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Functional Disabilities and Satisfaction After Total Knee Arthroplasty in Female Asian Patients
The Journal of Arthroplasty Vol. 25 No. 3 2010
Functional Disabilities and Satisfaction After Total Knee Arthroplasty in Female Asian Patients Tae Kyun Kim, MD, PhD,*y Sae Kwang Kwon, MD,* Yeon Gwi Kang, BS,* Chong Bum Chang, MD, PhD,*y and Sang Cheol Seong, MD, PhDy
Abstract: This study was conducted to investigate functional disabilities and patient satisfaction in Korean patients after total knee arthroplasty (TKA). Of 372 female patients who had undergone TKA with a follow-up longer than 12 months, 261 patients (70.2%) completed a questionnaire designed to evaluate functional disabilities, perceived importance, and patient satisfaction. The top 5 severe functional disabilities were difficulties in kneeling, squatting, sitting with legs crossed, sexual activity, and recreational activities. The top 5 in order of perceived importance were difficulties in walking, using a bathtub, working, recreation activities, and climbing stairs. Severities of functional disabilities were not found to be correlated with perceived importance. The 23 patients (8.8%) dissatisfied with their replaced knees had more severe functional disabilities than the patients satisfied for most activities. The dissatisfied patients tended to perceive functional disabilities in highflexion activities to be more important than the satisfied. Keywords: disability, satisfaction, total knee arthroplasty. © 2010 Elsevier Inc. All rights reserved.
Total knee arthroplasty (TKA) has been repeatedly documented to be one of the most satisfactory surgical procedures for pain relief and functional restoration in patients with advanced osteoarthritis. However, despite these well-documented successes of TKA, a significant portion of patients are dissatisfied with their replaced knees, which brings into question the validity of current outcome scoring systems for assessing functional outcomes as perceived by patients [1-3]. Outcomes as assessed by patient-driven scoring systems have typically not been as good as the satisfactory results assessed by physician-driven systems [3-6]. Recently, in addition to improvements in physician-driven objective outcome scales, patient satisfaction has attracted much attention
From the *Joint Reconstruction Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea; and yDepartment of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea. Supplementary material available at www.arthroplastyjournal.org. Submitted March 14, 2008; accepted January 30, 2009. Benefits or funds were received in partial or total support of the research material described in this article from the clinical research fund of Seoul National University Bundang Hospital (B-0702/042-103). T.K. Kim, MD, PhD, is a consultant for Smith & Nephew and B.BraunAesculap. No benefits or funds were received in support of this study. Reprint requests: Tae Kyun Kim, MD, PhD, Joint Reconstruction Center, Seoul National University Bundang Hospital, 300 Gumidong, Bundangu, Seongnam-si, Gyeonggi-do, Korea. © 2010 Elsevier Inc. All rights reserved. 0883-5403/09/2503-0021$36.00/0 doi:10.1016/j.arth.2009.01.018
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as a key parameter for the evaluation of the quality of life improvements offered by joint replacement surgery [36]. However, the literature is lacking detailed information concerning how patients assess the functions of their replacement knees and how they perceive residual functional disabilities. Currently, much effort is being expended to obtain more flexion and allow high-flexion activities, which are frequently required by followers of certain religions and by those that have adopted a traditional Asian lifestyle [7-10]. However, there are concerns regarding the longevities of TKAs due to the high-flexion activities made possible by increases in maximum flexion, which can increase stresses on articulating surfaces and implant-bone interfaces [11-14]. Understanding current functional disabilities, their perceived importance, patient satisfaction, and issues of concern after surgery is required for the development of optimal strategies to improve TKA outcomes in relation to high-flexion activities. However, no previous study has focused on postoperative functional disabilities and patients' satisfactions, particularly in Asian patients, for whom high-flexion activities have substantial implications. In a previous study, we investigated functional disabilities and issues of concern to female Asian patients before TKA [15]. High-flexion activities, such as kneeling, squatting, and sitting with crossed legs, were the most severely disabled functions but that patients did not perceive them to be as important as items related to pain
Functional Disability and Satisfaction After TKA Kim et al
relief and routine daily activities. However, as the primary goals of knee arthroplasty, that is, pain relief and the restoration of walking ability are achieved early during the postoperative period, it is likely that patients subsequently revise their priorities and redefine treatment success for previously considered secondary goals [16,17]. A recent study reported that the presence of residual symptoms and functional impairment and a failure to fulfill preoperative expectations are associated with patient dissatisfaction [3]. Then, if this is the case, residual high-flexion disabilities, as reported by previous studies [5,18], may be later perceived to be more important and a cause of patient dissatisfaction after TKA in Asian patients. Thus, this study was undertaken to investigate functional disabilities, their perceived importance, and patient satisfaction in Korean patients who have undergone TKA for advanced osteoarthritis. Specifically, we aimed to determine whether patients perceive residual highflexion disabilities to be more important than the primary goals, for example, pain relief and the restoration of normal daily activities such as walking and stair-climbing. We also attempted to establish whether residual highflexion disabilities are associated with patient dissatisfaction. It was hypothesized that Korean TKA patients would consider functional high-flexion disabilities to be more important than functional disabilities affecting routine daily activities and that residual functional highflexion disabilities are a cause of patient dissatisfaction with replaced knees.
Materials and Methods Four hundred seventy-three patients (738 knees) who had undergone TKA between November 2003 and March 2005 were considered for inclusion in this study. The inclusion criteria adopted were a diagnosis of primary osteoarthritis, the absence of postoperative complications affecting outcome, the absence of systemic comorbidities that prevented patients from experiencing the benefits of TKA, and the availability of a clinical outcome evaluated 12 months after surgery. Sixty patients (85 knees) were excluded for various reasons, that is, a diagnosis other than osteoarthritis (15); periprosthetic infection (4); death unrelated to surgery (2); significant medical problems unrelated to surgery (eg, a cardiovascular or cerebrovascular accident), Parkinson disease, or spine/hip fracture (8); and no visit to our clinic for a follow-up evaluation at more than 12 months postoperatively (31). Before questionnaires were posted to evaluate levels of patient satisfaction, an investigator (YGK) called all eligible patients to confirm mailing addresses; as a result, another 26 patients were excluded as they could not be contacted and no correct mailing address was available. Consequently, 387 (372 female and 15 male) patients (622 knees) were selected as candidates to mail the questionnaire.
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The questionnaire was composed of 3 parts. Part I requested sociodemographic data; part II evaluated level of patient satisfaction and how patients generally appreciated their physical activities after surgery; and part III evaluated functional disabilities and their perceived importance. Emphasis was placed on high-flexion activities in the questionnaire. Part I consisted of 7 questions relating to sex, ethnicity, preoperative and postoperative life styles, and willingness to convert from a traditional Asian lifestyle requiring high-flexion activities (ie, kneeling, squatting, sitting with legs crossed) to a Western style (Appendix A). Questions relating to lifestyles included place of residence (rural or urban), normal sitting style (on the floor or on a chair), and sleeping style (on a floor sleeping pad or on a bed). Question concerning willingness to change lifestyle were accompanied by a brief note explaining that a traditional lifestyle might reduce implant longevity. Part II of the questionnaire consisted of 4 questions, which addressed patient appreciation of postoperative physical activity and level of satisfaction with replacement knees (Appendix B). Patients were requested to compare their postoperative physical activities with their expectations and previous levels of physical activity. Patient satisfaction was evaluated using the grading system of the British Orthopedic Association with an explanation of the grading levels [19,20]. Part III, which was based on a previous study by Wright et al [21], contained 20 questions regarding current functional disabilities and their importance as perceived by patients. The questions received a binary or ordinal rating for severity; increasing levels represented more severe symptoms or disabilities. For comparison purposes, severity ratings were transformed to a 0 to 10 scale, where 0 was the best rating and 10 the worst. Each of the questions was accompanied by a visual analog scale ranging from 0 (not important at all) to 10 (extremely important) to evaluate the perceived importance of functional disabilities (Appendix C). Of the 387 patients who were sent the questionnaire, 270 (69.8%) completed the questionnaire. There were 261 female patients and 9 male patients. Nine male patients were excluded due to their small number, and therefore, 261 (70.2%) of 372 target female patients (424 knees) were finally included in this study. This study was approved by the institutional review board of our hospital, and an informed consent for the use of medical information was obtained from all patients. All patients were ethnic Koreans. Mean patient age was 68.4 years (SD, 5.8; range, 50-82). The mean patient height and weight were 151.9 cm (SD, 6.5; range, 135-168) and 61.7 kg (SD, 9.1; range, 36-98), and mean patient body mass index was 26.7 kg/m2 (SD, 3.4; range, 18-41). Seventy patients (26.8%) lived in rural areas and 191 (73.2%) in urban areas. After TKA, a considerable number of patients changed from a traditional lifestyle. One hundred eighty-one patients (70.2%) usually sat on the floor before surgery, but only 25 patients (9.7%) did so after
460 The Journal of Arthroplasty Vol. 25 No. 3 April 2010 surgery, and 174 patients (67.4%) slept on a floor sleeping pad before surgery, but only 28 patients (10.9%) did so after surgery. In addition, 139 patients (53.9%) knelt for religious reasons before TKA, but only 3 (1.2%) did so after TKA. All surgeries were performed by a single surgeon (TKK). Three hundred twenty-six TKAs were performed as bilateral procedures in 163 patients and the other 98 as unilateral procedures. Two hundred sixteen knees were implanted with fixed bearing prostheses (Genesis II; Smith & Nephew, Memphis, TN) and 208 with mobile bearing prostheses (E-motion; B. Braun-Aesculap, Tuttlingen, Germany). In all cases, a medial parapatellar arthrotomy approach was used, patellae were resurfaced, and implant fixations were carried out with cement. All clinical information was prospectively collected using predesigned datasheets and maintained in a database by an independent investigator (one of the authors). The clinical information included demographic data, preoperative clinical statuses, and postoperative outcomes evaluated at 6 and 12 months postoperatively and annually thereafter. Preoperative clinical statuses and postoperative outcomes were evaluated using knee range of motion (ROM), and American Knee Society knee and function scores [22], Western Ontario McMaster University Osteoarthritis Index scales [23], and Short Form-36 scores [24]. Range of motions were calculated by subtracting degree of flexion contracture from degrees of maximum flexion. An independent investigator (YGK) measured flexion contracture and maximum flexion to the nearest 5° by using a standard (38 cm) clinical goniometer, with the patient positioned in the supine position. The lateral femoral condyle was used as the landmark to center the goniometer with the proximal limb directed toward the greater trochanter and the distal limb toward the lateral malleolus. The postoperative mean scores of the 424 knees were significantly better than preoperative mean scores for all
Table 1. Summary of Preoperative and Postoperative Clinical Data Parameter
Preoperative
Postoperative
Flexion contracture Maximum flexion AKS knee score AKS function score WOMAC pain score WOMAC stiffness score WOMAC function score SF-36 physical component summary SF-36 mental component summary
13.5° (7.4°) 140.7° (13.3°) 46.0 (9.7) 53.2 (13.2) 11.9 (4.0) 5.0 (2.1) 42.4 (12.3) 28.2 (6.1) 39.8 (10.6)
0.0° (0.3°) 132.6° (10.2°) 95.5 (5.8) 95.5 (8.8) 2.1 (2.7) 1.5 (1.4) 14.5 (9.0) 44.0 (8.0) 49.0 (10.2)
AKS indicates American Knee Society; WOMAC, Western Ontario McMaster University Osteoarthritis Index; SF-36, Short Form-36. *Data are presented as means and SDs. Postoperative mean values were significantly better for all parameters than preoperative mean values (P b .01).
