Assuring the Happy TKA Patient

Total knee arthroplasty (TKA) is one of the most common operations in orthopedic surgery worldwide, and the effectiveness of TKA in relieving pain and improving function in the rheumatoid or osteoarthritic knee is undisputed. However, despite being described as mainly successful, only 81%-89% of patients are satisfied with the final result. In a prospective cross-sectional study of patient satisfaction after primary TKA, approximately one in five (19%) were not satisfied with their clinical outcome. Satisfactory pain relief varied between 72–86%, and satisfactory functional outcome was seen in between 70–84% of patients.

It seems clear that there are times when the patient’s and surgeon’s satisfaction with the outcome of TKA surgery are not aligned. Surgeons are more likely to be satisfied with satisfactory findings on X-ray and excellent range of motion, in patients who seem objectively to be doing well. Despite these objective outcomes, subjectively a significant number of patients are not satisfied with their outcomes. Our understanding of this discordance between patient and surgeon satisfaction is limited. Awareness of the existence, as well as identification of predictors of patient–surgeon discordance should help improve the dialogue that occurs between patient and surgeon, improving the clinical decision-making processes,making expectations more realistic and potentially enhancing patient outcomes.

How surgeons attempt to improve the situation? Based upon our experience, by coordination of multiple individual elements of patient care into an optimized multimodal approach, including targeted patient selection, enhanced patient education, a multimodal approach to postoperative analgesia, and early patient mobilization and physiotherapy. Focus on each the following five points can help to ensure patient safety is maintained, and satisfaction is enhanced. We would recommend them to all our colleagues:

  • Correct patient selection
  • Set appropriate expectations
  • Prevent the preventable complications
  • Know the finer points of the operation
  • Use pre & post operative pathways which allow for smooth flow through the system and & instills patient confidence

Correct patient selection: The surgeon has to ensure that the operation is done for the correct diagnosis. Specifically, pain referred from the back or the hip must be excluded.  In the setting of the patient presenting with both a painful knee (whether it’s arthritic on xray or not) in association with a stiff or painful hip (again whether arthritic or not on xray), diagnostic intra-articular injections with anesthetic agents may provide important diagnostic information In all cases, surgeons must ensure that the patient’s symptoms, signs and radiographic features clinically correlate before recommending surgery.

Set appropriate expectations: It is critical that surgeons consider and manage patient expectations prior to surgery. In has been demonstrated that patients whose expectations have been met are more satisfied with the outcomes following total joint replacement surgery. Patient expectation refers to the anticipation that given events are likely to occur during or as a result of medical care, in contrast to patient desires which reflect the patient’s wishes that a given event occur. Patients must be made aware, that despite being a highly successful procedure, only 81%-89% of patients are completely satisfied with the final result of a TKA, and even in the event of a successful operation, there will likely be some pain, some of the time.

Prevent preventable complications: The overall mortality rate following TKA is less than 1%, a figure that increases with increasing age, male sex, and the number of pre-existing medical conditions. The identification and optimization of such conditions prior to surgery is important in order to reduce perioperative complications. Skin necrosis and deep infection after total knee arthroplasty are not uncommon. Several predisposing factors, such as immunosuppression, malnutrition, steroid use, rheumatoid arthritis, multiple scars, and vascular disease contribute to the development of wound complications, as do prolonged tourniquet times and early knee flexion

Know the finer points of the operation: The surgeon must have intimate knowledge of both the instruments and implants he / she is using.  Experience and surgical volume are critically related.  There is evidence that, for total knee replacement, hospital and surgeon volume are both significantly associated with different outcome parameters, such as mortality, medical complications such as pneumonia, deep infection rates, functional status, and composite end points

Use of pre & post operative pathways which flows smoothly & instill patient confidence: It is important that routine preoperative assessment avoid unnecessary investigations. In our institution a standardized pre-operative order set has been established, in order to clearly indicate which tests need to be done and for which patients. This prevents excessive and unnecessary testing, which while providing little change in management, can in our opinion cause (in the event of extra radiographs or blood tests) distress for the patient. Education regarding pre- and post-operative procedures is also an important aspect of the preoperative process. All patients at our institution follow an identical post-operative plan, regardless of the treating surgeon. This allows both the patients and allied health care personnel to be aware of the expectations and normal course post surgery.

A fast-track surgery program is made to discharge patients between 2 and 4 days post-operatively. This based on the coordination of multiple individual elements of patient care into an optimized multimodal approach, and involves addressing the mindset of the patient, family and staff. An emphasis is made to enhanced patient education and “normalize” the patients as soon as possible, by encouraging them to wear their own clothes. Moreover, emphasizing early patient mobilization and physiotherapy is a critical part. . A smooth discharge is assisted by a routine follow-up phone call at 48 hours after discharge to trouble-shoot problems and address patient concerns.

Conclusion: To summarize, the strongest predictors of patient dissatisfaction following surgery include

  • Patient expectations that are not met, which is associated with a 10.7 times greater risk of dissatisfaction – therefore we recommend that surgeons “under promise and over deliver”.
  • Patients who have preoperative pain at rest (2.4 times greater risk of dissatisfaction), and patients whose xrays do not correlate with their clinical symptoms should not undergo total knee replacment – pick the right patients.
  • Low WOMAC scores in the first year postoperatively (2.5 times greater risk of dissatisfaction) – know the subtleties of the operation so that you achieve a good result.
  • Post operative complications requiring readmission (1.9 times greater risk of dissatisfaction) – avoid significant complications wherever possible.

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