3–6monthsaftersurgery.10,11

Majority ofpatientsreceiving TKAreportimprovedpain andfunction,12–14_whereas_15–30%_report_no_improvement15,16

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medical comorbidities, gender, mental health status,15,16

socialsupport,17,18_obesity,19_sedentary_lifestyle,_lack_of

walk-ing,bed riddenpatientsorincreasedwaitingtimeforknee replacement.20

Thesepatientsmaynottoleratetheoperativestressand lessofteninvolvethemselvesorcooperateinthe postopera-tivephysicaltherapyandhenceremaindeprivedofbeautiful outcomes of TKA. They often experience persistent pain, swelling,stiffnessanddifficulty inwalkingorperform rou-tineactivitiesandremaindissatisfiedincomparisontosome patientswhoperformreallywellfollowingTKAand experi-enceminimalpainordiscomfort.

Various studies have correlated the results from total kneereplacementswith variouspre surgicaland comorbid factors.10–17 _However,_little_has_been_described_regarding_the

effectsofpresurgicalwalkingstatusandpatient’seducation regardingtheprocedureonfunctionaloutcomesandQoLafter surgeryofpatientsunderwentsurgicaltreatment.

Thus,weprospectivelyanalyzedtheeffectofpreoperative walkingstatusandpatient’ssurgicaleducationonfunctional outcomes andthe three dimensionsofQoL(pain, physical functionandmentalhealth)afterelectivetotalknee arthro-plasty.

Materials

and

methods

A prospective cohort study was completed of patients undergoing unilateral primary TKAs for the treatment of kneeosteoarthritis.Patientswererecruitedandfollowedup between January 2014 and October 2015 at 3 centers in Bhubaneswar,Odisha,India. Weprospectivelyreviewed168 kneesin154patientswithkneeosteoarthritisadmittedfor TKAtoanalyzetheeffectofpreoperativewalkingstatusand patient’ssurgicaleducationonfunctionaloutcomesandQoL afterelectivetotalkneearthroplasty.14patientshada con-tralateralTKAwithin12monthsofthefirstprocedureduring thecourseofthestudy.Thestudywasapprovedby institu-tionalethicscommitteeandallpatientsprovidedagreement andconsentforinclusioninthestudy.

Weexcludedpatientswiththefollowing:functional illiter-acy,inflammatoryorotherseveremusculoskeletalconditions (e.g., rheumatoid arthritis, sciatica), metabolic or neoplas-ticdisease, and severe psychopathology, knee infection or comorbidity(definedasadiagnosis,suchasheartfailureor respiratorydiseasesevereenoughtoimpedetotal participa-tioninprocedures).

Patient selection, informed consent and patient details wereobtainedusingastandardprotocolbytwosurgeons(SKD, NP).Allsurgerieswereperformedbythesamesurgeonteam. Thesurgicaltechniquewasthesameinallcases:an antero-medialapproachwithoutpatellarresurfacingusingafemoral andtibialintramedullarycuttingguide.Thefemoraland tib-ial components were cemented.The prostheses used was standardorposteriorstabilizedP.F.C.® sigmaTM_knee_systems

(DePuyOrthopedics,Warsaw,IN,USA)inallpatients.

QoLoutcomemeasures

Functionalability:wereassessedwithWesternOntarioand McMaster’s Universities osteoarthritis index (WOMAC) and

FriedmannandWymanClassificationofFunctionalOutcome, theKneeSocietyScore(KSS),WalkingStatusGradingand 10-meterwalktest(10MWT)andShortForm-36Questionnaire (SF-36)forphysicalhealth.

Locomotorfunction

WereassessedusingWalkingStatusGrading,10-meterwalk test (10MWT) and the 30 second timed chair stand tests. Generalhealth,lowerlimbstrength,rangeofmovementand compliancewithexercisewerealsomeasured.

Painandsocialdisability

Wasassessedbythevisualanalogscale(VAS)forpainandthe CenterforEpidemiologicalStudiesDepressionScale(CESD10) formentalhealth.