Table 2. Ranking of Functional Disability Items Based on Severity Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Disability
Mean
SD
Difficulty in kneeling † Difficulty in squatting † Difficulty in sitting with legs crossed † Difficulty in sexual activity ‡ Difficulty in recreational activities Daytime pain Difficulty in sitting on and rising from a chair Difficulty in climbing stairs Difficulty in working Unequal leg length Difficulty in driving Nighttime pain Difficulty in walking Difficulty in using public transportation Limping Taking medicine for pain relief Leg deformity Need for walking aids Difficulty in putting on shoes/socks Difficulty in using a bathtub
8.7 8.5 7.8 4.1 3.8 3.1 2.7 2.6 2.6 2.5 2.3 1.9 1.6 1.6 1.2 1.2 1.1 0.7 0.5 0.5
2.3 2.5 3.1 5.0 3.4 2.3 3.4 1.9 3.0 4.3 3.8 4.0 2.1 3.7 1.8 2.4 2.3 1.6 1.7 2.2
*Severity levels were scored on a 10-point scale, where 0 indicates the least disabled and 10 the most disabled. †Indicates the 3 items associated with high-flexion activity. ‡Only 61 (23.4%) patients reported about sexual activity.
parameters (P b .01) (Table 1). The mean postoperative ROM was 132.6° ranging from 80° to 155°. Statistical analysis was performed using SPSS for Windows (version 12.0, SPSS, Chicago, IL), and P values of less than .05 were considered significant. Rankings of functional disabilities in severity and perceived importance were performed using mean values. To determine whether patient satisfaction is associated with the severities of functional disabilities, the mean functional disability severity scores of satisfied and dissatisfied patients were compared using the Mann-Whitney U test. In addition, perceived importance rankings were compared between satisfied and dissatisfied patients. To investigate the effects of implant type and whether unilateral or bilateral TKAs, functional outcomes (ROM, American Knee Society scores, Western Ontario McMaster University Osteoarthritis Index scores, Short Form-36 scores, patient satisfaction) at postoperative 12 months and ranks of functional disability severity and perceived importance were compared between the 125 patients with Genesis II and 136 patients with E-motion and between the 98 patients with unilateral TKA and the 163 patients with bilateral TKAs. Statistical significance of the differences between the 2 groups were determined using the Student t test.
Results The TKA patients had severe functional high-flexion disabilities at more than 12 months postoperatively, but they did not perceive these to be more important than other functional disabilities not associated with high-
Functional Disability and Satisfaction After TKA Kim et al
flexion activities. The top 5 items of severity were kneeling (8.7), squatting (8.5), sitting with legs crossed (7.8), sexual activity (4.1), and recreational activities (3.8) (Table 2). However, the top 5 issues of perceived importance were walking (8.2), using a bathtub (7.7), working (7.5), recreational activities (7.1), and climbing stairs (7.0) (Table 3). The severities of functional disabilities were not found to be correlated with perceived importance. The top 5 functional disability issues were ranked as 9th, 12th, 16th, 18th, and 4th for perceived importance, and the top 5 perceived issues were ranked as 13th, 20th, 9th, 5th, and 8th for severity. The 3 issues associated with high-flexion activities were in the top 3 for severity. However, they were not perceived to be as important as issues associated with routine daily activities including walking, using a bathtub, working, recreational activities, and stair-climbing. Comparisons of the functional outcomes and ranks of functional disability severity and perceived importance between the 2 groups by the implant type and whether unilateral or bilateral TKAs revealed no significant differences in most items (P N .05). To determine whether high-flexion disabilities are associated with patient dissatisfaction, we compared satisfied and dissatisfied patients with respect to these disabilities and their perceived importance. Of the 261 patients, 238 (91.2%) said they were satisfied with their replaced knees, and 23 (8.8%) were dissatisfied (20 were not committed and 3 were disappointed). The 23 dissatisfied patients had more severe functional disabilities for most items, including Table 3. Ranking of Functional Disability Items Based on Perceived Importance Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Item
Mean
SD
Difficulty in walking Difficulty in using a bathtub Difficulty in working Difficulty in recreational activities Difficulty in climbing stairs Limping Difficulty in using public transportation Difficulty in sitting on and rising from a chair Difficulty in kneeling † Unequal leg lengths Leg deformity Difficulty in squatting † Daytime pain Difficulty in putting on shoes/socks Difficulty in driving Difficulty in sitting with legs crossed † Night pain Difficulty in sexual activity ‡ Taking medicine for pain relief Need for walking aids
8.2 7.7 7.5 7.1 7.0 6.7 6.7 6.7 6.7 6.5 6.2 6.2 6.0 5.9 5.9 5.5 5.3 4.5 4.2 3.8
2.5 2.7 2.8 2.8 2.8 3.4 3.3 3.5 3.2 3.6 3.6 3.2 3.4 3.7 4.3 3.4 3.5 3.2 3.6 3.6
*Perceived importance was scored on a 10-point visual analog scale, where 0 indicates the least important and 10 the most important. †Indicates the 3 items associated with high-flexion activity. ‡Only 61 (23.4%) patients reported about sexual activity.
461
Table 4. Functional Disability Severity Scores of Satisfied and Dissatisfied Patients Rank † 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Satisfied Dissatisfied Significance (n = 238) (n = 23) (P)
Item Difficulty in kneeling ‡ Difficulty in squatting ‡ Difficulty in sitting with legs crossed ‡ Difficulty in sexual activity Difficulty in recreational activities Daytime pain Difficulty in sitting on and rising from a chair Difficulty in climbing stairs Unequal leg lengths Difficulty in working Difficulty in driving Nighttime pain Difficulty in using public transportation Difficulty in walking Leg deformity Limping Taking medication for pain relief Need for walking aid Difficulty in using a bathtub Difficulty in putting on shoes/socks
8.6 (2.4) 8.4 (2.5) 7.7 (3.1)
9.6 (1.5) 9.1 (2.1) 8.6 (3.2)
.011 § .121 .205
3.8 (4.9)
8.0 (4.5)
.101
3.5 (3.3)
6.5 (3.3)
b.001 §
2.8 (2.1) 2.5 (3.3)
6.0 (2.0) 5.2 (3.8)
b.001 § b.001 §
2.5 (1.9)
3.8 (1.5)
b.001 §
2.4 (4.3) 2.4 (2.9) 2.1 (3.6) 1.7 (3.7) 1.6 (3.6)
3.0 (4.7) 4.5 (3.1) 5.0 (7.1) 4.8 (5.1) 2.3 (4.3)
.514 .004 § .298 .013 § .394
1.5 (2.0) 1.1 (2.3) 1.1 (1.7) 0.9 (2.1)
2.8 (2.5) 0.7 (2.3) 2.9 (2.1) 3.9 (3.8)
.002 § .364 b.001 § .005 §
0.6 (1.6) 0.5 (2.2)
1.4 (2.1) 0.4 (2.1)
.103 .884
0.5 (1.6)
1.1 (2.1)
.194
*Data are presented as means and SDs. †Ranks were determined using mean severity scores for all subjects. ‡Indicates the 3 items associated with high-flexion activity. §Indicates statistical significant (P b .05).
the difficulty in kneeling than the satisfied patients (Table 4). In ranking of perceived importance, dissatisfied patients ranked the 3 items associated with highflexion activities higher than satisfied patients. Difficulties in kneeling, squatting, and sitting with legs crossed were ranked as the 9th, 12th, and 16th by satisfied patients, whereas dissatisfied patients ranked these as 5th, 7th, and 13th, respectively (Table 5). Notably, more satisfied than dissatisfied patients were willing to change their traditional lifestyles for the sake of implant longevity (P b .05). One hundred twenty-four (52.1%) of the 238 satisfied patients reported that they would not adopt a traditional style, whereas only 4 (17.4%) of 23 patients in the dissatisfied group were of this opinion (P = .028).
Discussion Total knee arthroplasty has been established to be one of the most successful treatment options for patients with advanced osteoarthritis causing severe pain and functional disability. However, despite its well-established efficacy in pain relief and functional restoration, it has been reported that TKA clinical outcomes using currently available prostheses and surgical techniques do
462 The Journal of Arthroplasty Vol. 25 No. 3 April 2010 Table 5. Ranks of Functional Disability Items Based on Perceived Importance for Satisfied and Dissatisfied Patients* Rank # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Satisfied (n = 238) Difficulty in walking Difficulty in using a bathtub Difficulty in working Difficulty in recreational activities Difficulty in climbing stairs Limping Difficulty in sitting and rising from a chair Difficulty in using public transportation Difficulty in kneeling † Unequal leg lengths Leg deformity Difficulty in squatting † Difficulty in putting on shoes/socks Difficulty in driving Daytime pain Difficulty in sitting with legs crossed † Nighttime pain Difficulty in sexual activity Taking medication for pain relief Need for walking aid
Dissatisfied (n = 23) 8.2 (2.5) 7.7 (2.8) 7.4 (2.9) 7.1 (2.8) 6.9 (2.9) 6.7 (3.4) 6.7 (3.5) 6.7 (3.3) 6.6 (3.3) 6.5 (3.7) 6.3 (3.6) 6.1 (3.3) 6.0 (3.8) 5.9 (4.3) 5.9 (3.4) 5.4 (3.4) 5.2 (3.6) 4.6 (3.2) 4.1 (3.6) 3.8 (3.7)
Difficulty in walking Difficulty in working Difficulty in using a bathtub Difficulty in climbing stairs Difficulty in kneeling † Difficulty in using public transportation Difficulty in squatting † Daytime pain Difficulty in recreational activities Limping Difficulty in sitting and rising from a chair Unequal leg lengths Difficulty in sitting with legs crossed † Nighttime pain Taking medication for pain relief Difficulty in driving Difficulty in putting on shoes/socks Leg deformity Need for walking aid Difficulty in sexual activity
8.2 (2.0) 8.1 (2.2) 7.5 (2.5) 7.4 (2.5) 7.4 (2.7) 7.4 (2.6) 7.3 (2.6) 7.2 (2.7) 6.9 (2.6) 6.8 (2.6) 6.8 (2.8) 6.8 (3.5) 6.7 (2.9) 6.6 (2.8) 6.1 (3.0) 6.0 (5.7) 6.0 (2.8) 5.2 (4.0) 4.1 (3.0) 4.0 (3.9)
*Data are presented as means and SDs. #Ranks were determined using mean. †Indicates the 3 items associated with high-Flexion activity.
not always meet patient expectations, which have markedly increased due to population aging and higher activity levels. Recently, high-flexion activities have attracted much attention, and great efforts are being made to increase maximum flexion after TKA. However, high-flexion activities can be associated with adverse effects on implant longevity, and thus, the real benefits of trials designed to increase maximum flexion should be evaluated after considering patient experiences after TKA. In the present study, we sought to elaborate on clinical outcomes as perceived by patients, in functional disabilities, satisfaction, and issues of concern after TKA. Specifically, we aimed to determine whether patients perceive residual high-flexion disabilities to be more important than the primary goals, for example, pain relief and the restoration of normal daily activities such as walking and stair-climbing. We also attempted to establish whether residual high-flexion disabilities are associated with patient dissatisfaction. When interpreting our findings, several limitations should be noted. First, the characteristics of our study population should be considered before extrapolating our findings to other patient populations. Because of the all female sex and the elderly nature (mean age, 68.4 years) of our patient population, our findings concern elderly women whose physical activities and lifestyles differ markedly from those of a different age or sex. Second, the patients enrolled in the present study were not the same as the patients enrolled in our previous study, in which we investigated the severities and perceived importance of functional disabilities and issues of concerns before TKA. However, we are unaware of any reason why the findings of our 2 studies should not be compared because we recruited
consecutive patients at the same center during similar study periods. Third, the method used to select patients in this study should be noted. Of the 372 patients sent a questionnaire, 261 (70.2%) completed and returned the questionnaire, which is a higher response rate than those reported by previous studies with similar research goals. Nevertheless, the clinical outcomes of nonresponders have been reported to be poorer than those of responders [25], and thus, it is conceivable that our findings concerning patient appreciations are optimistic. Finally, although we endeavored to design a questionnaire that provided sound comparative data pre-TKA and post-TKA, the questionnaire undoubtedly had shortcomings in comprehensively depicting patient functional statuses. In particular, we assumed that kneeling, squatting, and sitting with legs crossed represent high-flexion activities that are typically performed by Koreans [15,26]. However, no detailed information on kneeling or squatting was collected, and these activities may have been interpreted according to individual perceptions. In this study, we hypothesized that patients would revise their treatment goals once pain relief and the functional restoration of daily activities had been achieved and that residual functional high-flexion disabilities were likely to become more important factors of patient dissatisfaction. A recent study reported that TKA patients demonstrated a response shift in their outcome measures post-TKA [16], and to some extent, our findings concur with this view. In a previous preTKA study on 97 female Korean patients, we found that items related to pain, difficulty in walking, or apparent leg deformity or length discrepancy were ranked at high level both for severity and perceived importance
Functional Disability and Satisfaction After TKA Kim et al
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Table 6. Preoperative and Postoperative Rankings of Functional Disability Items Based on Severities and Perceived Importance* Before TKA Rank
Park et al [15]
Severity 1 Difficulty in squatting (9.1) † 2 Leg deformity (8.8) 3 Difficulty in kneeling (8.4) † 4 Unequal leg lengths (8.1) 5 Limping (8.0) Perceived importance 1 Difficulty in walking (10.0) 2 Daytime pain (9.9) 3 Limping (9.8) 4 Difficulty in climbing stairs (9.8) 5 Need for walking aids (9.7)
After TKA Current Study
Weiss et al [5]
Difficulty in kneeling (8.7) † Difficulty in squatting (8.5) † Difficulty in sitting with legs crossed (7.8) † Difficulty in sexual activity (4.1) Difficulty in recreational activities (3.8)
Difficulty in squatting (75%) † Difficulty in kneeling (72%) † Difficulty in gardening (54%) † Difficulty in downhill skiing (50%) Difficulty in turning and cutting (48%)
Difficulty in walking (8.2) Difficulty in using a bathtub (7.7) Difficulty in working (7.5) Difficulty in recreational activities (7.1) Difficulty in climbing stairs (7.0)
Difficulty in sexual activities (62%) Difficulty in stretching exercise (56%) Difficulty in kneeling (52%) † Difficulty in gardening (50%) † Difficulty in turning and cutting (49%)
*Numbers in parenthesis indicated mean values in the 10-point scales for severity and perceived importance (0, the least severe or important and 10, the most severe or important) for the study by Park et al. [15] and the current study while the percent of patients who expressed difficulties or importance is given for the study by Weiss et al. [5]. †Items associated with high-flexion activity.
(Table 6) [15]. In contrast, the present study demonstrates that at more than 12 months after TKS, patients do not experience pain or experience walking or stairclimbing difficulties but that they continue to perceive functional shortcomings in their abilities to perform daily activities such as walking and stair-climbing. Furthermore, the present study shows that items related to quality of life, that is, use of a bathtub, working, and recreational activities, which were ranked at low levels before surgery became the top 5 issues at more than 12 months postoperatively, indicating that patients' aspirations had been redirected toward an active lifestyle and recreational activities. Moreover, despite the continued presence of severe functional high-flexion disabilities, patients did not perceive these as being more important than other daily or recreational activities. To our surprise, comparisons of the perceived importance of functional disabilities in our Korean and Western patients (as reported by Weiss et al [5]) suggest that Western subjects perceive high-flexion activities such as kneeling and gardening to be more important (Table 6). None of the 3 high-flexion activities were included in the top 5 items in our study, whereas kneeling and gardening were ranked as third and fourth in the study by Weiss et al [5]. This finding seemingly contradicts our expectation that a traditional Asian lifestyle require high-flexion activities more so than the Western lifestyle. We speculate that this interesting finding is associated with cultural lifestyle and expectation differences. The lifestyle of a typical elderly Korean woman would perhaps require fewer high-flexion activities than a typical Western subject to whom kneeling and gardening are important for recreational activities. In addition, the finding that items associated with sports activities, that is, turning and cutting, were ranked among the top 5 items, indicates that Western patients' expectations differ from those of Korean patients. The other explanation could be associated with the differences in surgical timing between Korean
and Western patients. Our patients had an inability to perform high-flexion activities for some time, as typically they sought surgical treatment during latestage osteoarthritis and, thus, might have become more accustomed to a lifestyle not requiring high-flexion activities than their Western counterparts. Another hypothesis of the present study was that residual functional high-flexion disabilities would adversely affect patient satisfaction with their replacement knees. Our findings indicate that residual functional high-flexion disabilities would not cause patient dissatisfaction in most cases but that they might seriously affect satisfaction in certain subgroups of patients who could or would not modify their traditional lifestyles. As compared with satisfied patients, dissatisfied patients had greater mean severity scores for most activities including the 3 high-flexion activities, which suggests that overall poorer functional outcomes, not only those due to residual high-flexion disabilities, could cause patient dissatisfaction (Table 5). When we compared the perceived importance of items, no significant differences were found between the mean importance scores of satisfied and dissatisfied patients, but the rankings of the 3 items associated with highflexion activities were found to be higher for dissatisfied. Moreover, more satisfied patients than dissatisfied patients expressed a willingness to avoid high-flexion activities to promote implant longevity. This study concurs with our previous study reporting that dissatisfied patients after TKA had greater preoperative maximum flexion and postoperative decrease in maximum flexion—not the absolute amount of postoperative maximum flexion was associated with the occurrence of postoperative patient dissatisfaction [27]. This study demonstrates that patients remained severely disabled in high-flexion activities even after TKA. However, our findings indicate, despite this, that most Korean patients do not consider high-flexion activity disabilities to be more important than
464 The Journal of Arthroplasty Vol. 25 No. 3 April 2010 disabilities affecting routine daily activities. Furthermore, we found that high-flexion disabilities did not influence adversely patient satisfaction in most patients. Nevertheless, they are likely to cause considerable dissatisfaction among patients who are unprepared to modify their traditional lifestyles. Although there is little doubt that we need to endeavor to make highflexion activities possible to reduce patient dissatisfaction, efforts directed at increasing maximum flexion to make high flexion activities possible should also ensure prosthesis longevity and safety.