Waiting-time tosurgeryinweeksandlengthofhospital stayindays,werealsoincluded.Allthetestswereperformed anddatawereobtainedatbaselinebeforesurgery,1month, 3monthsand6monthsthroughface-to-faceinteractionand, whereappropriate,examinationofhospitalmedicalrecords. Dataonperioperativeandpostoperativecomplications, post-hospitalcareanddestinationatdischarge,compliancewith exercisewerealsomeasured,aswellasrehabilitationwere gatheredatthefollow-upinterviews.

Methodology

Thepreliminary dataof all thesepatients were enteredin thedatachartsat3centersandlaterwereenteredintothe registry at the parent institution. The patients were sub-jectedtohistory,clinicalexamination,standingSkiagramof BilaterallowerlimbswithkneeinAnteroposteriorand Lat-eralViewsandroutinebloodinvestigationslikebloodsugar, serum uric acid, serology, differential and complete blood countswereperformed.Preoperativelythepatientshad mul-tiplesessionswiththeoperatingsurgeons,wheretheywere counseled, motivated and explained in details about TKA procedure,natureofimplantsandtheoutcomesofsurgery. Post-operatively, the patientswere hospitalizedfor1week, during which time they received physiotherapy to achieve flexionof90andautonomouswalkingusingcanesorwalker cagesatdischarge.TKA,rehabilitation,andothertreatments were standardizedaccording tohospitalprotocols.Patients weretreatedwithlowmolecularweightheparinas prophy-laxis forthromboembolic events for1 month and 4 doses ofcefuroxime,1.5gwereadministeredasantibiotic prophy-laxis.Patientswereseen15daysaftersurgerytocheckthe surgical wound and remove staples. Follow-up at 1, 3, 6 monthsincludedradiography,clinicalevaluation,motivation and counseling, medications, physiotherapy and question-nairefillup.Homevisitswereperformedwhenrequired.The results were tabulated at 6 monthfollow up. Thetype of majorcomplicationsevaluatedafterdischargeincluded:knee stiffness,deformityofthelowerlimb,pain,extensormuscle weakness,superficialinfectionanddeepveinthrombosis.

Statisticalanalysis

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(satisfactoryvsunsatisfactory)andpatientswithgood surgi-calunderstanding(satisfactoryvsunsatisfactory)at1st,3rd and6thmonthaftersurgery.Theindependent-samples‘t’test wasperformedtocomparetwogroup’sscoresonthesame variable.ThevariablesweretabulatedintheExcelsoftware. Thedatawereanalyzeddescriptivelyandorganizedintables andgraphs.Avalueofp<0.05wasconsideredstatistically sig-nificant.The95%confidenceintervalsweremeasuredwhen appropriate.StatisticalanalyseswereperformedusingSPSS 13.0.(SPSSInc.,Chicago,IL,USA).

Results

Samplecharacterization

Thesamplecomposedof168kneein154patients: 72men (46.75%)and82women(53.24%).14patientshada contralat-eralTKAduringthecourseofthestudy:9men(64.28%)and 5women(35.71%).Theagesofthepatientsevaluatedranged from62years(minimum)to92years(maximum)withamean of76±6years.

Clinicalfactors

Among the patients evaluated; 96 patients (62.33%) were affectedontheirright-handsideand44patients(28.57%)were affectedontheirleft-handside.14patients(9.09%)had bilat-eralaffectionwithin12monthsofthefirstprocedureduring thecourseofthestudy.114patients(74.13%)weremarried,40 patients(25.98%)werewidowedand45%patientswere work-ingatthetimepresentationtohospital.

Among 168 knees; 12 knees (7.14%), had grade-II osteoarthritis,88 knees(52.38%)had grade-IIIosteoarthritis and68knees(40.47%)hadgrade-IVosteoarthritis(Fig.1)based ontheradiologicalclassification(Table1).

PreoperativeKneeRangeofmovements,Educationalstatus andcomorbiditiesamongthepatientsisoutlinedinTable2. ThemostfrequentwereDiabetesmellitusinFemales(62.1%) andHypertensioninMales(59.7%).Preoperatively,mean10 MWTresultsforself-selectedvelocitywas0.2m/sand Fast

180

160

140

120

100

80

60

40

20

0

Osteoarthritis 168

0

12

88

68

Knees: 168 Grade.1 Grade.2

Grade.3 Grade.4

Fig.1– Patternofkneeosteoarthritis(n=154).