References 1. Anderson JG, Wixson RL, Tsai D, et al. Functional outcome and patient satisfaction in total knee patients over the age of 75. J Arthroplasty 1996;11:831. 2. Dickstein R, Heffes Y, Shabtai EI, et al. Total knee arthroplasty in the elderly: patients' self-appraisal 6 and 12 months postoperatively. Gerontology 1998;44:204. 3. Noble PC, Conditt MA, Cook KF, et al. The John Insall Award: patient expectations affect satisfaction with total knee arthroplasty. Clin Orthop Relat Res 2006;452:35. 4. Mancuso CA, Salvati EA, Johanson NA, et al. Patients' expectations and satisfaction with total hip arthroplasty. J Arthroplasty 1997;12:387. 5. Weiss JM, Noble PC, Conditt MA, et al. What functional activities are important to patients with knee replacements? Clin Orthop Relat Res 2002;404:172. 6. Woolhead GM, Donovan JL, Dieppe PA. Outcomes of total knee replacement: a qualitative study. Rheumatology (Oxford) 2005;44:1032. 7. Akagi M. Deep knee flexion in the Asian population. In: Bellemans J, Ries MD, Victor J, editors. Total knee arthroplasty: a guide to get better performance. Germany: Springer, Heidelberg; 2005. p. 311. 8. Argenson JN, Komistek RD, Mahfouz M, et al. A high flexion total knee arthroplasty design replicates healthy knee motion. Clin Orthop Relat Res 2004;428:174. 9. Kim YH, Sohn KS, Kim JS. Range of motion of standard and high-flexion posterior stabilized total knee prostheses. A prospective, randomized study. J Bone Joint Surg Am 2005; 87:1470. 10. Li G, Schule SL, Zayontz SJ, et al. Improving flexion in total knee arthroplasty. In: Callaghan JJ, Rosenberg AG, Rubash HE, Simonian PT, Wickiewicz TL, editors. The adult knee. Philadelphia: Lippincott Williams and Wilkins; 2003; p. 1233. 11. Kanekasu K, Banks SA, Honjo S, et al. Fluoroscopic analysis of knee arthroplasty kinematics during deep flexion kneeling. J Arthroplasty 2004;19:998.
12. Lee SY, Matsui N, Kurosaka M, et al. A posteriorstabilized total knee arthroplasty shows condylar lift-off during deep knee bends. Clin Orthop Relat Res 2005; 435:181. 13. Nagura T, Dyrby CO, Alexander EJ, et al. Mechanical loads at the knee joint during deep flexion. J Orthop Res 2002;20: 881. 14. Thambyah A, Goh JC, De SD. Contact stresses in the knee joint in deep flexion. Med Eng Phys 2005;27:329. 15. Park KK, Shin KS, Chang CB, et al. Functional disabilities and issues of concern in female Asian patients before TKA. Clin Orthop Relat Res 2007;461:143. 16. Razmjou H, Yee A, Ford M, et al. Response shift in outcome assessment in patients undergoing total knee arthroplasty. J Bone Joint Surg Am 2006;88:2590. 17. Wilson IB. Clinical understanding and clinical implications of response shift. Soc Sci Med 1999;48:1577. 18. Noble PC, Gordon MJ, Weiss JM, et al. Does total knee replacement restore normal knee function? Clin Orthop Relat Res 2005;431:157. 19. Aichroth P, Freeman MAR, Smillie IS, et al. A knee function assessment chart. From the British Orthopaedic Association Research Sub-Committee. J Bone Joint Surg Br 1978;60: 308. 20. Waters TS, Bentley G. Patellar resurfacing in total knee arthroplasty. A prospective, randomized study. J Bone Joint Surg Am 2003;85:212. 21. Wright JG, Rudicel S, Feinstein AR. Ask patients what they want. Evaluation of individual complaints before total hip replacement. J Bone Joint Surg Br 1994;76:229. 22. Insall JN, Dorr LD, Scott RD, et al. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 1989; 248:13. 23. Bellamy N, Buchanan WW, Goldsmith CH, et al. 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. 24. Ware Jr JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30:473. 25. Kim J, Lonner JH, Nelson CL, et al. Response bias: effect on outcomes evaluation by mail surveys after total knee arthroplasty. J Bone Joint Surg Am 2004;86A:15. 26. Kim JM, Moon MS. Squatting following total knee arthroplasty. Clin Orthop Relat Res 1995;313:177. 27. Kim TK, Chang CB, Kang YG, et al. Causes and predictors of patient's dissatisfaction after uncomplicated total knee arthroplasty. J Arthroplasty 2009;24:263.
Functional Disability and Satisfaction After TKA Kim et al
Appendix A Part I of the questionnaire Name : Birth date : / / Survey date : / / Op date : / / (Rt / Lt) Please answer the following questions. 1. What is your gender? □ Female □ Male 2. What is your ethnic origin? □ Korean □ Other (specify: ) 3. Please choose the location in which you live. □ Urban area □ Rural area □ Other (specify: ) 4. Please choose the most appropriate lifestyle provided below. (1) Preoperatively □ Usually sit on a chair. □ Usually sit on the floor. (2) Postoperatively □ Usually sit on a chair. □ Usually sit on the floor. (3) If you changed lifestyle, was your replaced knee the reason? □ Yes □ No 5. Please choose your sleeping style. (1) Preoperatively □ On a bed □ On the floor with a sleeping pad. (2) Postoperatively □ On a bed □ On the floor with a sleeping pad. (3) If you changed life style, was the reason TKA? □ Yes □ No 6. If you have a religion, do you kneel for religious activities? (1) Preoperatively □ Yes □ No (2) Postoperatively □ Yes □ No (3) If you changed lifestyle, was your replaced knee the reason? □ Yes □ No 7. The longevity of your replaced knee can be influenced by the lifestyle you are living, and the traditional life style that requires high-flexion activities (kneeling, squatting, and sitting with legs crossed) may reduce the longevity of your replaced knee. Considering this, what would you do regarding your lifestyle? □ I would keep the traditional lifestyle despite its adverse effect on implant longevity. □ I would make efforts to avoid the high-flexion activities if possible. □ I would never try to perform high-flexion activities.
Appendix B Part II of the questionnaire Please answer the following questions. 1. After surgery, have you experienced any functional impairment that was not present preoperatively? □ No □ Yes
464.e1
2. What is your appreciation of your current physical activity as compared with your preoperative expectation? □ Better than expected □ As expected □ Poorer than expected 3. What is your appreciation of your current physical activity as compared with your preoperative level of physical activity? □ Better □ The same □ Poorer 4. How much are you satisfied with the replaced knee? A. Enthusiastic (I am extremely satisfied with my replaced knee and would be willing to undergo the same surgery if I needed another knee). B. Satisfied (I am generally satisfied with my replacement knee). C. Noncommitted (my replaced knee is satisfactory in some aspects and unsatisfactory in others). D. Disappointed (my replaced knee is disappointing and I regret my decision to select joint replacement).
Appendix C Part III of the questionnaire All questions have an additional query regarding a visual analog scale, which is required to evaluate your perceived importance of functional disabilities. Please answer the following questions. 1. Do you have daytime knee pain? — ( ) □ No. □ Occasionally with no compromise of activities. □ Yes, with most normal activities. □ Yes, which is severe enough to seriously limit my activities. □ I am crippled/bedridden because of knee pain. How important is the symptom or functional disability mentioned in the question above to the quality of your life? Please mark the box that best represents your opinion. Not important 0 1 2 3 4 5 6 7 8 9 10 Very at all □ □ □ □ □ □ □ □ □ □ □ important
2. Do you have difficulty in kneeling? □ I can kneel comfortably. □ I can kneel, but it is uncomfortable. □ I can kneel only for a while. □ I can't kneel because of my knee. 3. Does knee pain at night interfere with your sleep at least once a week? □ No □ Yes 4. Do you take any medication for to relieve your knee pain? □ None (less than once a week) □ Occasionally □ Everyday 5. How far can you usually walk? □ Unlimited distance or longer than 30 minutes. □ For longer than 10 minutes but less than 30 minutes.
464.e2 The Journal of Arthroplasty Vol. 25 No. 3 April 2010 □ Less than 10 minutes. 11. Do you have difficulty sitting with legs crossed? □ Only within my house. □ I can sit with legs crossed without discomfort. □ I am usually confined to a bed or chair. □ I can sit with legs crossed but with discomfort. 6. Can you climb stairs? □ I can sit with legs crossed but only for a while. □ Normally without using a banister. □ I can't sit with legs crossed because of my knee. □ With difficulty using a banister. 12. Can you use public transportation? □ One step at a time because of my knee (any □ Yes. □ No, because of my knee. manner). 13. Can you drive a car? □ Yes, but only with assistance. □ Can drive a car. □ With difficulty because of my □ I am unable to climb stairs because of my knee. knee. 7. How serious is your limp due to the knee? □ Unable to drive a car because of my knee. □ I don't □ None □ Mild □ Moderate □ Severe drive a car. 8. Do you ever use canes, crutches, or a walker because of 14. Can you do your normal job or housework? your knee? □ I am able to do usual job/housework. □ No. □ My work has been modified because of knee pain. □ I use a cane for long walks (longer than 30 minutes). □ I am unable to work because of my knee. □ I use a cane or crutch only outside the house. 15. Can you do perform your recreational activities □ I use a cane or crutch inside and outside the house. (hobbies, sports, other)? □ I use 2 canes, 2 crutches, or a walker, or I am □ Normally. □ My activities are modified because of wheelchair bound or bedridden. my knee. 9. Do you put on your own shoes and socks? □ I am unable to do so because of my knee. □ Without trouble. 16. Do you have difficulty in squatting? □ With difficulty or with “aids” needed because of the □ I can squat without discomfort. □ I can squat but with discomfort. knee. □ I can squat only for a while. □ I can't squat because □ I cannot without personal assistance. of my knee 10. How comfortably can you sit on and rise from 17. Does your knee interfere with your sexual activity a chair? (quality or frequency)? □ I can rise from a chair without upper □ No problem. □ With difficult because of my knee. extremity support and can sit for longer than □ I am not sexually active. 30 minutes. □ I can rise from a chair without upper 18. Can you take a tub bath? □ Yes. □ No. extremity support, but I can sit for only less 19. Have you noted any difference in leg lengths? than 30 minutes because of knee pain. □ No. □ Yes. □ I need upper extremity support to rise from a 20. Do you have deformity in your leg? chair but can sit for longer than 30 minutes. □ No. □ Only I can notice. □ I cannot rise from a chair independently or □ To an extent that others can notice even when I am need upper extremity support to rise and cannot dressed. sit for less than 30 minutes.
Functional Disabilities and Satisfaction After Total Knee Arthroplasty in Female Asian Patients Tae Kyun Kim, MD, PhD,*y Sae Kwang Kwon, MD,* Yeon Gwi Kang, BS,* Chong Bum Chang, MD, PhD,*y and Sang Cheol Seong, MD, PhDy
Abstract: This study was conducted to investigate functional disabilities and patient satisfaction in Korean patients after total knee arthroplasty (TKA). Of 372 female patients who had undergone TKA with a follow-up longer than 12 months, 261 patients (70.2%) completed a questionnaire designed to evaluate functional disabilities, perceived importance, and patient satisfaction. The top 5 severe functional disabilities were difficulties in kneeling, squatting, sitting with legs crossed, sexual activity, and recreational activities. The top 5 in order of perceived importance were difficulties in walking, using a bathtub, working, recreation activities, and climbing stairs. Severities of functional disabilities were not found to be correlated with perceived importance. The 23 patients (8.8%) dissatisfied with their replaced knees had more severe functional disabilities than the patients satisfied for most activities. The dissatisfied patients tended to perceive functional disabilities in highflexion activities to be more important than the satisfied. Keywords: disability, satisfaction, total knee arthroplasty. © 2010 Elsevier Inc. All rights reserved.
Total knee arthroplasty (TKA) has been repeatedly documented to be one of the most satisfactory surgical procedures for pain relief and functional restoration in patients with advanced osteoarthritis. However, despite these well-documented successes of TKA, a significant portion of patients are dissatisfied with their replaced knees, which brings into question the validity of current outcome scoring systems for assessing functional outcomes as perceived by patients [1-3]. Outcomes as assessed by patient-driven scoring systems have typically not been as good as the satisfactory results assessed by physician-driven systems [3-6]. Recently, in addition to improvements in physician-driven objective outcome scales, patient satisfaction has attracted much attention
From the *Joint Reconstruction Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea; and yDepartment of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea. Supplementary material available at www.arthroplastyjournal.org. Submitted March 14, 2008; accepted January 30, 2009. Benefits or funds were received in partial or total support of the research material described in this article from the clinical research fund of Seoul National University Bundang Hospital (B-0702/042-103). T.K. Kim, MD, PhD, is a consultant for Smith & Nephew and B.BraunAesculap. No benefits or funds were received in support of this study. Reprint requests: Tae Kyun Kim, MD, PhD, Joint Reconstruction Center, Seoul National University Bundang Hospital, 300 Gumidong, Bundangu, Seongnam-si, Gyeonggi-do, Korea. © 2010 Elsevier Inc. All rights reserved. 0883-5403/09/2503-0021$36.00/0 doi:10.1016/j.arth.2009.01.018
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as a key parameter for the evaluation of the quality of life improvements offered by joint replacement surgery [36]. However, the literature is lacking detailed information concerning how patients assess the functions of their replacement knees and how they perceive residual functional disabilities. Currently, much effort is being expended to obtain more flexion and allow high-flexion activities, which are frequently required by followers of certain religions and by those that have adopted a traditional Asian lifestyle [7-10]. However, there are concerns regarding the longevities of TKAs due to the high-flexion activities made possible by increases in maximum flexion, which can increase stresses on articulating surfaces and implant-bone interfaces [11-14]. Understanding current functional disabilities, their perceived importance, patient satisfaction, and issues of concern after surgery is required for the development of optimal strategies to improve TKA outcomes in relation to high-flexion activities. However, no previous study has focused on postoperative functional disabilities and patients' satisfactions, particularly in Asian patients, for whom high-flexion activities have substantial implications. In a previous study, we investigated functional disabilities and issues of concern to female Asian patients before TKA [15]. High-flexion activities, such as kneeling, squatting, and sitting with crossed legs, were the most severely disabled functions but that patients did not perceive them to be as important as items related to pain
Functional Disability and Satisfaction After TKA Kim et al
relief and routine daily activities. However, as the primary goals of knee arthroplasty, that is, pain relief and the restoration of walking ability are achieved early during the postoperative period, it is likely that patients subsequently revise their priorities and redefine treatment success for previously considered secondary goals [16,17]. A recent study reported that the presence of residual symptoms and functional impairment and a failure to fulfill preoperative expectations are associated with patient dissatisfaction [3]. Then, if this is the case, residual high-flexion disabilities, as reported by previous studies [5,18], may be later perceived to be more important and a cause of patient dissatisfaction after TKA in Asian patients. Thus, this study was undertaken to investigate functional disabilities, their perceived importance, and patient satisfaction in Korean patients who have undergone TKA for advanced osteoarthritis. Specifically, we aimed to determine whether patients perceive residual highflexion disabilities to be more important than the primary goals, for example, pain relief and the restoration of normal daily activities such as walking and stair-climbing. We also attempted to establish whether residual highflexion disabilities are associated with patient dissatisfaction. It was hypothesized that Korean TKA patients would consider functional high-flexion disabilities to be more important than functional disabilities affecting routine daily activities and that residual functional highflexion disabilities are a cause of patient dissatisfaction with replaced knees.
Materials and Methods Four hundred seventy-three patients (738 knees) who had undergone TKA between November 2003 and March 2005 were considered for inclusion in this study. The inclusion criteria adopted were a diagnosis of primary osteoarthritis, the absence of postoperative complications affecting outcome, the absence of systemic comorbidities that prevented patients from experiencing the benefits of TKA, and the availability of a clinical outcome evaluated 12 months after surgery. Sixty patients (85 knees) were excluded for various reasons, that is, a diagnosis other than osteoarthritis (15); periprosthetic infection (4); death unrelated to surgery (2); significant medical problems unrelated to surgery (eg, a cardiovascular or cerebrovascular accident), Parkinson disease, or spine/hip fracture (8); and no visit to our clinic for a follow-up evaluation at more than 12 months postoperatively (31). Before questionnaires were posted to evaluate levels of patient satisfaction, an investigator (YGK) called all eligible patients to confirm mailing addresses; as a result, another 26 patients were excluded as they could not be contacted and no correct mailing address was available. Consequently, 387 (372 female and 15 male) patients (622 knees) were selected as candidates to mail the questionnaire.
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The questionnaire was composed of 3 parts. Part I requested sociodemographic data; part II evaluated level of patient satisfaction and how patients generally appreciated their physical activities after surgery; and part III evaluated functional disabilities and their perceived importance. Emphasis was placed on high-flexion activities in the questionnaire. Part I consisted of 7 questions relating to sex, ethnicity, preoperative and postoperative life styles, and willingness to convert from a traditional Asian lifestyle requiring high-flexion activities (ie, kneeling, squatting, sitting with legs crossed) to a Western style (Appendix A). Questions relating to lifestyles included place of residence (rural or urban), normal sitting style (on the floor or on a chair), and sleeping style (on a floor sleeping pad or on a bed). Question concerning willingness to change lifestyle were accompanied by a brief note explaining that a traditional lifestyle might reduce implant longevity. Part II of the questionnaire consisted of 4 questions, which addressed patient appreciation of postoperative physical activity and level of satisfaction with replacement knees (Appendix B). Patients were requested to compare their postoperative physical activities with their expectations and previous levels of physical activity. Patient satisfaction was evaluated using the grading system of the British Orthopedic Association with an explanation of the grading levels [19,20]. Part III, which was based on a previous study by Wright et al [21], contained 20 questions regarding current functional disabilities and their importance as perceived by patients. The questions received a binary or ordinal rating for severity; increasing levels represented more severe symptoms or disabilities. For comparison purposes, severity ratings were transformed to a 0 to 10 scale, where 0 was the best rating and 10 the worst. Each of the questions was accompanied by a visual analog scale ranging from 0 (not important at all) to 10 (extremely important) to evaluate the perceived importance of functional disabilities (Appendix C). Of the 387 patients who were sent the questionnaire, 270 (69.8%) completed the questionnaire. There were 261 female patients and 9 male patients. Nine male patients were excluded due to their small number, and therefore, 261 (70.2%) of 372 target female patients (424 knees) were finally included in this study. This study was approved by the institutional review board of our hospital, and an informed consent for the use of medical information was obtained from all patients. All patients were ethnic Koreans. Mean patient age was 68.4 years (SD, 5.8; range, 50-82). The mean patient height and weight were 151.9 cm (SD, 6.5; range, 135-168) and 61.7 kg (SD, 9.1; range, 36-98), and mean patient body mass index was 26.7 kg/m2 (SD, 3.4; range, 18-41). Seventy patients (26.8%) lived in rural areas and 191 (73.2%) in urban areas. After TKA, a considerable number of patients changed from a traditional lifestyle. One hundred eighty-one patients (70.2%) usually sat on the floor before surgery, but only 25 patients (9.7%) did so after
460 The Journal of Arthroplasty Vol. 25 No. 3 April 2010 surgery, and 174 patients (67.4%) slept on a floor sleeping pad before surgery, but only 28 patients (10.9%) did so after surgery. In addition, 139 patients (53.9%) knelt for religious reasons before TKA, but only 3 (1.2%) did so after TKA. All surgeries were performed by a single surgeon (TKK). Three hundred twenty-six TKAs were performed as bilateral procedures in 163 patients and the other 98 as unilateral procedures. Two hundred sixteen knees were implanted with fixed bearing prostheses (Genesis II; Smith & Nephew, Memphis, TN) and 208 with mobile bearing prostheses (E-motion; B. Braun-Aesculap, Tuttlingen, Germany). In all cases, a medial parapatellar arthrotomy approach was used, patellae were resurfaced, and implant fixations were carried out with cement. All clinical information was prospectively collected using predesigned datasheets and maintained in a database by an independent investigator (one of the authors). The clinical information included demographic data, preoperative clinical statuses, and postoperative outcomes evaluated at 6 and 12 months postoperatively and annually thereafter. Preoperative clinical statuses and postoperative outcomes were evaluated using knee range of motion (ROM), and American Knee Society knee and function scores [22], Western Ontario McMaster University Osteoarthritis Index scales [23], and Short Form-36 scores [24]. Range of motions were calculated by subtracting degree of flexion contracture from degrees of maximum flexion. An independent investigator (YGK) measured flexion contracture and maximum flexion to the nearest 5° by using a standard (38 cm) clinical goniometer, with the patient positioned in the supine position. The lateral femoral condyle was used as the landmark to center the goniometer with the proximal limb directed toward the greater trochanter and the distal limb toward the lateral malleolus. The postoperative mean scores of the 424 knees were significantly better than preoperative mean scores for all
Table 1. Summary of Preoperative and Postoperative Clinical Data Parameter
Preoperative
Postoperative
Flexion contracture Maximum flexion AKS knee score AKS function score WOMAC pain score WOMAC stiffness score WOMAC function score SF-36 physical component summary SF-36 mental component summary
13.5° (7.4°) 140.7° (13.3°) 46.0 (9.7) 53.2 (13.2) 11.9 (4.0) 5.0 (2.1) 42.4 (12.3) 28.2 (6.1) 39.8 (10.6)
0.0° (0.3°) 132.6° (10.2°) 95.5 (5.8) 95.5 (8.8) 2.1 (2.7) 1.5 (1.4) 14.5 (9.0) 44.0 (8.0) 49.0 (10.2)
AKS indicates American Knee Society; WOMAC, Western Ontario McMaster University Osteoarthritis Index; SF-36, Short Form-36. *Data are presented as means and SDs. Postoperative mean values were significantly better for all parameters than preoperative mean values (P b .01).