Table1–Radiographicclassificationofdegenerative jointdisease.

Grade Description

Knees

0 Normal

1 Doubtfulnarrowingofjointspaceandpossible osteophyticlipping

2 Definiteosteophytesandpossiblenarrowingofjoint space

3 Moderatemultipleosteophytes,definitenarrowingof jointspace,somesclerosis,andpossibledeformityof boneends

4 Largeosteophytes,markednarrowingofjointspace, severesclerosis,anddefinitedeformityofboneends. Subchondralcystsmaybepresent.

Hips

0 Normal

1 Possiblenarrowingofjointspacemediallyandpossible osteophytesaroundthefemoralhead

2 Definitenarrowingofjointspaceinferiorly,definite osteophytes,andslightsclerosis

3 Markednarrowingofjointspace,slightosteophytes, somesclerosisandcystformation,anddeformityof femoralheadandacetabulum

4 Grosslossofjointspacewithsclerosisandcysts, markeddeformityoffemoralheadandacetabulum, andlargeosteophytes

Source:AdaptedfromtheCouncilforInternationalOrganization of Medical Sciences, 1963 (*From Weinstein SL, Buckwalter JA. Rheumaticdiseases:diagnosisandmanagement.Turek’s orthope-dics:principlesandtheirapplication,6thedition,p.154).

Table2–Clinicalcharacteristicsofthepatients.

Variables Female(82) Male(72)

N % N %

1.Knee(rangeofmovements)(n=168)

0–60◦_Flexion ₄₂ _51.2 ₂₈ _38.8

61–80◦_Flexion ₂₁ _25.6 ₂₂ _30.5

81–100◦_Flexion ₁₂ _14.6 ₁₃ _18.0

100–120◦_Flexion ₇ _8.5 ₉ _12.7

2.Educationalstatus(n=154)

Grade8orlower 17 20.7 10 13.8

Grade9–12 33 40.3 18 25.0

Bachelor’sdegree 20 24.3 26 36.2

Post-graduatedegree 12 14.7 18 25.0 3.Comorbities(n=154)

Hypothyroidism 26 31.7 18 25

Diabetesmellitus 51 62.1 38 52.7

Hypertension 45 54.8 43 59.7

Parkinsondisease 2 2.4 5 6.9

Alzheimer 3 3.6 8 11.1

velocitywas0.4m/s.Thepatientshadmoderatelylowquality oflifebothphysicallyandmentally,thebaselinemean SF-36PCSwas33.2andMCSwas35.4.Pre-operativeFunctional

scores(WOMAC,Friedmann-WymanScore,KSS,Walking

Sta-tusGrading,30secondtimedchairtest)andPainandMental Healthscores(VAS,CESD10)areoutlinedinTable3.

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Table3–Preoperativefunctionalkneescoresandpain andmentalhealthscores.

Variables Femaleknee(92) Maleknee(90)

Mean S.D. Mean S.D.

1.WOMACscores

Pain 14.3 4.2 13.6 3.8

Function 44.7 14.6 38.5 10.5

Stiffness 5.2 1.6 4.4 1.8

2.KSS

Kneescore 37.3 16.2 49.2 18.4

Functionscore 31.5 13.8 42.5 15.7

3.30secondchairtest 3 1.2 4 2

4.VAS 8.8 1.2 6.9 2.9

5.CESD10 8.2 1.4 6.4 2.4

N % N %

6.Friedmann–Wymanscore

Good 17 20.7 10 13.8

Fair 33 40.3 18 25.0

Poor 20 24.3 26 36.2

7.Walkingability

Gr.IV 8 8.6 9 10

Gr.III 12 13.0 11 12.2

Gr.II 41 44.8 41 45.6

Gr.I 31 33.6 29 32.2

(VAS,CESD10)inFemaleandMaleKneeat1st,3rdand6th monthareoutlinedinTables4and5.