Table 2. Ranking of Functional Disability Items Based on Severity Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Disability
Mean
SD
Difficulty in kneeling † Difficulty in squatting † Difficulty in sitting with legs crossed † Difficulty in sexual activity ‡ Difficulty in recreational activities Daytime pain Difficulty in sitting on and rising from a chair Difficulty in climbing stairs Difficulty in working Unequal leg length Difficulty in driving Nighttime pain Difficulty in walking Difficulty in using public transportation Limping Taking medicine for pain relief Leg deformity Need for walking aids Difficulty in putting on shoes/socks Difficulty in using a bathtub
8.7 8.5 7.8 4.1 3.8 3.1 2.7 2.6 2.6 2.5 2.3 1.9 1.6 1.6 1.2 1.2 1.1 0.7 0.5 0.5
2.3 2.5 3.1 5.0 3.4 2.3 3.4 1.9 3.0 4.3 3.8 4.0 2.1 3.7 1.8 2.4 2.3 1.6 1.7 2.2
*Severity levels were scored on a 10-point scale, where 0 indicates the least disabled and 10 the most disabled. †Indicates the 3 items associated with high-flexion activity. ‡Only 61 (23.4%) patients reported about sexual activity.
parameters (P b .01) (Table 1). The mean postoperative ROM was 132.6° ranging from 80° to 155°. Statistical analysis was performed using SPSS for Windows (version 12.0, SPSS, Chicago, IL), and P values of less than .05 were considered significant. Rankings of functional disabilities in severity and perceived importance were performed using mean values. To determine whether patient satisfaction is associated with the severities of functional disabilities, the mean functional disability severity scores of satisfied and dissatisfied patients were compared using the Mann-Whitney U test. In addition, perceived importance rankings were compared between satisfied and dissatisfied patients. To investigate the effects of implant type and whether unilateral or bilateral TKAs, functional outcomes (ROM, American Knee Society scores, Western Ontario McMaster University Osteoarthritis Index scores, Short Form-36 scores, patient satisfaction) at postoperative 12 months and ranks of functional disability severity and perceived importance were compared between the 125 patients with Genesis II and 136 patients with E-motion and between the 98 patients with unilateral TKA and the 163 patients with bilateral TKAs. Statistical significance of the differences between the 2 groups were determined using the Student t test.
Results The TKA patients had severe functional high-flexion disabilities at more than 12 months postoperatively, but they did not perceive these to be more important than other functional disabilities not associated with high-
Functional Disability and Satisfaction After TKA Kim et al
flexion activities. The top 5 items of severity were kneeling (8.7), squatting (8.5), sitting with legs crossed (7.8), sexual activity (4.1), and recreational activities (3.8) (Table 2). However, the top 5 issues of perceived importance were walking (8.2), using a bathtub (7.7), working (7.5), recreational activities (7.1), and climbing stairs (7.0) (Table 3). The severities of functional disabilities were not found to be correlated with perceived importance. The top 5 functional disability issues were ranked as 9th, 12th, 16th, 18th, and 4th for perceived importance, and the top 5 perceived issues were ranked as 13th, 20th, 9th, 5th, and 8th for severity. The 3 issues associated with high-flexion activities were in the top 3 for severity. However, they were not perceived to be as important as issues associated with routine daily activities including walking, using a bathtub, working, recreational activities, and stair-climbing. Comparisons of the functional outcomes and ranks of functional disability severity and perceived importance between the 2 groups by the implant type and whether unilateral or bilateral TKAs revealed no significant differences in most items (P N .05). To determine whether high-flexion disabilities are associated with patient dissatisfaction, we compared satisfied and dissatisfied patients with respect to these disabilities and their perceived importance. Of the 261 patients, 238 (91.2%) said they were satisfied with their replaced knees, and 23 (8.8%) were dissatisfied (20 were not committed and 3 were disappointed). The 23 dissatisfied patients had more severe functional disabilities for most items, including Table 3. Ranking of Functional Disability Items Based on Perceived Importance Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Item
Mean
SD
Difficulty in walking Difficulty in using a bathtub Difficulty in working Difficulty in recreational activities Difficulty in climbing stairs Limping Difficulty in using public transportation Difficulty in sitting on and rising from a chair Difficulty in kneeling † Unequal leg lengths Leg deformity Difficulty in squatting † Daytime pain Difficulty in putting on shoes/socks Difficulty in driving Difficulty in sitting with legs crossed † Night pain Difficulty in sexual activity ‡ Taking medicine for pain relief Need for walking aids
8.2 7.7 7.5 7.1 7.0 6.7 6.7 6.7 6.7 6.5 6.2 6.2 6.0 5.9 5.9 5.5 5.3 4.5 4.2 3.8
2.5 2.7 2.8 2.8 2.8 3.4 3.3 3.5 3.2 3.6 3.6 3.2 3.4 3.7 4.3 3.4 3.5 3.2 3.6 3.6
*Perceived importance was scored on a 10-point visual analog scale, where 0 indicates the least important and 10 the most important. †Indicates the 3 items associated with high-flexion activity. ‡Only 61 (23.4%) patients reported about sexual activity.
461
Table 4. Functional Disability Severity Scores of Satisfied and Dissatisfied Patients Rank † 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Satisfied Dissatisfied Significance (n = 238) (n = 23) (P)
Item Difficulty in kneeling ‡ Difficulty in squatting ‡ Difficulty in sitting with legs crossed ‡ Difficulty in sexual activity Difficulty in recreational activities Daytime pain Difficulty in sitting on and rising from a chair Difficulty in climbing stairs Unequal leg lengths Difficulty in working Difficulty in driving Nighttime pain Difficulty in using public transportation Difficulty in walking Leg deformity Limping Taking medication for pain relief Need for walking aid Difficulty in using a bathtub Difficulty in putting on shoes/socks
8.6 (2.4) 8.4 (2.5) 7.7 (3.1)
9.6 (1.5) 9.1 (2.1) 8.6 (3.2)
.011 § .121 .205
3.8 (4.9)
8.0 (4.5)
.101
3.5 (3.3)
6.5 (3.3)
b.001 §
2.8 (2.1) 2.5 (3.3)
6.0 (2.0) 5.2 (3.8)
b.001 § b.001 §
2.5 (1.9)
3.8 (1.5)
b.001 §
2.4 (4.3) 2.4 (2.9) 2.1 (3.6) 1.7 (3.7) 1.6 (3.6)
3.0 (4.7) 4.5 (3.1) 5.0 (7.1) 4.8 (5.1) 2.3 (4.3)
.514 .004 § .298 .013 § .394
1.5 (2.0) 1.1 (2.3) 1.1 (1.7) 0.9 (2.1)
2.8 (2.5) 0.7 (2.3) 2.9 (2.1) 3.9 (3.8)
.002 § .364 b.001 § .005 §
0.6 (1.6) 0.5 (2.2)
1.4 (2.1) 0.4 (2.1)
.103 .884
0.5 (1.6)
1.1 (2.1)
.194
*Data are presented as means and SDs. †Ranks were determined using mean severity scores for all subjects. ‡Indicates the 3 items associated with high-flexion activity. §Indicates statistical significant (P b .05).
the difficulty in kneeling than the satisfied patients (Table 4). In ranking of perceived importance, dissatisfied patients ranked the 3 items associated with highflexion activities higher than satisfied patients. Difficulties in kneeling, squatting, and sitting with legs crossed were ranked as the 9th, 12th, and 16th by satisfied patients, whereas dissatisfied patients ranked these as 5th, 7th, and 13th, respectively (Table 5). Notably, more satisfied than dissatisfied patients were willing to change their traditional lifestyles for the sake of implant longevity (P b .05). One hundred twenty-four (52.1%) of the 238 satisfied patients reported that they would not adopt a traditional style, whereas only 4 (17.4%) of 23 patients in the dissatisfied group were of this opinion (P = .028).
Discussion Total knee arthroplasty has been established to be one of the most successful treatment options for patients with advanced osteoarthritis causing severe pain and functional disability. However, despite its well-established efficacy in pain relief and functional restoration, it has been reported that TKA clinical outcomes using currently available prostheses and surgical techniques do
462 The Journal of Arthroplasty Vol. 25 No. 3 April 2010 Table 5. Ranks of Functional Disability Items Based on Perceived Importance for Satisfied and Dissatisfied Patients* Rank # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Satisfied (n = 238) Difficulty in walking Difficulty in using a bathtub Difficulty in working Difficulty in recreational activities Difficulty in climbing stairs Limping Difficulty in sitting and rising from a chair Difficulty in using public transportation Difficulty in kneeling † Unequal leg lengths Leg deformity Difficulty in squatting † Difficulty in putting on shoes/socks Difficulty in driving Daytime pain Difficulty in sitting with legs crossed † Nighttime pain Difficulty in sexual activity Taking medication for pain relief Need for walking aid
Dissatisfied (n = 23) 8.2 (2.5) 7.7 (2.8) 7.4 (2.9) 7.1 (2.8) 6.9 (2.9) 6.7 (3.4) 6.7 (3.5) 6.7 (3.3) 6.6 (3.3) 6.5 (3.7) 6.3 (3.6) 6.1 (3.3) 6.0 (3.8) 5.9 (4.3) 5.9 (3.4) 5.4 (3.4) 5.2 (3.6) 4.6 (3.2) 4.1 (3.6) 3.8 (3.7)
Difficulty in walking Difficulty in working Difficulty in using a bathtub Difficulty in climbing stairs Difficulty in kneeling † Difficulty in using public transportation Difficulty in squatting † Daytime pain Difficulty in recreational activities Limping Difficulty in sitting and rising from a chair Unequal leg lengths Difficulty in sitting with legs crossed † Nighttime pain Taking medication for pain relief Difficulty in driving Difficulty in putting on shoes/socks Leg deformity Need for walking aid Difficulty in sexual activity
8.2 (2.0) 8.1 (2.2) 7.5 (2.5) 7.4 (2.5) 7.4 (2.7) 7.4 (2.6) 7.3 (2.6) 7.2 (2.7) 6.9 (2.6) 6.8 (2.6) 6.8 (2.8) 6.8 (3.5) 6.7 (2.9) 6.6 (2.8) 6.1 (3.0) 6.0 (5.7) 6.0 (2.8) 5.2 (4.0) 4.1 (3.0) 4.0 (3.9)
*Data are presented as means and SDs. #Ranks were determined using mean. †Indicates the 3 items associated with high-Flexion activity.
not always meet patient expectations, which have markedly increased due to population aging and higher activity levels. Recently, high-flexion activities have attracted much attention, and great efforts are being made to increase maximum flexion after TKA. However, high-flexion activities can be associated with adverse effects on implant longevity, and thus, the real benefits of trials designed to increase maximum flexion should be evaluated after considering patient experiences after TKA. In the present study, we sought to elaborate on clinical outcomes as perceived by patients, in functional disabilities, satisfaction, and issues of concern after TKA. Specifically, we aimed to determine whether patients perceive residual high-flexion disabilities to be more important than the primary goals, for example, pain relief and the restoration of normal daily activities such as walking and stair-climbing. We also attempted to establish whether residual high-flexion disabilities are associated with patient dissatisfaction. When interpreting our findings, several limitations should be noted. First, the characteristics of our study population should be considered before extrapolating our findings to other patient populations. Because of the all female sex and the elderly nature (mean age, 68.4 years) of our patient population, our findings concern elderly women whose physical activities and lifestyles differ markedly from those of a different age or sex. Second, the patients enrolled in the present study were not the same as the patients enrolled in our previous study, in which we investigated the severities and perceived importance of functional disabilities and issues of concerns before TKA. However, we are unaware of any reason why the findings of our 2 studies should not be compared because we recruited
consecutive patients at the same center during similar study periods. Third, the method used to select patients in this study should be noted. Of the 372 patients sent a questionnaire, 261 (70.2%) completed and returned the questionnaire, which is a higher response rate than those reported by previous studies with similar research goals. Nevertheless, the clinical outcomes of nonresponders have been reported to be poorer than those of responders [25], and thus, it is conceivable that our findings concerning patient appreciations are optimistic. Finally, although we endeavored to design a questionnaire that provided sound comparative data pre-TKA and post-TKA, the questionnaire undoubtedly had shortcomings in comprehensively depicting patient functional statuses. In particular, we assumed that kneeling, squatting, and sitting with legs crossed represent high-flexion activities that are typically performed by Koreans [15,26]. However, no detailed information on kneeling or squatting was collected, and these activities may have been interpreted according to individual perceptions. In this study, we hypothesized that patients would revise their treatment goals once pain relief and the functional restoration of daily activities had been achieved and that residual functional high-flexion disabilities were likely to become more important factors of patient dissatisfaction. A recent study reported that TKA patients demonstrated a response shift in their outcome measures post-TKA [16], and to some extent, our findings concur with this view. In a previous preTKA study on 97 female Korean patients, we found that items related to pain, difficulty in walking, or apparent leg deformity or length discrepancy were ranked at high level both for severity and perceived importance
Functional Disability and Satisfaction After TKA Kim et al
463
Table 6. Preoperative and Postoperative Rankings of Functional Disability Items Based on Severities and Perceived Importance* Before TKA Rank
Park et al [15]
Severity 1 Difficulty in squatting (9.1) † 2 Leg deformity (8.8) 3 Difficulty in kneeling (8.4) † 4 Unequal leg lengths (8.1) 5 Limping (8.0) Perceived importance 1 Difficulty in walking (10.0) 2 Daytime pain (9.9) 3 Limping (9.8) 4 Difficulty in climbing stairs (9.8) 5 Need for walking aids (9.7)
After TKA Current Study
Weiss et al [5]
Difficulty in kneeling (8.7) † Difficulty in squatting (8.5) † Difficulty in sitting with legs crossed (7.8) † Difficulty in sexual activity (4.1) Difficulty in recreational activities (3.8)
Difficulty in squatting (75%) † Difficulty in kneeling (72%) † Difficulty in gardening (54%) † Difficulty in downhill skiing (50%) Difficulty in turning and cutting (48%)
Difficulty in walking (8.2) Difficulty in using a bathtub (7.7) Difficulty in working (7.5) Difficulty in recreational activities (7.1) Difficulty in climbing stairs (7.0)
Difficulty in sexual activities (62%) Difficulty in stretching exercise (56%) Difficulty in kneeling (52%) † Difficulty in gardening (50%) † Difficulty in turning and cutting (49%)
*Numbers in parenthesis indicated mean values in the 10-point scales for severity and perceived importance (0, the least severe or important and 10, the most severe or important) for the study by Park et al. [15] and the current study while the percent of patients who expressed difficulties or importance is given for the study by Weiss et al. [5]. †Items associated with high-flexion activity.
(Table 6) [15]. In contrast, the present study demonstrates that at more than 12 months after TKS, patients do not experience pain or experience walking or stairclimbing difficulties but that they continue to perceive functional shortcomings in their abilities to perform daily activities such as walking and stair-climbing. Furthermore, the present study shows that items related to quality of life, that is, use of a bathtub, working, and recreational activities, which were ranked at low levels before surgery became the top 5 issues at more than 12 months postoperatively, indicating that patients' aspirations had been redirected toward an active lifestyle and recreational activities. Moreover, despite the continued presence of severe functional high-flexion disabilities, patients did not perceive these as being more important than other daily or recreational activities. To our surprise, comparisons of the perceived importance of functional disabilities in our Korean and Western patients (as reported by Weiss et al [5]) suggest that Western subjects perceive high-flexion activities such as kneeling and gardening to be more important (Table 6). None of the 3 high-flexion activities were included in the top 5 items in our study, whereas kneeling and gardening were ranked as third and fourth in the study by Weiss et al [5]. This finding seemingly contradicts our expectation that a traditional Asian lifestyle require high-flexion activities more so than the Western lifestyle. We speculate that this interesting finding is associated with cultural lifestyle and expectation differences. The lifestyle of a typical elderly Korean woman would perhaps require fewer high-flexion activities than a typical Western subject to whom kneeling and gardening are important for recreational activities. In addition, the finding that items associated with sports activities, that is, turning and cutting, were ranked among the top 5 items, indicates that Western patients' expectations differ from those of Korean patients. The other explanation could be associated with the differences in surgical timing between Korean
and Western patients. Our patients had an inability to perform high-flexion activities for some time, as typically they sought surgical treatment during latestage osteoarthritis and, thus, might have become more accustomed to a lifestyle not requiring high-flexion activities than their Western counterparts. Another hypothesis of the present study was that residual functional high-flexion disabilities would adversely affect patient satisfaction with their replacement knees. Our findings indicate that residual functional high-flexion disabilities would not cause patient dissatisfaction in most cases but that they might seriously affect satisfaction in certain subgroups of patients who could or would not modify their traditional lifestyles. As compared with satisfied patients, dissatisfied patients had greater mean severity scores for most activities including the 3 high-flexion activities, which suggests that overall poorer functional outcomes, not only those due to residual high-flexion disabilities, could cause patient dissatisfaction (Table 5). When we compared the perceived importance of items, no significant differences were found between the mean importance scores of satisfied and dissatisfied patients, but the rankings of the 3 items associated with highflexion activities were found to be higher for dissatisfied. Moreover, more satisfied patients than dissatisfied patients expressed a willingness to avoid high-flexion activities to promote implant longevity. This study concurs with our previous study reporting that dissatisfied patients after TKA had greater preoperative maximum flexion and postoperative decrease in maximum flexion—not the absolute amount of postoperative maximum flexion was associated with the occurrence of postoperative patient dissatisfaction [27]. This study demonstrates that patients remained severely disabled in high-flexion activities even after TKA. However, our findings indicate, despite this, that most Korean patients do not consider high-flexion activity disabilities to be more important than
464 The Journal of Arthroplasty Vol. 25 No. 3 April 2010 disabilities affecting routine daily activities. Furthermore, we found that high-flexion disabilities did not influence adversely patient satisfaction in most patients. Nevertheless, they are likely to cause considerable dissatisfaction among patients who are unprepared to modify their traditional lifestyles. Although there is little doubt that we need to endeavor to make highflexion activities possible to reduce patient dissatisfaction, efforts directed at increasing maximum flexion to make high flexion activities possible should also ensure prosthesis longevity and safety.