ThereweresignificantimprovementintermsofKSS, Walk-ingStatusGrading,30secondtimedchairtest,WOMACscores, Friedmann–WymanScores,10MWT,VASandCESD10, post-operativelyandover1st(p=0.02),3rd(p=0.04)and6th(p=0.02) monthfollowup. At3rdmonthpost-operatively, we found significant improvementinmean 10MWT resultsfor self-selectedvelocitywhichimprovedto0.5m/sandFastvelocity to0.9m/s(p<0.01).Thepatientshadmoderatelygoodquality oflifebothphysicallyandmentally,thebaselinemeanSF-36 PCSwas47.4andMCSwas59.2(p<0.01).

Patient’smotivationandunderstandingofsurgical proce-dure were assessedbyprimary surgeonsas satisfactory or unsatisfactory.PatientswitheducationalstatusGrade9and abovehadbettercomplianceandinvolvement.Thismaybe attributabletointerestandactivitylevelsinthem.

Moreover, patients with better preoperative functional activity and satisfactory understanding ofTKA, performed functionallywellandleadgoodqualitylifeat1st,3rdand6th months(p<0.01).

Discussion

Osteoarthritis (OA), the mostcommon jointdisease, isage related,affectingmorethan80%ofpeopleovertheageof55.21

Itismorecommoninwomen, especiallyaftermenopause. OA ofthe knees iscommon,and riskis stronglylinkedto body mass index.21 _Symptoms _include _pain _with _walking,

standingupfromachair,climbingordescendingstairs;and stiffness afterperiods ofrest.With newor increased pain thereisanaturaltendencytoreduceactivity,sodoesmuscle bulkandstrength,whichmayleadtodecreasedjointstability, worseningofjointdegeneration,andfurtherdeclinein func-tionalstatuswhichcanhavemajorsystemicconsequences, affectingcardiovascularhealth,emotionalhealth,andsense ofwell-being.Breaking thiscyclerequiresateamapproach targetedtowardeducatingthepatientandfamily,alteringthe patient’slifestyle,offeringassistivedevices,andprescribing bothphysicalandpharmacotherapy.

Theheterogeneityofosteoarthritisarisesfromthemany factors thatcancontributetocartilage damage.TKA isthe most effective surgical procedure for reducing pain and increasing functional capacity, correct the deformity and improvethepatient’squalityoflife(QoL)4–8_when

conserva-tivetreatmentfails.9_In_Canada,_with_8,734_joint_replacement

surgeries in 2004–2005 to >10,000 in 2006–2007, estimated

Table4–Post-operativefunctionalkneescoresinfemalesat1st,3rdand6thmonths.

Variables 1stmonth 3rdmonth 6thmonth

Mean S.D. Mean S.D. Mean S.D.

1.WOMACscores

Pain 6.3 1.2 3.2 1.1 2 0.8

Function 21 8.6 16.4 6.4 10.2 7.8

Stiffness 3.8 1.1 2.2 0.8 1.8 1

2.KSS

Kneescore 64.2 12.4 72.8 16.8 78.2 17.2

Functionscore 55.8 10.6 64.2 12.4 68 12.8

3.30secondchairtest 4 1.8 4 2 5 2.4

4.VAS: 5.8 2.2 4.2 1.4 3 0.8

5.CESD10: 4.2 0.8 3.4 1 2.8 0.6

6.Friedmann–Wymanscore N % N % N %

Good 48 52.3 52 56.5 64 69.5

Fair 40 43.4 38 41.3 26 28.2

Poor 4 4.3 2 2.2 2 2.2

7.Walkingability

Gr.IV 32 8.6 37 41.1 63 70.0

Gr.III 30 13.0 33 36.7 19 21.1

Gr.II 22 44.8 16 17.7 8 8.9

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Table5–Post-operativefunctionalkneescoresinmalesat1st,3rdand6thmonths.

Variables 1stmonth 3rdmonth 6thmonth

Mean S.D. Mean S.D. Mean S.D.