References 1. Anderson JG, Wixson RL, Tsai D, et al. Functional outcome and patient satisfaction in total knee patients over the age of 75. J Arthroplasty 1996;11:831. 2. Dickstein R, Heffes Y, Shabtai EI, et al. Total knee arthroplasty in the elderly: patients' self-appraisal 6 and 12 months postoperatively. Gerontology 1998;44:204. 3. Noble PC, Conditt MA, Cook KF, et al. The John Insall Award: patient expectations affect satisfaction with total knee arthroplasty. Clin Orthop Relat Res 2006;452:35. 4. Mancuso CA, Salvati EA, Johanson NA, et al. Patients' expectations and satisfaction with total hip arthroplasty. J Arthroplasty 1997;12:387. 5. Weiss JM, Noble PC, Conditt MA, et al. What functional activities are important to patients with knee replacements? Clin Orthop Relat Res 2002;404:172. 6. Woolhead GM, Donovan JL, Dieppe PA. Outcomes of total knee replacement: a qualitative study. Rheumatology (Oxford) 2005;44:1032. 7. Akagi M. Deep knee flexion in the Asian population. In: Bellemans J, Ries MD, Victor J, editors. Total knee arthroplasty: a guide to get better performance. Germany: Springer, Heidelberg; 2005. p. 311. 8. Argenson JN, Komistek RD, Mahfouz M, et al. A high flexion total knee arthroplasty design replicates healthy knee motion. Clin Orthop Relat Res 2004;428:174. 9. Kim YH, Sohn KS, Kim JS. Range of motion of standard and high-flexion posterior stabilized total knee prostheses. A prospective, randomized study. J Bone Joint Surg Am 2005; 87:1470. 10. Li G, Schule SL, Zayontz SJ, et al. Improving flexion in total knee arthroplasty. In: Callaghan JJ, Rosenberg AG, Rubash HE, Simonian PT, Wickiewicz TL, editors. The adult knee. Philadelphia: Lippincott Williams and Wilkins; 2003; p. 1233. 11. Kanekasu K, Banks SA, Honjo S, et al. Fluoroscopic analysis of knee arthroplasty kinematics during deep flexion kneeling. J Arthroplasty 2004;19:998.
12. Lee SY, Matsui N, Kurosaka M, et al. A posteriorstabilized total knee arthroplasty shows condylar lift-off during deep knee bends. Clin Orthop Relat Res 2005; 435:181. 13. Nagura T, Dyrby CO, Alexander EJ, et al. Mechanical loads at the knee joint during deep flexion. J Orthop Res 2002;20: 881. 14. Thambyah A, Goh JC, De SD. Contact stresses in the knee joint in deep flexion. Med Eng Phys 2005;27:329. 15. Park KK, Shin KS, Chang CB, et al. Functional disabilities and issues of concern in female Asian patients before TKA. Clin Orthop Relat Res 2007;461:143. 16. Razmjou H, Yee A, Ford M, et al. Response shift in outcome assessment in patients undergoing total knee arthroplasty. J Bone Joint Surg Am 2006;88:2590. 17. Wilson IB. Clinical understanding and clinical implications of response shift. Soc Sci Med 1999;48:1577. 18. Noble PC, Gordon MJ, Weiss JM, et al. Does total knee replacement restore normal knee function? Clin Orthop Relat Res 2005;431:157. 19. Aichroth P, Freeman MAR, Smillie IS, et al. A knee function assessment chart. From the British Orthopaedic Association Research Sub-Committee. J Bone Joint Surg Br 1978;60: 308. 20. Waters TS, Bentley G. Patellar resurfacing in total knee arthroplasty. A prospective, randomized study. J Bone Joint Surg Am 2003;85:212. 21. Wright JG, Rudicel S, Feinstein AR. Ask patients what they want. Evaluation of individual complaints before total hip replacement. J Bone Joint Surg Br 1994;76:229. 22. Insall JN, Dorr LD, Scott RD, et al. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 1989; 248:13. 23. Bellamy N, Buchanan WW, Goldsmith CH, et al. 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. 24. Ware Jr JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30:473. 25. Kim J, Lonner JH, Nelson CL, et al. Response bias: effect on outcomes evaluation by mail surveys after total knee arthroplasty. J Bone Joint Surg Am 2004;86A:15. 26. Kim JM, Moon MS. Squatting following total knee arthroplasty. Clin Orthop Relat Res 1995;313:177. 27. Kim TK, Chang CB, Kang YG, et al. Causes and predictors of patient's dissatisfaction after uncomplicated total knee arthroplasty. J Arthroplasty 2009;24:263.
Functional Disability and Satisfaction After TKA Kim et al
Appendix A Part I of the questionnaire Name : Birth date : / / Survey date : / / Op date : / / (Rt / Lt) Please answer the following questions. 1. What is your gender? □ Female □ Male 2. What is your ethnic origin? □ Korean □ Other (specify: ) 3. Please choose the location in which you live. □ Urban area □ Rural area □ Other (specify: ) 4. Please choose the most appropriate lifestyle provided below. (1) Preoperatively □ Usually sit on a chair. □ Usually sit on the floor. (2) Postoperatively □ Usually sit on a chair. □ Usually sit on the floor. (3) If you changed lifestyle, was your replaced knee the reason? □ Yes □ No 5. Please choose your sleeping style. (1) Preoperatively □ On a bed □ On the floor with a sleeping pad. (2) Postoperatively □ On a bed □ On the floor with a sleeping pad. (3) If you changed life style, was the reason TKA? □ Yes □ No 6. If you have a religion, do you kneel for religious activities? (1) Preoperatively □ Yes □ No (2) Postoperatively □ Yes □ No (3) If you changed lifestyle, was your replaced knee the reason? □ Yes □ No 7. The longevity of your replaced knee can be influenced by the lifestyle you are living, and the traditional life style that requires high-flexion activities (kneeling, squatting, and sitting with legs crossed) may reduce the longevity of your replaced knee. Considering this, what would you do regarding your lifestyle? □ I would keep the traditional lifestyle despite its adverse effect on implant longevity. □ I would make efforts to avoid the high-flexion activities if possible. □ I would never try to perform high-flexion activities.
Appendix B Part II of the questionnaire Please answer the following questions. 1. After surgery, have you experienced any functional impairment that was not present preoperatively? □ No □ Yes
464.e1
2. What is your appreciation of your current physical activity as compared with your preoperative expectation? □ Better than expected □ As expected □ Poorer than expected 3. What is your appreciation of your current physical activity as compared with your preoperative level of physical activity? □ Better □ The same □ Poorer 4. How much are you satisfied with the replaced knee? A. Enthusiastic (I am extremely satisfied with my replaced knee and would be willing to undergo the same surgery if I needed another knee). B. Satisfied (I am generally satisfied with my replacement knee). C. Noncommitted (my replaced knee is satisfactory in some aspects and unsatisfactory in others). D. Disappointed (my replaced knee is disappointing and I regret my decision to select joint replacement).
Appendix C Part III of the questionnaire All questions have an additional query regarding a visual analog scale, which is required to evaluate your perceived importance of functional disabilities. Please answer the following questions. 1. Do you have daytime knee pain? — ( ) □ No. □ Occasionally with no compromise of activities. □ Yes, with most normal activities. □ Yes, which is severe enough to seriously limit my activities. □ I am crippled/bedridden because of knee pain. How important is the symptom or functional disability mentioned in the question above to the quality of your life? Please mark the box that best represents your opinion. Not important 0 1 2 3 4 5 6 7 8 9 10 Very at all □ □ □ □ □ □ □ □ □ □ □ important
2. Do you have difficulty in kneeling? □ I can kneel comfortably. □ I can kneel, but it is uncomfortable. □ I can kneel only for a while. □ I can't kneel because of my knee. 3. Does knee pain at night interfere with your sleep at least once a week? □ No □ Yes 4. Do you take any medication for to relieve your knee pain? □ None (less than once a week) □ Occasionally □ Everyday 5. How far can you usually walk? □ Unlimited distance or longer than 30 minutes. □ For longer than 10 minutes but less than 30 minutes.
464.e2 The Journal of Arthroplasty Vol. 25 No. 3 April 2010 □ Less than 10 minutes. 11. Do you have difficulty sitting with legs crossed? □ Only within my house. □ I can sit with legs crossed without discomfort. □ I am usually confined to a bed or chair. □ I can sit with legs crossed but with discomfort. 6. Can you climb stairs? □ I can sit with legs crossed but only for a while. □ Normally without using a banister. □ I can't sit with legs crossed because of my knee. □ With difficulty using a banister. 12. Can you use public transportation? □ One step at a time because of my knee (any □ Yes. □ No, because of my knee. manner). 13. Can you drive a car? □ Yes, but only with assistance. □ Can drive a car. □ With difficulty because of my □ I am unable to climb stairs because of my knee. knee. 7. How serious is your limp due to the knee? □ Unable to drive a car because of my knee. □ I don't □ None □ Mild □ Moderate □ Severe drive a car. 8. Do you ever use canes, crutches, or a walker because of 14. Can you do your normal job or housework? your knee? □ I am able to do usual job/housework. □ No. □ My work has been modified because of knee pain. □ I use a cane for long walks (longer than 30 minutes). □ I am unable to work because of my knee. □ I use a cane or crutch only outside the house. 15. Can you do perform your recreational activities □ I use a cane or crutch inside and outside the house. (hobbies, sports, other)? □ I use 2 canes, 2 crutches, or a walker, or I am □ Normally. □ My activities are modified because of wheelchair bound or bedridden. my knee. 9. Do you put on your own shoes and socks? □ I am unable to do so because of my knee. □ Without trouble. 16. Do you have difficulty in squatting? □ With difficulty or with “aids” needed because of the □ I can squat without discomfort. □ I can squat but with discomfort. knee. □ I can squat only for a while. □ I can't squat because □ I cannot without personal assistance. of my knee 10. How comfortably can you sit on and rise from 17. Does your knee interfere with your sexual activity a chair? (quality or frequency)? □ I can rise from a chair without upper □ No problem. □ With difficult because of my knee. extremity support and can sit for longer than □ I am not sexually active. 30 minutes. □ I can rise from a chair without upper 18. Can you take a tub bath? □ Yes. □ No. extremity support, but I can sit for only less 19. Have you noted any difference in leg lengths? than 30 minutes because of knee pain. □ No. □ Yes. □ I need upper extremity support to rise from a 20. Do you have deformity in your leg? chair but can sit for longer than 30 minutes. □ No. □ Only I can notice. □ I cannot rise from a chair independently or □ To an extent that others can notice even when I am need upper extremity support to rise and cannot dressed. sit for less than 30 minutes.