1.WOMACscores

Pain 5.3 1.2 2.8 1.4 1.4 0.9

Function 23 8.6 14 6.4 8 6.4

Stiffness 3.6 1.4 1.8 1 0.6 1.6

2.KSS

Kneescore 73.2 16.8 82.4 12.7 8.2 10.2

Functionscore 62.8 14.9 74.3 15.2 82 7.5

3.30secondchairtest 4 2.1 5 1.8 6 1.2

4.VAS 4.8 1.4 3.8 1.1 2.6 0.6

5.CESD10 3.8 0.5 3.2 1.2 1.8 0.8

6.Friedmann–Wymanscore N % N % N %

Good 54 60.0 58 64.5 72 80.0

Fair 33 36.6 30 33.3 16 17.3

Poor 3 3.3 2 2.2 2 2.2

7.Walkingability

Gr.IV 24 8.6 32 34.8 54 58.6

Gr.III 32 13.0 40 43.6 28 30.4

Gr.II 32 44.8 18 19.5 8 8.6

Gr.I 4 33.6 2 2.1 2 2.1

figureisexpectedtobebeyond20,000TJAby2020withan annualcostof$230million.22 _Various_potential_risk_factors

forpersistentpain,functionallimitations,andclinical dissat-isfactionaftersuccessfulelectiveorthopedicproceduresare infection,instability, looseningof theprosthesis, increased waitingtimeforsurgery,20_lack_of_surgical_information,_female

gender,23 _depression,15 _anxiety,6,16,24_obesity19 _and_complex

regionalpainsyndrome.

Hudaketal.25_outlined_various_assumptions_that_constrain

patientsagainstTotalJoint Arthroplasties,i.e., firstly,some participantsviewosteoarthritisnotasadiseasebut as nor-malpartofaging.Secondly,despitebeingcandidatesforTJA accordingtomedicalcriteria,manyparticipantsbelieved can-didacyrequiredalevelofpainanddisabilityhigherthantheir currentlevel.Thirdly,someparticipantsbelievedthatifthey eitherrequiredorwould benefitfrom TJA,theirphysicians wouldadvisesurgery.Forbetterpost-surgicaloutcomes,these issueshavetobeaddressedinsurgeon-patientmeetings pre-operatively.

Theresults ofcurrent study point to a conclusionthat patients with active lifestyle, good preoperative walking ability,ROMandunderstandingofkneearthroplasty preop-erativelyhad significantimprovementsinfunctional ability followingTKAinearlyandlatepost-surgeryperiodsas com-paredtopatientswithsedentarylifestyleswithpoorwalking ability,kneestiffnessandpoorunderstandingofTKA(p<0.01). Inspiteofrepeatedattemptssomepatientsfailtounderstand theintriguesofthesurgicalprocedureprobablyduetotheir lit-eracylevels,socialtension,oldage,ignoranceorcognitiveand comorbidlimitations.Thesepatientsoftenhaveapoor preop-erativewalkingabilityandfunctionalkneescores,arelikelyto bedissatisfiedfollowingTKAandinvolvelessinpost-surgical rehabilitation.

Arthroplastysurgeonsmustbeabletodistinguishbetween patients with sedentary lifestyles, poor preoperative knee scoresandunderstandingwhoare likelytohavepersistent painandclinicaldissatisfactionfromthosethatareactually

likelytoimprovewiththejointreplacementsurgery.Surgeons mayguideformergrouppatientstoappropriatenonsurgical interventionsandphysicaltraining,allowingtimefor enhanc-ingtheirqualityoflife(physical,mentalandsocial)beforethey areplannedforsurgicalintervention.

Surgeonsmust alsoincorporateandaddress these com-ponentsinto discussionswithTKAcandidatesand educate them regarding the surgical procedure, nature of implants andhowtheprocedurewouldaffecttheirlifestyleandwhat their expectationsfrom TKA should be.These crucial con-siderations should boost their confidence; enhance their involvementandcooperationinpost-surgicalrehabilitation, therebyimprovingtheirQoL,functionalresultsandpostTKA experience.

Conclusion

TKA candidateswithgood preoperativewalkingabilityand understandingofkneearthroplastyhaveabetterqualityoflife (QoL)inearlyandlatepost-surgeryperiods.Patient’slifestyle andunderstandingsignificantlyenhancesthepostoperative functionalability.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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